Deciding the best course for pregnant women grappling with depression has long been a tricky and contentious issue, and the debate has once again kicked up.
According to a new review, pregnant women who take selective serotonin reuptake inhibitors (SSRIs) -- a popular type of antidepressants -- may have a greater risk of pregnancy complications, including birth defects, pre-term birth and miscarriage. But some mental health experts have panned the study, saying it overstates the risks of SSRIs and downplays their benefits in treating depression in pregnant women.
"There needs to be greater awareness of the scientific evidence regarding use of these drugs," study author Dr. Adam Urato, chairman of obstetrics and gynecology at MetroWest Medical Center in Massachusetts, told HuffPost.
He said the study was unfairly characterized as an attack on pregnant women taking SSRIs, since its publication in the journal Human Reproduction.
The new review used only studies evaluating depressed women who were taking antidepressants -- studies that have often been retrospective and relatively small. Many were conducted in animals, not humans.
Nonetheless, Urato said he still thinks the data documenting potential problems associated with SSRI use during pregnancy is "substantial." The problems include increased risk of miscarriage, birth defects, preterm birth, newborn behavioral syndrome, pulmonary hypertension of the baby, as well as longer-term neurobehavioral issues, the review states.
"The data is concerning, and it's growing as we do more and more studies," Urato said. "We would encourage transparency here. We would encourage readers to look at these studies."
The review also casts doubt on using SSRIs to better the outcome of a pregnancy, stating, "there is no evidence of improved pregnancy outcomes with antidepressant use.”
"One recurring argument against our paper is that depression itself leads to pregnancy complications -- [for example] stillbirth and preterm birth -- and antidepressants treat the depression, thus improving pregnancy outcomes," Urato said in a follow-up email to HuffPost.
"I am looking at my desk at the 41 studies that have looked at depression, SSRI use and preterm birth. The scientific studies in this area are very consistent. The group that has the high rates of preterm birth is the SSRI-treated group."
Alice Domar, executive director of the Domar Center for Mind/Body Health and an author of the study, said that women with a history of severe depression should consider being on antidepressants during their pregnancies. But for women with more mild to moderate depression, cognitive behavioral therapy (CBT), may be effective, she said.
"It bothers me that the assumption is that if a woman reports being sad, the automatic bias is to put her on medication," she said. "Especially if you look at the CBT research -- over and over again, it is shown to be good."
But Dr. Samantha Meltzer-Brody, director of the perinatal psychiatry program at the University of North Carolina at Chapel Hill, dismissed the notion that antidepressants are the standard recommendation for pregnant women with depressive symptoms.
The review fails to account for the "many, many risks" associated with untreated depression, particularly among women whose depression is severe, she said. Chief among those, she said, is the potential for self-harm.
In an email to HuffPost, Dr. Gail Robinson, director of the Women’s Mental Health Program at the University Health Network in Toronto, echoed those criticisms. She called the study methodologically flawed and claimed it "cherry picks" papers that support the authors' conclusion.
In a letter Robinson drafted to the editor of Human Reproduction, she explained that SSRI use in pregnancy is usually considered when women have moderate to severe depression.
"Prenatal depression can lead to missed obstetric appointments, poor diet and sleep, substance abuse and an increased risk of suicide," Robinson wrote. “As well, women with untreated depression during pregnancy have an increase in preterm births and low birth weight babies due to the depression itself."
In 2009, the American College of Obstetricians and Gynecologists (ACOG) and the American Psychiatric Association issued a joint report on treating women with depression during pregnancy. It found that women with mild or no symptoms for at least six months may want to taper or stop taking antidepressants before becoming pregnant, however, women with severe depression should continue taking medication. Overall, it concluded that the available research on antidepressant use during pregnancy has not adequately controlled for all the factors that can affect birth outcomes.
According to estimates cited in that report, between 14 and 23 percent of pregnant women will experience a depressive episode. Among other things, women with depression may feel hopeless, have difficulty concentrating and sleeping, and feel a loss of interest in activities they once enjoyed, according to the National Institute of Mental Health. Women with such symptoms should seek help right away.
Prozac, Celexa, Zoloft, Paxil and Lexapro are all SSRIs, which are considered the most popular type of antidepressant, according to the National Institute of Mental Health. Overall, females are two-and-a-half-times more likely to take antidepressants than men, according to the Centers for Disease Control and Prevention.