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Pregnant, depressed and confused? New guidelines clarify antidepressant risks, benefits

August 21, 2009 |  5:00 pm

Depression hits women in the childbearing years more than any other demographic, but how to deal with this most common of mental afflictions poses a conundrum: antidepressant medications have become the first line of defense against depression; but there's growing research evidence that they pose risks to a developing fetus.

It's a tightrope that obstetricians on the front lines of patient care have walked for years without guidance from their own leaders or the profession of psychiatry. Busy, concerned but operating in unfamiliar terrain, many obstetricians have pulled out their pads, written a prescription for an antidepressant, and hoped for the best. No surprise, then, that by 2003, 13% of pregnant women had taken an antidepressant at some point in their pregnancy -- twice the rate that was seen in 1999.

But on Friday, the American Psychiatric Assn. and the American College of Obstetricians and Gynecologists put a safety net under obstetricians and the pregnant women they treat. In a first-ever set of guidelines, the two physician groups offered obstetricians and their patients a set of clear road maps for treating depression in pregnancy.

The guidelines were published simultaneously in the ACOG journal Obstetrics and Gynecology and in the APA's journal, General Hospital Psychiatry.

The upshot: For many pregnant women showing signs of depression, talk therapy can help manage symptoms with no risk to a developing fetus and good prospects of success. But for some, including those who are suicidal, have a personal history of disabling depression, or also suffer from more serious mental illness such as bipolar disorder or psychosis, the benefits of antidepressants are likely to outweigh the drugs' risks to a developing fetus.

The guidelines provide a comprehensive review and assessment of the research findings that exist on the risks that antidepressant medications pose for babies before and after birth. But they also take account of another, less conclusive body of research findings: those that suggest that having a severely depressed mother can be bad indeed for a baby before and after birth and well into his or her childhood.

Dr. Charles Lockwood, a professor of obstetrics at Yale University and one of the guidelines' nine authors, hailed the joint venture as a call to obstetricians to look routinely for signs of depression in their patients of childbearing age and for psychiatrists to step up to their role in the care of such women. Noting that roughly four of five women of childbearing age consider their ob/gyn a primary care physician,  Lockwood said obstetricians are "uniquely positioned" to intervene early in depression. That will improve the physical and mental well-being not only of women over their lifespans, but their children's as well, he said.

Dr. Sudeepta Varma, a psychiatrist at New York University's Langone Center, said her profession has too long left obstetricians on their own to care for depressed patients -- a lack of involvement she believes will change with the issuance of the new guidelines.

"I think psychiatrists have been reluctant to take on the care of pregnant patients," said Varma. The new guidelines should make psychiatrists and mental health professionals "more comfortable" in doing so. She added that they should prompt a greater interest on the part of obstetricians, as well, to develop professional relationships with psychiatrists and psychotherapists, and to seek their help more routinely in sorting through a depressed patient's options. 

"We should have more communication with each other," she said.

-- Melissa Healy