Grounded Pregnancy: Treating Depression During Pregnancy – What’s Safe?

Welcome to Grounded Pregnancy, the new series where I explore topics related to pregnancy and childbirth, without woo or natural childbirth bullshit. As an added bonus, you get to join me for the next few months, as I grow a tiny human in my uterus. Feel free to message me with your pregnancy and childbirth-related questions and concerns, and I will find you woo-free answers. Please note that while well-researched and beautifully written, this article shouldn’t be a substitute for medical advice. Please consult your health care provider.

Amanda writes:

Congrats on your pregnancy! I was wondering if you had found any research on birth defects when taking antidepressants during pregnancy vs. birth defects with untreated depression. That’s like the one thing I’m terrified of when I actually decide to have children. I’ve talked about it with my GP and my therapist, and they’ve both taken the approach of whatever it takes to get me and my baby through the pregnancy.

Thanks! Great question, and for me, one that hits close to home. I am currently being treated for antenatal depression. It feels weird writing those words. (Keep breathing, Steph). I am a bit embarrassed to admit that I sat on this post for a couple of weeks. I decided to go ahead and hit publish, because I want fewer people to feel alone or ashamed to get help, and I know from experience that there’s a lot of misinformation out there about medications and pregnancy.

Before I got help for my depression, things were bad. I didn’t know if it was hormones, my sometimes overwhelming home life, pregnancy anxiety, election season, hot weather, or the fact that I went from training for a marathon to puking 10 times a day in a little over a month, but life went from BAD to WORSE faster than one can say what the actual fuck. And to make matters worse, I live in the Midwest. Mental health (or really anything unpleasant or uncomfortable) is not something people generally talk about here. Add a dose of guilt for not feeling happy during my planned pregnancy, and I was literally suffering in silence. I didn’t know what to do, who to tell or if there was anything I could do. Finally, my feelings of sadness and hopelessness had become so intense that I knew I needed help. And then my Obstetrician asked me how I was feeling. And I, gulp, verbally vomited on her for about ten minutes. It was a scary conversation, but I am so glad I spoke up.

I’m not alone. According to the American Congress of Obstetricians and Gynecologists, between 14-23% of people will struggle with some symptoms of depression during pregnancy. Generally speaking, the risks of untreated depression can outweigh the risks of treatment, even when you add pregnancy to the mix. If left untreated, pregnant people with depression are at higher risk for postpartum depression and anxiety. They are also more likely to experience pregnancy complications, abuse drugs and alcohol and not receive prenatal care. Fuck, some days it’s hard leaving the house to get the mail, let alone getting exercise, eating “right” and going to prenatal appointments. And I can’t even have a glass of wine to take the edge off.

Luckily, safe and effective treatment options – including therapy and medications – are available to treat depression and other mental health conditions during pregnancy. For me, and many pregnant people, the best option was to start (and plan to continue throughout my pregnancy) a selective serotonin reuptake inhibitor medication (SSRI). Thanks to an effort in recent years to study the safety and efficacy of medications during pregnancy, we now know a lot more about how these drugs impact pregnancy and potential links with birth defects.

What do we know? A CDC study published last year in the British Medical Journal re-assessed several previously reported links between SSRI medication use during pregnancy (specifically – citalopram, escitalopram, fluoxetine, paroxetine, sertraline) and birth defects. While researchers confirmed links between fluoxetine and paroxetine and certain types of birth defects, researchers did not confirm links between sertraline, the SSRI used most often, and any of the birth defects observed in previous studies. Additionally, it’s important to note that all of the reported birth defects are extremely rare, meaning that the actual risk for a birth defect among babies born to people taking one of these medications is still very low.

To learn more, I consulted one of my favorite woo-free obstetrics providers – Lise Hauser, DNP, APN, CNM.

1. What advice do you have for someone who is pre-conception planning and currently needs medication(s) for mental health conditions?

I advise these women to talk to the provider who prescribes their medication. It may be a relatively simple switch of SSRI, or it may be more complex, if the condition is more complex than depression, or if the woman suffers from major or refractory depression. The BMJ study provided reassuring evidence for some SSRIs during pregnancy, but suggested that some birth defects occur 2-3.5 times more frequently among the infants of women treated with paroxetine or fluoxetine early in pregnancy.

2. Are there any medications that are considered safe during pregnancy (or perhaps it’s best to say – safer than the risks not treating mental health concerns)?

Zoloft (Sertraline) is generally considered safest in pregnancy and postpartum.

3. What kinds or prenatal screening do women’s health providers do for mental health?

The most common prenatal screening tool for depression is one developed to screen for postpartum depression, the Edinburgh Postpartum Depression Scale. It’s been translated into many, many languages, and is pretty straightforward. Though we’ve had some odd moments with refugees, who basically live in a chronically depressed state, and why wouldn’t they? We do our best. In our practice, we routinely screen for depression at 26-28 weeks gestation, and at 4-6 weeks postpartum. But we will also ask a patient to take the survey anytime we’re worried about her.

4. If someone learns they are pregnant and they are currently taking medications for mental health conditions, what should be their next step?

If someone learns she is pregnant and is taking meds, her first step should be to make an appointment with a knowledgeable obstetric provider, such as an obstetrician, family medicine physician, or certified nurse midwife. They can advise her based on the latest evidence, and also refer her to a maternal-fetal medicine physician for further counseling if desired.

Important Note: Abruptly stopping the use of medicines to treat mental health conditions can have serious consequences. The CDC advises that pregnant people not change medications or stop taking medications without first talking with their doctor about available options.

How am I doing? After three weeks of Zoloft, I am finally starting to feel like a normal human again, well I guess as normal as I ever feel, my provider is kind and supportive, and we have a plan. If you are pregnant or hope to get pregnant and have depression, you are not alone. You can do this. Any shame I have about taking an antidepressant is brightly out-shined by how I feel. Suck it stigma, make way for science.

References: 

The Management of Depression During Pregnancy: A Report from the American Psychiatric Association and The American College of Obstetricians and Gynecologists, Obstetrics & Gynecology (September 2009) and General Hospital Psychiatry (September/October 2009).

BMJ. 2015 Jul 8;351:h3190. doi: 10.1136/bmj.h3190. Specific SSRIs and birth defects: Bayesian analysis to interpret new data in the context of previous reports. Reefhuis J, Devine O, Friedman J, Louik C, Honein MA; National Birth Defects Prevention Study.

Treating for Two: Safe Medication Use During Pregnancy. Key Findings—A Closer Look at the Link Between Specific SSRIs and Birth Defects, Centers for Disease Control and Prevention, July 2015

Featured Image Credit: United Nations Photo