An estimated 15% of women in their reproductive years take antidepressants, raising concerns about the possibility of birth defects associated with these medications, according to a report by the Centers for Disease Control and Prevention.
Depression is a debilitating condition that affects about 30% of women between 18 and 44 years of age, and if untreated may lead to more mental health problems and increase the risk of heart disease and other conditions. This week, the U.S. Preventive Services Task Force recommended screening all adults — and pregnant women and women who recently gave birth, in particular — for depression at least once.
However, there have been some worrying reports that taking certain antidepressants during pregnancy might also increase the risk of rare birth defects in the heart, brain and other organs.
Another concern is that many women taking antidepressants may not even realize they are pregnant, at least for the first few weeks. About half of all pregnancies in the United States are unplanned.
“Early pregnancy is time that is critical for baby’s development and because so many women may be taking medications without knowing they are pregnant, we wanted to get a better sense of trends of antidepressant use of all women of reproductive age,” said Jennifer N. Lind, epidemiologist in the CDC’s Birth Defects Branch and co-author of the report that was released on Thursday in the CDC Morbidity and Mortality Weekly Report.
The researchers found that 13.8% of women 25 to 29 years old and 16.7% of women 30 to 34 years old had been prescribed at least one antidepressant between 2008 and 2013. The rate of prescribing is highest among the oldest age group of women, 20.9% among women 40-44 compared with only 8.3% among women 15 to 19.
The most commonly prescribed antidepressants across all the women in the study were Zoloft (sertraline) and Wellbutrin (bupropion). Among women between 25 and 34, the most common were Zoloft and Oleptro (trazodone).
It is unclear from the data if the women who filled a prescription actually took the medication, Lind said. Researchers used data on prescriptions among women who had private insurance, although research has suggested that rates of prescribing could be higher among women on Medicaid.
The report recommends that the many women of reproductive age who are taking antidepressants, as well as those who are considering taking antidepressants, talk with their doctors, ideally before they become pregnant, about which treatment option is best for them and their baby. Counseling can also be part of treatment, in addition to or as an alternative to antidepressants
“We understand that many women need to take antidepressants to appropriately manage their health condition, and women shouldn’t stop or change their routine without talking with their health care provider,” Lind said.
“I think every patient should speak with their doctor about the use of antidepressants, whether they are of reproductive age or not, but for women of reproductive age, they should not just speak with their doctor but someone who is a specialist in perinatal psychiatry,” said Dr. Toby D. Goldsmith, assistant professor of psychiatry and behavioral sciences at Emory University and director of the Emory Women’s Mental Health Program.
“More likely than not, if a woman comes to me with a psychiatric illness that I believe I can treat with an antidepressant, the risk of not treating that is, in my opinion, greater than the questionable risk of treating it.”
Some studies have suggested that the increase in birth defect risk is due more to women suffering from untreated depression, and the lifestyles associated with depression, such as poor diet and alcohol use. In addition, women who take antidepressants may be taking other medications, such as anticonvulsant agents, that have also been linked with birth defects.
The CDC recently launched an initiative called Treating for Two that aims to provide women and doctors with better guidance about the safest medications during pregnancy. In last year’s report, they addressed the use of opioid medication among women of reproductive age.
“We want to spread the message that women of reproductive age should talk with their doctor about all the medications they are taking and get to a healthy place and then address the pregnancy [they would like to have],” said Dr. Siobhan Dolan, medical adviser to the March of Dimes and an obstetrician and geneticist at Montefiore Medical Center in New York.
Dolan agrees with the CDC report’s call for more research to help guide women with depression and their doctors in deciding what is the best treatment option. But knowing what we know now, she advises that women see if they can get symptom relief through counseling or by taking a single antidepressant instead of two or three.
For women who are starting an antidepressant, they should think about the “safest medication for their period of pregnancy,” Dolan said. A study published in 2015 found that many of the SSRI antidepressant medications were not associated with birth defects, including Zoloft (sertraline), however Paxil (paroxetine) and Prozac (fluoxetine) in early pregnancy were associated with small increases in the risk of babies being born with heart and neurological defects.
But Dolan stresses that the risk is still very small. For example, the study found that the risk of a heart birth defect increased from 10 in 10,000 babies among women not taking an antidepressant to 24 in 10,000 babies among mothers who took Paxil in early pregnancy. The risk of neurological defects increased from 2 in 10,000 babies to 7 in 10,000.
However, for every study that suggests a birth defect risk associated with antidepressant use during pregnancy, there are more studies that have found these medications are safe, said Dr. Lee S. Cohen, director of the Center for Women’s Mental Health at Massachusetts General Hospital, and author of a study that found that heart birth defect risk was associated with untreated depression among expecting mothers and not antidepressant use.
“We are at a point where we have truly vast amounts of data from multiple sources regarding the safety of SSRIs, and I don’t think we have data suggesting that one SSRI is more or less safe than another SSRI,” Cohen said. “So at the end of the day, and in our center, if a woman decides to take an antidepressant during pregnancy, she typically stays on the one that got her well because nothing trumps keeping pregnant women well during pregnancy,” he said.
Nevertheless, there are areas where more research is needed, Cohen said. In particular, the question remains unanswered whether there could be long-term neurobehavioral outcomes in children whose mothers took antidepressants during pregnancy.
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