Editorial: Should we use SSRIs in pregnancy?

Between 3.1% and 4.9% of women experience major depression during pregnancy, and up to 15% of pregnant women have clinical depression of some sort.¹ Left untreated, 50% of women who are depressed during pregnancy will experience a postpartum exacerbation, which itself carries a 15% risk of attempted suicide.² Besides the psychological anguish a depressed mother feels, evidence suggests that if her condition goes untreated, her fetus may be at increased risk of prematurity, fetal growth restriction, stillbirth, and low Apgar scores.²

Psychotherapy appears to work well in the treatment of depressed patients, with one randomized clinical trial suggesting a 60% remission rate compared to 15.4% in a parenting education control group.³ Such therapy also appears to improve maternal-infant bonding. Unfortunately, the availability of practitioners trained in validated therapies for depression is quite limited, insurance coverage is frequently unavailable, and out-of-pocket expense can be significant. So, ob/gyns and mental health providers have increasingly turned to SSRIs to treat depressed pregnant patients. In general, these drugs have few side effects, are well tolerated and easy to administer, have high compliance rates, and are more effective than tricyclic antidepressants and monoamine oxidase (MAO) inhibitors. Initial reports suggested that SSRIs were safe and effective in pregnancy, with no discernable increased risk of adverse neonatal effects or teratogenicity.⁴

These reports seem to suggest that pregnant women should not be treated with SSRIs. But they must be balanced against another very recent report of a nearly 70% risk of relapse among previously depressed pregnant women after discontinuing antidepressants-chiefly SSRIs (see also Clinical Insights).⁶