Depression and pregnancy...

January 13, 2004

http://www.nytimes.com/2004/01/13/health/psychology/13DEPR.html

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January 13, 2004

Dealing With Depression and the Perils of Pregnancy

By LAURIE TARKAN

hen Klein, a 32-year-old social worker in Los Angeles, discovered

that she was pregnant, she immediately stopped taking her antidepressant to

avoid exposing her baby to it. She had made the same choice with her first

child and experienced only the normal ups and downs of pregnancy.

This time was drastically different. Several weeks after going off the drug

Zoloft she slid into a major depression, which left her crying all day,

feeling overwhelmed by simple tasks like going to the supermarket, feeling

too tired to move, and extremely anxious, worrying about the pregnancy, her

2-year-old son and her job.

" I'd spend all day crying and I couldn't stop, " Ms. Klein said. " I hated

that my son saw me like that. " When she was feeling the most overwhelmed,

she said, she thought of giving away the new baby to her sister.

In her 15th week of pregnancy, she broke down in tears in front of her

obstetrician, who recommended that she go back on Zoloft. The doctor told

her that the risk of not taking it was greater than the risk of taking it.

" I was still worried about the effects of the medication on my baby, but I

knew I needed to do something, " Ms. Klein said. " I couldn't function anymore

the way I was going. "

She took a lower dosage of Zoloft to minimize exposure to the baby. It was

just enough to keep her functioning, but not quite enough to alleviate the

depression completely. After her son was born, she resumed her full dose and

now says she feels much happier.

For some women, especially those with a history of significant depression,

the risks of abandoning antidepressants during pregnancy may be far greater

to the mother and the fetus than taking the drugs themselves.

Those who abruptly stop taking their medications, often on the advice of

their obstetricians, put themselves in danger of a relapse. Others who

switch to lower dosages may still suffer depressive symptoms.

Although there are known risks to taking antidepressants in pregnancy, and

there may be unknown risks, mental health experts do not advise all pregnant

women or those planning to conceive to stop their drug regimens.

" Most physicians would say we don't know what the risks of these medications

are, so the safest thing to do is to go off them, " said Dr. Lori Altshuler,

a professor of psychiatry at the University of California, Los Angeles and

the director of the Mood Disorders Research Program there. " The fact is,

there are tremendous risks to the mother when she goes off antidepressants,

and I don't think there's an appreciation on the part of the physician or

the patient just how serious these are. "

About 75 to 80 percent of women who go off antidepressants will relapse

during the pregnancy, said Dr. Lee Cohen, director of the Perinatal and

Reproductive Psychiatry Clinical Research Program at Massachusetts General

Hospital. Some pregnant women with major depression have reported having

suicidal thoughts or were unable to function at work or take care of their

older children.

Depression in pregnancy is associated with poor eating, missing prenatal

appointments and use of substances like tobacco and alcohol, Dr. Cohen said.

Missing prenatal visits alone is a strong predictor of problems, among them

premature babies and low birth weights.

Depressed women also have a higher rate of obstetrical complications and

preterm deliveries, and a review of 11 studies has shown that they have 45

percent more miscarriages, said Dr. Gideon Koren, a pediatrician and the

director of the Motherisk program at the University of Toronto, a

risk-counseling service for pregnant women.

In addition, being depressed during pregnancy is a strong predictor of

postpartum depression, which can lead to poor mother-infant bonding and has

been linked to emotional, behavioral and learning problems in the child.

In one study, Dr. Koren's group followed women who called the Motherisk hot

line, which receives about 5,000 calls a year regarding the use of

psychiatric drugs. Of 34 women who called and said they had stopped taking

an antidepressant, a benzodiazepine (used to treat anxiety) or both, all

reported withdrawal symptoms and psychological problems. Eleven reported

suicidal thoughts, and four of them were admitted to hospitals.

Estimates from various studies indicate that about about 12 percent to 20

percent of pregnant women are depressed, yet the diagnosis may go

undetected. About 12 percent of women in the general population suffer a

depressive disorder each year.

According to one recent study published in The Journal of Women's Health, 20

percent of women screened in the waiting rooms of obstetrical clinics scored

in the depression range, with fewer than 15 percent of those in that

category indicating that they had received any formal treatment for

depression, like psychotherapy, medication or counseling.

Some mental health experts believe that doctors set a much higher threshold

to medicate pregnant women suffering depression than they do for pregnant

women suffering other diseases like high blood pressure, peptic ulcer

disease, bronchitis and other infections.

" I think the categorical belief is that depression is something you get over

rather than something you take medication for, " said Dr. Zachary N. Stowe,

director of the Women's Mental Health Program at Emory University in

Atlanta.

" We have more research on the safety of antidepressants in pregnant women

than any other class of drugs in the world, " Dr. Stowe said.

A number of studies have confirmed that neither the older tricyclic

antidepressants nor the newer and more popular selective serotonin reuptake

inhibitors, or S.S.R.I.'s, are associated with an increased risk of

malformations in newborns.

" We have over 2,000 cases of women who have been exposed to Prozac during

the first trimester, 400 cases of women exposed to Celexa, and several

hundred cases for other S.S.R.I.'s like Zoloft and Paxil, " Dr. Altshuler

said. No study has shown an increased risk of congenital malformations,

experts agree.

One study from Stanford, published in The Journal of Pediatrics, however,

did find an increase in minor anomalies like delays in fine motor skills and

increased tremors in babies 6 to 40 months old, though these findings did

not show up in several longer-term studies.

Dr. Hendrick, associate professor in the department of psychiatry

and biobehavioral sciences at the University of California, Los Angeles,

said the findings " show that it is important not to assume these medications

are safe simply because they do not seem to produce birth defects. "

There is also concern about the long-term effects of antidepressants on a

child's brain development.

Again, only a few studies have followed babies into childhood, the longest

being up to age 6. These have found no association between exposure and a

child's learning and behavioral development.

" Even though the data are very limited, " Dr. Altshuler said, " it's

encouraging that there aren't any studies that find that exposure in utero

leads to any behavioral changes, lower I.Q. or failure to reach normal

development or milestones. "

Recent studies, however, are finding that babies exposed to antidepressants

in the third trimester of pregnancy have a higher rate of newborn

complications, like respiratory distress, shivering, hypoglycemia and

jaundice.

One study by Dr. Koren's group looked at 55 newborns exposed to paroxetine,

known as Paxil, during the third trimester. Twelve exposed newborns had

complications requiring intensive treatment and prolonged hospitalization,

compared with three in a control group. These symptoms, though worrisome,

are transient, disappearing in one or two weeks.

Paroxetine appears to take a larger toll on newborns than other S.S.R.I.'s.

" It's such a hard decision, " Dr. Altshuler said. " The evidence we have to

date doesn't show any compelling risk to the developing fetus, but we have

very limited data. "

" I think it's really a question of accepting that there is no risk-free

decision here, " she said. " You have to weigh the risk of the mother

relapsing by going off medication, and the potential risk that the fetus may

have some long-term effects from this medication. "

Most experts agree there is some risk to taking antidepressants. Dr. Stowe

noted, " I don't use the word safe, but if the woman is depressed or anxious

to the point that she needs to be treated, then an antidepressant is better

than leaving her untreated. "

Dr. Hendrick added, " My threshold for treating depression in pregnancy is

certainly much higher than in a woman who is not pregnant. "

People who choose to go off antidepressants can instead be treated with

psychotherapy during pregnancy, but experts say that this may not be

effective in women with major depression.

If women go off antidepressants, it is important to taper off the drugs

gradually over a period of a couple of weeks, to avoid withdrawal symptoms.

Some women choose to stay off antidepressants during the first trimester,

the period of fetal organ formation, although many will relapse before the

end of the trimester. Others go off antidepressants toward the end of the

third trimester to avoid newborn complications.

There is not enough data to recommend one drug over the other, but most

experts believe women are safer with drugs that have been studied the most,

like the tricyclics or Prozac. Some doctors do not recommend that women

switch during pregnancy because the drug they switch to may not be effective

for them.

A lesser but not insignificant problem is that many depressed women who are

breast-feeding will not take antidepressants, or they will go back on the

drugs but choose not to breast-feed their infants.

Most experts believe that the risk to the nursing infant is minimal. " Most

of these drugs get into the breast milk in very small amounts, and it's not

considered a risk, " said Adrienne Einarson, assistant director of the

Motherisk program.

" If a woman needs to be treated for depression, it's certainly not a reason

to stop breast-feeding, " she said.

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January 13, 2004