Beyond the baby blues

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Do antidepressants in pregnancy pose a real risk to the fetus? A Sunnybrook psychiatrist is researching this and other issues

The patient is newly pregnant and feeling restless or moody. She may be sleeping more, her appetite has changed and she has been feeling exhausted more often. Unexplained aches and pains start to appear in various places.

In the past, these typical symptoms may have been written off as simply the "baby blues." But while they are all common symptoms of the first few months of pregnancy, they are also possible indicators of antenatal depression.

"It's often difficult to diagnose depression during pregnancy because many of the physical symptoms often mimic pregnancy itself," says Dr. Sophie Grigoriadis, a psychiatrist at Sunnybrook's Women's Mood and Anxiety Clinic: Reproductive Transitions.

It's also more common than is generally thought. Nearly 13 per cent of women experience major depression while pregnant, and up to 18 per cent experience a depressive disorder of some kind. While public awareness about postpartum depression has made gains in the past few years, says Dr. Grigoriadis, achieving the same for mood disorders during pregnancy – and easing the stigma that surrounds it – still has a way to go.

"People often think that pregnancy is a great time of excitement and joy, and a large number of women do experience that," she says. "But, for some women, it's not, and it's important to acknowledge it. It can be confusing for them, because they start to worry even more that they're not loving this the way they're told they should."

She recounts the experience of one patient, a high-functioning lawyer who had developed some symptoms of depression early on during a pregnancy, but decided not to pursue treatment. "When she had the baby, she just hit rock-bottom. She didn't want to take care of herself … had no interest in the baby. At the same time, she thought herself a horrific mother," says Dr. Grigoriadis, describing the cyclical feelings of apathy and guilt that often present themselves in antenatal and postpartum depression. Eventually realizing she needed help, she sought out Dr. Grigoriadis. Through a combination of psychotherapy and medication, she improved over time, though there were post-pregnancy issues that still had to be dealt with: Had leaving her depression untreated negatively affected the early development of her child? Might things have been different had she taken medication during her pregnancy?

SAFETY FIRST

It's questions like these that prompted Sunnybrook to establish the Women's Mood and Anxiety Clinic: Reproductive Transitions in 2011. While the clinic acts as a resource centre and research program for mood disorders across a woman's reproductive life span, much of its research is focused on pregnancy and the complex decisions that arise around the treatment of mood disorders before and after childbirth. One of Dr. Grigoriadis's primary research interests, for example, has been the complex – and controversial – question around the safety of taking antidepressant medications while pregnant.

In 2005 the drug manufacturer GlaxoSmithKline published a study on the effects of taking Paxil during pregnancy, concluding that infants exposed to the antidepressant medication were at risk of congenital heart defects. The U.S. Food and Drug Administration and Health
Canada followed suit with public warnings about the drug soon after, along with a few other selective serotonin reuptake inhibitor (SSRI) medications,  sparking concern among the medical community and its patients about the safety of taking antidepressants during pregnancy.

"It was difficult to tease apart the literature, because there was contradictory evidence," says Dr. Grigoriadis, who notes that similar studies published since 2005 offered wildly conflicting conclusions, making treatment decisions for doctors difficult. Part of the reason for this is that clinical trials of such drugs aren't performed on pregnant women for ethical reasons. They're often population studies and surveys conducted after birth.

Since then, Dr. Grigoriadis has set out to sift the results. She has been collating the outcomes of a wide range of antidepressant and pregnancy studies and assessing the quality of the studies themselves, along with colleagues from a range of institutions such as the University Health Network, Women's College Hospital, Centre for Addiction and Mental Health and the University of Toronto (where she also teaches).

"We wanted to see if they used randomized methods or not, or control groups or not. For example, a lot of papers did not control for things like other psychotropic medications, alcohol, cigarettes or drugs. When you do that, you can't tease apart A from B."

Her recent efforts, published in the Journal of Clinical Psychiatry in April 2013 and the British Medical Journal last January, found cases for both sides of the debate. SSRI medications did pose slight risks of cardiovascular malformations, or pulmonary hypertension (a lung condition) to the fetus if taken late-term, but it was also found that untreated depression had effects on pregnancy, too, from premature delivery to problems with breastfeeding initiation.

"We embarked on this to make sense of the data," says Dr. Grigoriadis, "but we're also making a reference guide that highlights key findings for doctors to use when talking to their patients. These papers were the preliminary steps – ultimately it's important to ensure women have access to all the relevant information." Her team is currently piloting a version of it with local physicians. They hope to have it ready for nationwide use by next year.

This content was produced by The Globe and Mail's advertising department, in consultation with Sunnybrook. The Globe's editorial department was not involved in its creation.