Depression is very, very common and its prevalence peaks during childbearing years.  Many women start their pregnancies on an antidepressant and the questions then ensue….
  • Have I caused harm to my baby?
  • What are the risks to my newborn if I am on an antidepressant?
  • Should I continue using the antidepressant or should I stop?
  • Should I switch do a different antidepressant?
  • Should I wean off the antidepressant at some point?
  • Can I breast feed if I am taking an antidepressant?

 Let’s address these questions individually, but with the caveat that there is no 100% perfect answer.  Each patient’s individual risks and benefits must be assessed and the patient and her physician can then decide on an effective strategy.  

Have I caused harm to my baby?

There are ethical dilemmas in performing quality studies of antidepressant use and fetal anomalies.  As you can imagine, it would be hard to convince women to be randomized in a study with a particular antidepressant. 

Overall, there is no difference in rates of major structural malformations amongst women who use antidepressants and women who do not.  One particular medication called Paxil (or Paroxetine) has been shown in one study to increase cardiac malformations.  (However, other larger studies have not been able to replicate this result.) 

If you are on an antidepressant and get pregnant, you can be comfortable that your risk for having a baby with a major structural malformation is about the same as anyone else.  This likely holds true even for Paxil, although given the aforementioned study, I would recommend stopping it pre-conceptually.

What are the risks to my newborn if I take antidepressants?

The catchwords that you will hear about for newborns born to mothers taking antidepressants are “withdrawal” and “respiratory” problems. 

Neonatal abstinence syndrome (NAS) or “withdrawal” occurs in 15-30% of newborns whom have been exposed to antidepressants in the third trimester.  NAS signs can include irritability, weak cry, faster breathing, temperature fluctuations, and low blood sugar.  These all peak in the first two days of life and always resolve by two weeks of life.

Persistent pulmonary hypertension of the newborn (PPHN) or “respiratory” problems occurs in about 1 to 2 per 1000 of all births.  This is a serious complication that could lead to death.  In women taking antidepressants (especially in the third trimester) this risk increases to 6 per 1000.  So while you may hear that there is a 6 times higher likelihood to have serious “respiratory” problems, the ABSOLUTE increase in risk is very low, just a few per 1000.  

Should I continue using the antidepressant or should I stop?

If possible, this question should first be addressed prior to conception.  However, in reality, that is not possible most of the time.  I think it is important for you as a patient (and for us as your doctors) to decide your risk of a major depressive episode during your pregnancy. 

If you are someone, for example, who has had multiple major depressive episodes in your life, or have a strong family history of mood disorders, or have been suicidal at some point in your life, or have failed therapy as an alternative to medications, or have many stressors in your life currently, then you likely have a greater benefit to continuing antidepressants than any risks that they pose. 

Untreated depression can affect a pregnancy and potentially development of offspring.  Thus, it is important to weigh the benefits of antidepressants verses the risks.

Should I switch to a different antidepressant?

Given the FDA “Category D” status of Paxil, if you are on this medication prior to conception, ideally you could transition to a different antidepressant before conception.  If you have conceived on Paxil, then your absolute risk of a major cardiac malformation is still very low.  We would perform a more detailed sonogram in the second trimester.

Should I wean off the antidepressant at some point?

Many obstetricians support a strategy of weaning off the antidepressant in the third trimester to decrease the risk of the aforementioned “withdrawal” and “respiratory” problems.  I would agree with this strategy in women of low risk of a severe depressive episode in the third trimester.  If you are someone at high risk of a recurrent episode (ie when you stopped medication in the past, you had a relapse) then continuing antidepressants provides a greater benefit than risk. 

Can I breast feed on an antidepressant?

As with studies during pregnancy, there is poor data on breast-feeding while on antidepressants.  Overall, antidepressants have a very low detectable level in the blood of women who take them and thus an even lower level in breast milk.  In fact, Zoloft (sertraline) and Paxil (paroxetine) are essentially undetectable in breast milk.

The take home points 

  • If you are at a low risk of depression off medication, wean before you get pregnant.
  • If you become depressed in pregnancy and need medication, or are continuing on a medication you started prior to conception, feel comfortable with the overall safety profile of antidepressants.
  • Avoid Paxil if you are trying to conceive unless this is the only feasible option
  • If you are at low risk for depression off medication and you desire weaning, then weaning is a good option.  You can restart medications post partum.
  • If you are at high risk for depression off medication, please continue your antidepressant and feel comfortable that the absolute risk of a serious complication is low (6/1000).
  • Breastfeeding is considered safe while taking antidepressants.