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.
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I saw two Psychiatrists who both assured me Seroxat was safe to use in pregnancy. My own inner doubts prevented me from upping my dosage as advised, but I knew to ignore them would be to go against doctors orders. It was my own research which led me to feel my concerns were justified.
There are a lot of angry comments coming through from mothers on social media and in forums saying that to question the safety of antidepressants in pregnancy is ‘scaremongering’ and that GP’s who suggest pregnant women stop an antidepressant are irresponsible because they don’t understand the significance of the illness. It’s tricky to have a conversation around this which empowers not patronizes and which doesn’t leave new mums feeling guilty about their treatment options.
There have been two recent blog posts around SSRI’s which have left me uneasy. The first a piece by mother Hayley Carter which came off the back of the tragic Charlotte Bevan case in Bristol. http://ourhayley.wordpress.com/2014/12/09/i-took-antidepressants-when-i-was-breastfeeding-and-when-i-was-pregnant/ The author makes no reference to risks versus benefits and doesn’t acknowledge that these types of medications affect people in different ways. I doubt very much the blog author intended it to frighten women, but it reads to me like a sort of pharma propaganda- unless you want to harm yourself and your baby in pregnancy you had better stay on your medication etc.
Whilst not directly talking about pregnancy I was also forwarded a post today written by Professor Jim Lucey (medical director of St. Patricks Hospital Dublin) who wrote a recent intro to SSRI’s. http://www.my1000hours.com/introduction-to-medication-prof-jim-lucey In his defence it is only an introduction but even so statements like “Antidepressants save lives” and “Antidepressants are not addictive” are bold statements which leave little room for discussion.
If we want to encourage women to make smart health choices we have to give both sides of the story and allow a dialogue between patient and doctor which factors in their individual needs. It can’t be a one size fits all approach. I’m worried that in trying to reassure women around issues of safety we could potentially be doing more harm than good.
Sarah,
Well meaning people like the writer of that blog, Bressie, can unintentionally misinform their numerous fans. He says when it comes to depression and anxiety, it can be quite frightening and confusing – as there is so much information on the internet. He says his friend, Professor Jim Lucey, is one of the most respected Psychiatrists in the country.
He also said in a previous article – ” “Anxiety, depression,” he explains, “all of these things are caused by a lack of serotonin in your brain. It’s a chemical imbalance, and the one thing sport and physically challenging yourself does, is it gives you serotonin — that’s a fact, no matter who you are. People have this idea about depression; that it’s a ghost, it’s a mythical, magical thing. It’s not. it’s science”.
Despite the lack of any scientific evidence, and however well-intentioned, Bressie obviously believes in the tale of the chemical imbalance. I can’t honestly say whether Jim Lucey believes it too, but he might find a longer chat with his friend may prove beneficial.
Hi Leonie,
I must admit I hadn’t heard of Niall Breslin until recently when I saw a talk he gave in Dublin about his experiences of anxiety and depression. I don’t know a great deal about him but I thought his talk was very moving and very brave. If he is able to use his public profile to encourage young people to seek help and to reduce stigma around mental health then I applaud him. I’m sure his experiences will resonate with many.
The potential pitfall is what happens after you ask for help. I worry that there’s a tendency to write out a prescription and we sometimes forget to treat the individual. Its easy to put people into a box. ‘depressed’ ‘anxious’ or whatever. A friend of mine left a concert early recently, she felt weak and unwell and vomited on her way home. Her GP diagnosed anxiety and prescribed a beta blocker. She wasn’t anxious! She explained this to the doctor but they insisted she took the prescription.
From my own experience I have heard GP’s often say things like “This drug is effective for most people.” and “most people don’t have any ill effects.” What happens if you’re not most people? I’m not against medication but I think people ought to be warned about potential side effects and to be encouraged to revisit their GP if they have concerns. The pregnancy debate is a difficult one of course because instead of treating one person you’re now effectively treating two. Whereas mum can voice concerns baby cant and we might not know if any damage has been done until its too late.
When I was pregnant I was taking zoloft for PTSD. I told the doctor I wanted to taper off for the sake of the baby but he became angry and adamant that I keep taking the drug. I asked him if it was safe and he said he didn’t know. Next thing I know he’s making me sign some kind of waiver freeing him of any fault if the baby is harmed or born addicted. How is that legal? It was like he was saying “You HAVE to do this, but if something goes wrong its on you not me.” Ive never heard of this before! I feel so deceived and guilty even though I know I didn’t cause this. but that never ever ever takes the guilt away.