The Dilemma of the Depressed Mother-to-Be

For pregnant women taking antidepressants, balancing mental health and fetal health can lead to difficult choices.

Eight years ago when I started taking antidepressants, having a baby was the furthest thing from my mind. I was 25, and desperately unhappy for reasons I had trouble explaining.

It wasn’t the first time I had felt this way—I’d experienced bouts of intense anxiety and depression since I was 19. It would always start with a nagging unwanted thought that would morph into a cyclical internal monologue that grew into a tornado of negativity inside me. I would wake up crying. Sometimes I couldn’t work.

I had difficulty identifying whether I was anxious about real events in my life, or whether I was legitimately ill and my brain wasn’t functioning as it should.

This confusion provoked agony. If I passed a hospital I would find myself wishing I had a disease more universally acknowledged as a physical ailment, so I could be treated and either get better or die.

Over the years, numerous doctors and psychologists suggested I try antidepressants. I resisted. To me, drugs were a cop-out, a Band-Aid solution for those too weak to recognize the source of their problems and tackle them head on. But this valiant and judgmental attitude gradually withered as my tactics failed to defeat my mental anguish. Finally, I faced an unwanted possibility: What if my problem was biological, buried deep in the dendrites and synapses of my brain? What if tackling my problems meant taking the antidepressants I had so readily dismissed?

My family doctor assured me the drugs were safe and non-habit-forming, and that for a lot of people, they helped. I left with a prescription for Effexor, and have been taking the drug ever since.

Now I’m 33, and life looks a lot different than when I gulped down the first of the roughly 2,800 peach colored pills I’ve since ingested. Something new is swirling inside my mind: the idea of a child.

So it was with a special kind of horror that, during an afternoon of aimless internet meandering, I happened upon the world of “Effexor Babies.” Typing in this search term reveals link after link to news reports, blogs, and forum discussions detailing a range of negative outcomes in the pregnancies of women on Effexor. Many studies reveal an increase in the risk of a range of birth defects, some of them potentially deadly. I was terrified—and shocked that no one had warned me of these outcomes when I started the drug.

In the U.S., lawsuits over these infants are common enough that there are lawyers who dedicate their practices to trying Effexor lawsuits. In 2011, the drug made Canadian headlines when two babies from British Columbia died mysteriously shortly after birth, both born to mothers who were taking high doses of the drug.

And it’s not just Effexor. In fact my drug, better known as Venlafaxine, belongs to a class of drug called SNRIs, which make up only a small proportion of antidepressants prescribed to women annually. The vast majority are prescribed SSRIs, which you may recognize by their brand names: Paxil, Prozac, Zoloft, Lexapro, and Celexa.

When it comes to these drugs and pregnancy, the data is abundant and conflicting. It seems that for every study finding SSRIs will endanger the unborn child, there is another concluding they will have no negative effect at all.

Perhaps the most comprehensive review of current research in the field to date was published in the journal Frontiers in Cell Neuroscience in May of 2013. After examining 181 studies of SSRI use during pregnancy, scientists found a small increase in the risk of congenital malformations like heart defects and in problems with infant neurodevelopment. Still, its frustratingly ambiguous final summary stated only that more research is needed before anything definitive can be said about the risks and benefits of SSRI exposure to unborn babies.

Further obfuscating this issue is the plentiful evidence that suggests depression left untreated could have as grave an impact on a pregnant woman’s child as antidepressants.

To me, a woman taking one of these drugs and already prone to mental distress, the data presented an agonizing conundrum. How was I to know which would be worse for my unborn child: a mother on antidepressants, or a potentially anxious and depressed mother?

More concerning still is how common this predicament is poised to become. Today, SSRIs make up the class of drug most prescribed to pregnant women for chronic disease. According to the American Pregnancy Association, some 13 per cent of pregnant American women are taking them.

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One reason we don’t know more about the effects of SSRI use during pregnancy is because, for ethical reasons, we don’t allow pregnant women in clinical trials. This means that women using SSRIs during pregnancy must do so off-label. Hedging their liabilities, most drug companies advise would-be moms to carefully consider the “risks and benefits” of treatment during pregnancy.

“I was told the benefits far outweighed the risks,” Nicole Rawkins told me over the phone from her home in Kamloops, British Columbia. The mother of two explained that both her doctor and pharmacist told her it was safe to take 450 mg of Effexor—twice the general limit recommended by the drug’s makers—during her second pregnancy, so she did.

Her son Grayson was born on January 24, 2011 and had to spend five days in the hospital before he could be taken home because he was suffering breathing problems. Grayson weighed less than her first child and slept a lot, but Rawkins just thought he was a good baby. Then one night when he was two months old, Grayson went to sleep and never woke up. The official coroner’s report stated the cause of death only as Sudden Infant Death Syndrome, but an autopsy report notes that the Effexor Rawkins was taking was a risk factor in the death.

“Nothing is more devastating than losing a baby, and nine months of being depressed is better than that,” says Rawkins. When she became pregnant again in 2012, she went against her doctor’s advice and stopped taking her medication completely.

“I felt one hundred percent better than when I was pregnant with Grayson,” says Rawkins. Her daughter was born healthy. “Women should understand that even if it is small, that risk is there.”

I began sifting through the existing scientific evidence in the hopes of better understanding these “risks and benefits.” Researchers have explored whether the drugs increase the risk of a wide range of negative outcomes, including miscarriage, cardiac malformation, preeclampsia, preterm birth, decreased birth weight, and major congenital malformations.

Some studies show a very moderately elevated risk; others show no elevation at all.

Some of these outcomes have the potential to be fatal. I learned that heart defects are a serious concern, though studies in this area again conflict. At least one drug, Paxil, now carries a warning that states use during pregnancy may elevate the risk of certain birth defects, particularly heart malformations. The warning is based on studies that found women who took Paxil during the first three months of pregnancy had a 1.5 to 2 percent risk of having a child with a heart defect compared to 1 percent in the general population—an elevation, but a small one.

Another potentially deadly outcome is persistent newborn pulmonary hypertension (PPHN), a condition that occurs when a newborn’s cardiac system fails to transition normally after birth. Numerous studies have shown that SSRI use late in pregnancy increases the risk of PPHN, some by as much as fivefold. In 2006, the FDA issued a public health advisory based on a study that found six times the risk of PPHN, but then five years later issued a retraction of sorts after subsequent studies did not find an elevated risk.

Even in the face of such muddy conclusions, to me the choice initially seemed obvious: Stop taking the meds and tough it out for the sake of the child. My reasoning was straightforward: There seemed to be a consensus, however foggy, that the drugs increased the risks of certain negative outcomes, if only very slightly.

I was also weighing the benefits. If I was going to take a drug during pregnancy that posed any risk at all, I wanted to be sure that it was doing something. I hadn’t been deeply depressed for a long time. Was it possible that I’d been on these drugs for years while experiencing little or no beneficial effect? And if so, why was I still on them?

The efficacy of antidepressants has certainly been questioned in recent years. The drugs were initially approved based on tests showing they were more effective than a placebo, but in many of those trials, the margins were very, very small. In 2008, a high-profile study by Harvard University’s Dr. Irving Kirsch looked at these studies, and found the efficacy of antidepressants to be “clinically insignificant” over a sugar pill, particularly for people with mild to moderate depression. After reexamining existing studies, Kirsch found that the drugs had a clinically significant effect only in people with very extreme cases of depression.

Some potential risk; low potential benefit. My conclusion? Taking these drugs during pregnancy simply didn’t make sense. But it’s very easy to say you can live without antidepressants while you’re still on them.

“Many people see psychiatric treatment and psychiatric drugs as optional,” says Dr. Simone Vigod. “But as you know, it sure doesn’t feel optional.”

As a psychiatrist at University of Toronto’s Women’s College Hospital and a scientist at its Women’s College Research Institute, Vigod acknowledges that it appears the drugs may moderately elevate the risks of certain negative outcomes. However, she is more concerned that the current state of alarm around SSRIs and pregnancy may discourage women who genuinely need these drugs from using them.

Vigod also echoes what might be the only consensus in the field: Every case needs to be considered individually. She gives the example of a woman who went on antidepressants a decade ago for a mild to moderate depression and only continued treatment because there was never a clear reason to stop.

“This is a low-risk scenario,” says Vigod. Here, stopping treatment before pregnancy might make sense.

At the other end of the spectrum would be a woman with severe panic disorder whose previous attempt to stop treatment resulted in a relapse that required a year of recovery.

“Just suffering through it is not good for you, or your child,” says Vigod.

For Kate Alderson, going off her daily dose of 150 mg of Zoloft never felt like an option.

“I don't think I would be here today if I hadn't found effective drug therapy,” says the 34-year-old of the crippling depression and anxiety she endured. “Not because I wanted to die, but because I couldn't live day after day with so much pain and suffering.”

The mother of two continued to take her medication through both pregnancies.

“I knew in my heart that I didn't have a choice,” says Alderson. “I genuinely don't believe that I could go off the medication for the duration of a pregnancy and survive.  If I didn't feel like taking antidepressants was an absolute necessity, I might feel differently about it.”

Though she used to be open about her depression and anxiety, Alderson says she’s learned it’s easier to keep it private.

“There is a double whammy of shame when you take antidepressants when pregnant,” says Alderson. “First, there is the ‘You have mental health issues and you are taking an antidepressant’ judgment, and then there is the ‘How dare you risk your fetus’ judgment.”

It’s easy to see why some would-be moms might feel incredible societal pressure to go off their medication for the sake of the baby, yet many experts say this can do more harm to the child than good.

Why? Because there is plenty of evidence suggesting that untreated depression during pregnancy can also be harmful to the child. Most of this evidence suggests a secondary connection—it’s not the depression itself that will hurt the infant, but rather the fact that a depressed mom is less likely to stay healthy and take good care of herself during pregnancy and more likely to engage in negative behaviors like drinking and smoking. And in the severely depressed, there’s also the possibility that the mother may not survive the pregnancy.

It was this knowledge that convinced Vancouver mom Zoe Le Good to continue taking medication through both her pregnancies—first Prozac and then Zoloft.

“I felt that the drugs were the safer way to go,” says Le Good of her decision. After consulting with a psychiatrist at Vancouver Women’s Hospital’s Reproductive Mental Health Clinic, Le Good decided that being severely depressed during and after pregnancy would be more risky for her children than staying on her medication. Her pregnancies were both easy and her children are healthy and happy, yet she can’t help but worry.

“I was nervous during my pregnancies, and I still am,” says Le Good. “Any sort of behaviour difficulty my children have—even if it’s probably normal—will make me wonder: ‘Is it because I took antidepressants while I was pregnant?’”

There’s no one-size-fits-all answer, and so the trick then becomes teasing out what makes sense for each individual.

Several months ago, after a painful tapering-off process accompanied by awful withdrawal symptoms, I took the last few grains of a drug I never fully understood. Even if the risk of harm the drug posed to my future children was relatively small, for me, it felt like an unnecessary risk, and I was convinced the drugs weren’t doing much anyways.

At first I was fine, but as the weeks turned into months, I experienced a downward slide unlike anything that had come before. I was constantly anxious, obsessively worrying about the future, cyclically pondering the worst possible outcome of every situation until I was greeting every day with uncontrollable tears, practically bedridden. My agony was immeasurable.

When it got to the point where I could no longer work or do the things I loved, I went back on Effexor. It was in those moments that I learned the truth in Visgod’s words: Sometimes ending treatment is simply not an option.

This choice is so far from simple. I will never judge a woman for putting her own mental health first, and I would never presume to question the decisions of others who share my conundrum but not my specific circumstances. Ultimately, it boils down to a difficult individual choice—hopefully well-informed, hopefully carefully considered—and above all, hopefully optimizing the health of both mother and child. My plan is to seek other forms of treatment like talk and cognitive behavioral therapy and attempt to taper off again, but I’ve also accepted that ending drug treatment completely may simply not be an option for me.