While we know the importance of postpartum depression screening, depression prior to and during pregnancy is common and serious. Women who choose to discontinue antidepressant therapy during pregnancy because of concerns about the impact of the medication on the fetus can lead to significant worsening of depression. Therefore, it is important to understand the potential harms of antidepressant therapy during pregnancy. Human and animal studies have been inconclusive. Singal et al (10.1542/peds.2019-1157) investigated neurodevelopmental outcomes in 5-year-olds born to women who used a selective serotonin reuptake inhibitor (SSRI) or a selective serotonin norepinephrine inhibitor (SNRI) during their pregnancy.
The authors used a population-based cohort of over 266 thousand mother child-dyads in Manitoba Canada between 1996 to 2014, following until 2015. Women who had at least 2 antidepressant prescriptions dispensed during pregnancy (n=2055) were compared to those who were noted to be depressed 90 days prior to conception through delivery but did not have SSRIs or SNRIs dispensed during their pregnancy (n=10017). Development was assessed using a teacher administered questionnaire in kindergarten (which included 3048 total children). This study found a significantly increased risk of developmental vulnerability in at least 2 of 5 developmental domains identified by the questionnaire (i.e. the Early Development instrument or EDI) compared to those children not exposed to antidepressants (21.43% vs 16.16%). In addition, children born to mothers who used SSRIs or SNRIs had an increased risk of having deficits in language and cognition.
Should pregnant women avoid antidepressant medication during pregnancy as a result of the findings in this study? Not necessarily according to an accompanying commentary by Drs. Galbally and Snellen (10.1542/peds.2019-3578), who note that the study, though well done and with large numbers of mothers and offspring, uses a developmental instrument that is better for determining school readiness than formal detection of cognitive or language abnormalities. In fact the commentary authors cite studies that question the validity and reliability of the EDI for detecting vulnerability in multiple developmental domains. They also point out some confounding variables that were not controlled for that might have affected the results as well, and call for better measures of neurodevelopment to be applied to cohorts of children whose mother used antidepressants during pregnancy before we can definitively weigh the risks and benefits of use of these medications during pregnancy. If a mother-to-be has suicidal ideations off her medication, it seems prudent to continue it. Alternatively, close monitoring is critical, even with non-pharmacological therapy. While we are not following mothers before they deliver, this study should be shared with your obstetrical colleagues and if an SSRI or SNRI is being used by a pregnant mother of a future patient for your practice. You’ll be better prepared to think about the consequences of antidepressant use during pregnancy by linking to this study and commentary and learning more.
