Prescribing antidepressants to depressed pregnant women

Dr Payne, director of the Women’s Mood Disorders Center and an associate professor of psychiatry and behavioral sciences at Johns Hopkins University, has written a commentary on the website of the American Psychiatric Association entitled “Yes or No: Prescribing Antidepressants to Pregnant Patients”.


Her main argument is summarized in the abstract of the article:

“Women and their physicians should compare the risk of exposure to medication — not with the risk of no exposure, but with the risks of exposure to maternal psychiatric illness, which are not benign for either mother or child.”

So if you take antidepressants, there may be some adverse effects from it (or not), but the alternative is depression, and that certainly is not a good option for either mother or child.

“From a purely clinical perspective, it is important not to overlook the risks of untreated maternal psychiatric illness to both the mother and child.”

It’s hard to disagree here. Dr Payne then goes through a number of recent articles published on the topic of antidepressant intake during pregnancy and adverse effects, and lists limitations and future directions. It’s an insightful overview and I recommend you to read the commentary.

A main limitation, however, is the strong and unwarranted assumption that at least the large majority of pregnant women actually do improve when taking antidepressants — which is not supported by evidence. I have actually found very little data on efficacy studies in pregnant women, and the ones I found have tiny samples (please do let me know if you know studies here, this is not my field of expertise). This means we must draw conclusions of how efficacious antidepressants are in pregnant women from research on other samples — and most of you will know that there is strong consensus in the field that antidepressants are only slightly more effective than placebo medication.

Kirsch et al. [1], for instance, meta-analyzed all conducted antidepressant drug trials registered with the FDA (not only the published ones, to work around publication bias), and found that antidepressants only outperform placebo in the upper end of the very severely depressed patients; on top of that, they show that “the increased benefit for extremely depressed patients seems attributable to a decrease in responsiveness to placebo, rather than an increase in responsiveness to medication” (p. 266). Similar results were obtained by other big studies from Pigott et al. [2] and Khan & Brown [3].

This somewhat questions the conclusion drawn by Dr Payne. If antidepressants — that can cause considerable adverse effects in depressed patients — do not substantially increase the likelihood that a pregnant woman remits from her depression compared to placebo, it is questionable whether the estimated 1% risk of a very severe complication (as mentioned in the commentary by Dr Payne) is worth taking.

  1. Kirsch, I., Deacon, B. J., Huedo-Medina, T. B., Scoboria, A., Moore, T. J., & Johnson, B. T. (2008). Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Medicine, 5(2), e45. doi:10.1371/journal.pmed.0050045
  2. Pigott, H. E., Leventhal, A. M., Alter, G. S., & Boren, J. J. (2010). Efficacy and effectiveness of antidepressants: current status of research. Psychotherapy and Psychosomatics, 79(5), 267–79. doi:10.1159/000318293
  3. Khan, A., & Brown, W. A. (2015). Antidepressants versus placebo in major depression : an overview. World Psychiatry, 14, 294–300. doi:10.1002/wps.20241

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