Pregnancy, supposed to be a joyous
time can be a positively harrowing experience for women
being treated with antidepressant drugs. The fear of
harming their unborn child by continuing their medication
must be weighed against the dangers of letting their
condition go unchecked. You can bet they will look to
you for advice on how to make this very tough decision.
And what you have to say may well surprise them.
BABIES
AND BLUES
Physicians once believed that pregnancy actually alleviated
the symptoms of depression. Unfortunately, we now know
the opposite is true. "Depression often gets worse during
pregnancy, though we don't know why," says Dr Shaila
Misri, co-director of the reproductive mental health
program at BC Women's Hospital and Health Centre. According
to Dr Don Davis, president of the Society of Obstetricians
and Gynecologists of Canada (SOGC), the physical and
emotional changes that occur during pregnancy can take
their toll on a woman's mental health. "Just the concern
of how their illness is going to affect their pregnancy
and their child's health can cause distress — fatigue
added to that doesn't help," he says. Hormonal changes
also affect mood, of course, as can the physical changes
of pregnancy. "To many of us this is a beautiful change,
but there are women who are very uncomfortable with
weight gain," he points out. "All these things can make
pre-existing depression worse."
MATERNAL
INSTINCT
As many of your patients who have suffered from or are
currently living with depression can tell you, medication
can be a real lifesaver — but most believe their
delicate condition means they will have to suffer through
their illness drug-free. Not so, says Dr Misri. "There
are two issues here: exposure to medication and exposure
to illness. Neither is a particularly good choice, but
if you have to make it, we know that leaving the mom
untreated is really not a good option," she says.
Dr Davis agrees. While the SOGC's
official position is that women shouldn't use any medication
during pregnancy unless it's absolutely necessary, it
does recognize that if a patient's depression is serious
enough to warrant medication, they're probably better
off staying on it because abrupt withdrawal can be very
dangerous. Even gradually tapering off, he adds, can
cause problems.
"I think patients need to be reassured,
they want to be as confident as they can that they're
doing the best things for themselves and their baby,"
Dr Davis says. "Many women are ready to 'take their
lumps,' that is manage their condition on their own,
just so long as the baby is well. That's the wonderful
thing about mothers — they're very self-sacrificing.
But the danger is that they'll become overwhelmed by
their underlying depression, and that doesn't serve
anyone."
PROS
AND CONS
The scientific literature is beginning to support that
notion. "A ton of research is now showing depression
itself has an adverse effect on the developing fetus,"
says Dr Misri. Untreated depression or anxiety during
pregnancy has been shown to lead to premature labour
and delivery. Women who stop taking their medication
are five times more likely than women who continue it
to experience a relapse, and the risk of postpartum
depression also goes up. Even after birth, children
can suffer from a mother's untreated condition —
studies have shown that the cognitive, social and psychological
development of a child can be affected.
Of course, there are also studies
— and these are the ones your patients are likely
to hear about — that show antidepressants can be
harmful to the fetus. A small study found babies of
women who took SSRIs in the second half of their pregnancy
were six times more likely to have a serious breathing
problem called persistent pulmonary hypertension. And
a recent study showed as many as one third of babies
born to mothers who took SSRIs experience short-term
withdrawal, symptoms of which include tremors, increased
crying and difficulty feeding. But to Dr Misri, the
evidence — and her personal experience — tells
her the risks to the baby aren't significant enough
to warrant putting the mother at risk. "The overwhelming
majority of these babies are fine — they really
are. Hence the advocacy for treatment."
A
BIG CAVEAT
The exception is paroxetine — Health Canada has
warned pregnant women shouldn't take the drug due to
an increased risk of fetal heart defects. If your patient
is taking paroxetine when she becomes pregnant, you'll
need to work with her to make the switch to another
medication. Tricyclics also are not recommended for
pregnant women.
Despite all the evidence, patients
with milder symptoms of depression or those who have
progressed well with treatment may insist on discontinuing
their medication during pregnancy. Again, it's a very
individual decision — but one that shouldn't be
made without your counsel. "If you're going to discontinue
medication, it must be done very gradually and the patient
must be monitored closely," Dr Davis warns. "Patients
should be told that they have a responsibility to their
unborn child to report any adverse situations themselves,
and maintain an open relationship with their physician
so intervention can occur quickly if it's needed," he
adds.
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