Did Research Find Taking Antidepressants In Pregnancy Really Causes 500% Increase In Heart Defects?
Terrifying headlines loomed last week about pregnancy and antidepressants. Did you see them?
Antidepressants Linked to Heart Defects in Newborns - Yahoo! Health
Taking Antidepressants in Early Pregnancy Linked to Child Heart Defects - Medical News Today
If you were reading Twitter on the day this news came out, you might have seen this: "SSRIs pose up to 500% increased risk of heart defects if taken early in pregnancy according to 1 study #postpartum #ppd" 500%!
If you did see any of these headlines, and if you happen to be pregnant and on an antidepressant, then you were probably standing on a ledge somewhere with a loved one trying to talk you down. This is very scary stuff. So let's take a look at the study that led to those headlines and see what all this really means to you.
Notice the risk is for a very specific birth defect of the heart. Not "antidepressants are linked to heart defects" as many headlines read. Notice the increase risk is small, and there's no clear causation like the headlines infer. How much is the risk?
Of all women who give birth, .05% will have a child with a septal heart defect. Of all women who give birth who take a selective serotonin reuptake inhibitor -- a class of antidepressants commonly known as SSRIs -- during the first trimester, .09% will have a child with a septal heart defect.
The researchers also broke the data down further by taking a look at the increase in risk for specific SSRI antidepressants. They found no increase at all in risk for septal heart defects for women taking fluoxetine (Prozac) or paroxetine (Paxil). The risk went up one-half of a percentage point for those taking citalopram (Celexa), and one percentage point for those taking sertraline (Zoloft).
Is there an increase in risk of septal heart defect with certain medications? Yes. Do the researchers know why? No.
"Pederson and colleagues also could not exclude the possibility that something about depression itself, rather than the treatments, accounted for the increase in heart defects."
Is this a study we should pay attention to? Yes, but it's not definitive. A sidebar of the original Medical News Today story entitled "Action Steps" indicated that one purpose of their article was to "explain that this study was a retrospective analysis of medical records, a relatively weak form of evidence." I didn't see that reported in most places.
Additionally, it appears that the researchers did not control for things like whether the mom took prenatal vitamins or used alcohol, among other compounding factors. Lauren Hale at Sharing the Journey wrote last week that they also didn't actually know whether the women in the study took their medication as prescribed, or whether they took it at all ... only that their prescriptions were filled.
"Pederson and colleagues noted that variations in compliance or errors in records could have affected the findings. They also acknowledged that previous studies of individual drugs have not consistently identified birth-defect risks associated with SSRIs."
One of my missions here at Postpartum Progress is to make sure women get all the information they need and to remediate sensationalist or misguided reporting related to perinatal mood and anxiety disorders that sometimes takes place, while also publicizing the balanced, informed reporting that we are grateful to see.
One of the experts I spoke with about this new research said "Unfortunately, statistics are always translated to make the results look as scary as possible, especially in pregnancy. It is called negative framing." In other words, saying there is a five-fold increase in the risk of a birth defect gets much more attention than saying that 99% of women will have a health baby.
In a commentary just published in the Journal of Clinical Psychiatry, Adrienne Einarson writes:
"A recent Google search (June 23, 2009) using the keywords 'antidepressants, pregnancy' revealed 1,420,000 results, many describing how 'dangerous/harmful' antidepressants are to take in pregnancy, with many sites warning women not to take antidepressants if they are pregnant. Studies that do not find evidence for harm more often than not are ignored by the media, such as in the recent Vogue article that focused only on studies that reported adverse effects."
I recall the titillating headline on the front cover of that Vogue issue read something like "The Shocking Truth About Antidepressants & Pregnancy". Then there was the completely unbalanced article about postpartum depression screening from Time magazine. Such biased representations are unfair, and are often made by the same outlets and individuals who trumpet the importance of informed consent in healthcare. I suppose they mean informed consent only if the information supports their point of view. If you want to make sure new moms and moms-to-be have the right information, then why not give it to them straight and let them decide?
Thankfully, some responsible news outlets treated the study as it should have been treated. WebMD reported that "women who take antidepressants during pregnancy have a small increased risk for a specific heart defect ... The new study shows the overall risk for congenital heart problems associated with SSRIs to be quite low." (Other balanced and well-reported pieces include this one from the New York Times, and a related piece from the same paper on the Well blog with comments from readers.)
Even the Danish researchers agree with that statement as quoted in the WebMD story:
"The bottom line is the risk associated with SSRI use appears to be very small, and this has to be balanced against the very real risk associated with having untreated depression during pregnancy," study researcher Lars H. Pederson of Aarhus University tells WebMD.
This is rarely pointed out. There are risks NO MATTER WHICH DECISION YOU MAKE. Those who are vehemently against anyone taking antidepressants during pregnancy often leave out the fact that there are many risks to the children of women who suffer depression and choose to go untreated during pregnancy.
One finding of the study which does raise new concern, across everyone reporting, is that of women taking two or more antidepressants during the first trimester. Of the 400,000 cases that were part of the study, according to Medical News Today, 2,315 (.05%) of unexposed babies had septal heart defects, 12 (.09%) of SSRI exposed babies had septal heart defects, and 4 (2.1%) of babies exposed to more than one type of SSRI in the first trimester had septal heart defects.
"How does Pedersen and colleagues' study contribute to clinicians' and patients' decisions about the use of SSRIs in pregnancy, and how should this be weighed against the risks of non-treatment? The answer remains as before -- if an increased risk for major congenital malformations does exist, this study and others suggest that the absolute risk for the individual pregnant woman is very low. Furthermore, each of the more commonly used drugs in this class has been implicated in at least one study, so it is difficult to conclude that one SSRI is 'safer' than another ... Clinicians and patients need to balance the small risks associated with SSRIs against those associated with undertreatment or no treatment."
The answer remains as before. Talk to your doctor and work together to make the choice that is right for you.