Editorial Note: This post is by Adam Urato. There are other Adam Urato posts on RxISK (see Antidepressants and Autism and Autism Awareness Day) about the use of antidepressants in pregnancy and by women of child-bearing years. This post appeared first on Mad in America. The image is from an article by Gideon Koren that seriously proposes putting the image of a pregnant woman on antidepressant medication in order to allay women’s concerns.
The issue of antidepressants and pregnancy is a hot topic in Britain right now following the death of Charlotte Bevan a few weeks ago. It’s a hot topic everywhere. It will feature again in next week’s post – Massacre of Innocence.
Depression during pregnancy is an important issue. Depression should not be ignored and depressed pregnant women deserve good treatment and care. Part of that good care, though, is providing them with full and correct information. I care for pregnant women taking antidepressants on a daily basis and too often they tell me that the only counseling they received about the medication was, “my doctor told me it’s safe in pregnancy.”
In certain scenarios antidepressant use could be considered to be safer than the alternatives (for example, a patient who is suicidal when she stops her medications or one who would use cigarettes, alcohol, or illegal drugs). But these scenarios don’t mean that the chemicals (antidepressants) themselves are safe — only that they may be less risky than the alternatives.
Antidepressants simply cannot be considered to be “safe” in pregnancy and the five point argument below explains why this is the case:
By antidepressants, I am referring here mostly to the selective serotonin reuptake inhibitors (SSRIs) – drugs like Prozac, Zoloft, Celexa, and Lexapro – which are the most commonly used antidepressants during pregnancy. However, much of the argument below would also apply to other antidepressants as well.
This post will review the evidence in this area and address the counterarguments.
If you look at the 5 point argument above, it’s easy to see why the fact that these drugs aren’t safe in pregnancy is not rocket science.
No one can argue with Point #1 above. Serotonin is a critical molecule for fetal development and normal function of the serotonin system is essential for proper human development. Serotonin plays a role in the formation of the brain, heart, lungs, gut, blood platelets, and other organ systems and we are discovering new and important functions for serotonin all the time. No one can argue (with a straight face) that serotonin is not crucial for human fetal development.
Point 2 is also an established scientific fact. SSRI antidepressants are not naturally occurring substances. They are synthetic chemical compounds made in chemical factories and they disrupt the serotonin system. Scientists still aren’t exactly sure about all of the ways in which the SSRIs affect the human body, but it is clear that they do alter the serotonin system.
Point 3 is also an established scientific fact. The SSRIs cross the placenta and enter into the fetus. Just putting Points 1, 2, and 3 together, one should easily conclude that the SSRI antidepressants are likely to cause some type of harm in fetal development.
This is precisely what we see in animal studies (Point 4) and human studies (Point 5). The animal studies show increased rates of heart problems, craniofacial abnormalities, death, brain abnormalities, and long-term neurobehavioral changes in the exposed offspring.
Human studies show that SSRI use during pregnancy is associated with miscarriage, birth defects, preterm birth, preeclampsia, decreased fetal head size, newborn behavioral syndrome, seizures, neonatal EKG changes, childhood brain malformations, and long-term neurobehavioral issues like ADHD and autism.
What do we think will happen when we send these chemicals into the developing baby throughout the pregnancy?
Recognizing the tricks and traps of the Key Opinion Leaders
There are many “experts” from various centers out there emphasizing the safety of these drugs in pregnancy and they have been doing so over the past two decades. Much of the public does not realize that many of the leading centers of psychiatry and pregnancy (the so-called Perinatal Psychiatry units) and many of the “experts” have been (and are being) funded by the antidepressant makers themselves. The drug companies have been paying these experts (the so-called Key Opinion Leaders—or KOLs for short) and funding these units, and the message that gets delivered tends to downplay any safety concerns. This has been reviewed in detail here, here, and here.
Many of these experts seem to be following the same basic playbook that can be summarized as follows:
The issue of the safety of antidepressants in pregnancy has never been more important as more and more women of childbearing age take these medications and exposure rates during pregnancy increase worldwide. The topic really is not that complicated. It’s just common sense that serotonin plays a crucial role in fetal development. The antidepressants cross the placenta, into the developing fetus, and chemically alter that serotonin system. So it shouldn’t surprise us that animal and human research is showing harm and this is what I see clinically with actual patients more and more.
With good evidence that many patients will get as much benefit (or more) from non-drug approaches to depression such as psychotherapy and exercise, it is clear that these modalities should be emphasized in the treatment of pregnant women and women of childbearing age. No one should be telling pregnant women what to do, but the key issue is providing patients and the public with full information so that they can make the best decisions for themselves. They should be then be supported in their decisions and given the best care possible.