Depression during and after pregnancy: The ongoing debate about treatment

February 13, 2012

Within the last year, several studies have been published linking the use of anti-depressants during pregnancy to scary outcomes in babies. Probably the most disturbing was a study published last summer in the Archives of General Psychiatry linking anti-depressant use during pregnancy to an increased risk of autism spectrum disorders. Just last month, a study was published in the British Medical Journal linking usage of anti-depressants during pregnancy to persistent pulmonary hypertension. Yet at the same time, research studies also continue to be published that link the impact of untreated depression in mothers during pregnancy to different kinds of developmental delays in newborns, as well as linking untreated postpartum depression with an increased risk of behavioral problems in infants and toddlers. Talk about damned if you do, and damned if you don’t!


Now just add the layer of stigma that mental illness carries, in general, multiply that by 10 for new mothers, and you have a recipe for disaster! It’s no wonder most women don’t disclose how they are feeling to anyone, or ever make their way in for mental health treatment! Geez, Louise!


I want to offer some thoughts on what is sure to be an ongoing debate, but that may provide some ideas about the current research as well as some guidelines on how to make an informed decision if you are a pregnant or postpartum woman struggling with a mood or anxiety disorder or are in the role of working with this population to support women making decisions about treatment.


#1 Let go of “cause and effect” thinking
The problem with the scientific model is that it is limited by what can be objectively, and ethically measured (more on this in a minute), and follows a cause and effect model: A leads to B leads to C. However, in real life, things just don’t work this way. Outcomes are based on a confluence of multiple factors interacting, and we often do not know (at least completely) what factors created an outcome. Human development is a remarkable example of this – how a fetus develops in utero is an amazing combination of 2 people’s entire genetic history, plus how their genes interacted with their unique environments across their lifetimes so far, plus the environment in utero, etc. Somehow, miraculously, most infants are born relatively typical. However, there are a small percentage of infants that are born with medical complications or birth defects to the general population. Studies on birth defects have uncovered many helpful things that are now part of prenatal care and public health information, however, fully 70% of birth defects have no known cause. It is uncomfortable to live with this level of uncertainty and vulnerability, but the truth is, most of the time the correct answer to the question, “why did this happen?” is “I don’t know”.


#2 We know more about anti-depressants than any other class of drugs (and that’s a dangerous thing!)
OK, so that isn’t saying much, but due to the stigma surrounding “psychotropic” medications, a tremendous amount of research has been done on anti-depressant medications. Unfortunately, due to the limitations of this research (see more below) a ton of “associations” have been uncovered between anti-depressants and unwanted outcomes in babies but have not proved “causation” and so we have no coherent way to make sense of them or to appreciate the ways these associations may be better explained by other factors not included in the research hypothesis or model. Pregnant women with other chronic health conditions may receive treatment with other medications that cross the placenta or are secreted into breastmilk postpartum, and may have some impact on the fetus or baby (most likely relatively mild and transient) but are not met with the same kind of hysteria for what are clearly social and political reasons.