jeudi 4 juin 2015

Differing Views On Antidepressants During Pregnancy

Differing Views On Antidepressants During Pregnancy

The question of taking antidepressants during pregnancy is extremely intimate and complicated. Research studies evaluating the risks and benefits are mixed. There are documented harms, like an elevated risk of pre-term birth. But there are also the documented harms of untreated depression. In other words, it’s a deeply personal health decision that requires judgement based on a body of data that offers no easy answers.

The latest on this fraught debate comes from Andrew Solomon who wrote a long piece published in last Sunday’s New York Times Magazine, “The Secret Sadness,” with this basic message: “Pregnant women who are depressed often fear taking the medication they rely on. But not treating their depression can be just as dangerous.”

Pregnancy silhouette (Chris Martino/Flickr)

Solomon, whose own depression is well documented in his powerful book, “The Noonday Demon: An Atlas of Depression,” (The Times piece will be added as a new chapter in the book) begins the magazine article with an anecdote about Mary Guest, “a lively, accomplished 37-year-old woman” who “fell in love, became pregnant and married after a short courtship.”

Struggling with depression for much of her life, Mary took various antidepressant and anti-anxiety drugs, Solomon writes, but decided to discontinue the meds during pregnancy. But Mary’s mood and behavior “spiralled downward” so, “near the end of her fifth month of pregnancy, she finally, reluctantly, resumed taking an antidepressant,” he writes.

Then, at 6-and-a-half months pregnant, and convinced that something was wrong with her fetus, Mary “went to the 16th floor of the building where her parents lived and jumped to her death.” Solomon quotes Mary’s mother saying: “We feel, rightly or wrongly, that if Mary had stayed on her medications, or even gone back on them sooner, it’s possible she would have survived.”

It’s an intense and moving message.

But Dr. Adam Urato, an assistant professor at Tufts University School of Medicine in Boston and a Maternal-Fetal Medicine physician at Tufts Medical Center and MetroWest Medical Center in Framingham, Mass. says he’s got an important message too: that antidepressants can also cause harm. Urato writes and lectures on this topic frequently, and says he feels that Solomon’s piece didn’t offer the complete picture. (Here’s Urato’s full rebuttal to Solomon’s article on the website “Mad In America,” published by journalist Robert Whitaker.

Solomon quotes Urato in the Times story (in fact, some of the quotes come from a post Urato wrote for CommonHealth). But Urato says his views weren’t fully reflected. Here, edited are a few of Urato’s points:

1. Anecdotes Have Limitations

No one wants a pregnant woman to kill herself. An article in which pregnant women stop their medications and kill themselves while others continue on their meds and have happy outcomes is sure to push readers in an obvious direction. However, such anecdotes are limited.

For example, the author could have told stories of women who stayed on their medications, weren’t counseled regarding the risks, and had severely impaired babies.

Or women who stayed on their medications and increased the doses and then committed suicide.

Anecdotes can be powerful stories and emotionally sway readers. But for every anecdote supporting one viewpoint, there is another one to support some other viewpoint. That is why we need to be scientific and ask what exactly these medications are doing for the moms and the babies. For example, the scientific research does not support many of Andrew Solomon’s anecdotes. In the actual studies, the women who stay on their medications are more likely to have pregnancy complications (e.g. preterm birth, preeclampsia, and newborn complications) than the depressed women who do not take medications.

Even Solomon points out that antidepressants are associated with some negative health outcomes:

“They [antidepressants] heighten the risk of miscarriage, preterm birth and low birth weight. They cause a slight increase in the risk of a potentially serious lung condition in newborns called persistent pulmonary hypertension. Up to 30 percent of babies exposed in utero to S.S.R.I.s develop neonatal adaptation syndrome, which entails difficulty latching on for feeding, a tremor, a weak cry, respiratory distress and sometimes reflux and sneezing, though these symptoms usually go away within a few days. There have been occasional reports of seizures and of changed sleep patterns. There have also been some gross motor delays, with exposed babies not sitting up unassisted until 16 days later than babies in a control group, though this is still within the range of normal development, and the differences have vanished by the time the children are 19 months old.”

2. Chemicals And Consequences

I have been lecturing and writing on this topic for the past decade and one of the things that stands out most to me is that there is some public misunderstanding about the fact that the agents that we call “antidepressants” are actually synthetic chemical compounds that are made in large chemical factories. When pregnant moms take these drugs, these chemical compounds are going into the baby’s organs and affecting essential processes all throughout the baby and for the entire pregnancy. (Chemicals are everywhere, of course, but I’m talking specifically about synthetic chemical compounds here.)  But I think the key question is: “What exactly happens when these foreign chemicals are entering into the baby throughout development?”

This is a crucial question for the public and this is the question that we (the public, doctors, etc.) need answered. It seems absurd for us to think that there is no effect to the baby from exposure to these compounds.

I have communicated with Andrew Solomon by phone and email on this topic and I encouraged him to help advance the public discourse on this topic by using his article to talk about the “chemical” aspects of this problem. What exactly does happen when these chemicals are entering into the baby throughout development? While I don’t think it’s appropriate to quote my communications with him directly, I do feel comfortable saying that he gave me the impression that he wanted to get into this “chemical” area in this current essay but that the “chemical toxicity” aspect is considered too technical for New York Times readers.

3. The Diabetes Comparison

Many defenders of antidepressants like to use insulin and diabetes as a supporting example for the “helpful antidepressant model.”   (“You wouldn’t ever tell a pregnant diabetic not to take insulin would you?” )  But this example actually works against their argument.  I take care of pregnant diabetics on a daily basis and I can tell you both from first-hand experience and from what the scientific research studies show that proper treatment of diabetes with insulin leads to better pregnancy outcomes — and it is not hard to show this.  The treated diabetics do better with their pregnancy outcomes — they have fewer birth defects, less preeclampsia, etc.  The fact that we keep seeing the exact opposite with antidepressant use during pregnancy shows that the “helpful antidepressant model” above is broken.

4. Give Pregnant Moms The Facts

Depression during pregnancy can be a tremendous challenge for women, their families, and their medical providers. I take care of patients with depression during pregnancy on a daily basis and I can tell you, first hand, that it is heart wrenching and that I strongly believe that these women need excellent treatment and care. Part of that excellent treatment, I think, is getting these patients correct information so that they can make the best decisions about how to handle their depression.

But, while I strongly believe that the drugs cause harm, I don’t believe that a pregnant woman should be told that she should take a medication or that she should not take a medication. That is an individual choice and one that should be respected. What I do think such women need is an honest discussion about what the best available scientific evidence suggests are the risks, benefits, and alternatives to the various approaches. The woman should then decide what’s best for her (in consultation with her family, mental health providers, other medical providers, and others whom she chooses.) She should be supported in her decision (whatever it may be) and given the best care possible throughout her pregnancy and beyond.

The question of what long-term effects these drugs may have remains unclear. Solomon writes:

New research is looking at whether the drugs may have harmful longer-term consequences. S.S.R.I.s are still relatively new, so no one knows what effects exposure in utero may have on children as they grow up. Jay Gingrich, the Sackler Institute professor of clinical developmental psychobiology at Columbia, said the immediate postpartum effects of antidepressants about which clinicians such as Urato are concerned are usually insignificant. But the brain changes profoundly during fetal development and early childhood, and it changes profoundly again during adolescence and early adulthood. Gingrich, working with colleagues, exposed mice to S.S.R.I.s during the equivalent of the human third trimester of pregnancy and early infancy and found that they developed abnormalities not at the stage corresponding to human infancy but in adolescence. They showed reduced working memory, and therefore had problems with spatial tasks that mice not exposed to S.S.R.I.s solved easily.

A continuing and as yet unpublished study of mothers and children in Finland, on which Gingrich is consulting, is looking at whether these findings are echoed in adolescents exposed to S.S.R.I.s in utero. Gingrich feels there may be cause for concern. Lee Cohen of Harvard is undertaking a parallel study, hoping to chart what he calls “both the positive and negative effects” of prenatal exposure to drugs.

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