By KJ DELL’ANTONIA
A study published in the British Medical Journal this week provides stronger evidence that taking some antidepressants during pregnancy doubles the risk of a baby developing pulmonary hypertension. Researchers have long suspected a link between the use of selective serotonin reuptake inhibitors, or SSRIs, and the condition, but previous studies have been small and inconclusive (with results ranging from there being no link to a six times greater risk).
This research, based on 1.6 million births in Denmark, Finland, Iceland, Norway or Sweden from 1996 to 2007, showed that among women using SSRIs, the risk of persistent pulmonary hypertension for infants more than doubled (particularly for use late in pregnancy). It’s still a small risk: 3 in 1000 births, as opposed to 1.2 per 1000 births overall. But it’s a small risk of a serious problem.
Pulmonary hypertension, Dr. Juliette Madan, a pediatrician at the Dartmouth Hitchcock Medical Center explained, is diagnosed when an infant struggles to get enough oxygen into her lungs, and therefore into her bloodstream. The condition can be deadly, although Dr. Madan said that it’s usually treatable — with possible lifelong consequences.
But other research suggests that untreated depression during pregnancy has its own risks, including pre-term birth and low birth weight. Given that, how should a pregnant woman and her doctor weigh the competing risks?
The answer to that may depend on whom you’re talking to. Dr. Madan, who works in her hospital’s neonatal intensive care unit, said that from her perspective, some obstetricians may have less experience with the neonatal risks. “Their focus is the health of their patient for nine months,” she told me. Some women have no choice but to take medications during their pregnancy, but she worries that women who could possibly do something different aren’t getting enough information.
Dr. Ariela Frieder, a psychiatrist at Montefiore Medical Center who specializes in treating pregnant and postpartum women, has never had a patient whose infant was diagnosed with pulmonary hypertension. “I think this is a very good study,” she said, “but the problem is always that you cannot separate the risks of the severe depression itself with the risks of the medication. And the risks here are still small. Women who have lived with severe depression know how hard it is to live with.”
Dr. Frieder believes that her patients are the ones most capable of assessing the risks and benefits related to their own conditions. This work will affect how she counsels her patients, but not what she recommends. “You are always going to try to treat them first with psychotherapy,” she said. “But if they are severely depressed, they are going to need medication.”
The debate — internal and external — over the use of antidepressants during pregnancy has been around as long as antidepressants have been available, with research changing over time. “There’s not a one-size-fits-all answer,” Dr. Kimberly Yonkers, the lead author of a joint report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists told The New York Times in 2009, and that advice still stands. No generalizations apply. Treatment decisions must be made on a case-by-case basis.
A case-by-case basis that’s a new struggle for every patient, every time.