Q Is it reasonable to continue SSRIs during pregnancy?

We have fewer data on reproductive outcomes with bupropion and venlafaxine use than with SSRIs or tricyclic antidepressants, but this lack of data does not necessarily mean there is a lack of adverse outcomes.

Weighing the risks

Add PPHN to the list of other reported risks of SSRIs during pregnancy, such as minor physical anomalies (no functional or cosmetic significance), preterm birth, decreased birth weight, neurobehavioral effects, and neonatal syndrome.^2,5 These risks have not included major malformations or long-term developmental deficits in childhood.^1,5

Untreated depression itself poses risks: preterm birth, growth restriction, preeclampsia, neonatal neurobehavioral effects, and impaired maternal function.⁶

After weighing these risks with her physician, a woman could reasonably decide that the benefits of drug treatment outweigh the risks, or she could decide the opposite. Certainly evidence-based nondrug therapies such as psychotherapy (cognitive behavioral or interpersonal psychotherapy), electroconvulsive therapy, and bright light therapy should be considered.⁷ However, not all women elect, respond to, or have access to such treatments.

Bottom line: No absolutes

Although our ability to quantitatively weight treatment choices improves with the publication of studies such as these, the path to the most favorable outcome remains a highly individualized decision with no absolutes. Continuing use of antidepressants does not guarantee that remission will be sustained. Careful monitoring and dose adjustment are necessary in order to maintain adequate serum levels in women who take tricyclics,⁸ particularly during the third trimester. Higher dose requirements also have been described for SSRIs because of increased drug metabolism during pregnancy.⁹

If the gravida decides to continue antidepressant therapy, she should choose the drug (an SSRI, tricyclic, or bupropion) that is most effective for her.