Q: Is it safe to take antidepressants during my pregnancy?  If not, what do I do?

Clinical depression is a major problem in the United States.  It is more prevalent in women than men, with a peak age between 25-44 years of age.  Not surprisingly, this is a significant problem during pregnancy.  An estimated 14-23 percent of women will experience depressive disorders during pregnancy.

Differentiating between depression and "normal" symptoms of pregnancy is difficult, due to the overlap of symptoms such as mood changes, sleep disturbances, loss of energy, and appetite changes.  Untreated depression is associated with a significantly increased chance for postpartum depression.  Evidence for adverse pregnancy outcomes related to depression is less convincing.  Patients who conceive while on antidepressants and discontinue their medications have almost three times the risk for significant relapse of their depression during their pregnancy. Many patients are understandably reluctant to begin or continue medications for depression during pregnancy.  The risks and benefits of drug therapy must be carefully weighed by each patient and her medical care provider.

The most frequently used medications are the Selective Serotonin Uptake Inhibitors (SSRIs).  These include fluoxetine, sertraline, citalopram and paroxetine.   Although the evidence linking these medications to birth defects is limited, with the exception of paroxetine they are classified as Category C by the Food and Drug Administration (FDA), indicating they should be used only if the prescriber feels the benefit outweighs the risk.  Paroxetine is a Category D drug, with conflicting studies associating it with heart abnormalities, and is best avoided during pregnancy.  Late pregnancy use of these medications may be associated with neonatal jitteriness, transient rapid breathing in the newborn, and increased newborn admissions to neonatal intensive care.  These symptoms are usually mild and short-lived, and will resolve themselves by the time the baby is two weeks old.  The risk of treatment must be balanced against the risks of no treatment.  These include continuation or worsening of untreated depression and a high likelihood of relapse.

Another class of medications are the Tricyclic Antidepressants (TCAs).  These are also FDA Category C.  They tend to have significantly greater maternal side effects and do have an overdose potential.  They are used less frequently than SSRIs.  Other medications such as Bupropion, Venalafaxine, and Duloxtine may be effective in some patients.  These are Category C except for Bupropion which is Category B.

For those who cannot tolerate or choose not to use medications, a trial of psychotherapy may be successful, although it is less likely to succeed as a sole modality in those who have significant depression.  Many patients elect to try this first, instituting medications when their symptoms continue or progress.  Finally, electroconvulsive therapy (ECT) is considered safe in pregnancy but is reserved for those who have failed other therapies and have very severe depression.

Robert S. Goldfarb, M.D., is an obstetrician and gynecologist at Henry Ford West Bloomfield Hospital in West Bloomfield, Michigan.  His clinical interests include general obstetrics, menopause and minimally invasive surgery.  He is also an assistant clinical professor of obstetrics and gynecology at Wayne State University in Detroit.