In this web-exclusive Q&A, Amy Salisbury, PhD addresses the seriousness of MDD and its long and short-term effects on both mother and child. Dr. Salisbury also discusses the treatment options she will investigate in her research around Fetal and Infant Response to SRI Treatment (F.I.R.S.T.).
Each year, thousands of pregnant women face the difficult decision of whether or not to treat their Major Depressive Disorder (MMD) with antidepressant medication. In an effort to understand how the use of antidepressant medication (SRIs) and depressed mood can affect children born from these pregnancies, $3 million has been awarded to the Brown Center for the Study of Children at Risk at Women & Infants.
Why is it important to study the effects of antidepressants on fetal and newborn health?
From the limited amount of information we have, about 30% of the infants born after their mothers took antidepressant medications during pregnancy have some medical and/or behavioral difficulties. The symptoms range from jitteriness and tremors to respiratory distress and pulmonary hypertension. The more serious symptoms occur very rarely, while the less serious ones tend to occur more frequently. The problem is that we don't know why these problems occur, why they only occur for 30% of infants, and which medications of the SRI's are more likely to cause the problems. We also do not know if the symptoms are related to the depression in addition to the medication use, since depression during pregnancy has also been linked to some behavioral and developmental problems for infants.
How does this study to differ from your past research concerning medication use during pregnancy?
In this study we will be examining the effects of the medication and depression on the fetus prior to birth as well as carefully following the infants for the first month following birth. Most of the prior medication studies have only looked at the babies after birth. We want to know if there are any effects on the developing fetus as well. We want to be able to help women struggling with treatment decisions during pregnancy to make more informed choices. Some women are taken off their medications during pregnancy, only to relapse into a severe depression. The consequences of a severe depression may be worse for the developing infant than the medication itself.
What is a Major Depressive Disorder (MDD), and what are the warning signs for women who may be suffering from MDD during pregnancy?
MDD is a disorder that affects about 1 in 4 women in their lifetime. Men also experience MDD, but the rate is about half as many as women. MDD is a mood disorder that usually presents as feelings of sadness, very low mood, and/or irritability that persists for most of the day nearly every day for at least 2 weeks. In addition to low or irritable mood, many people lose interest in their usual activities or in socializing with others. Often, appetite and sleep are decreased or increased, and significant changes in energy can occur. Mild depression may not impair a person's ability to function completely, but most say that it takes a lot of effort to do what they normally accomplish in a day. Severe depression can result in a complete shutdown of a person's ability to function, interact with family members or go to work or school. Hopelessness is common with severe depression, and thoughts of one's own death or suicide can result. Some will experience temporary relief from over-eating, drinking alcohol, or taking drugs. All of which can cause more harm than good.
Signs of depression:
- Persistent low mood
- Persistent irritability or agitation
- Social withdrawal
- Loss of interest in activities
- Loss or gain of appetite/weight
- Trouble sleeping or sleeping too much
- Restlessness/can't sit still
- Talking or moving more slowly than usual
- Persistent low energy
- Feelings of guilt, worthlessness or hopelessness
- Difficulty concentrating or making decisions
- Thoughts of death or suicidal thinking
In pregnant or postpartum women, it is easy to overlook the symptoms of depression because can be attributed to the fatigue of the pregnancy or new baby. Persistence of low mood or irritability and/or lack of enjoyment are key symptoms to look for. OR if a person is not able to take care of themselves or their children, it is time to call for help.
What are the long- and short-term dangers of untreated MMD to mother and child?
In the short term, the mother may not be able to properly care for her child – which can make her feel even worse and lead to worsening of symptoms. Many women can provide the basics for their children, even with fairly significant depression. But the quality of interaction and care is often not what it should be or what they would like it to be if they felt better. Long-term untreated depression may lead to significant problems for the child – including depression, anxiety, behavioral problems and sleep disorders. We are hopeful that our data will improve our knowledge of long term outcomes of both treated and untreated depression during pregnancy and the postpartum period.
What treatments currently exist for MMD?
Current treatments include:
- Psychotherapy or group therapy
- Herbal therapy
- Electroconvulsive therapy
- Light therapy and other alternative treatments are being developed
What dangers might antidepressants pose for the fetus?
The main antidepressants being prescribed now are the serotonin reuptake inhibitors (SRIs), such as Zoloft, Prozac, Paxil and Celexa, among others. These medications are often used because they tend to cause fewer side effects for the patient. As with all medications, there is the potential that the medication may change the development of the fetus' central nervous system or other developing systems. There does seem to be a slightly higher miscarriage rate in women who take these medications. There is no data to support major birth defects. To date, there are no published studies on humans on the prenatal effects of these medications on fetal development. We just completed a pilot study on this question and will be publishing the results later this year.
What potential effects could antidepressants have on newborn health and behavior?
The only major medical events associated with SRI use following delivery have been pulmonary hypertension of the newborn (PPHN) and respiratory distress. These occur only in rare cases. The majority of reports are of tremors, excessive startling, and problems feeding. These symptoms appear to last for about 2 weeks and then subside. Long term effects are not known, but there have not been any reports of any major difficulties in children exposed to these medications.
How will you measure the effects of the antidepressants on the fetuses and newborns?
The F.I.R.S.T. study will examine neurobehavior in the infants prior to birth to determine if there are symptoms present prior to withdrawal of the medication. A nurse trained in obstetrical ultrasound and fetal heart rate monitoring conducts a non-diagnostic ultrasound to watch fetal movement patterns at 28 and 32 weeks of pregnancy. After birth, the infants' sleep, reflexes, motor tone and behavior are assessed over the first month of life. For participating in this study, mom's receive cash incentives as well as a copy of the DVD recording and pictures from their non-diagnostic fetal ultrasound.
What are the potential clinical outcomes of your findings?
We are looking for any signs of fetal well-being or difficulties as a result of MDD or medication treatment. We are also considering the possibility that medication treatment may be beneficial to fetal development, despite short-term difficulties.
Who is eligible for this study, and how can interested women learn more about participating?
We welcome all healthy, pregnant women, between the ages of 18 and 40, who are less than 30 weeks gestation, to call for more information. We are enrolling women who have never suffered from depression as well as those who are currently depressed. We will include all depressed women regardless of their current or chosen treatment. We are studying the natural course of the depression and treatment, and we will not interfere in what a woman and her health care provider decides.
For more information, email firstname.lastname@example.org or call us at (401) 453-7960.
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