Antidepressants and Pregnancy, So whats the big deal?

Antidepressants and Pregnancy, So Whats the Big Deal?

Jessica Listman-Ward
Frostburg State University

Antidepressants and Pregnancy, So whats the big deal?

Antidepressants and Pregnancy, So Whats the Big Deal?
Introduction
Depression is on the rise in todays society. According to the CDC 1 in 10 adults suffers from
depression, and it is twice as likely for women than men (CDC, 2011). This is a significant amount of
people. Many physicians are using antidepressants to help treat these adults. With depression on the
rise there needs to be additional research into the safety of the medications we are prescribing. There is
not enough information on medications and how they interact with a pregnancy.
This is a four part research paper that will begin to look at antidepressants and pregnancy
together. This paper will begin with looking at a research question in two ways, the scientific method
and the PICO method. The scientific method uses a hypothesis and variables to answer a research
question. Most often this is the one that people are familiar with. The PICO method is a way of looking
at the same research in a similar way. P stands for the population that will be looked at during the
research. I stands for the intervention that will help the population. C is the comparison and O stands
for outcome, or what you wish to see from the experiment (Schmidt &Brown, 2009, p. 70). This is
followed by scholarly articles, websites and current evidence based practice (EBP) on the topic. This
includes two general website and a general article, two scholarly articles and two scholarly websites,
and one EBP source. The last part consists of reviewing the literature and making practice
recommendations.
Part One
Research Question
Depression rates among Americans are steadily increasing. Women have been identified as the
most vulnerable for depression. There is little research done with effects of medication to women or to

Antidepressants and Pregnancy, So whats the big deal?

children. The rate of depression among childbearing women is increasing rapidly (CDC, 2011). With that
in mind, is it safe to stop or change antidepressants during pregnancy?
Problem Statement
It is common knowledge that medications do affect the developing fetus. We do not need to
put women and their unborn children at risk to learn this. If medications have side effects on a woman
who isnt pregnant, we can safely assume that it will for a child. Do the benefits of antidepressant
therapy outweigh the risks to the developing fetus?
Purpose Statement
The purpose of this study is to determine how safe antidepressants are for pregnant mothers.
We need to know if there are medications that are safer to give a pregnant mother that will still help
treat her depression.
Hypothesis
Working closely with your OB/GYN and discussing all options will help pregnant mothers decide
if it is safe to continue antidepressant treatment. The benefits of antidepressant therapy do outweigh
the risks to the fetus.
Independent variable: education from OB/GYN, educating mothers
Dependent variable: depression
Part Two
PICO
In pregnant women does the use of educational programs, supplements and one on one
teaching about antidepressants and treatment with an OB/GYN at the initial prenatal and following visits
help decrease the risk to the developing fetus?

Antidepressants and Pregnancy, So whats the big deal?

Part Three
General Article
General articles are those found in magazines or newspapers that everyone reads. The
particular article that I found was published in USA Today. It was written Karen Weintraub who is a
general staff writer for the magazine that comes out in the Sunday paper. It is written in laymen terms
so that everyone can understand the article.
The article discusses a study that was done by a group of OB/GYN practitioners. While it does
not present any information about specific antidepressant medications, it does present some excellent
points. Ideally we would like to have the answers for patients on how safe medications are for them,
especially when a woman is pregnant. Ethically this is out of the question. It is hard to foresee any
woman placing herself or her unborn child at risk for the sake of science. Most women wouldnt
willingly do so.
As a result, the article makes note that most of what we do know is based on studies done on
laboratory animals. There have also been studies done with men and how medications affect them. We
know that there is a difference between men and women so we cant assume that the side effects for
each will be the same. This article shows that there is a difference in medications on a woman who is
not pregnant and one that is pregnant (Weintraub, 2013, p. 5). With this in mind we need to inform
women to have a good conversation with their doctor prior to pregnancy to see if there are medications
that they should be taking in the event that they do become pregnant. Educating patients ahead of time
is a simple way of protecting the fetus. Just as we educate patients prior to and after a surgical
procedure, we need to education women in childbearing years. The more knowledgeable they are, the
better the decision.

Antidepressants and Pregnancy, So whats the big deal?

This article only briefly mentions the study done by the OB/GYN practitioners. It does provide a
good overview of the need for prenatal education, but it does not go into great detail about why. This
would not make a good primary source. I would reference the study that was published in Human
Reproduction, and then refer to the USA Today article for basic information only. I do believe that this
article is a good general read. It is a good example of a secondary source, since it can be considered a
review of the study (Schmidt & Brown, 2009, p. 79). It does not appear to have any contradictory
information. Most people do not take the time to do additional research, but rather they chose to
believe what they see on talk shows or in printed articles like this one. This article does support the
concept of the 5 Ss. This article is a traditional literature review, since it supports a particular point
(Schmidt & Brown, 2009, p. 241). The article also acts as a summary, since it provides a simple to the
point explanation on the original study (Schmidt & Brown, 2009, p. 243).
Scholarly Articles
The first scholarly article that I found during my research was Antidepressant Use During
Pregnancy: Current Controversies and Treatment Strategies. This is a peer reviewed article that was
published in the medical journal Clinical Obstetrics Gynecology. I was able to find this article through
the search engine EBSCO host. When looking for articles directly related to what I wanted it became
difficult. You can find numerous articles on depression and pregnancy, but it is harder to find articles
that link them both together. I discovered that most articles talk about post-partum pregnancy. I had to
weed through the articles and specify my search requirements. After that I was able to find articles
directly related to what I needed. This article discusses weighing the risks and benefits to using
antidepressants during pregnancy.
This article was linked to the NIH website and funded by the government. While this may mean
that it presents some bias, the information that is included in the article is useful for physicians and their
patients. It is a good example of a primary source since it is the original article that was published

Antidepressants and Pregnancy, So whats the big deal?

(Schmidt & Brown, 2009, p. 79). It isnt based on the research of others. The original article that I found
was written by two doctors who work in perinatal medicine. This article does provide great guidance to
medical professionals about the use of antidepressants during pregnancy. The article supports the
concept of propositional knowledge since it comes from a research study (Schmidt & Brown, 2009, p.
235). In addition this article supports the pyramid of evidence because it is a study (Schmidt & Brown,
2009, p. 236).
The second article is based on a study done on infants whose mothers used SSRI antidepressants
during pregnancy. The article Study Links SSRI Use and Neonatal Heart Defects was published in The
American Journal of Nursing. Unlike the other scholarly article that I found, this one is written from the
perspective of nurses. The article is written by Tammy Worth a nurse who has been publishing clinical
articles in perinatal nursing for over 10 years. This article discusses the trends that nurses have seen in
infants that had mothers taking SSRI antidepressants during pregnancy. This article serves as a primary
source since it is a direct account (Schmidt & Brown, 2009, p. 79). It also supports the idea of
propositional knowledge and represents the study portion of the evidence pyramid. The article does
find a direct link between maternal SSRI use and neonatal heart defects (Worth, 2010, p. 20). It suggests
that women who are pregnant or trying to get pregnant discuss the options with their doctor. If they
are currently on an SSRI they should switch to another type of antidepressant.
General Websites
I found the website articles by Googling pregnancy and depression. After pulling up those
webpages I was able to narrow the sites down to those that discussed antidepressant medications
during pregnancy. The first website I found had great information about pregnancy. It discusses the
changes a woman can expect during pregnancy and medications in general. After talking about basic
information it discusses common medication issues, one of them being antidepressants.

Antidepressants and Pregnancy, So whats the big deal?

The Mayo Clinic website offered great information about using antidepressants during
pregnancy. The article which was compiled by the staff of the Mayo Clinic breaks down pregnancy by
each trimester. It lists the potential risks to the fetus throughout each of the three trimesters. The
article also discusses lifestyle changes that may help with depression. It suggests that women speak
honestly with their OB/GYN during appointments, and that it is normal to have some sense of anxiety
during pregnancy (Mayo Clinic, 2012). If women feel helpless and lost during pregnancy additional
medications may be added to their regimen. The website strongly suggests discussing all medications
with your doctor before starting, changing or stopping any medications, especially antidepressants
(Mayo Clinic, 2012).
For someone who isnt in the medical field the website is easy to navigate. It is quick to find the
information regarding pregnancy and antidepressant use. The quality of the information is good. It is a
website that can be trusted since it is a reputable site. It isnt a homemade site with personal
information on it. The site also provides additional links to allow the user to research the information
further. Some of the links are the journal articles that I found when doing my own research. The site
acts as a summary in the 5 Ss of evidence (Schmidt & Brown, 2009, p. 243). Overall, I think that this site
is a good source for someone looking to gain additional information on depression during pregnancy.
The second website I used was WebMD.com. This site was similar to the Mayo Clinic one. It
offered great information on how to manage preexisting conditions during pregnancy. One of which is
depression. The article was written by Kathleen Doheny a staff writer for the website. It was reviewed
by Brunilda Nazario, MD. She is an obstetrician who practices in Massachusetts.
The article discusses how antidepressants have been linked to stillborn births and newborn
deaths (Doheny, 2013). When looking at the risks versus the benefits, Im not sure that a mother would
risk death to her child by taking an antidepressant. The article focuses on how dangerous SSRIs can be

Antidepressants and Pregnancy, So whats the big deal?

during pregnancy. It recommends discussing the pros and cons of the medication with a doctor before
continuing it during pregnancy (Doheny, 2013). The article followed a study of women taking SSRIs
from 1996-2007. There was an increase in stillborn births for women on SSRI are compared to those
who werent on the medication. Women taking SSRIs had 4.62 for every 1,000 births compared to
3.69 per 1,000 for women not on drugs (Doheny, 2013). Those taking an SSRI antidepressant have an
increased risk of their child dying before the age of one. With this in mind a proper discussion of all the
medications needs to take place with their doctor.
This article was a great source of information. It once again shows that there are
antidepressants that arent safe for a woman to be taking during pregnancy. It is always important for
women to discuss all medications with their doctors when they are planning to become pregnant or are
pregnant. Since this website article is a compilation of many studies it is a secondary source (Schmidt &
Brown, 2009, p. 79).
Scholarly Websites
The two scholarly websites that I have chosen for my research are www.ncbi.nlm.nih.gov and
www.biomedcentral.com. Both websites can be found through Google Scholars web search. These
sites offer excellent information on the use of antidepressants during pregnancy. Since they are
scholarly websites they have information that has been checked several medical professionals.
Therefore when people read information off of these sites, particularly the information on
antidepressants during pregnancy, they can rest assured that the information is truthful and accurate.
The first website is the NIH website. It is a government based website. The article that I found
was written by three perinatal doctors from Massachusetts. The article is backed by the University of
Massachusetts Medical School. It was published in a printed version and online in the version that I
found through the NIH website. Both are scholarly sources.

Antidepressants and Pregnancy, So whats the big deal?

The study focused on the impact of the medications on infants immediately after birth. The
study had three main goals i) review the risks of untreated depression and anxiety, ii) review the
literature on risks of exposure to antidepressants during pregnancy, iii) discuss the strengths and
weaknesses of the different study designs used to evaluate those risks (Byatt et al., 2012, p. 95). The
study shows the infants are exposed to antidepressants in utero and have trouble adjusting after birth.
Postnatal adaptation syndrome (PNAS) did occur in a small portion (30%) of the infants that were
studied (Byatt et at., 2012, p. 100). This means that those infants had a hard time adjust to life after
birth since they became used to having antidepressants in their system. In addition the study also
showed that persistent pulmonary hypertension (PPHN) occurred in infants that had mothers taking
antidepressants (Byatt et al., 2012, p. 102). The article recommends that no woman go without
treatment for depression. In addition, it is vital to have a careful discussion, tailored to each patient,
which incorporates the evidence to date (Byatt et al., 2012, p. 113). This source is a primary one and it
follows the 5 Ss. It falls under the first S, which is study (Schmidt & Brown, 2009, p. 236). It is a valid
source and study which backs the idea that not all antidepressants are safe during pregnancy.
The second article was written by a group of doctors from the Netherlands. This article focuses
on what general practitioners (GPs) and pharmacists should know about antidepressant use for
pregnant mothers. It is published on the BioMed website so it is easy to find. The only thing that I dont
like is that one of the contributing doctors works for a pharmaceutical company. This means that there
may be some bias in the information. While this study focuses on pregnant women in the Netherlands
the information can still be used elsewhere around the world. In the Netherlands 2% of all pregnant
women are exposed to antidepressants (Ververs et al., 2009). They have identified the risks associated
with the use of antidepressants. The article is a peer reviewed article that is backed by medical
professionals and organizations. It is a study so it qualifies for the 5 Ss of evidence. In addition it is also
a primary source. It includes qualitative data.

Antidepressants and Pregnancy, So whats the big deal?

Evidence Based Practice Source
The evidence based practice source that I have found involves the use of dietary supplements to
treat depression. It focuses on depression during pregnancy and postnatal. I was able to find it through
the EBSCO host search engine. I was able to use the Cochrane approach to find the article. This is a
peer reviewed source that is used by medical professionals. It provides access to reviews and trials
(Schmidt & Brown, 2009, p. 321). The study suggests that there may be a link between dietary
supplements and a decrease in depression.
The article was written by a group of perinatal doctors who have spent several years researching
pregnancy related depression. The article is a primary source that is a case study. It asks the question of
how dietary supplements can prevent and help with depression. The research suggests that there is a
link between dietary deficiencies and depression in pregnant women. The article is valid and supports
evidence based practice.
Part Four
Three Practice Recommendations
1. Patients who are planning to get pregnant and have a history of depression should
discuss this with their primary care and OB/GYN doctors.
2. There needs to be further research done regarding the use of dietary supplements
over antidepressants during pregnancy. There is not enough information regarding
the safety of these for pregnant women.
3. There needs to be further follow up on the effects of antidepressants on pregnant
women and their fetuses.
Practice Recommendations Supporting Literature
Patients need to discuss their family and personal history at length with their doctor to
determine which form of treatment and medication is best. If a patient is planning on getting

Antidepressants and Pregnancy, So whats the big deal?

pregnant and is currently on medication for depression this conversation needs to occur as soon
as possible. It can be dangerous to stop or immediately change a medication, and so a slow
taper from one medication to another may need to be done. As we have learned from the SSRI
studies, these are particularly dangerous for pregnant women to take. These medications cant
be stopped abruptly. If a woman is taking an SSRI, then a change must take place prior to the
pregnancy. We need to try and prevent and damage that can occur to the fetus during the first
trimester.
Depression is on the rise in North America. It is estimated that 10% of the perinatal
population has experienced depression prior to pregnancy (Payne, J.L. & Meltzer-Brody, S.,
2009, p. 470). Patients need to be more proactive in discussing their medications with doctors.
Treating depression during pregnancy can be challenging. The choice to continue with the
current treatment, or to change to another must be looked at in terms of the exposure to the
fetus (Payne, J.L. & Meltzer-Brody, S., 2009, 472). Current research shows that there is a link
between maternal depression and the preterm births. Premature babies are at risk for
developmental delays and extended stays in the NICU. If we can avoid this, by having a
conversation prior to pregnancy and changing medications, than it is best to do so.
Whenever possible it is always better to avoid medications during pregnancy. New
studies show that there may be a link between depression and dietary deficiencies. Diets
lacking in certain vitamins, minerals or other nutrients may cause depression in some women
(Miller et al., 2013, p. 1). We have seen a trend in dietary deficiencies and disorders. We know
that diets that lack Vitamin D can cause osteoporosis. With this in mind, it only makes sense
that these deficiencies may be linked to diseases like depression. The study shows that omega-3
fatty acids, iron, folate, vitamin B12, vitamin D and calcium could be what are lacking in the diet

Antidepressants and Pregnancy, So whats the big deal?

(Miller et al., 2013, p. 10). While there is no doubt that people have dietary deficiencies, this is
the only study that looks at the link to depression. Since this is new research we need further
proof before we can safely say that there is direct link.
There seems to be little follow up with the potential risks to newborns. We know the
risks to adults taking medications. There is not enough research on what the long term effects
can be to a child who was born to a mother being treated for depression. The majority of the
studies that I have found only follow newborns from birth to one year of age. We do not know
if any of these medications can cause long term damage to children after one year. In fact the
research itself states, more research is needed to account for all safety issues (Ververs et al.,
2009).
GRADE Ranking
GRADE is a way to rate research that may soon become universally accepted. It stands
for Grades of Recommendations, Assessment, Development, and Evaluation (Schmidt &Brown,
2009, p. 322). It is a way of appraising information for its clinical significance. It ranks the
strength and quality of the research into high, moderate, low, and very low (Schmidt & Brown,
2009, p. 322). In addition it also states whether or not the recommendation is strong or weak.
The GRADE rankings for the three practice recommendations are:
1. Strong, high
2. Strong, low
3. Strong, high
Summary
There is not enough consistent information to show that antidepressants are safe during
pregnancy. It seems that there are some that are safer than others. Women need to weigh the

Antidepressants and Pregnancy, So whats the big deal?

risks and the benefits to make a decision. They need to work closely with their primary care and
OB/GYN to ensure their safety and the safety of their developing fetus. Once the patient is
educated it is up to them to make their own decision. In general medications during pregnancy
should be avoided, but when there is a risk to a mother they are unavoidable. Proper education
and preparation can help reduce the risk to both the mother and the fetus.

Antidepressants and Pregnancy, So whats the big deal?

References

Byatt, N. Deligiannidis, K. & Freeman, M. (2012). Antidepressant Use in Pregnancy. NCBI.

Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23240634
Doheny, K. (2013). Antidepressants During Pregnancy: Safe? WebMD. Retrieved from
http://www.webmd.com/baby/news/20121228/antidepressants-pregnancy
Miller, B., Murray L., Kent, T., & Macfarlane, B. (n.d.). Dietary supplements for preventing
Depression. Retrieved from http://summaries.cochrane.org/CDC009104/dietarySupplements-for-preventing-depression
N.A. (2011). Depression Statistics. Centers of Disease Control and Prevention. Retrieved
from http://www.cdc.gov/features/dsdepression/
Payne, J.L., & Meltzer-Brody, S. (2009). Antidepressant Use During Pregnancy: Current
Controversies and Treatment Strategies. Clinical Obstetrics Gynecology, 52(3), 469-482.
Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719677
Schmidt, N.A., & Brown, J.M. (2009). Evidence-based practice for nurses: appraisal and
application of research. Sudbury, MA: Jones and Bartlett Publishers.
Staff. (2012). Antidepressants: Safe during pregnancy?. Mayo Clinic. Retrieved from
http://www.mayoclinic.com/health/antidepressants/
Ververs, T., Dijik, L., Yousofi, S. Schobben, F., & Visser, G. (2009). Depression during
pregnancy: views on antidepressant use and information sources of general
practitioners and pharmacists. BMC Health Services Research. Retrieved from
http://www.biomedcentral.com/1472-6963/9/119/abstract
Weintraub, K. (2012). Antidepressants and pregnancy: New review finds a risk. USA Today.
Retrieved from http://www.usatoday.com/story/news/nation/2012/10/31/pregnancyAntidepressants/1669595/
Worth, T. (2010). Study Links SSRI Use and Neonatal Heart Defects. The American Journal of
Nursing, 110(1), 20-21.