Making Decisions About Antidepressant Treatment in Pregnancy

Abstract

Depression is a common complication of pregnancy and is estimated to affect 9.2% of pregnant women in highincome countries, according to a 2017 meta-analysis. 1 Prenatal depression is associated with negative outcomes, including elevated risk of postpartum depression and chronic mental illness in women, preterm birth and other perinatal complications, and child developmental, social, and behavioral problems. 2 As such, treatment of depression in pregnancy is a priority for affected women, their children, and their families. Psychotherapies may be effective to treat depression of mild and moderate severity; however, antidepressants may be required to effectively treat more severe depression or when therapy does not lead to remission. 3 Therefore, the short-term and longterm outcomes of fetal exposure to antidepressant medications must be considered.In this issue of JAMA, Christensen et al 4 present a population-based cohort study that evaluated the association between maternal antidepressant prescriptions filled during pregnancy and standardized language and mathematics test scores of Danish school-aged children assessed at ages 7 to 17 years. Among 575 369 children, 10 198 (1.8%) were born to mothers who filled an antidepressant prescription during pregnancy. After controlling for several key confounders, no statistically significant association was found between maternal prescription fills for antidepressant medication (assumed to represent in utero antidepressant exposure) and child standardized language scores (on a 100-point scale, mean score among children with maternal antidepressant prescription fills, 53.4; mean score among children without maternal antidepressant prescription fills, 56.6; adjusted difference, −0.1 [95% CI, −0.6 to 0.3]). 4 A small statistically significant absolute difference was found for standardized mathematics scores among children with maternal antidepressant prescriptions fills, compared with children without maternal antidepressant prescription fills (mean scores, 52.1 vs 57.4, respectively; adjusted difference, −2.2 [95% CI, −2.7 to −1.6]). 4 The authors suggest that the small difference in mathematics scores "unlikely represents a clinically relevant" finding and recommend that any concerns about the small absolute differences in standardized mathematics scores should be weighed against the clinical benefits of treating maternal depression in pregnancy. 4 A substantial amount of research has focused on antidepressants in pregnancy, especially in the last decade. [5][6][7] Randomized clinical trials on the use of antidepressants in pregnancy cannot be conducted because of ethical consider-

Perinatal mental health and COVID-19: Navigating a way forward

“…Psychotherapy is often effective in depression of mild and moderate severity, but antidepressants may be required in more severe depression or when therapy does not lead to remission. This is already a complex decision for patients and clinicians in balancing potential benefits and harms in each individual situation ( Brown and Vigod, 2021 ) and will need to also include the additional risks of untreated or undertreated illness during pandemic and post-pandemic situations.…”