SSRIs and pregnancy: benefits outweigh risks

3 minute read

The body of evidence suggests anti-depressants are still safe for expectant mothers who need them


Pregnant women can be reassured that the benefits of antidepressant use are still likely to outweigh the risks, despite new research linking serotonin inhibition to congenital malformations, an Australian fertility expert says.

The prospective cohort study of 18,500 pregnant Quebec women analysed the birth outcomes of those taking antidepressants in the first trimester, compared with those diagnosed with depression but not taking medication.

Medications that inhibited serotonin reuptake, including SSRIs, SNRIs and amitriptyline, appeared to increase the risk of organ-specific defects, the authors said.

But Dr Joseph Sgroi, a Melbourne gynaecology, obstetrics and fertility specialist, said women could be reassured the overall body of evidence suggested these medications were safe to take during pregnancy.

“Taking yourself off antidepressant medication at any point of time without consulting a medical professional can actually put you, and potentially your baby, at a greater risk of harm,” he said.

In addition, the maternal-child bond could diminish if the mother was in a depressive state as the pregnancy got closer to term, Dr Sgroi said.

The study, led by a consultant for plaintiffs in lawsuits involving antidepressants and birth defects, found the prevalence of antidepressant use during pregnancy doubled over the 10 years.

The authors concluded that infants were at a higher risk of cardiac, musculoskeletal, craniofacial, digestive and respiratory defects, as well as craniosynostosis, if they had been exposed to serotonin inhibitor drugs in utero.

Caution with antidepressant use during pregnancy was warranted, and clinicians should explore alternative, non-drug options, they said.

But despite the trend towards increasing risk of overall congenital malformations with other popular antidepressants, citalopram was the only one that reached significance, with an odds ratio of 1.36.

Citalopram use almost doubled the odds of musculoskeletal defects and quadrupled the odds of craniosynostosis, the authors found.

Dr Sgroi said it was important that women of childbearing age be informed about the risks and benefits of their medication, particularly in relation to their pregnancy.

But while this study added to the body of literature on the impacts of medicines, a recent update to the Royal Women’s Hospital guidelines on pregnancy and breastfeeding determined that citalopram was safe, based on a review of 22 different articles, he said.

As with any medication, if the clinician felt it was unnecessary then the patient should not be on it, Dr Sgroi said.

“There are certainly some elements of neonatal withdrawal associated with citalopram use during pregnancy, and very, very rarely there has been documented evidence of persistent pulmonary hypertension,” he said.

If, for example, a patient had been on an SSRI for reactive depression, but were now stable and the initial trigger for the depression had diminished or was no longer present, then it might be appropriate to stop the medication prior to pregnancy while monitoring the patient, he said.

“Then if the woman becomes pregnant, the clinician can have that in the back of their mind that this patient is at risk of perinatal depression and postpartum depression,” Dr Sgroi said.

“But if they do need to be on it for clinical reasons, and, in fact, their mental health will suffer for not being on it, then that is a clear argument to keep patients on the medication,” Dr Sgroi said.

BMJ 2016; online 12 January 

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