Antidepressants during pregnancy, risks for mother and child

Abstract

The use of antidepressant drugs during pregnancy is increasing without firm evidence on safety or efficacy. When managing depression and anxiety with antidepressants, the expected benefits must outweigh the risks. For health care processionals it is difficult to balance the benefits against the risks because scientific data on the effects of each antidepressant are limited and findings incontestable. Untreated depression may have negative impact on child development. In this thesis the relation between antidepressant use during pregnancy and adverse effects on mother and child are studied. The thesis consists of four parts: I. qualitative research on the need for information and current policies on pharmaco-therapeutic management of depression during pregnancy. Our survey provides insight into the main concerns of both patients and medical professionals, and gives an overview of the way health care professionals deal with dilemmas when treating depression and anxiety during pregnancy. II. Our study on prevalence and patterns of antidepressant use during pregnancy and the relation with child health care use in the first year after birth, showed that 2% of all pregnant women use an antidepressant. Children of mothers who used antidepressants showed more health care use than the children of the control group of healthy mothers. III. Animal studies on short and long term effects and on the influence of dosing showed that fetal exposure to antidepressants resulted in permanent effects on the development of the heart and central nerve system which were dose dependent. IV. Our clinical multi disciplinary cohort study on effects of antidepressants on perinatal outcome and fetal/infant development (OAZE, Dutch: Onderzoek Antidepressiva tijdens Zwangerschap; een Evaluatie) showed ontogenetic changes in fetal neurobehavior induced by standard and high SSRI doses. Morover we found that maternal paroxetine plasma concentrations diverged according to the maternal CYP2D6 genotype. Antidepressant use during pregnancy was associated with symptoms of poor neonatal adaptation which requires clinical treatment or observation, smoking and maternal stress added to the risk of poor neonatal adaptation. In our cohort study we did not find differences in infant temperament at 3 and 8 months after birth between children of mothers who used antidepressants during pregnancy compared to those who stopped using the medication early in pregnancy. Conclusions Pregnancy is a state in which all treatment modalities that are normally being considered safe have to be re-evaluated. Patients and health care providers find it difficult to balance risks and benefits and consider it extremely disappointing to discover that essential information is lacking. Experts in the field are not univocal about the risks associated with continuing antidepressants during pregnancy and there is little knowledge about the effects of discontinuation or switching to alternative therapies. With the joint efforts of researchers, drug companies and governmental institutions knowledge about safety and efficacy of antidepressants during pregnancy should grow; hopefully to such an extent that in the future women will feel reassured knowing that the best evidence based treatment is chosen for her and her baby. Putting effort in prosperous pregnancies is investing in a whole new generation.