Today’s post ended up evolving into something of a guest post from Ms Future PharmD, with an assist from yours truly. It has been really interesting and illuminating getting to know the expertise that is out there on the blogroll this way. Every one of us has something unique to offer, from both personal and professional knowledge. So if you see something interesting in the news, on any relevant topic that interests you, please send it to us with your thoughts here. Similarly, if you have a site suggestion, don’t hesitate to drop us a line here.
In this post, we examine a recent blurb from Babble discussing the risk of SSRI during pregnancy. We recognize that within this community, the incidence of anxiety and depression related to infertility, loss, and pregnancy are likely higher than the general population of similar demographics. PAIL recommends that you always consult with your healthcare professional to choose a treatment path that is right for you, your child, and your circumstances – whatever that path is. Please take care of yourself, and understand that others are trying to do the same.
Last week, Ms Future PharmD emailed us about an “article” (it’s a paragraph at best – let’s call it a blurb) about SSRI (selective serotonin re-uptake inhibitor) use during pregnancy, complete with evidence trail leading back to the clinical study. To say this piqued my curiousity both personally and professionally is an understatement. I have mentioned before that I dealt with crippling anxiety during my pregnancy with HGB, but may not have confided that I subsequently went on an SSRI (an agonizing decision made while breastfeeding) to treat severe PPD afterwards. (Please feel free to email me if you would like to know more about this experience and the choices I had to make – I have not blogged about it to date). I have also mentioned that in my professional life, I use clinical drug trials to support brand messaging for pharmaceuticals (albeit for a different audience than the general public, 90% of the time). When I read the Babble blurb on SSRI use during pregnancy, I immediately saw the problem. Ms Future PharmD had this to say when she initially contacted us:
Here’s the trail of discovery: first I read it at a Babble article (yes, I should stop…) This is the article the Babble author references. Here’s the actual study (freely accessible) – via Human Reproduction It seems to have been addressed in a pile of regular newspapers as well as some TV news outlets. Here’s one from a Boston TV news station.
I also saw it pop in my Twitter feed via Postpartum Progress here and again at Babble here (both pieces by Katherine Stone @ Postpartum Progress and both worthwhile reads in my opinion). So, what is causing all the stir? Here is the original blurb from Babble, in its entirity:
SSRI Risky During PregnancyAccording to a new study, “there is clear and concerning evidence of risk with the use of the SSRI antidepressants by pregnant women, [and] that these drugs lead to worsened pregnancy outcomes.” Additionally, there is no evidence at all of any benefits of using these antidepressants during pregnancy — not for the mother or the baby. Source; Medical Xpress
Preface: I’m not your doctor, or a doctor at all, so this doesn’t count as medical advice. See your own doctor or get a referral to a specialist if you have questions about your own health. SSRIs are a group of medications used to treat depression and anxiety that might do something to serotonin levels in your brain but we aren’t sure yet exactly how they work. Popular ones are Proz.ac (fluoxetine) and Zo.loft (sertraline) although there are a whole bunch of diverse drugs in the class.
One of the things that makes me really mad about this article is the things it isn’t telling you. It doesn’t really have anything new to say. All of science says that SSRI antidepressants are helpful for some people and not for others (publication bias or not). This isn’t new, yet this article gets all excited about it as if this is something new. (Sidenote: publication bias means that if your study doesn’t find your drug beneficial, you don’t publish it, but it gets reported to the FDA. This article reviews all the studies, not just the published ones. Having no access to unpublished articles, we don’t know if the only reason they weren’t published was that the findings weren’t positive. There could be other problems too.) All of our research says that CBT (cognitive behavioral therapy a.k.a. talk therapy) is as beneficial as or more beneficial than SSRIs alone. That’s not new either.
The big things that are missing from the (second, summary) article are an explanation of the magnitude of effects seen, or how big a deal it is that the SSRI changes pregnancy outcomes. There’s a higher risk of cardiac defects, yes. The difference is 0.09% with no SSRI or 0.1% with it. Is that fundamentally different? Probably not. How much shorter are pregnancies when the mom takes an SSRI? The article makes a big fuss about how gestation is shorter but never admits how much shorter (it’s less than a week shorter). They mention an increased risk of miscarriage, but again skip mentioning how much higher. In one of the studies they cite, the SSRI-taking women had a 13% miscarriage rate and those without had a rate of 8%. The usually accepted miscarriage rate is 12-15% in the population, so that isn’t actually evidence that the SSRIs had a thing to do with it.
When we get to the section specifically on SSRIs and infertility, the authors conclude that we should study it more because the evidence is sparse and that sperm counts might be affected by SSRI usage. Yes, there’s one study that showed that couples treated for depression while undergoing infertility treatment got pregnant at much higher rates, but it was published in a not-so-reputable journal (not a good sign of its credibility) and it only sampled 140 couples (hardly enough to conclude anything about every infertility patient everywhere, other than to say treating mental health is important). All this fuss and the real conclusion is that we should study it more? News media, read the article.
This article also spends a lot of time talking about how SSRI use is associated with negative outcomes in pregnancy (hypertension for example). That tells us not much about whether the SSRI is being used because the pregnant person is otherwise at increased risk of hypertension (say due to anxiety or obesity or something else) or if the SSRI causes the hypertension, and since most studies are done after the pregnancy ends (retrospectively), there’s no way to really know. Likewise, perhaps someone with a history of loss gets depressed and then an SSRI. Does the next miscarriage really have to do with the SSRI? It’s hard to know without a whole lot more study.
The biggest thing left out of this article is what happens in depressed women who get pregnant and aren’t treated at all for depression. The outcomes are worse than those in women taking SSRIs and include more miscarriages and preterm births.
The thing that makes me the most upset reading this article is the focus on the fetus. Yep, fetuses are important if you’re trying to have a baby (duh) but so are mothers. Nowhere does the article talk about the incidence of postpartum depression or psychosis in mothers treated with SSRIs or CBT (it’s lower based on the research we have). Nowhere does it talk about quality of life for depressed pregnant mothers who are untreated, or her support people. Nowhere does it talk about the long-term consequences to relationships of women being untreated or possibly undertreated for depression/anxiety during pregnancy. Untreated depression is not a pretty thing and that’s why we treat it. Treatment of some sort is probably a really good idea if it was in place before pregnancy and stopping suddenly is not a great idea either (brains are slow to adapt to changing medications that alter their functioning so you have to taper down, and this doesn’t mean the medicine is horrible for you, it means your brain is good at adapting).
Overall I’d say that this article is sensational and doesn’t include literature that is important to the decision on how to treat a woman who’s depressed and is/may become pregnant. The guidance from the leading medical folks is still “consider the risks and benefits carefully before treating or changing treatment.” This article doesn’t change that at all, so if this might be you, be sure you get the treatment you need to be healthy and have a doctor you know is an expert in depression treatment during pregnancy supervising your care. The article does make a good point that it’s important to have a qualified specialist treating pregnant women, especially those with infertility to cope with.
Did/do you struggle with anxiety/depression related to your ALI journey? Pregnancy? Postpartum period?
Have you previously written about these experiences, and would you be willing to share them again by linking in the comments?
What is your impression of the Babble blurb? Would you have clicked the “source” link to find out more?
Have you taken (or decided not to take) an SSRI during pregnancy or while breastfeeding? What factors went into your decision?
Do you feel that there is enough accessible information about these issues made easily available to the average woman?
What questions would you ask your doctor (or have asked) if faced with this decision?
**Please be mindful of your comments in this discussion. The choice to take medication or not is extremely personal and sometimes difficult. Thank you.**