antidepressant use in pregnancy, and child development?

Q.The use of antidepressants during and after pregnancy is a controversial issue. The potential exposure of the developing child to substances which might have adverse effects would always be something we'd want to avoid, if possible. But when illness coincides with pregancy, the choice must be made, to treat or not to treat. I want to be very clear, at the outset, that I am not expressing any kind of opinion about the appropriateness of antidepressant therapy during pregnancy. I will present information about what happens if antidepressant exposure of the developing child occurs. I will also present some corollary information that might have an influence on the decision-making process (much of that in part two).

A.It is not considered ethical to conduct human experiments involving pregnant women. Only recently has it been considered ethical to even conduct drug trials on women of child-bearing age, and only because we now know that drugs sometimes have different effects in women than in men. Great care is taken to ensure that women are not pregnant during clinical drug trials. Once a drug is approved for sale, and goes into common use, it is no longer possible to ensure that drug exposure never occurs during pregnancy. Many pregnancies are unplanned. In other cases, illness occurs that is sufficiently serious as to warrant some kind of intervention, notwithstanding the pregnancy. All we can do is observe, to learn what happens during the pregnancy, at birth, and during child development. There are two kinds of studies which might be conducted. A prospective study is one in which a mother-child pair is identified as antidepressant-exposed dur ing pregnancy, and they watch to see what happens. The other sort is a retrospective analysis, where they know what happened at birth, and they look back at identifiable risk factors which might have influenced the birth outcome. (I think a prospective study might give better information, because medical staff are alerted in advance, and are paying attention. It's less likely that a significant detail will be overlooked.) There are no hits on Pubmed for the search terms "teratogen and SSRI". All relevant abstracts discovered using "birth defect and SSRI" as search terms are referenced here (1-4). The search terms "teratogen and antidepressant" revealed no further relevant information. A search using the terms "birth defect and antidepressant" turned up two more relevant hits among hundreds (5,6), but those are consistent with all other references. I can find no evidence that prenatal exposure to either tricyclic or SSRI antidepressants is associated with birth defects. Even multidrug exposure is not associated with increases in birth defects. There appears to be no difference in the incidence of miscarriage and stillbirth, when comparing antidepressant-medicated mothers (AMM) and unmedicated mothers (UM) (1,4,6). Some studies report no greater incidence of prematurity in AMM (1,3), while others report a higher incidence (2,4,5,7). Reference 2 reports lower birth weight in both SSRI-antidepressant and non-SSRI antidepressant mothers, but also raises the concern that this may be an effect of the underlying disease state. Depression, anxiety, and stress are all associated with premature birth and low birth weight (see second essay).

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