Antidepressants During Pregnancy: Separating Facts from Fear
A recent meeting convened by the Food and Drug Administration (FDA) has raised concerns about the safety of selective serotonin reuptake inhibitors (SSRIs) during pregnancy. A panel of experts, some with a history of skepticism about antidepressants, discussed the possibility of adding a black box warning—the FDA's most serious warning—to these drugs due to potential risks to a developing fetus. However, we are concerned that the claims made at this meeting contradict decades of research and could endanger pregnant people and their babies.
As a perinatal mental health psychologist and a reproductive psychiatrist and neuroscientist, we've seen firsthand that mental illness, including suicide and overdose, is the leading cause of maternal death in the U.S. While all medications have risks and benefits, research consistently shows that for pregnant people, the benefits of SSRIs often outweigh the risks of both the drugs themselves and, more importantly, the risks of untreated depression.
The Biology of Brain Health During and After Pregnancy
Pregnancy and the postpartum period are times of significant change, with rapid shifts in hormones and brain function. This period, known as matrescence, allows the brain to become more plastic and adapt to the demands of motherhood. These brain changes are essential for a person to bond with their baby, regulate emotions, and solve problems.
However, these same rapid changes can make a person especially vulnerable to mental illness, and this risk is even higher for those with a previous history of depression. When depression occurs, it interferes with brain plasticity, making it difficult for the brain to adapt and getting it "stuck" in cycles of negative thoughts and emotions. Untreated depression can impair a mother's ability to bond with and care for her baby, leading to withdrawal or overprotectiveness.
SSRIs work by promoting brain plasticity, which can help a person feel more positive, increase gratification in motherhood, and improve cognitive flexibility for problem-solving. While psychotherapy is also effective and can lead to similar brain changes, people with severe symptoms often need medication to get to a place where they can benefit from therapy.
Understanding the Risks
Many studies have examined the effects of SSRIs on developing fetuses. Some data link SSRI use to preterm birth and low birth weight, but it's important to note that depression during pregnancy is also linked to these same outcomes, making it difficult to determine the exact cause.
Another condition linked to SSRI use is neonatal adaptation syndrome, which can cause infants to be jittery, irritable, or have abnormal muscle tone. However, this condition usually resolves within two weeks and does not have long-term health implications.
The FDA panel focused heavily on these potential risks, with some panelists incorrectly claiming that SSRIs cause autism or birth defects. These claims run contrary to major studies, including a summary by the Massachusetts General Hospital Center for Women's Health, which found no association between SSRI use and miscarriage, birth defects, or developmental conditions like autism spectrum disorder. The panel also dismissed clinical depression as a "normal" part of pregnancy, which perpetuates the long-standing dismissal of women's health concerns and ignores the rigorous criteria used to diagnose these disorders.
In contrast, the risks of untreated depression are very serious and include:
Preterm birth and low birth weight.
Higher risk of preeclampsia, a potentially fatal condition for both mother and fetus.
Behavioral problems and impaired cognition in the child later on.
A significantly heightened risk of suicide, which accounts for approximately 8% of all maternal deaths.
When compared to these life-threatening risks, the risks associated with SSRIs are minimal.
The Path Forward
The American College of Obstetricians and Gynecologists (ACOG) recommends that all perinatal mental health treatments, including **SSRIs**, remain available. For many individuals, the most effective approach is a combination of medication and psychotherapy. Other evidence-based treatments such as **bright light therapy, exercise, and proper nutrition** can also be beneficial.
It's understandable that a person may feel guilt or shame about taking medication during pregnancy. However, the available data suggests that this guilt is unwarranted. Should the FDA decide to place a black box warning on antidepressants, we know from history that this could lead to a decrease in prescriptions and a rise in the negative consequences of untreated mental illness. The best thing we can do for pregnant people and their babies is to provide accurate information and ensure access to all available treatment options.
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