Antidepressant use during pregnancy: How to avoid clinical and legal pitfalls

Discuss this article at www.facebook.com/CurrentPsychiatry

Recently there has been an increase in advertising soliciting participants for class-action lawsuits involving birth defects and antidepressants, particularly sertraline. Many psychiatrists are unsure why these ads are running in seemingly every medium because there has been no change in the FDA pregnancy classification for most selective serotonin reuptake inhibitors (SSRIs), except for paroxetine going from a C to a D rating in 2005.¹ Some studies have found SSRIs increase the risk of adverse birth outcomes and others have not, which makes it difficult for clinicians to know what to discuss with patients regarding the risks and benefits of using antidepressants during pregnancy, as well as the risks of untreated major depressive disorder (MDD).

It can be hard to encourage some patients to take necessary medications in the best of circumstances, let alone suggest that a pregnant woman take a medication that has been labeled “dangerous.” This article seeks to alleviate physicians’ fears about being caught in a no-win situation by:

• explaining factors that may have led to this increase in class-action lawsuits
  
• clarifying the risks of using certain medications and not treating depression
  
• suggesting ways physicians can protect themselves and their patients.
  

The FDA’s position

In July 2006, the FDA issued a public health advisory regarding SSRI use during pregnancy and the possibility of persistent pulmonary hypertension (PPHN).² This warning was based on a single study that found the risk of developing PPHN (baseline rate: 1 to 2 per 1,000 births) was 6 times greater for fetuses exposed to SSRIs in late pregnancy.³ Many legal websites highlight this 2006 warning as proof of SSRIs’ danger. However, because subsequent studies have had conflicting results, the FDA’s current position is that the risks of using SSRIs during pregnancy are “unknown” (Box).^1-4

Box

Risks of depression

Although most physicians know the risks of untreated MDD, they tend to minimize or forget these risks when a woman becomes pregnant. Pregnant women with MDD face not only the expected risks of their psychiatric illness but additionally face risks of pre-eclampsia, suicide (20% of deaths in the postpartum period are due to suicide), and infanticide.^5-10 Risks to the fetus include poor prenatal care, increased risk of intrauterine exposure to drugs or alcohol, increased exposure to maternal cortisol with resulting neurodevelopmental changes, preterm delivery, low birth weight, and failure to thrive.^6-8 Later difficulties for the child of a mother with untreated depression may include poor stress adaptation, decreased cognitive performance, and behavioral difficulties because of poor mother-child bonding and other factors.⁶

See Table 1 for key statistics regarding pregnancy and depression.

Table 1

Statistics on pregnancy and depression

There are approximately 6 million pregnancies each year in the United Statesa
There are approximately 4 million live births each year in the United Statesa
Two percent to 3% of healthy pregnancies result in a birth defect or miscarriageb-d
Sixty percent to 70% of birth complications occur due to an unknown caused
Rates of depression during pregnancy are 7% to 25%b,e,f
Approximately 13% of pregnant women take an antidepressant during pregnancye
Fifteen percent of women with untreated depression in pregnancy attempt suicideb
Twenty percent of deaths in the postpartum period are due to suicidee
Women who discontinue antidepressants are 5 times more likely than women who continue medications in pregnancy to have a relapse of depressiong,h
SSRIs are the antidepressant class most frequently prescribed to pregnant womeni
Sertraline is one of the most frequently prescribed antidepressants perinatally and has low concentration in breast milk and infant serumj,k
SSRIs: selective serotonin reuptake inhibitors American Pregnancy Association. Statistics. http://www.americanpregnancy.org/main/statistics.html. Accessed December 20, 2012. Hasser C, Brizendine L, Spielvogel A. SSRI use during pregnancy. Current Psychiatry. 2006;5(4):31-40. Altshuler L, Richards M, Yonkers K. Treating bipolar disorder during pregnancy. Current Psychiatry. 2003;2(7):14-26. Cott A, Wisner K. Psychiatric disorders during pregnancy. Internat Rev Psychiatry. 2003;15(3):217-230. Meltzer-Brody S. New insights into perinatal depression: pathogenesis and treatment during pregnancy and postpartum. Dialogues Clin Neurosci. 2011;13(1):89-100. Kieler H, Artama M, Engeland A, et al. Selective serotonin reuptake inhibitors during pregnancy and risk of persistent pulmonary hypertension in the newborn: population based cohort study from the five Nordic countries. BMJ. 2012;344:d8012. doi:10.1136/bmj.d801. U.S. Food and Drug Administration. Public health advisory: treatment challenges of depression in pregnancy and the possibility of persistent pulmonary hypertension in newborns. http://www.fda.gov/ Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders /DrugSafetyInformationforHeathcareProfessionals/PublicHealthAdvisories/ucm124348.htm. Published July 19, 2006. Accessed December 20, 2012. Cohen LS, Altshuler LL, Harlow BL, et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA. 2006;295(5):499-507. Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Gen Hosp Psychiatry. 2009;31(5):403-413. Berle JO, Spigset O. Antidepressant use during breastfeeding. Curr Womens Health Rev. 2011;7(1):28-34. Friedman SH, Nagle-Yang S, Parsons S. Maternal mental health in the neonatal intensive care unit. NeoReviews. 2011;12(2):e85-e93.

 

Limitations of research

Because of ethical difficulties in studying MDD treatment during pregnancy, most data are retrospective and prone to detection and confounding biases, such as^11-15:

• the risks associated with depression
  
• comorbid conditions such as obesity
  
• maternal age
  
• poor prenatal care
  
• how the baby was delivered (eg, Caesarean sections have higher rates of PPHN)¹³
  
• illicit substance use
  
• effects of other medications (80% of pregnant women use medications, including nonsteroidal anti-inflammatory drugs [NSAIDs], which are associated with PPHN).^11,16
  

No medication is 100% safe during pregnancy and all pregnancies have risks. In the United States, 2% to 3% of pregnancies produce infants with malformations,¹⁷ which makes it hard to determine if a defect is caused by a medication or occurred spontaneously. This is the baseline risk of all malformations; individual malformations are rare and it is difficult to conduct studies that have adequate power to demonstrate the risk for a specific malformation.

There are several potential adverse outcomes to consider when prescribing psychotropics to a pregnant woman, including miscarriage, malformation, preterm delivery, perinatal toxicity, and behavioral teratogenesis (Table 2).^6,7 SSRIs have been implicated in adverse outcomes, but there is no strong evidence that they increase the miscarriage rate, and several studies found no increase in birth defects.^6,13,18-20 Regarding teratogenesis, the FDA switched paroxetine from class C to class D because of a potential 1.5% to 2% risk of fetal cardiac malformation, compared with a 1% baseline rate in the general population.²¹ Drug toxicity or withdrawal in a neonate also is a risk; however, this condition is self-limited and managed supportively by neonatology.²² Behavioral teratogenesis—neurobehavioral problems that develop later in a child’s life—remains a hypothetical concern; research has been conflicting, and studies often used flawed methodology.

Evidence linking SSRIs to an increased risk of adverse birth outcomes often has been based on large, retrospective health system database cohort studies looking at SSRI exposure and associations with conditions such as PPHN, cardiac anomalies, attention-deficit/hyperactivity disorder, and autism.^10,23,24 However, correlation is not the same as causation. It is difficult to prove or disprove the causative factor of adverse outcomes in these studies because:

• these databases were not designed to answer these types of exposure questions (eg, limitations in data collected, such as other potential causes not recorded)
  
• they have many confounding biases (undocumented illicit substance use, possible minimization of smoking history, publication basis for positive findings, etc.)
  
• individuals who provided the data did not follow a standardized method (eg, variability among individual clinicians).
  

Many of these limitations are evident in a 2009 study by Pedersen et al,²³ who reported the prevalence of septal heart defects was 0.5% (2,315/493,113) among unexposed children and 0.9% (12/1,370) among children exposed to 1 SSRI during early pregnancy (odds ratio [OR]=1.99 [1.13 to 3.53]). Based on this study’s data, the number needed to harm—the number of patients you would need to treat to encounter 1 adverse outcome—was 246, which suggests a relatively low risk. When data for the entire study is reviewed, the ORs for either minor birth defects (control: 7,373/493,113 vs SSRI exposed: 39/1,370; OR=0.88 [0.54 to 1.41]) or major birth defects (control: 15,518/493,113 vs SSRI exposed: 55/1,370; OR 1.21 [0.91 to 1.62]) were not statistically significant (major and minor malformations were defined using European Surveillance of Congenital Anomalies coding).

Not to case aspersions on this group’s work, it should be noted that this study had limitations, including that the researchers:

• did not take into account SSRI dosage
  
• did not measure depression severity or remittance
  
• were not able to fully account for potential exposures (eg, over-the-counter NSAIDs)
  
• were unable to confirm that patients took their medications because the variable measured was prescriptions filled
  
• did not interview participants about their medication use or symptoms.
  

In addition, researchers noted that mothers who filled their antidepressant prescription at least twice also were likely to have other factors that put them at higher risk for having a child with birth defects—such as older age or smoking. The biggest problem with the study was a lack of a control group, such as depressed women who did not receive medication (eg, the risk of depression itself could explain the rise, or those with more severe depression could be prescribed antidepressants).¹⁵

In a more recent study,²⁴ 33 of 11,014 infants exposed to SSRIs after gestational week 20 developed PPHN (absolute risk: 3 per 1,000 births, compared with an incidence of 1.2 per 1,000 births in the general population), with an adjusted OR of 2.1 (95% CI 1.5 to 3.0). Although the authors warned that the results suggest a “class effect,” the rate of PPHN also was higher for mothers with a history of a psychiatric hospitalization within the last 10 years who were not taking medication (OR=1.3, 95% CI 1.0 to 1.6) and the OR for escitalopram (1.5, CI 0.2 to 10.5) was not statistically significant. This study did include a control group, but the 10-year window may have been too wide to represent a group with similar comorbid risks. Similar to the previously discussed study, mothers prescribed SSRIs were older, 1.7 times more likely to be smokers, and twice as likely to be prescribed NSAIDs. The study did not analyze the risk factors of smoking and body mass index because of an initial subset analysis (which was not reported) finding that these known risk factors for PPHN “did not confound the results.”²⁴

 

Table 2

Potential concerns when treating pregnant women with psychotropics

Miscarriage (spontaneous abortion)
Malformation (teratogenesis)
Preterm delivery
Perinatal syndrome (toxicity or withdrawal in neonate; usually self-limited and related to serotonin overstimulation or withdrawal; symptoms may include disrupted sleep irritability jitteriness or abnormal breathing)
Behavioral teratogenesis (later behavioral problems in child eg lower IQ developmental delays or autism)
Lactation compatibility or plans to bottle-feed
Source: References 6,7

The basis of class-action lawsuits

Interest in class-action lawsuits involving birth defects and antidepressants, particularly sertraline, appears to be increasing. Many websites advertising these lawsuits quote unnamed articles from reputable medical journals to support the claim that the medications are dangerous and cause a wide range of birth defects. Although some of the birth defects mentioned are specific, others (eg, “breathing problems” or “gastrointestinal side effects”) are so broad that any problem or complication could conceivably be attributed to the antidepressant. The degree of causation—if any at all—for many of these conditions has not been determined. A national advertising campaign looking for any problem may be occurring because the exact risks are “unknown.”¹

The 2009 U.S. Supreme Court ruling in Wyeth v Levine²⁵ allows individuals to sue manufacturers of branded medications in state and federal court for lack of proper labeling. However, the 2011 U.S. Supreme Court case of PLIVA, Inc. v Mensing²⁶ prohibits state lawsuits against manufacturers of generic medications over labeling because by federal (superseding) law, generic manufacturers must use the same warnings as the branded medication. This may in part explain why many medications targeted in commercials and websites for class-action lawsuits are branded products, even though generics are available.

The focus of these types of lawsuits has been on drug manufacturers, in part because of the success of past litigation. Past class- and single-action lawsuits involving birth defects against pharmaceutical companies, such as Richardson-Merrell Inc.—the manufacturer of thalidomide and Bendectin, the branded version of a combination of pyridoxine and doxylamine used to treat nausea and vomiting during pregnancy—were successful. Although limb defects with thalidomide were scientifically proven, Bendectin was never conclusively shown to cause birth defects even though it had been prescribed to 40% of pregnant women at one point. The legal theory behind the lawsuits is that the manufacturers should have done more research to determine the potential for birth defects.²⁷ In a case against SmithKline Beecham Corporation,²⁸ which makes Paxil, the branded version of the SSRI paroxetine, a jury found the manufacturer negligent for failing to warn about Paxil’s association with cardiac defects. The result was a $2.5 million jury verdict. Since that case, the manufacturer has settled >800 additional suits for >$1 billion. Because this risk of using paroxetine has been established, physicians should discuss this risk with their patients as part of an informed consent because they could be liable if they don’t.²¹ This legal concept is known as the “learned intermediary doctrine,” which states that once the risk is known, the intermediary (eg, the physician) is responsible to ensure that a product (eg, medication) is used appropriately. The 2011 FDA statement saying the risk for SSRIs during pregnancy is unknown¹ is important because it removes physicians as “learned intermediaries.”

Protect your patient and yourself

An estimated 13% of pregnant women take antidepressants; SSRIs are the most commonly used antidepressant during and after pregnancy.⁹ Although not every depressed pregnant woman requires medication, those with moderate to severe depression often do. Rational medication decisions, informed consent, and good documentation are important when treating these women. Discuss the risks of untreated illness as well as the risks of medications to ensure that the patient understands that avoiding medication does not guarantee a safe pregnancy. Suggest psychotherapy and electroconvulsive therapy as options when appropriate. When possible, include the patient’s partner and family in the discussion to help improve compliance and potentially reduce strife.²⁹ The psychiatrist or patient should discuss the medication plan with the patient’s obstetrician or family physician.

Whenever possible, consider using monotherapy, continuing a previously “successful” medication, and using the lowest effective dose.⁵ Clinicians may “underdose” medications because they believe this will lessen the risk from exposure, but this is risky because the fetus is still being exposed to the medication as well as the negative effects of undertreated MDD. If SSRIs are used throughout the pregnancy, the newborn may require additional observation to monitor for potential perinatal syndromes or PPHN.

 

^6,22

Many women become pregnant while being treated for depression. Approximately one-half of all pregnancies are unplanned, so women using antidepressants may unknowingly expose their fetus to medication.³⁰ For this reason, it is important to discuss potential pregnancy and birth control concerns with all women of childbearing age before initiating pharmacotherapy.³¹ If an unintended pregnancy occurs, tell your patient to contact you before stopping any medications. Lawsuits also can occur because of wrongful death by suicide or infanticide because of lack of treatment; risk of untreated illness should not be treated lightly.

Related Resources

• Motherisk. www.motherisk.org.
  
• Organization of Teratology Information Specialists. www.otispregnancy.org.
  
• Massachusetts General Hospital Center for Women’s Mental Health. www.womensmentalhealth.org.
  

Drug Brand Names

• Escitalopram • Lexapro
  
• Paroxetine • Paxil
  
• Sertraline • Zoloft
  

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Acknowledgments

The authors appreciate suggestions on prior versions of the manuscript from Miriam Rosenthal, Jaina Amin, Sarah Nagle-Yang, Sonal Moratschek, J.P. Shand, and Scott R. Miller.

Discuss this article at www.facebook.com/CurrentPsychiatry

Recently there has been an increase in advertising soliciting participants for class-action lawsuits involving birth defects and antidepressants, particularly sertraline. Many psychiatrists are unsure why these ads are running in seemingly every medium because there has been no change in the FDA pregnancy classification for most selective serotonin reuptake inhibitors (SSRIs), except for paroxetine going from a C to a D rating in 2005.¹ Some studies have found SSRIs increase the risk of adverse birth outcomes and others have not, which makes it difficult for clinicians to know what to discuss with patients regarding the risks and benefits of using antidepressants during pregnancy, as well as the risks of untreated major depressive disorder (MDD).

It can be hard to encourage some patients to take necessary medications in the best of circumstances, let alone suggest that a pregnant woman take a medication that has been labeled “dangerous.” This article seeks to alleviate physicians’ fears about being caught in a no-win situation by:

• explaining factors that may have led to this increase in class-action lawsuits
  
• clarifying the risks of using certain medications and not treating depression
  
• suggesting ways physicians can protect themselves and their patients.
  

The FDA’s position

In July 2006, the FDA issued a public health advisory regarding SSRI use during pregnancy and the possibility of persistent pulmonary hypertension (PPHN).² This warning was based on a single study that found the risk of developing PPHN (baseline rate: 1 to 2 per 1,000 births) was 6 times greater for fetuses exposed to SSRIs in late pregnancy.³ Many legal websites highlight this 2006 warning as proof of SSRIs’ danger. However, because subsequent studies have had conflicting results, the FDA’s current position is that the risks of using SSRIs during pregnancy are “unknown” (Box).^1-4

Box

Risks of depression

Although most physicians know the risks of untreated MDD, they tend to minimize or forget these risks when a woman becomes pregnant. Pregnant women with MDD face not only the expected risks of their psychiatric illness but additionally face risks of pre-eclampsia, suicide (20% of deaths in the postpartum period are due to suicide), and infanticide.^5-10 Risks to the fetus include poor prenatal care, increased risk of intrauterine exposure to drugs or alcohol, increased exposure to maternal cortisol with resulting neurodevelopmental changes, preterm delivery, low birth weight, and failure to thrive.^6-8 Later difficulties for the child of a mother with untreated depression may include poor stress adaptation, decreased cognitive performance, and behavioral difficulties because of poor mother-child bonding and other factors.⁶

See Table 1 for key statistics regarding pregnancy and depression.

Table 1

Statistics on pregnancy and depression

There are approximately 6 million pregnancies each year in the United Statesa
There are approximately 4 million live births each year in the United Statesa
Two percent to 3% of healthy pregnancies result in a birth defect or miscarriageb-d
Sixty percent to 70% of birth complications occur due to an unknown caused
Rates of depression during pregnancy are 7% to 25%b,e,f
Approximately 13% of pregnant women take an antidepressant during pregnancye
Fifteen percent of women with untreated depression in pregnancy attempt suicideb
Twenty percent of deaths in the postpartum period are due to suicidee
Women who discontinue antidepressants are 5 times more likely than women who continue medications in pregnancy to have a relapse of depressiong,h
SSRIs are the antidepressant class most frequently prescribed to pregnant womeni
Sertraline is one of the most frequently prescribed antidepressants perinatally and has low concentration in breast milk and infant serumj,k
SSRIs: selective serotonin reuptake inhibitors American Pregnancy Association. Statistics. http://www.americanpregnancy.org/main/statistics.html. Accessed December 20, 2012. Hasser C, Brizendine L, Spielvogel A. SSRI use during pregnancy. Current Psychiatry. 2006;5(4):31-40. Altshuler L, Richards M, Yonkers K. Treating bipolar disorder during pregnancy. Current Psychiatry. 2003;2(7):14-26. Cott A, Wisner K. Psychiatric disorders during pregnancy. Internat Rev Psychiatry. 2003;15(3):217-230. Meltzer-Brody S. New insights into perinatal depression: pathogenesis and treatment during pregnancy and postpartum. Dialogues Clin Neurosci. 2011;13(1):89-100. Kieler H, Artama M, Engeland A, et al. Selective serotonin reuptake inhibitors during pregnancy and risk of persistent pulmonary hypertension in the newborn: population based cohort study from the five Nordic countries. BMJ. 2012;344:d8012. doi:10.1136/bmj.d801. U.S. Food and Drug Administration. Public health advisory: treatment challenges of depression in pregnancy and the possibility of persistent pulmonary hypertension in newborns. http://www.fda.gov/ Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders /DrugSafetyInformationforHeathcareProfessionals/PublicHealthAdvisories/ucm124348.htm. Published July 19, 2006. Accessed December 20, 2012. Cohen LS, Altshuler LL, Harlow BL, et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA. 2006;295(5):499-507. Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Gen Hosp Psychiatry. 2009;31(5):403-413. Berle JO, Spigset O. Antidepressant use during breastfeeding. Curr Womens Health Rev. 2011;7(1):28-34. Friedman SH, Nagle-Yang S, Parsons S. Maternal mental health in the neonatal intensive care unit. NeoReviews. 2011;12(2):e85-e93.

 

Limitations of research

Because of ethical difficulties in studying MDD treatment during pregnancy, most data are retrospective and prone to detection and confounding biases, such as^11-15:

• the risks associated with depression
  
• comorbid conditions such as obesity
  
• maternal age
  
• poor prenatal care
  
• how the baby was delivered (eg, Caesarean sections have higher rates of PPHN)¹³
  
• illicit substance use
  
• effects of other medications (80% of pregnant women use medications, including nonsteroidal anti-inflammatory drugs [NSAIDs], which are associated with PPHN).^11,16
  

No medication is 100% safe during pregnancy and all pregnancies have risks. In the United States, 2% to 3% of pregnancies produce infants with malformations,¹⁷ which makes it hard to determine if a defect is caused by a medication or occurred spontaneously. This is the baseline risk of all malformations; individual malformations are rare and it is difficult to conduct studies that have adequate power to demonstrate the risk for a specific malformation.

There are several potential adverse outcomes to consider when prescribing psychotropics to a pregnant woman, including miscarriage, malformation, preterm delivery, perinatal toxicity, and behavioral teratogenesis (Table 2).^6,7 SSRIs have been implicated in adverse outcomes, but there is no strong evidence that they increase the miscarriage rate, and several studies found no increase in birth defects.^6,13,18-20 Regarding teratogenesis, the FDA switched paroxetine from class C to class D because of a potential 1.5% to 2% risk of fetal cardiac malformation, compared with a 1% baseline rate in the general population.²¹ Drug toxicity or withdrawal in a neonate also is a risk; however, this condition is self-limited and managed supportively by neonatology.²² Behavioral teratogenesis—neurobehavioral problems that develop later in a child’s life—remains a hypothetical concern; research has been conflicting, and studies often used flawed methodology.

Evidence linking SSRIs to an increased risk of adverse birth outcomes often has been based on large, retrospective health system database cohort studies looking at SSRI exposure and associations with conditions such as PPHN, cardiac anomalies, attention-deficit/hyperactivity disorder, and autism.^10,23,24 However, correlation is not the same as causation. It is difficult to prove or disprove the causative factor of adverse outcomes in these studies because:

• these databases were not designed to answer these types of exposure questions (eg, limitations in data collected, such as other potential causes not recorded)
  
• they have many confounding biases (undocumented illicit substance use, possible minimization of smoking history, publication basis for positive findings, etc.)
  
• individuals who provided the data did not follow a standardized method (eg, variability among individual clinicians).
  

Many of these limitations are evident in a 2009 study by Pedersen et al,²³ who reported the prevalence of septal heart defects was 0.5% (2,315/493,113) among unexposed children and 0.9% (12/1,370) among children exposed to 1 SSRI during early pregnancy (odds ratio [OR]=1.99 [1.13 to 3.53]). Based on this study’s data, the number needed to harm—the number of patients you would need to treat to encounter 1 adverse outcome—was 246, which suggests a relatively low risk. When data for the entire study is reviewed, the ORs for either minor birth defects (control: 7,373/493,113 vs SSRI exposed: 39/1,370; OR=0.88 [0.54 to 1.41]) or major birth defects (control: 15,518/493,113 vs SSRI exposed: 55/1,370; OR 1.21 [0.91 to 1.62]) were not statistically significant (major and minor malformations were defined using European Surveillance of Congenital Anomalies coding).

Not to case aspersions on this group’s work, it should be noted that this study had limitations, including that the researchers:

• did not take into account SSRI dosage
  
• did not measure depression severity or remittance
  
• were not able to fully account for potential exposures (eg, over-the-counter NSAIDs)
  
• were unable to confirm that patients took their medications because the variable measured was prescriptions filled
  
• did not interview participants about their medication use or symptoms.
  

In addition, researchers noted that mothers who filled their antidepressant prescription at least twice also were likely to have other factors that put them at higher risk for having a child with birth defects—such as older age or smoking. The biggest problem with the study was a lack of a control group, such as depressed women who did not receive medication (eg, the risk of depression itself could explain the rise, or those with more severe depression could be prescribed antidepressants).¹⁵

In a more recent study,²⁴ 33 of 11,014 infants exposed to SSRIs after gestational week 20 developed PPHN (absolute risk: 3 per 1,000 births, compared with an incidence of 1.2 per 1,000 births in the general population), with an adjusted OR of 2.1 (95% CI 1.5 to 3.0). Although the authors warned that the results suggest a “class effect,” the rate of PPHN also was higher for mothers with a history of a psychiatric hospitalization within the last 10 years who were not taking medication (OR=1.3, 95% CI 1.0 to 1.6) and the OR for escitalopram (1.5, CI 0.2 to 10.5) was not statistically significant. This study did include a control group, but the 10-year window may have been too wide to represent a group with similar comorbid risks. Similar to the previously discussed study, mothers prescribed SSRIs were older, 1.7 times more likely to be smokers, and twice as likely to be prescribed NSAIDs. The study did not analyze the risk factors of smoking and body mass index because of an initial subset analysis (which was not reported) finding that these known risk factors for PPHN “did not confound the results.”²⁴

 

Table 2

Potential concerns when treating pregnant women with psychotropics

Miscarriage (spontaneous abortion)
Malformation (teratogenesis)
Preterm delivery
Perinatal syndrome (toxicity or withdrawal in neonate; usually self-limited and related to serotonin overstimulation or withdrawal; symptoms may include disrupted sleep irritability jitteriness or abnormal breathing)
Behavioral teratogenesis (later behavioral problems in child eg lower IQ developmental delays or autism)
Lactation compatibility or plans to bottle-feed
Source: References 6,7

The basis of class-action lawsuits

Interest in class-action lawsuits involving birth defects and antidepressants, particularly sertraline, appears to be increasing. Many websites advertising these lawsuits quote unnamed articles from reputable medical journals to support the claim that the medications are dangerous and cause a wide range of birth defects. Although some of the birth defects mentioned are specific, others (eg, “breathing problems” or “gastrointestinal side effects”) are so broad that any problem or complication could conceivably be attributed to the antidepressant. The degree of causation—if any at all—for many of these conditions has not been determined. A national advertising campaign looking for any problem may be occurring because the exact risks are “unknown.”¹

The 2009 U.S. Supreme Court ruling in Wyeth v Levine²⁵ allows individuals to sue manufacturers of branded medications in state and federal court for lack of proper labeling. However, the 2011 U.S. Supreme Court case of PLIVA, Inc. v Mensing²⁶ prohibits state lawsuits against manufacturers of generic medications over labeling because by federal (superseding) law, generic manufacturers must use the same warnings as the branded medication. This may in part explain why many medications targeted in commercials and websites for class-action lawsuits are branded products, even though generics are available.

The focus of these types of lawsuits has been on drug manufacturers, in part because of the success of past litigation. Past class- and single-action lawsuits involving birth defects against pharmaceutical companies, such as Richardson-Merrell Inc.—the manufacturer of thalidomide and Bendectin, the branded version of a combination of pyridoxine and doxylamine used to treat nausea and vomiting during pregnancy—were successful. Although limb defects with thalidomide were scientifically proven, Bendectin was never conclusively shown to cause birth defects even though it had been prescribed to 40% of pregnant women at one point. The legal theory behind the lawsuits is that the manufacturers should have done more research to determine the potential for birth defects.²⁷ In a case against SmithKline Beecham Corporation,²⁸ which makes Paxil, the branded version of the SSRI paroxetine, a jury found the manufacturer negligent for failing to warn about Paxil’s association with cardiac defects. The result was a $2.5 million jury verdict. Since that case, the manufacturer has settled >800 additional suits for >$1 billion. Because this risk of using paroxetine has been established, physicians should discuss this risk with their patients as part of an informed consent because they could be liable if they don’t.²¹ This legal concept is known as the “learned intermediary doctrine,” which states that once the risk is known, the intermediary (eg, the physician) is responsible to ensure that a product (eg, medication) is used appropriately. The 2011 FDA statement saying the risk for SSRIs during pregnancy is unknown¹ is important because it removes physicians as “learned intermediaries.”

Protect your patient and yourself

An estimated 13% of pregnant women take antidepressants; SSRIs are the most commonly used antidepressant during and after pregnancy.⁹ Although not every depressed pregnant woman requires medication, those with moderate to severe depression often do. Rational medication decisions, informed consent, and good documentation are important when treating these women. Discuss the risks of untreated illness as well as the risks of medications to ensure that the patient understands that avoiding medication does not guarantee a safe pregnancy. Suggest psychotherapy and electroconvulsive therapy as options when appropriate. When possible, include the patient’s partner and family in the discussion to help improve compliance and potentially reduce strife.²⁹ The psychiatrist or patient should discuss the medication plan with the patient’s obstetrician or family physician.

Whenever possible, consider using monotherapy, continuing a previously “successful” medication, and using the lowest effective dose.⁵ Clinicians may “underdose” medications because they believe this will lessen the risk from exposure, but this is risky because the fetus is still being exposed to the medication as well as the negative effects of undertreated MDD. If SSRIs are used throughout the pregnancy, the newborn may require additional observation to monitor for potential perinatal syndromes or PPHN.

 

^6,22

Many women become pregnant while being treated for depression. Approximately one-half of all pregnancies are unplanned, so women using antidepressants may unknowingly expose their fetus to medication.³⁰ For this reason, it is important to discuss potential pregnancy and birth control concerns with all women of childbearing age before initiating pharmacotherapy.³¹ If an unintended pregnancy occurs, tell your patient to contact you before stopping any medications. Lawsuits also can occur because of wrongful death by suicide or infanticide because of lack of treatment; risk of untreated illness should not be treated lightly.

Related Resources

• Motherisk. www.motherisk.org.
  
• Organization of Teratology Information Specialists. www.otispregnancy.org.
  
• Massachusetts General Hospital Center for Women’s Mental Health. www.womensmentalhealth.org.
  

Drug Brand Names

• Escitalopram • Lexapro
  
• Paroxetine • Paxil
  
• Sertraline • Zoloft
  

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Acknowledgments

The authors appreciate suggestions on prior versions of the manuscript from Miriam Rosenthal, Jaina Amin, Sarah Nagle-Yang, Sonal Moratschek, J.P. Shand, and Scott R. Miller.

Discuss this article at www.facebook.com/CurrentPsychiatry

Recently there has been an increase in advertising soliciting participants for class-action lawsuits involving birth defects and antidepressants, particularly sertraline. Many psychiatrists are unsure why these ads are running in seemingly every medium because there has been no change in the FDA pregnancy classification for most selective serotonin reuptake inhibitors (SSRIs), except for paroxetine going from a C to a D rating in 2005.¹ Some studies have found SSRIs increase the risk of adverse birth outcomes and others have not, which makes it difficult for clinicians to know what to discuss with patients regarding the risks and benefits of using antidepressants during pregnancy, as well as the risks of untreated major depressive disorder (MDD).

It can be hard to encourage some patients to take necessary medications in the best of circumstances, let alone suggest that a pregnant woman take a medication that has been labeled “dangerous.” This article seeks to alleviate physicians’ fears about being caught in a no-win situation by:

• explaining factors that may have led to this increase in class-action lawsuits
  
• clarifying the risks of using certain medications and not treating depression
  
• suggesting ways physicians can protect themselves and their patients.
  

The FDA’s position

In July 2006, the FDA issued a public health advisory regarding SSRI use during pregnancy and the possibility of persistent pulmonary hypertension (PPHN).² This warning was based on a single study that found the risk of developing PPHN (baseline rate: 1 to 2 per 1,000 births) was 6 times greater for fetuses exposed to SSRIs in late pregnancy.³ Many legal websites highlight this 2006 warning as proof of SSRIs’ danger. However, because subsequent studies have had conflicting results, the FDA’s current position is that the risks of using SSRIs during pregnancy are “unknown” (Box).^1-4

Box

Risks of depression

Although most physicians know the risks of untreated MDD, they tend to minimize or forget these risks when a woman becomes pregnant. Pregnant women with MDD face not only the expected risks of their psychiatric illness but additionally face risks of pre-eclampsia, suicide (20% of deaths in the postpartum period are due to suicide), and infanticide.^5-10 Risks to the fetus include poor prenatal care, increased risk of intrauterine exposure to drugs or alcohol, increased exposure to maternal cortisol with resulting neurodevelopmental changes, preterm delivery, low birth weight, and failure to thrive.^6-8 Later difficulties for the child of a mother with untreated depression may include poor stress adaptation, decreased cognitive performance, and behavioral difficulties because of poor mother-child bonding and other factors.⁶

See Table 1 for key statistics regarding pregnancy and depression.

Table 1

Statistics on pregnancy and depression

There are approximately 6 million pregnancies each year in the United Statesa
There are approximately 4 million live births each year in the United Statesa
Two percent to 3% of healthy pregnancies result in a birth defect or miscarriageb-d
Sixty percent to 70% of birth complications occur due to an unknown caused
Rates of depression during pregnancy are 7% to 25%b,e,f
Approximately 13% of pregnant women take an antidepressant during pregnancye
Fifteen percent of women with untreated depression in pregnancy attempt suicideb
Twenty percent of deaths in the postpartum period are due to suicidee
Women who discontinue antidepressants are 5 times more likely than women who continue medications in pregnancy to have a relapse of depressiong,h
SSRIs are the antidepressant class most frequently prescribed to pregnant womeni
Sertraline is one of the most frequently prescribed antidepressants perinatally and has low concentration in breast milk and infant serumj,k
SSRIs: selective serotonin reuptake inhibitors American Pregnancy Association. Statistics. http://www.americanpregnancy.org/main/statistics.html. Accessed December 20, 2012. Hasser C, Brizendine L, Spielvogel A. SSRI use during pregnancy. Current Psychiatry. 2006;5(4):31-40. Altshuler L, Richards M, Yonkers K. Treating bipolar disorder during pregnancy. Current Psychiatry. 2003;2(7):14-26. Cott A, Wisner K. Psychiatric disorders during pregnancy. Internat Rev Psychiatry. 2003;15(3):217-230. Meltzer-Brody S. New insights into perinatal depression: pathogenesis and treatment during pregnancy and postpartum. Dialogues Clin Neurosci. 2011;13(1):89-100. Kieler H, Artama M, Engeland A, et al. Selective serotonin reuptake inhibitors during pregnancy and risk of persistent pulmonary hypertension in the newborn: population based cohort study from the five Nordic countries. BMJ. 2012;344:d8012. doi:10.1136/bmj.d801. U.S. Food and Drug Administration. Public health advisory: treatment challenges of depression in pregnancy and the possibility of persistent pulmonary hypertension in newborns. http://www.fda.gov/ Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders /DrugSafetyInformationforHeathcareProfessionals/PublicHealthAdvisories/ucm124348.htm. Published July 19, 2006. Accessed December 20, 2012. Cohen LS, Altshuler LL, Harlow BL, et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA. 2006;295(5):499-507. Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Gen Hosp Psychiatry. 2009;31(5):403-413. Berle JO, Spigset O. Antidepressant use during breastfeeding. Curr Womens Health Rev. 2011;7(1):28-34. Friedman SH, Nagle-Yang S, Parsons S. Maternal mental health in the neonatal intensive care unit. NeoReviews. 2011;12(2):e85-e93.

 

Limitations of research

Because of ethical difficulties in studying MDD treatment during pregnancy, most data are retrospective and prone to detection and confounding biases, such as^11-15:

• the risks associated with depression
  
• comorbid conditions such as obesity
  
• maternal age
  
• poor prenatal care
  
• how the baby was delivered (eg, Caesarean sections have higher rates of PPHN)¹³
  
• illicit substance use
  
• effects of other medications (80% of pregnant women use medications, including nonsteroidal anti-inflammatory drugs [NSAIDs], which are associated with PPHN).^11,16
  

No medication is 100% safe during pregnancy and all pregnancies have risks. In the United States, 2% to 3% of pregnancies produce infants with malformations,¹⁷ which makes it hard to determine if a defect is caused by a medication or occurred spontaneously. This is the baseline risk of all malformations; individual malformations are rare and it is difficult to conduct studies that have adequate power to demonstrate the risk for a specific malformation.

There are several potential adverse outcomes to consider when prescribing psychotropics to a pregnant woman, including miscarriage, malformation, preterm delivery, perinatal toxicity, and behavioral teratogenesis (Table 2).^6,7 SSRIs have been implicated in adverse outcomes, but there is no strong evidence that they increase the miscarriage rate, and several studies found no increase in birth defects.^6,13,18-20 Regarding teratogenesis, the FDA switched paroxetine from class C to class D because of a potential 1.5% to 2% risk of fetal cardiac malformation, compared with a 1% baseline rate in the general population.²¹ Drug toxicity or withdrawal in a neonate also is a risk; however, this condition is self-limited and managed supportively by neonatology.²² Behavioral teratogenesis—neurobehavioral problems that develop later in a child’s life—remains a hypothetical concern; research has been conflicting, and studies often used flawed methodology.

Evidence linking SSRIs to an increased risk of adverse birth outcomes often has been based on large, retrospective health system database cohort studies looking at SSRI exposure and associations with conditions such as PPHN, cardiac anomalies, attention-deficit/hyperactivity disorder, and autism.^10,23,24 However, correlation is not the same as causation. It is difficult to prove or disprove the causative factor of adverse outcomes in these studies because:

• these databases were not designed to answer these types of exposure questions (eg, limitations in data collected, such as other potential causes not recorded)
  
• they have many confounding biases (undocumented illicit substance use, possible minimization of smoking history, publication basis for positive findings, etc.)
  
• individuals who provided the data did not follow a standardized method (eg, variability among individual clinicians).
  

Many of these limitations are evident in a 2009 study by Pedersen et al,²³ who reported the prevalence of septal heart defects was 0.5% (2,315/493,113) among unexposed children and 0.9% (12/1,370) among children exposed to 1 SSRI during early pregnancy (odds ratio [OR]=1.99 [1.13 to 3.53]). Based on this study’s data, the number needed to harm—the number of patients you would need to treat to encounter 1 adverse outcome—was 246, which suggests a relatively low risk. When data for the entire study is reviewed, the ORs for either minor birth defects (control: 7,373/493,113 vs SSRI exposed: 39/1,370; OR=0.88 [0.54 to 1.41]) or major birth defects (control: 15,518/493,113 vs SSRI exposed: 55/1,370; OR 1.21 [0.91 to 1.62]) were not statistically significant (major and minor malformations were defined using European Surveillance of Congenital Anomalies coding).

Not to case aspersions on this group’s work, it should be noted that this study had limitations, including that the researchers:

• did not take into account SSRI dosage
  
• did not measure depression severity or remittance
  
• were not able to fully account for potential exposures (eg, over-the-counter NSAIDs)
  
• were unable to confirm that patients took their medications because the variable measured was prescriptions filled
  
• did not interview participants about their medication use or symptoms.
  

In addition, researchers noted that mothers who filled their antidepressant prescription at least twice also were likely to have other factors that put them at higher risk for having a child with birth defects—such as older age or smoking. The biggest problem with the study was a lack of a control group, such as depressed women who did not receive medication (eg, the risk of depression itself could explain the rise, or those with more severe depression could be prescribed antidepressants).¹⁵

In a more recent study,²⁴ 33 of 11,014 infants exposed to SSRIs after gestational week 20 developed PPHN (absolute risk: 3 per 1,000 births, compared with an incidence of 1.2 per 1,000 births in the general population), with an adjusted OR of 2.1 (95% CI 1.5 to 3.0). Although the authors warned that the results suggest a “class effect,” the rate of PPHN also was higher for mothers with a history of a psychiatric hospitalization within the last 10 years who were not taking medication (OR=1.3, 95% CI 1.0 to 1.6) and the OR for escitalopram (1.5, CI 0.2 to 10.5) was not statistically significant. This study did include a control group, but the 10-year window may have been too wide to represent a group with similar comorbid risks. Similar to the previously discussed study, mothers prescribed SSRIs were older, 1.7 times more likely to be smokers, and twice as likely to be prescribed NSAIDs. The study did not analyze the risk factors of smoking and body mass index because of an initial subset analysis (which was not reported) finding that these known risk factors for PPHN “did not confound the results.”²⁴

 

Table 2

Potential concerns when treating pregnant women with psychotropics

Miscarriage (spontaneous abortion)
Malformation (teratogenesis)
Preterm delivery
Perinatal syndrome (toxicity or withdrawal in neonate; usually self-limited and related to serotonin overstimulation or withdrawal; symptoms may include disrupted sleep irritability jitteriness or abnormal breathing)
Behavioral teratogenesis (later behavioral problems in child eg lower IQ developmental delays or autism)
Lactation compatibility or plans to bottle-feed
Source: References 6,7

The basis of class-action lawsuits

Interest in class-action lawsuits involving birth defects and antidepressants, particularly sertraline, appears to be increasing. Many websites advertising these lawsuits quote unnamed articles from reputable medical journals to support the claim that the medications are dangerous and cause a wide range of birth defects. Although some of the birth defects mentioned are specific, others (eg, “breathing problems” or “gastrointestinal side effects”) are so broad that any problem or complication could conceivably be attributed to the antidepressant. The degree of causation—if any at all—for many of these conditions has not been determined. A national advertising campaign looking for any problem may be occurring because the exact risks are “unknown.”¹

The 2009 U.S. Supreme Court ruling in Wyeth v Levine²⁵ allows individuals to sue manufacturers of branded medications in state and federal court for lack of proper labeling. However, the 2011 U.S. Supreme Court case of PLIVA, Inc. v Mensing²⁶ prohibits state lawsuits against manufacturers of generic medications over labeling because by federal (superseding) law, generic manufacturers must use the same warnings as the branded medication. This may in part explain why many medications targeted in commercials and websites for class-action lawsuits are branded products, even though generics are available.

The focus of these types of lawsuits has been on drug manufacturers, in part because of the success of past litigation. Past class- and single-action lawsuits involving birth defects against pharmaceutical companies, such as Richardson-Merrell Inc.—the manufacturer of thalidomide and Bendectin, the branded version of a combination of pyridoxine and doxylamine used to treat nausea and vomiting during pregnancy—were successful. Although limb defects with thalidomide were scientifically proven, Bendectin was never conclusively shown to cause birth defects even though it had been prescribed to 40% of pregnant women at one point. The legal theory behind the lawsuits is that the manufacturers should have done more research to determine the potential for birth defects.²⁷ In a case against SmithKline Beecham Corporation,²⁸ which makes Paxil, the branded version of the SSRI paroxetine, a jury found the manufacturer negligent for failing to warn about Paxil’s association with cardiac defects. The result was a $2.5 million jury verdict. Since that case, the manufacturer has settled >800 additional suits for >$1 billion. Because this risk of using paroxetine has been established, physicians should discuss this risk with their patients as part of an informed consent because they could be liable if they don’t.²¹ This legal concept is known as the “learned intermediary doctrine,” which states that once the risk is known, the intermediary (eg, the physician) is responsible to ensure that a product (eg, medication) is used appropriately. The 2011 FDA statement saying the risk for SSRIs during pregnancy is unknown¹ is important because it removes physicians as “learned intermediaries.”

Protect your patient and yourself

An estimated 13% of pregnant women take antidepressants; SSRIs are the most commonly used antidepressant during and after pregnancy.⁹ Although not every depressed pregnant woman requires medication, those with moderate to severe depression often do. Rational medication decisions, informed consent, and good documentation are important when treating these women. Discuss the risks of untreated illness as well as the risks of medications to ensure that the patient understands that avoiding medication does not guarantee a safe pregnancy. Suggest psychotherapy and electroconvulsive therapy as options when appropriate. When possible, include the patient’s partner and family in the discussion to help improve compliance and potentially reduce strife.²⁹ The psychiatrist or patient should discuss the medication plan with the patient’s obstetrician or family physician.

Whenever possible, consider using monotherapy, continuing a previously “successful” medication, and using the lowest effective dose.⁵ Clinicians may “underdose” medications because they believe this will lessen the risk from exposure, but this is risky because the fetus is still being exposed to the medication as well as the negative effects of undertreated MDD. If SSRIs are used throughout the pregnancy, the newborn may require additional observation to monitor for potential perinatal syndromes or PPHN.

 

^6,22

Many women become pregnant while being treated for depression. Approximately one-half of all pregnancies are unplanned, so women using antidepressants may unknowingly expose their fetus to medication.³⁰ For this reason, it is important to discuss potential pregnancy and birth control concerns with all women of childbearing age before initiating pharmacotherapy.³¹ If an unintended pregnancy occurs, tell your patient to contact you before stopping any medications. Lawsuits also can occur because of wrongful death by suicide or infanticide because of lack of treatment; risk of untreated illness should not be treated lightly.

Related Resources

• Motherisk. www.motherisk.org.
  
• Organization of Teratology Information Specialists. www.otispregnancy.org.
  
• Massachusetts General Hospital Center for Women’s Mental Health. www.womensmentalhealth.org.
  

Drug Brand Names

• Escitalopram • Lexapro
  
• Paroxetine • Paxil
  
• Sertraline • Zoloft
  

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Acknowledgments

The authors appreciate suggestions on prior versions of the manuscript from Miriam Rosenthal, Jaina Amin, Sarah Nagle-Yang, Sonal Moratschek, J.P. Shand, and Scott R. Miller.