Safety of Antidepressants During Pregnancy

Overview of Safety Profile

Antidepressant use, particularly SSRIs, among pregnant women has been increasing, with up to 12% of pregnant women in the US filling prescriptions for SSRIs by 2013 2
Antidepressants cross the placenta and can be found in amniotic fluid and cord blood, raising theoretical concerns about fetal exposure 3
While rodent studies have shown adverse effects of perinatal antidepressant exposure on neurodevelopment, between-species differences limit the generalizability of these findings to humans 1, 4

Converging evidence from multiple study designs suggests that associations between prenatal antidepressant exposure and neurodevelopmental problems (particularly ASD and ADHD) are largely due to confounding factors rather than medication effects 2, 5
The American College of Obstetricians and Gynecologists review provides reassurance that antidepressant use during pregnancy is unlikely to substantially increase the risk of autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) 6

SSRIs may be associated with a small increased risk of preterm birth compared to untreated women with depression 7
The FDA revised its 2006 advisory on SSRI use after the 20th week of gestation in 2011, stating that conflicting findings make it unclear whether SSRIs during pregnancy cause PPHN 7

Paroxetine was classified as pregnancy category D by the FDA in 2005 due to concerns about congenital cardiac malformations 7
Paroxetine and sertraline are the most commonly prescribed antidepressants during breastfeeding 7

Untreated depression during pregnancy is associated with premature birth and decreased initiation of breastfeeding 7

The American Psychiatric Association and American College of Obstetricians and Gynecologists recommend a stepped approach to treatment of depression during pregnancy 6
For mild depression with recent onset (≤2 weeks), monitoring and encouraging exercise and social support 6
For mild depression not improving within two weeks or moderate-to-severe depression, evidence-based treatment should be offered 6
Antidepressants may be a superior option for women with history of severe suicide attempts or severe depression with previous positive response to medication 6
Continuing antidepressants during pregnancy may be advisable for women who have previously relapsed when discontinuing treatment 6

Treatment decisions should consider severity of current symptoms 5
Treatment decisions should consider previous mental health history 5
Treatment decisions should consider patient treatment preferences 5
Routine screening for depression during pregnancy is recommended using validated tools such as the Patient Health Questionnaire, Hospital Anxiety and Depression Scale, or Edinburgh Postnatal Depression Scale 6