Worried mothers-to-be are increasingly asking this question in the wake of a flurry of new studies linking antidepressants and anti-anxiety drugs with everything from heightened risk of miscarriage to birth defects and autism.
The answer, experts say, is complicated.
“I try to stay away from the ‘safe or not safe’ discussion and frame it in terms of risks vs. risks,” says Mary Kimmel, MD, assistant professor and medical director of the Perinatal Psychiatry Inpatient Unit at University of North Carolina. “There is a risk to taking medication, but there is also a risk to not treating.”
Maternal Mental Health Issues on the Rise
In some cases, a pregnancy is unintended, leading to complicated emotions. In others, shifting hormones and a predisposition to depression collide to worsen existing mood disorders or bring previously undiagnosed ones to the surface. Often, women are ashamed to speak up, says Shoshana Bennett, PhD, a perinatal psychologist, and author of Beyond the Blues: Understanding and Treating Prenatal and Postpartum Depression and Anxiety (2019 Updated Edition).
“There is an expectation that you are supposed to be happy and excited,” she says. “The reality is, women are not always happy that they are pregnant.” Counseling can be helpful; medications are not the only option.
As attention to prenatal mood disorders has risen, so has the number of women taking medication for it, with about 10% of pregnant U.S. women taking antidepressants and 1% taking benzodiazepines. That concerns some clinicians, who say that while medication is key for severe cases, other options -- like nutritional interventions, better sleep, and psychotherapy -- may work as well or better for mild to moderate cases.
“Is it wonderful that this is now being regarded as something real and needing treatment? Yes,” says Bennett, who often starts with nondrug options, before recommending medication. “Do we jump to medication too quickly some time? Yes. I believe we do.”
Risks Can Be Small, but Real
Anick Berard, PhD, professor, and a perinatal pharmacology researcher at the University of Montreal, notes that because it is considered unethical to ask a healthy pregnant woman to take a drug for a research study, clinical trials on risks and benefits for mom-to-be and baby are hard to find.
To fill the gap, she’s followed pregnancies in Quebec for 17 years, looking at birth outcomes for nearly 450,000 mothers, and published dozens of studies.
One, published last year in the journal JAMA Psychiatry, found that women who take benzodiazepines like Xanax or Ativan for anxiety in early pregnancy are anywhere from 60% to three times more likely to have a miscarriage, depending on which one they’re taking.
Another, published in 2017, found that those who took certain antidepressants (selective serotonin reuptake inhibitors, or SSRIs) in the first trimester were more slightly more likely to have children with defects of the heart, lungs, digestive system, face, and other organs.
Other large studies have linked antidepressant use during pregnancy with an increased risk of preterm birth and gestational hypertension (high blood pressure). One, published in the journal Pediatrics, found that boys with autism spectrum disorder were three times as likely to have been exposed to SSRIs in utero.
“Serotonin is essential for musculoskeletal, organ and brain development, and SSRIs work by blocking this molecule,” Berard says. “As a result, it has the potential to lead to a wide range of birth defects.”
Meanwhile, some studies suggest that for women with mild to moderate depression antidepressant efficacy is questionable. About 13% of women who take antidepressants during pregnancy remain depressed.
“Given that antidepressants don’t do that well for women with mild to moderate depression and that there is some risk, I think it leans to the side of more risky than not for them,” Berard says. “That being said, every woman should talk to her doctor to see what’s right for her.”
The Risks of Doing Nothing
Kimmel stresses that untreated depression and anxiety come with their own risks.
Depressed mothers are less likely to attend prenatal visits or take their prenatal vitamins and more likely to smoke, drink and use drugs -- all factors that can lead to preterm and low-birth weight babies.
“We also know that depression and anxiety during pregnancy is associated with a child being more likely to have depression and anxiety and other psychiatric disorders later in life,” Kimmel says.
“But there are times when someone may be doing all the right things and still be depressed or even suicidal,” she says, noting that there can be underlying biological reasons. “In that case medication may be really important.”
The Right Medication at the Right Dose
Kimmel suspects that some women may not respond well to antidepressants, because they are not taking enough or not taking the right one. Due to changes in blood volume and metabolism during pregnancy, women already taking antidepressants may have to take a higher dose to maintain the same effect.
While she generally does not recommend benzodiazepines for pregnant women, she warns that abruptly halting them is not advised.
And she stresses that some medications come with more risks than others.
“If you do need medication, our objective is to use the right medication and the lowest effective dose to get you well,” she says.
Her advice to those mulling this tough question: “Talk to your doctor about it and keep talking with your doctor about it. Different decisions can be made at different times to be sure you are doing all you can for your mental health.”
Dos and Don’ts
Do talk to your doctor if you are already on medication and considering pregnancy.
Don't suddenly go off your medication because you are pregnant. Rapid withdrawal can come with its own risks to both you and your baby.
Do make sure you are taking the right dose. Some medication doses must be increased to work effectively during pregnancy.
Do ask your doctor about your medication’s safety profile. Some are safer during pregnancy than others.
Do ask your doctor what other steps you can take to prevent depression. Some psychotherapies have been shown to help.
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