6/27/07 – U.S. NEWS & WORLD REPORT

Pregnant women with depression often find themselves choosing between the lesser of two evils. Should they take antidepressants and risk the slight but real possibility of birth defects? Or should they forgo treatment and chance a relapse?

Two new studies published in this week’s New England Journal of Medicine could help women make a more informed decision.

One study of nearly 10,000 infants born with birth defects and nearly 6,000 healthy infants found that women who took sertraline (Zoloft) in the first few months of pregnancy had twice the risk of having a baby born with a heart defect, while those on paroxetine (Paxil) had more than three times the risk. Paxil also increased the risk of a rare hernia called an omphalocele. But this doesn’t mean antidepressants are unsafe: The heart defects seen in the study normally occur in 5 out of 10,000 babies, so a doubling of the risk means they occur in 10 in 10,000 and a tripling in 15 in 10,000—thus, a baby’s risk is still far less than 1 percent.

“The results are pretty reassuring, though we did find some increased risk relating to specific drugs,” says study leader Carol Louik, an assistant professor of epidemiology at Boston University. The second study from the University of British Columbia also found a tripling of heart defects in babies born to mothers who took Paxil as well as an increased risk of neural tube defects. What’s interesting is that neither study found any significant increase in birth defects from Prozac, Lexapro, and other antidepressants that, like Zoloft and Paxil, fall into the category of selective serotonin reuptake inhibitors.

“As the evidence grows, it’s becoming clearer in my mind that the link between SSRIs and birth defects is tenuous at best but probably real,” says Charles Lockwood, chair of obstetrics, gynecology, and reproductive science at Yale University School of Medicine and spokesperson for the American College of Obstetricians and Gynecologists. ACOG already recommends against the use of Paxil in pregnancy because of previous research suggesting it increases heart defects, but Lockwood says he’s not yet convinced that other SSRIs pose smaller risks. He believes that pregnant women taking any SSRI should get regular sonograms to check for fetal heart defects and that bupropion (Wellbutrin), a non-SSRI, should be considered as a first line of therapy; it’s mild and considered to be the safest antidepressant but it also may not work as well for severe depression.

While some women certainly need to stay on their antidepressant throughout pregnancy to avoid a relapse, others may get the same benefits from psychotherapy.

“If someone can do OK without her medication, that’s fine, but she needs to be monitored closely,” says Carolyn Robinowitz, president of the American Psychiatric Association. Untreated depression can cause premature birth and low birthweight and possibly increase the risk of miscarriage. What’s more, depressed mothers may be more likely to have poor eating habits or abuse alcohol or drugs—all potentially harmful to the fetus.

“There’s a careful tightrope that patients and doctors have to walk to minimize exposure to antidepressants but to avoid depression in pregnancy as well,” says Lockwood.

The new findings come on the heels of other research out earlier in the week linking antidepressants to accelerated bone loss in the elderly.