Using SSRIs in pregnancy
The decision to use antidepressants during pregnancy needs to be made with great care and scrutiny, particularly among those who suffer from more mild to moderate depression where nonpharmacologic interventions, such as cognitive behavioral therapy (CBT), are appropriate and may, in some cases, be used as a first-line treatment. However, the greatest concern for those clinicians who manage the care of women who suffer from depression before or during pregnancy centers on extrapolation of the same treatment algorithm used for women with mild depression to those with more refractory disease. Indeed, the clinical scale is weighted toward antidepressant treatment for women with more malignant refractory depression, whose journey to emotional well-being has been long and arduous, and where maintenance antidepressant therapy has been a cornerstone of treatment. Given the small absolute risk associated with SSRI use during pregnancy, our threshold to threaten that well-being should be very high. Relapse or new onset of depression during pregnancy is of great importance because no factor more strongly predicts postpartum depression than depression during pregnancy – and the adverse effects of postpartum depression on long-term development of children and the well-being of the mother and her family are substantial.
The debate over the most appropriate use of SSRIs during pregnancy will invariably continue. Careful reading of the relevant data and appreciating the conclusions made that are justified and, conversely, where the data fail to absolutely inform leaves clinicians in a position to share with patients what we know and what we don’t know. Clinicians then can tailor ultimate decisions based on available information from the scientific literature, patient’s wishes, and individual clinical histories.
Dr. Cohen is the director of the Center for Women’s Mental Health at the Massachusetts General Hospital in Boston, which provides information about pregnancy and mental health here. He has been a consultant to manufacturers of SSRIs.
