by Meghan Drummond<\/p>\n
Mental illness is the leading pregnancy complication. And if left untreated, it can have devastating consequences for both a mother and her developing fetus. Nearly 23% of maternal deaths in the perinatal period are fueled by mental health issues.
The most common of these, depression, has a variety of treatments available that have been proven effective. But a lack of information and data has often led to recommendations that leave women trying to white-knuckle through a problem with no help. With discussion of adding a black box warning for pregnancy on SSRIs, conflicting messaging is causing additional confusion.
Jennifer Payne, MD<\/a>, a reproductive psychiatrist and Director of the Reproductive Psychiatry Research Program at UVA, is trying to bring expertise and nuance to the conversation. She shared why treatment is important throughout pregnancy, the risks of not treating, and how providers can have these challenging conversations with their patients.
\u201cIf two patients have the same stage and grade of cancer, and one has untreated depression, their risk of dying from the cancer is twice that of the person without depression,\u201d Payne explains. \u201cThis is because there are significant physical effects of depression in the body, on the immune system, on inflammation, etc., that affect outcomes of medical illness.\u201d
These physiological changes can also have impacts on the developing fetus. Many of which are still not wholly understood. But some studies<\/a> have found an association between untreated depression and:
It also is a predictor of developing postpartum depression.
\u201cOne of the strongest risk factors for PPD is being depressed during pregnancy, and depression often worsens after delivery,\u201d Payne says.
The risk of postpartum depression is already high. It affects nearly 1 in 8 women in the year following birth. Certain factors, like age and number of children, can influence that risk. But nothing is as indicative as untreated depression during pregnancy. \u00a0
Postpartum depression has significant health impacts, including for the infant. \u201cThere is robust literature demonstrating that PPD has significant effects on the exposed infant\u2019s IQ, language development, and risk for behavioral and psychological problems.\u201d
The risk of suicide is also high. Roughly 20% of maternal deaths<\/a> in the first year after birth were due to suicide. It goes without saying, this also has profound impacts for a child\u2019s development.
At UVA Health\u2019s Perinatal Mood Disorders Clinic, Payne provides consultations for patients both before and during pregnancy.
With 50% of pregnancies in the United States being unplanned, it\u2019s not always possible to evaluate medications beforehand. But Payne encourages patients to talk to professionals and not drop medications without discussion.
\u201cAny patient who has had moderate to severe psychiatric illness should likely stay on her psychiatric medication during pregnancy,\u201d Payne says. \u201cThe relapse rate is extremely high when medications are stopped for pregnancy.\u201d
If a patient is already pregnant and has been taking a medication, Payne says usually they won\u2019t change medications. \u201cWe generally don\u2019t change medications since the fetus is already exposed and we try to limit the number of exposures.\u201d
For patients who have worsening symptoms or who have the opportunity to consult prior to getting pregnant, there are many more options. \u201cWe may experiment with trying to use an older medication with more information, or try to get the patient on as few medications as possible.
Earlier this year, a proposal was made to put a black box warning on SSRIs for their use during pregnancy. Many times, black box warnings can provide information to physicians and patients about a potential adverse outcome.
But Payne says there\u2019s a lack of clarity around when a black box warning should be issued. \u201cSSRIs were associated with cardiac defects when taken during pregnancy in early studies that did not control for confounding by indication. This means they didn\u2019t control for psychiatric illness and other associated behaviors and risk factors. Later studies which controlled for these factors did not find an association between SSRI use in pregnancy and cardiac defects in exposed infants.\u201d
The flaws of the original studies mean that a black box warning would be based on bad evidence and may even be contributing to additional negative health outcomes since untreated depression itself carries so many risks.
The risk of stopping antidepressants cold turkey is also significant, and with a black box warning, many will stop as soon as they see a positive pregnancy test.
Currently, Payne recommends looking to specialists in that exact field for guidance. For pregnancy and psychiatric medication, she recommends the American College of Obstetrics and Gynecology and the American Psychiatric Association.
ACOG\u2019s Statement.<\/a>
APA Statement<\/a>.\u00a0
For some reason, the logic of \u201chealthy mom, healthy baby,\u201d doesn\u2019t seem to encompass mental health in public perception, Payne notes. She believes it\u2019s because many people aren\u2019t well educated about the risks of mental illness. \u201cThey dismiss depression as something to just \u2018muscle through\u2019 when, in reality, perinatal mental illness has significant and measurable effects not only on the mother, but also on the exposed child.\u201d
Patients with epilepsy are cautioned to keep taking their anti-seizure medications, since seizures are bad for babies. Patients with asthma are told to keep taking their medications, because a lack of oxygen is bad for babies. But many physicians have a hard time applying this same logic to medications taken for depression or anxiety. That\u2019s why Payne is working to help advance the knowledge that the physiological effects of untreated mental health ailments can be just as damaging.
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