Weigh your options to treat depression during pregnancy
Q: I have been on SSRI medicines for depression for five years. I'm trying to get pregnant, and I hear that SSRIs might be dangerous. What do I need to know?
A: I love to receive questions that I can answer confidently. Yours is not one of them. The evidence from different studies is conflicting. Here's my best attempt to weigh the risks against the benefits.
Treating depression is important for both your sake and your baby's. Untreated depression during pregnancy increases your risk of postpartum depression. It also makes it more likely that your baby will be lethargic, irritable and underweight at birth.
But what kind of treatment?
Medication is one option. The selective serotonin reuptake inhibitors (SSRIs) are the most common drugs prescribed for depression. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), fluvoxamine (Luvox) and paroxetine (Paxil).
Another option is "talk therapy." This can be traditional one-on-one sessions with a therapist. It also can mean family therapy, involving you, your spouse and possibly other family members.
Cognitive behavioral therapy (CBT) is a particular talk-therapy technique that can help you learn ways to think positively and solve problems. Even if your doctor says you need to continue taking medication along with talk therapy, you may be able to lower your dose or reduce the length of time you need the medication.
You can also explore other non-drug options. For example, consider exercise (under your doctor's supervision) or mindfulness meditation to help manage your depression.
The question you're asking is whether the SSRIs pose a risk to your baby -- in particular, a risk of causing birth defects. I don't think such a risk has been proved beyond doubt. But I think studies suggest there may be a small but real risk from some SSRIs.
A large study was conducted by the U.S. Centers for Disease Control and Prevention and published in 2015. It involved nearly 30,000 babies. The study compared the medicines that babies with and babies without birth defects had been exposed to.
Most of the SSRIs, including the most commonly prescribed SSRI (sertraline), did not seem to be linked to birth defects. However, paroxetine and fluoxetine were. For those two SSRIs, the risk was small, but real.
The FDA, the American College of Obstetrics and Gynecology and the American Academy of Family Physicians have stated that paroxetine likely is unsafe in pregnancy.
Guidelines from the American Psychiatric Association and the American College of Obstetricians and Gynecologists recommend medication for expectant mothers with severe depression (except paroxetine). But for pregnant women with mild to moderate depression, they recommend psychotherapy.
Only your doctor can make specific recommendations for you. But my general advice is this: If in the years before pregnancy your depression has been severe, you will probably need medication along with talk therapy during the pregnancy.
In that case, the risk to you and your baby from not taking medication is probably greater than the risk of taking it.
• Dr. Komaroff is a physician and professor at Harvard Medical School. For questions, go to AskDoctorK.com.