Autism, Pregnancy, and SSRIs: When the Media Distorts the Facts

There is increasing attention by the media to perinatal depression and specifically to the use of antidepressants in pregnancy. Although such attention raises awareness of perinatal depression, many of the headlines highlight-to the point of sensationalizing-the potential negative effects of SSRIs in pregnancy. In the case of in utero exposure to SSRIs and a possible increased risk of autism and autism spectrum disorders (ASDs), the literature to date is mixed.

A recent study in JAMA Pediatrics, which unlike several earlier negative studies found an association between SSRI exposure in utero and increased rates of ASD, has received a disproportionate amount of attention in the media.¹ The headlines and subsequent articles rarely discussed the limitations of the clinical findings. Notably, the study by Boukhris and colleagues¹ failed to take into consideration that parental psychiatric illness itself is associated with an increased risk of ASD in their children. Two larger, well-controlled epidemiological studies failed to find an association between prenatal exposure to antidepressant medication and ASDs.^2,3 These well-designed reassuring studies received little notoriety in the press, as is common for negative studies.

[[{"type":"media","view_mode":"media_crop","fid":"46656","attributes":{"alt":"iQoncept/shutterstock.com","class":"media-image media-image-right","id":"media_crop_7754082125611","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5428","media_crop_rotate":"0","media_crop_scale_h":"177","media_crop_scale_w":"200","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"iQoncept/shutterstock.com","typeof":"foaf:Image"}}]]Soon after the media frenzy over the Boukhris article, I received a concerned call from a pregnant patient who was distraught after her ultrasound at 20 weeks. To my relief, the results of her ultrasound were completely normal. Unfortunately, my patient’s obstetrician had erroneously warned her that because she had remained on sertraline throughout her pregnancy, her baby was at significant risk of having autism.

Although this patient had made an informed decision with a reproductive psychiatrist who had reviewed the risks and benefits of staying on sertraline during pregnancy, she started to second-guess her decision of remaining on the medication. The obstetrician was unaware of the severity of this patient’s anxiety disorder, and the fact that she was unable to function at work or care for her toddler when her symptoms of anxiety recurred. Fortunately, this patient reached out for reassurance, and the risk-benefit conversation she had previously had was reiterated. Even if we are to believe the positive studies, the risk of autism in offspring exposed to SSRIs is less than 3%.

We know there can be serious consequences for women with severe depression and anxiety disorders who discontinue their antidepressants in pregnancy.

I was similarly disheartened when I received a Medscape Psychiatry Top News summary in my email inbox on January 7, 2016. The top “most-read” news story by psychiatrists in 2015, according to Medscape, was “Two Antidepressants Linked to Birth Defects.” The news article cited the case-control study by Reefhuis and colleagues,⁴ which was widely criticized by experts in the field for failing to control for maternal psychiatric illness and for possible recall bias.

Even if we assume the associations from this case-control study to be true, the absolute risk of birth defects remained extremely low. It is important to note that the increased risk still remained below the 5% risk of malformations seen in the general population, unrelated to any medication exposures. The “most read” headline misses the clinically relevant information for patients and clinicians: specifically that the study had significant limitations and the findings are within the baseline risk for birth defects.

We know there can be serious consequences for women with severe depression and anxiety disorders who discontinue their antidepressants in pregnancy. In a prospective study, Cohen and colleagues⁵ found the rate of recurrence in women who chose to discontinue their antidepressant around the time of conception was 68%. My colleagues and I have treated pregnant women with severe recurrences of depression or severe anxiety disorders after discontinuing SSRIs that resulted in suicidal ideation, psychiatric hospitalization or, in some cases, thoughts of terminating a previously desired pregnancy.

On a positive note, the field of reproductive psychiatry is rapidly growing, with an explosion of current clinical research, specialized post-residency training programs, and clinically useful resources. There are now 10 post-residency reproductive psychiatry training programs in the US. As a result, the pool of providers with evidence-based training in the field, who will help patients and clinicians make informed decisions about using psychiatric medications in the perinatal period, has expanded dramatically over the past 10 years. As the literature grows, we have excellent resources for both clinicians and patients to better understand the relevance of new studies.

Massachusetts General Hospital’s excellent website www.womensmentalhealth.org now has a monthly “roundup” of recent publications with summaries of the research findings. Another advance in the field includes the FDA’s recent update of its classification of medications in pregnancy and lactation. The FDA categories A through X, which were often misleading and out of date, have been phased out as of June 2015.

Clinicians can disseminate the growing resources to help our patients and colleagues make informed decisions by weighing the evidence-based risks and benefits of SSRI treatment in pregnancy.

With more education and information, clinicians and patients will rely less and less on these outdated categories. In addition, organizations such as Postpartum Support International (PSI) have accessible online resources for patients and clinicians. PSI coordinators are able to connect countless women with well-informed clinicians who can provide effective treatment for perinatal mood and anxiety disorders.

We will never have enough front-line psychiatrists with specialized training in reproductive psychiatry to treat all women with perinatal depression and anxiety. But we can disseminate the growing resources to help our patients and colleagues make informed decisions by weighing the evidence-based risks and benefits of SSRI treatment in pregnancy.

Useful Websites

• MGH Center for Women’s Mental Health: www.womensmentalhealth.org

• Postpartum Support International: www.postpartum.net

• Promoting Maternal Mental Health During and After Pregnancy: www.mcpapformoms.org

• The Reproductive Toxicology Center: www.reprotox.org

Disclosures:

Dr Greene is Director of Women’s Mental Health, at NYC Health + Hospitals/Bellevue Hospital Center, and Training Director, Women’s Mental Health Fellowship, New York University School of Medicine in New York. She reports no conflicts of interest concerning the subject matter of this article.

References:

1. Boukhris T, Sheehy O, Mottron L, Bérard A. Antidepressant use during pregnancy and the risk of autism spectrum disorder in children. JAMA Pediatr. 2016;170:117-124.

2. Sørensen MJ, Grønborg TK, Christensen J, et al. Antidepressant exposure in pregnancy and risk of autism spectrum disorders. Clin Epidemiol. 2013; 5:449-459.

3. Hviid A, Melbye M, Pasternak B. Use of selective serotonin reuptake inhibitors during pregnancy and risk of autism. N Engl J Med. 2013;369:2406-2415.

4. Reefhuis J, Devine O, Friedman JM, et al. Specific SSRIs and birth defects: bayesian analysis to interpret new data in the context of previous reports. BMJ. 2015;351:h3190.

5. Cohen LS, Altshuler LL, Harlow BL, et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA. 2006;295:499-507.