Prescribing pregnant women that suffer from depression with anti-depressant and mood-stabilizing medication often represents a certain challenge, due to the fact that it is quite normal for such women to experience a variety of psychological anxieties, during the course of the childbearing process. In his article “Psychiatric Medications During Pregnancy”, Piave Lake states: “Depression during pregnancy is often underdiagnosed, in part because of the overlap of symptoms with normal pregnancy-related physiologic changes” (Lake, 2009, p. 1).
The same suggestion can be found in Wantana Suppaseemanont’s article “Depression in Pregnancy: Drug Safety and Nursing Management”: “Prenatal care nurses should be able to distinguish depressive disorders from pregnant-related physiologic changes and grief behaviors. Although pregnancy can cause changes in sleep, appetite, or energy, depressed pregnant women are likely to complain more about sleep deprivation and fatigue than non-depressed mothers” (Suppaseemanont, 2006, p. 13). This; however, does not mean that physicians should be prompted to adopt an ignorant attitude towards pregnant women that complain about feelings of mental inadequateness, because – if left untreated, depression is likely to negatively affect the overall wellness of an unborn child, as well.
Therefore, when it comes to prescribing pharmacological treatment to pregnant women that are being positively diagnosed with depression, a well-balanced approach must be adopted – that is, the benefits of taking such medicine need to be carefully measured against the potential risks, associated with the same practice. In her article “Psychotropic Medication in Pregnancy: Ethical Aspects and Clinical Management”, Sarah Allison substantiates the validity of such our suggestion by saying: “What makes the issue of taking psychotropics in pregnancy so difficult is that sometimes the mother’s mental health treatment contradicts optimal fetal well-being.
In many ways, the debate over whether women should take psychotropic medications during pregnancy is an issue of psychiatric parity, or of the physical problems of pregnancy being prioritized over the psychiatric problems of a woman who is pregnant” (Allison, 2004, p. 196). In other words, suggestions that pregnant women should simply stay away from resorting to psychotropics while dealing with depression, are equally wrong as suggestions that the medicinal treatment of such women’s depression should solely be thought of within a context of how this treatment can benefit future mothers’ mental wellness.
Thus, it represents the matter of foremost importance for physicians to be able to correctly identify the physiological subtleties of pregnant women’s depression because it is namely women’s genetically predetermined susceptibility towards depression, which accounts for the major risk factor when women’s capability to give birth to a healthy offspring is concerned.
In the article, from which we have already quoted, Piave Lake provides us with insight on other major risk factors, within the same context: family history of depression, presence of comorbid psychiatric illnesses, and particularly frequent mood episodes. Also, the author implies that healthcare professionals are still a long way off from being able to provide pregnant women with 100% reliable diagnosis, as to the essence of such women’s psychological anxieties: “Screening tools can be useful to identify depression in the pregnant patient, although the most reliable tool to the user with pregnant women has not bee determined” (Lake, 2009, p. 2).
Apparently, the methods of defining the subtleties of pregnant women’s depression do not differ much from those that used to be utilized by psychologists even as far back as fifty years ago, because the effectiveness of these methods appears to directly correspond to the extent of physician’s professional experience, rather than to technological progress in the field of psychology: “The physician can ask, “How are you feeling?” and “Are you able to enjoy your usual activities?” Answers to these questions should prompt the physician to investigate the possibility of depression further” (Lake, 2009, p. 2).
It is only after a pregnant woman’s mental anxieties have been positively identified as being particularly strong and as such that correspond to particularities of her overall physiological constitution, that physicians should consider her depression becoming the subject of pharmacological, rather than psychological therapy. Given the fact that pregnant women’s pathological depression represents a comparatively new issue, in the field of healthcare, the practical effects of anti-depressants and mood stabilizers on such women have not been thoroughly studied yet. However, since we are aware of the neuro-chemical mechanics behind the effect, produced by these medications, there can be no doubt that pregnant women suffering from depression, should always observe moderation while taking anti-depressants.
In their article “Selective Serotonin Reuptake Inhibitors (SSRIs) in Pregnancy: A Review”, Robin Fleschler and Melissa Peskin state: “SSRIs cross the placenta and have been detected in the cord vein blood at birth. Because of the physiological changes in pregnancy (such as the 50% increase in blood volume by about 24 weeks), SSRIs may become somewhat diluted and have a diminishing effect. Dosage, therefore, should be carefully monitored according to the changing physiology of pregnancy” (Fleschler & Peskin, 2008, p. 359). In the next part of this paper, we will briefly analyze medications that are being commonly prescribed to pregnant women that deal with depression and will also outline possible dangers, associated with these medications’ usage.
Venlafaxine – an anti-depressant that is being commonly prescribed to people suffering from major depression and a variety of anxiety disorders. So far, there is no evidence as to this medication’s ability to negatively affect the fetus’ well-being. The most recent study “Maternal Use of Venlafaxine near Term: Correlation between Neonatal Effects and Plasma Concentrations”, conducted by Nina Boucher, Gideon Koren and Louise Beaulac-Baillargeon on the subject of Venlafaxine’s effects on pregnant women and their offspring, has failed to provide the general public with conclusive proof as to this medication’s potential harmfulness: “The nature of neonatal adverse effects in the offspring after maternal use of Venlafaxine at term remains being not fully understood” (Boucher, Koren & Beaulac-Baillargeon, 2009, p. 404). As for today, most physicians do not take pregnant women’s physical condition into particular consideration, while prescribing them this drug.
Tricyclic antidepressants (Clomipramine, Dosulepin, Doxepin, Imipramine, Lofepramine, Trimipramine, Amitriptyline, Butriptyline Desipramine, Nortriptyline, Protriptyline, and Dibenzepin) – even though that no direct link has been found between these medications and congenital malformations, physicians usually recommend women to avoid taking them, during the time of pregnancy if possible, due to the lack of information onto the full spectrum of side-effects, associated with these anti-depressants.
Trazodone and Nafasodone – some of the most powerful “serotonin boosters”, available for prescription. If used in moderate doses, they are believed to have no effect on the mother or fetus’ physical condition. In their study “A Multicentre Prospective Study to Determine the Safety of Trazodone and Nefazodone Use during Pregnancy”, Adrienna Einarson, Lori Bonari, Sharon Voyer-Lavigne, Antonio Addis, Doreen Matsui, Yvette Johnson and Gideon Koren have come to the conclusion that both medications are comparatively safe, within a context of pregnant women resorting to them: “We have completed 147 follow-ups.
There were 121 (82.4%) live births, 20 (13.6%) spontaneous abortions, and 6 (4%) therapeutic abortions. Of the live births, there were 2 (1.6%) major malformations. In all cases, drug exposure occurred during the first trimester, with 52 (35%) of the women using these drugs throughout pregnancy. We found no statistically significant differences among the 3 groups in any of the endpoints of interest that we examined. Our results suggest that these drugs do not increase the rates of major malformations above the baseline rate of 1% to 3%” (Einarson, Bonari, Voyer-Lavigne, Addis, Matsui, Johnson & Koren, 2003, p. 106). Nevertheless, pregnant women with heart conditions are being strongly advised against taking both medications.
Mirtazapine – tetracyclic antidepressant, used in the treatment of mild depression. No data is available as to this medication’s potentially dangerous effects on pregnant women and fetuses’ condition.
Burporion – even though this medication was originally meant to be used as an anti-depressant, it is now being commonly prescribed as a smoking cessation aid. As for today, only very few studies had been conducted as to this medication’s potentially harmful effects on pregnant women’s health – however, the results of these studies have confirmed the absence of any links between Burporion and birth defects. The overwhelming majority of physicians consider this drug as being absolutely safe to be taken by pregnant women. In his article “Bupropion
Appears Safe in Pregnant Women: not Linked to Increase in Major Fetal Dejects: First Study in Pregnancy”, Nicholas Mulcahy states: “Bupropion does not appear to increase the risk for major fetal malformation and seems effective in decreasing smoking in pregnant women, according to interim results of an ongoing trial… In the prospective, observational, controlled study, 101 women are enrolled for Bupropion treatment (either for smoking cessation or depression) and 100 are enrolled as controls. To date, mean birth weight, gestational age at the time of delivery, and rates of birth defects, miscarriages, and therapeutic abortions were not significantly different between the two groups” (Mulcahy, 2003).
Carbamazepine – a drug that is being most commonly used in the treatment of epilepsy. Some doctors also prescribe it as a mood stabilizer. Given this medication’s high toxicity, pregnant women are being strongly advised against taking it. This particular medication is believed to be capable of causing an infant’s developmental delay. Nevertheless, most empirical studies that were meant to scientifically substantiate physicians’ negative attitude towards this drug, have proven to be inconclusive.
For example, in the conclusion of their study “Effects of Prenatal Exposure to Carbamazepine on Brainstem Auditory Evoked Potentials in Infants of Epileptic Mothers”, Adrián Poblano, Aurora Belmont, Jesús Sosa, Jorge Ibarra, Yolanda Rosas, Vivián López and Saúl Garza state: “We studied 20 mothers and their infants. All mothers had uncomplicated pregnancies and deliveries. None of the patients exhibited side effects of the drug.
All infants were born with 5-minute Apgar scores over 7 points (two infants with a low 1-minute Apgar score recovered at 5 minutes without evidence of alterations in blood oxygen concentration), and all were born at term with weight and length in the normal range according to gestational age”. At the same time, authors do recognize a possibility for this drug to negatively affect embryo’s neuro-system, while in the womb: “There is indirect evidence as to the fact that Carbamazepine disturbs brain development by inhibiting neuronal growth and differentiation as well as corticogenesis and gliogenesis; however, further studies need to be conducted on this subject” (Poblano, Belmont, Sosa, Ibarra, Rosas, Lopez & Garza, 2002, p. 366).
Lamotrigine – is an anticonvulsant medication that is being usually prescribed for people affected by epilepsy and bipolar disorder. According to only the study, conducted on the subject of this drug’s possible effects on 23 infants’ neurodevelopment, no deviations have been reported, up until the time when toddlers have reached the age of 12 months. In recent years; however, more and more doctors recommend pregnant women to withhold from taking Lamotrigine, in order to avoid complications, during the labor.
In her article “Pregnant Women on Lamotrigine Have Greater Risk of Seizures When Drug Levels are Low: Presented at AES”, Paula Moyer provides us with the insight into the fact that taking Lamotrigine by pregnant women increases the risk of seizures: “Because Lamotrigine is associated with relatively low rates of malformations, physicians are prescribing it more often to women with epilepsy who are in their reproductive years.
However, as with many medications, Lamotrigine clearance has been reported to increase during pregnancy, resulting in low blood concentrations of the drug and, therefore, more frequent seizures. In fact, such exacerbations have been reported in 45% to 75% of women on Lamotrigine monotherapy, according to the investigators” (Moyer, 2006). At present time, pharmacologists work on designing alternatives to Lamotrigine.
Mood stabilizers (Lithium, Valproate) – medications used in the treatment of a variety of psychological anxieties, particularly mania and depression. Due to these drugs’ popularity, the effects of Lithium and Valproate on women’s pregnancy have been thoroughly researched. The risk of offspring being born with mental and physical deformities, due to its exposure to Lithium and Valproate, while in the womb, is commonly assumed as quite significant. In their article “Lithium during Pregnancy: Drug Effects and Their Therapeutic Implications”, Kimberly Yonkers, Bertis Little and Dana March point out numerous risks and challenges, associated with pregnant women talking Lithium: “Treating bipolar illness during pregnancy poses a number of challenges. First-trimester exposure to Lithium may be associated with a slightly increased risk of heart malformations.
Fetal and neonatal Lithium toxicity has been reported by several authors… There continue to be risks of toxicity for the neonate if the mother breastfeeds while receiving Lithium. For this reason, most experts recommend against breastfeeding if the mother requires lithium. In the neonate, even ‘therapeutic’ doses of Lithium have been associated with toxicity, as the immature renal system is less able to clear Lithium” (Yonkers, Little & March 1998, p. 268). Nevertheless, most physicians do not think that ingestion of Lithium poses a particular danger to the well-being of pregnant women and the offspring, because the absolute risk, associated with taking these drugs, is assumed as being comparatively low.
As we have stated earlier, despite the fact that the practice of prescribing pregnant women with anti-depressants is often believed to be essentially counter-beneficial, such practice can be hardly avoided, especially nowadays, when the percentile ratio of people suffering from psychological disorders in Western countries continues to increase at an alarming rate. Therefore, physicians must apply extra effort to ensure that their decision to prescribe pregnant women anti-depressants and mood stabilizers is being fully justified by considerations of reason.
Bibliography
Allison, S. (2004). Psychotropic Medication in Pregnancy: Ethical Aspects and Clinical Management. Journal of Prenatal & Neonatal Nursing. 18(3),194-205.
Bodnar, L., M.; Sunder, K., & Wisner, K. (2006). Treatment With Selective Serotonin Reuptake Inhibitors During Pregnancy: Deceleration of Weight Gain Because of Depression or Drug? American Journal of Psychiatry, 163 (6), 286-991.
Boucher, N., Gideon., K., & Beaulac-Baillargeon, L. (2009). Maternal Use of Venlafaxine near Term: Correlation between Neonatal Effects and Plasma Concentrations. Therapeutic Drug Monitoring. 31(3), 404-409.
Cain, J. (2006). Antidepressant use during pregnancy. Journal of Women’s Health. 106 (5), p64L-64O.
Chaudron, L. (2007). Treating Pregnant Women with Antidepressants: The Gray Zone. Journal of Women’s Health, 16 (4), 551-553.
Cunningham, M., & Zayas, L. (2002). Reducing Depression in Pregnancy: Designing Multimodal Interventions. Social Work, 47(2), 114-123.
Deave, T., Heron, J., Evans, J., & Emond, A. (2008). The Impact of Maternal Depression in Pregnancy on Early Child Development. An International Journal of Obstetrics & Gynecology, 115 (8),1043-1051.
Einarson, A., Bonari, L., Voyer-Lavigne, S., Addis, A., Matsui, D., Johnson, Y., & Koren, G. (2003). A Multicentre Prospective Study to Determine the Safety of Trazodone and Nefazodone Use during Pregnancy. Canadian Journal of Psychiatry, 48 (2), 106-109.
Fleschler, R., & Peskin, M. (2008). Selective Serotonin Reuptake Inhibitors (SSRIs) in Pregnancy: A Review. American Journal of Maternal Child Nursing. 33(6), 355-361.
Freeman, M. & Gelenberg, A. (2005). Bipolar Disorder in Women: Reproductive Events and Treatment Considerations. Acta Psychiatrica Scandinavica, 112 (2), 88-96.
Freeman, M. (2007). Antenatal Depression: Navigating the Treatment Dilemmas. American Journal of Psychiatry, 164 (8),1162-1165.
Gold, L. (1999). Treatment of Depression during Pregnancy. Journal of Women’s Health & Gender-Based Medicine. 8 (5), 7.
Lake, P. (2009). Psychiatric Medications During Pregnancy. Postgraduate Obstetrics & Gynecology. 29 (11), 1-7.
Lamberg, L. (2005). Risks and Benefits Key to Psychotropic use during Pregnancy and Postpartum Period. JAMA: Journal of the American Medical Association, 294 (13),1604-1608.
Manber, R., Blasey, C., & Allen, J. (2008). Depression Symptoms During Pregnancy. Archives of Women’s Mental Health, 11 (1), 43-48.
Mulcahy, N. (2003). Bupropion Appears Safe in Pregnant Women: not linked to Increase in Major Fetal Dejects: First Study in Pregnancy. Bnet. Web.
Moyer, P. (2006). Pregnant Women on Lamotrigine Have Greater Risk of Seizures When Drug Levels are Low: Presented at AES. Doctor’s Guide. Web.
O’Keane, V., & Marsh, M. (2007). Depression during Pregnancy. BMJ: British Medical Journal, 334 (7601),1003-1005.
Poblano, A., Belmont, A., Sosa, J., Ibarra, J., Rosas, Y., Lopez, V. & Garza, S. (2002). Effects of Prenatal Exposure to Carbamazepine on Brainstem Auditory Evoked Potentials in Infants of Epileptic Mothers. Journal of Child Neurology, 17 (5), 364-368.
Schmiege, S., & Russo, N. (2005). Depression and Unwanted First Pregnancy: Longitudinal Cohort Study. BMJ: British Medical Journal, 331 (7528),1303-1306.
Suppaseemanont, W. (2006). Depression in Pregnancy: Drug Safety and Nursing Management. The American Journal of Maternal / Child Nursing. 31(1), 10-15.
Yonkers, K., Little, B. & March, D. (1998). CNS Drugs, 9 (4), 261-269.