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 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.
Depression Carries Health Risks
“If 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,” Payne explains. “This 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.”
These physiological changes can also have impacts on the developing fetus. Many of which are still not wholly understood. But some studies have found an association between untreated depression and:
- Low birth weight
- Small for gestational age
- Preterm birth
- Still birth
- Perinatal complications
- Increased operative delivery
It also is a predictor of developing postpartum depression.
Postpartum Depression Already a Significant Problem
“One of the strongest risk factors for PPD is being depressed during pregnancy, and depression often worsens after delivery,” 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.
Postpartum depression has significant health impacts, including for the infant. “There is robust literature demonstrating that PPD has significant effects on the exposed infant’s IQ, language development, and risk for behavioral and psychological problems.”
The risk of suicide is also high. Roughly 20% of maternal deaths in the first year after birth were due to suicide. It goes without saying, this also has profound impacts for a child’s development.
Medication Counseling During Pregnancy
At UVA Health’s 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’s not always possible to evaluate medications beforehand. But Payne encourages patients to talk to professionals and not drop medications without discussion.
“Any patient who has had moderate to severe psychiatric illness should likely stay on her psychiatric medication during pregnancy,” Payne says. “The relapse rate is extremely high when medications are stopped for pregnancy.”
If a patient is already pregnant and has been taking a medication, Payne says usually they won’t change medications. “We generally don’t change medications since the fetus is already exposed and we try to limit the number of exposures.”
For patients who have worsening symptoms or who have the opportunity to consult prior to getting pregnant, there are many more options. “We may experiment with trying to use an older medication with more information, or try to get the patient on as few medications as possible.
The Problem with Black Box Warnings
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’s a lack of clarity around when a black box warning should be issued. “SSRIs were associated with cardiac defects when taken during pregnancy in early studies that did not control for confounding by indication. This means they didn’t 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.”
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.
Mental Health a Crucial Part of Maternal Health
For some reason, the logic of “healthy mom, healthy baby,” doesn’t seem to encompass mental health in public perception, Payne notes. She believes it’s because many people aren’t well educated about the risks of mental illness. “They dismiss depression as something to just ‘muscle through’ when, in reality, perinatal mental illness has significant and measurable effects not only on the mother, but also on the exposed child.”
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’s why Payne is working to help advance the knowledge that the physiological effects of untreated mental health ailments can be just as damaging.
