I had a friend over the other night. I'll refer to her as Kelly for the sake of privacy. We were taking about pregnancy and crossed over to the topic of medication in pregnancy. She has a history of depression and has been taking antidepressants for about 4 years. Kelly is getting married soon and she plans to start a family in the near future. She recently spoke to her OBGYN about her about her options regarding medication in pregnancy. She has been working with this particular doctor since adolescence.
Kelly's doctor shared a new study on antidepressants and autism with her, explaining that if she were to continue on her antidepressant that she would have to locate another healthcare provider. There was no mention of a referral made.
This story took me back to my initial conversation with my longstanding OBGYN. He was similarly limited and uncomfortable with my questions regarding lithium in pregnancy. After explaining to him that I reviewed the research and I intended to remain on my medication in pregnancy, he quickly referred me to a maternal fetal specialist. Thank goodness!! It was obvious the idea of working with me as a patient through pregnancy on my medication was anxiety-provoking. I hung up the phone feeling apprehensive and frustrated. Thankfully for me the referral proved to be a true asset. We had a good experience with our first child birth, and most importantly a great line of communication throughout.
Getting back to the study...
It's important when looking at any research study to consider the design as well as the motive. This study, which linked antidepressants to autism, made major news for obvious reasons. The autism debate is far from over. The study and headlines are based on 31 children diagnosed with autism whose mothers took antidepressants in their second and third trimesters. This works out to an increase in relative risk of 87% (JAMA, 2016). Before you react to that staggering number, remember the risk is relative, NOT absolute. This risk of autism is comparable to other studies. "An 87% increase works out to a risk of 1.3% – that's an increase of 0.6% in the rate of autism. This doesn't sound nearly so dramatic as 87%" (Salzberg, 2015).
Another important note is the children who were "diagnosed with autism" were not exactly diagnosed with autism. According to the authors, "autism spectrum disorder was defined as a medical service claim or a hospitalization with a diagnosis of ASD" (JAMA, 2016). Given this information, one can conclude that the children in this study were evaluated for autism, not diagnosed. If they simply used the actual diagnosed cases versus the evaluated cases their findings would not be nearly as compelling.
In another news, a 2013, large-scale study, published in the New England Journal of Medicine, found that antidepressant use during pregnancy was NOT associated with an increased risk of autism. This study looked at exactly the same class of antidepressants, selective serotonin uptake inhibitors (SSRIs), as the JAMA 2016 study (Salzburg, 2015). Equally interesting, in two JAMA papers published in the last year, researchers found that other variables, including genetics, may be more strongly associated with autism than exposure to antidepressants (TIME, 2017).
When you look at the relative risk compared to the general population, the risk these medications pose to the developing fetus are low, especially when considering the potential risks for not taking them! Symptoms of depression can occur anytime during pregnancy and as late as one year postpartum. Of course, every women needs to speak to her healthcare provider. However, when your own healthcare provider proves to be a dead end be sure to look elsewhere. Maternal fetal health doctors specialize in high risk pregnancies and women with chronic health issues. Get a good referral and move forward knowing that these delicate healthcare decisions should not be made in haste, but with a team that supports your vision of health! Do your own homework and find a doctor that meets your needs.