WOMEN'S HEALTH
March 9, 2010

Psychiatric Drugs and Pregnancy

Timing makes a difference when it comes to taking antidepressant and anti-anxiety drugs while pregnant.

Taking medications during pregnancy — both prescription and over−the−counter — can be dangerous for the developing fetus. Drugs can cause a variety of unwanted effects including premature birth, abnormal birth weight, physical defects, developmental and neurological abnormalities, and others. But many pregnant women have conditions that are important to treat, so doctors and patients must weigh the risks of using medications against the risks to the mother and fetus of not treating the mother effectively. Some recent studies looked at the effects of antidepressant and anti−anxiety drugs as well as the alternative therapy, acupuncture.

Early on, when organs such as the heart, lungs, kidneys, and nervous systems are forming, a drug may have a different effect than later when overall growth, rather than the development of basic organs and structures, is the primary process.

Timing Places A Role

The risk medications pose is often related to the trimester during which they are used. Early on, when organs such as the heart, lungs, kidneys, and nervous systems are forming, a drug may have a different effect than later when overall growth, rather than the development of basic organs and structures, is the primary process. Similarly, the dose of medication and the length of time that the fetus is exposed can both alter the risk. Information about the risk/benefit balance of drugs is gathered through testing on animal models and extensive patient monitoring and is available through the Federal Drug Administration, the National Institute of Health, and many medical websites.

Because many people now use antidepressants, a recent study examined the effects of medications prescribed to treat depression and anxiety when used during pregnancy. Researchers were specifically concerned about the impact of these medications on the risk of preterm birth which is associated with many newborn problems from early breathing difficulties to later neurodevelopmental abnormalities and even, increased risk of death in the newborn period. In the United States, about 8 % of pregnant women take antidepressants. Often these are selective serotonin reuptake inhibitors (SSRI), such a Prozac, Paxil, Zoloft and Lexapro and selective serotonin and norepinephrine reuptake inhibitors (SNRI) such as Effexor. This group of medications can also be used to treat anxiety as can another category of medications, benzodiazepines, which include the tranquilizers Ativan, Xanax and Valium.

The investigators studied 2793 pregnant women and collected social, economic, demographic, and medical information about them. They followed them through their pregnancies and deliveries and noted their medication use, including psychiatric drugs, and any pregnancy/delivery complications. They also evaluated the newborns and checked their length of gestation, birth weights, APGAR scores (immediate assessment of newborn's condition following birth), need for treatment in neonatal ICU, and histories of problems with respiration.

About 23% of the women taking psychiatric medications had a preterm (before 37 weeks gestation) delivery, while only about 9% of the women who did not use these medications delivered early.

About one out of ten of the mothers in the study took psychiatric medications during pregnancy. Three−quarters of those women took only one medication, with another 25% taking two or three medicines. About 23% of the women taking psychiatric medications had a preterm (before 37 weeks gestation) delivery, while only about 9% of the women who did not use these medications delivered early. As the number of medications taken by the women in the study increased, so did the risk of preterm delivery.

Antidepressants' Effects

Interestingly, the risk of preterm delivery associated with SSRI/SNRI use only occurred if the medication was started in the second or third trimester. If the mothers started the drug either before pregnancy or in the first trimester and continued it throughout the pregnancy, there was no increased risk of preterm birth. The study data suggested that every SSRI and SNRI might not carry the same risk of preterm delivery. But the study population was too small to draw definitive conclusions about which among these drugs were more or less risky.

Anti−Anxiety Drugs' Effects

The study also showed that if mother used a benzodiazepine during pregnancy, she had an increased risk of preterm delivery, as well as increased risk of having a newborn with a low birth weight, a lower 5 minute APGAR score (reflecting some distress immediately after birth), an increased risk of being admitted to the neonatal intensive care unit and an increased risk of having early respiratory problems. None of the medications studied caused smaller than normal infants. SSRI/SNRI medications increased the risk of a low birth weight infant but did not increase the chances of low APGAR scores, NICU admission, or respiratory distress.

Interestingly, the risk of preterm delivery associated with SSRI/SNRI use only occurred if the medication was started in the second or third trimester. If the mothers started the drug either before pregnancy or in the first trimester and continued it throughout the pregnancy, there was no increased risk of preterm birth.

The researchers call for continued studies to clarify which specific medications are risky, when in pregnancy the exposure is most troublesome, and what other factors may be contributing to the problems seen in infants whose mothers use psychiatric medications.

The Dangers of Taking No Medication

It is important to remember that untreated depression and anxiety also pose risks to the pregnant mother and her fetus. Women who are depressed or anxious may not be able to take proper care of themselves during pregnancy. They may have poor nutrition, fail to obtain regular prenatal care, and use alcohol or other substances to self−treat their symptoms. Studies have shown that when a pregnant a woman is anxious, stressed, or depressed, she may have a higher cortisol (stress hormone) levels. Cortisol can cross the placenta and directly affect the developing fetus and can cause changes in the placental blood flow that affects the nutrient delivery to the fetus. Other studies have shown differences in the important brain chemicals, dopamine and serotonin, in infants of highly anxious mothers. They have also shown changes in the newborn activity levels as well as brain wave patterns in these infants.

Depression and anxiety during pregnancy should be addressed professionally and pregnant women should not delay seeking help, for fear of having to take a "risky" medication. There are both pharmacologic and non−pharmacologic interventions to address anxiety and depression.

One Alternative: Acupuncture

One treatment for depression that does not involve taking medication is acupuncture. It has been used in China, Japan, and Korea for years to treat mental health disorders and has been the subject of much study in the west.

When treating depression, the acupuncturist evaluates the patient and needles specific points known to be effective for balancing the energy flow that is related to depression. The treatment is individually tailored to the patient on each visit. Researchers have attempted to provide a neurochemical explanation for the effectiveness of acupuncture. One model proposes that the needles stimulate nerve fibers that cause the release of serotonin and other brain chemicals that are important in regulation of mood. A report published 2008 looked at eight studies of acupuncture and depression and concluded that it was an effective treatment which could significantly reduce the severity of depression. In 2004, a pilot study that assessed the effectiveness of acupuncture on symptoms of depression in pregnant women showed a positive outcome. The same researchers recently reported on the outcome of a similar but larger study with equally positive results.

The group receiving the acupuncture specific to depression had a significantly greater reduction in the depression rating scale scores than either of the control groups. The scores dropped by 53%.

The recent study divided 150 pregnant women who meant objective diagnostic criteria for depression into three groups. One group was treated with acupuncture specific to treatment of depression, one was treated with "control" acupuncture, meaning acupuncture points that were not involved in depression, and one group received massage therapy. In order to maintain similar conditions in each group, the therapists were instructed not to provide conversation, counseling, or music along with their treatment. There were 12 treatment sessions over a two−month period. The participants were evaluated with a standardized depression rating scale at four and eight weeks. . The lower the score on the rating scale, the fewer or less severe were the symptoms of depression.

The group receiving the acupuncture specific to depression had a significantly greater reduction in the depression rating scale scores than either of the control groups. The scores dropped by 53%. This meant that their symptoms of depression such as poor sleep, poor appetite, feelings of worthlessness, became less troubling. Sixty three percent of the acupuncture for depression group responded positively to the treatment while 44% and 37.5% of the control acupuncture and massage groups responded to treatment. This outcome compares favorably with a study of psychotherapy treatment ("talk therapy") of depression during pregnancy that showed a 52% reduction in symptoms after 16 weeks. Acupuncture also compared favorably when compared to cognitive therapy (a specific type of talk therapy) as well as treatment with antidepressant medication. Eight weeks of acupuncture dropped the depression rating scale score from 21.5 to 11.5 compared with eight weeks of antidepressant medication, 20.3−14.8 and eight weeks of cognitive therapy, 20.6 to 15.7.

Acupuncture has few side effects. The most commonly reported are discomfort at the point where the needle is inserted or bleeding at the site. The rate of unexpected complications of pregnancy did not differ among the three study groups. The authors concluded that acupuncture is a safe and effective treatment for depression in pregnant women.

Women who wish to explore acupuncture or other non pharmacologic therapies for treatment of depression during pregnancy should be sure that their provider is experienced in treating pregnant women, as this can offer some additional challenges. While alternative therapies are often considered harmless because they are "natural," that is not necessarily the case, especially during pregnancy. Women may wish to consult their primary care physicians or their obstetricians regarding appropriate referrals and safety concerns.

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