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Pregnant Question

Depression Study Fuels Debate On Whether to Treat With Drugs

By Marc Siegel
Special to The Washington Post
Tuesday, March 1, 2005; Page HE01

A study last month in The Lancet, a major British medical journal, uncovered 93 cases of seizures in infants whose mothers had been taking selective serotonin reuptake inhibitor (SSRI) antidepressants, most commonly Paxil (paroxetine).

The article suggests that a baby whose mother is using SSRIs may suffer withdrawal symptoms including seizures when the child is born and abruptly stops getting the drug through the mother's bloodstream. But the study -- based on a survey of reports of adverse drug reactions -- contains no definitive evidence of this effect. There has been no clinical trial comparing infants whose moms did and didn't take Paxil during pregnancy. (Paxil is available to pregnant women by prescription, though manufacturer GlaxoSmithKline says on its Web site that some complications, including seizures, have been reported in babies whose mothers had used the drug during pregnancy.)

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However inconclusive, the Lancet report has provoked a new alarm about the effects of these antidepressant medications, whose safety in older children and whose impact on suicide has been widely questioned recently. It also has refocused attention on a crucial issue: Which is worse, the side effects of an imperfect but effective drug, or the serious condition it is intended to treat?

It is generally agreed that less medical intervention during pregnancy is better, since medications given to the mother may harm the fetus. But though often undiagnosed, depression in pregnancy is quite common, with an estimated 10 to 25 percent of pregnant women in the United States having clinical signs of depression.

More important, numerous studies have documented the adverse effects of maternal depression on fetal and infant well-being. Untreated depression during pregnancy has been associated in several studies with premature labor and low birth weight. A Danish study published in The Lancet in 2000 reported that maternal emotional distress led ultimately to congenital malformations. A study from Emory University in 2001 revealed that infants whose mothers had been depressed during pregnancy showed a higher than normal stress response at the age of 6 months. Depressed women are also at higher risk for using alcohol, drugs and tobacco, as well as for very poor diet and sleep habits, all of which have been shown to impair fetal development more than antidepressants do.

Continuing maternal depression is also a danger to the child during the postpartum and early childhood periods. Recent data indicate that maternal depression is a major predictor of poor bonding and negative parenting behaviors, including less interaction, more yelling and spanking.

"The poor-sleeping, poor-eating, high-stress condition of untreated depressed mothers-to-be [is] far more likely to lead to preterm birth or other complications in the newborn than antidepressant medication," said Andrei Rebarber, associate professor of maternal fetal medicine at New York University.

Rebarber said obstetricians need to carefully screen patients for common symptoms of depression: abnormal emotional instability, inadequate weight gain and possible substance abuse.

How to Treat?

Once the decision has been made to treat depression during pregnancy, consideration should be given to psychotherapy, which is the first choice for mild to moderate symptoms. Interpersonal psychotherapy, where pregnant women work on developing new motherhood skills, has shown encouraging results in preliminary studies. Group psychotherapy, which helps treat social isolation, has also been recently shown to be effective.

But severe depression has been found to respond better to medication, with psychotherapy as a helpful adjunct. The decision to prescribe an antidepressant is based on the consideration that the risks of the treatment are outweighed by the risks of the depression. A psychiatrist should be involved, at least initially.

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