Often treatment with both medication and therapy is necessary to help women who have moderate to severe symptoms of depression and anxiety during pregnancy. If someone has many active and distressing symptoms, difficulty with taking care of themselves or fulfilling the usual roles they play as a parent, partner, employee, etc., or if they are suicidal, medications usually need to be considered.
If medication is required, it can be added to psychological treatments, such as counseling or therapy, and lifestyle suggestions, including sleeping well and eating well. Antidepressant medications are the most common class of drugs used in the pregnancy period and are effective treatments for both depression and anxiety disorders. The most commonly used class of antidepressant and anti-anxiety medications is called SSRIs (selective serotonin reuptake inhibitors). Drugs in this category are often very helpful for pregnant people, but other classes of antidepressants may be effective too. Often people require more than one psychiatric medication to address their symptoms; benzodiazepines, other sleep aids, or antipsychotic medications are also sometimes added.
Prior to starting medication during pregnancy, patients can consider the following points, and engage in a discussion with their health care providers:
- There is not a perfectly risk-free decision about using medication during pregnancy. The risks and benefits of treatment versus non-treatment or under-treatment should be weighed.
- If a woman stops medication during pregnancy, there is a risk of relapse or recurrence of symptoms, especially if she has had several previous episodes or a recent episode of mental health problems. She may also experience uncomfortable discontinuation effects that mimic depression or anxiety if she abruptly stops the medication.
- For babies exposed to SSRIs in utero, there does not appear to be a substantially increased risk of malformations above the rate in the general population, which is 2-3% (paroxetine has been associated with possibly slightly increased risk of cardiac malformations, but these findings are inconsistent), or an increased risk of persistent pulmonary hypertension of the newborn (PPHN). In addition, birth complications, including spontaneous abortion or stillbirths, are not increased among babies exposed to SSRIs in utero.
- Studies that have examined the long-term effects on children who were exposed in utero to SSRIs do not indicate an increased risk of cognitive, emotional, language or behavioural effects on children. There is no significant increased risk of autism spectrum disorders among children exposed to antidepressants in utero.
- Neonatal withdrawal may occur in 15-30% of babies. This means that some newborns show symptoms of jitteriness, breathing distress, and excessive crying but these go away on their own and should resolve fully within 48-72 hours. There is no evidence of long-term effects from this withdrawal. No specific treatments are required if withdrawal effects are noticed, but sometimes babies may need some extra oxygen. None of the medical evidence supports patients stopping medication late in pregnancy to avoid this effect.
- Patients and their health care providers can go to Mother To Baby (www.mothertobaby.org) for more detailed information about medication use in pregnancy.
- Common side effects when starting SSRIs may include stomach upset, headaches, dry mouth and jitteriness, but these may resolve within 1-2 weeks of use. Longer-term side effects may consist of difficulty having an orgasm, weight gain, vivid dreams or insomnia.
- Often the antidepressant doses must be increased as someone gets further along in pregnancy, due to increases in blood volume and changes in liver metabolism. People should take the dose that is effective to treat their symptoms. There is no data to show that higher doses lead to an increased risk of fetal or neonatal effects.
- There is no specific first-choice antidepressant. Medication should be chosen based on its safety profile, a medication that worked in the past, a medication that has been effective for close family members, tolerance of side effects, interactions with other medications, and awareness of other medical issues. Patients may experience benefits from medication immediately, or it may take 4-6 weeks at a therapeutic dose for full effectiveness to be noticed.
- Treatment guidelines suggest continuing medication for at least 6-12 months from remission (the time when someone feels well) for less severe or first episodes. Usually, it is advisable to continue medication until at least one year postpartum. At that time, slowly tapering off medication is recommended as long as someone is getting a decent amount of sleep and there are not a lot of external stressors. For women with a more lengthy and complex psychiatric history, longer or ongoing treatment may be required.