Psychiatric drugs can be used with caution in pregnancy, say experts

BMJ 2013; 346 doi: (Published 13 June 2013) Cite this as: BMJ 2013;346:f3852
  1. Janice Hopkins Tanne
  1. 1New York

The increase in risk of birth defects from use of psychotropic drugs during pregnancy is small, said two experts at a press briefing in New York last week.

The possible risk should be balanced against the risks of the mother’s psychiatric illness, said Kimberly Yonkers, a psychiatrist and director of the perinatal psychiatric research program at Yale University School of Medicine in New Haven, Connecticut, and Christina Chambers, director of clinical research at Rady Children’s Hospital and the department of pediatrics at the University of California at San Diego.

Each year more than 500 000 pregnancies in the United States are to women who have psychiatric illnesses, and about a third of all pregnant women take a psychotropic drug at some time during pregnancy, the American College of Obstetricians and Gynecologists has said.1

There is a 3% risk of birth defect in any pregnancy, and the use of antidepressants seems to increase the 3% risk by about 20% to 3.2%, Chambers told the press briefing, held by the March of Dimes, a non-profit organization that aims to prevent birth defects, premature birth, and infant mortality. She said that this was a difficult concept to get across to pregnant women, who tended to think that the risk was either 100% or zero.

Many young women have been using prescription drugs such as antidepressants, antianxiety drugs, and drugs for attention deficit disorders since they were teenagers, but questions arose when they planned to become pregnant or became pregnant. The use of prescription drugs during the first trimester has increased, and about 70% of women take at least one prescription drug during pregnancy, the Centers for Disease Control and Prevention has estimated.

There has also been a big increase in the use of drugs for stomach ulcers, migraines, and asthma, and of opioids, anticonvulsants, neuroleptics, sedatives, and antihistamines, Yonkers said. Their possible role in causing birth defects was mostly unknown.

The potential teratogenicity of any drug must be weighed against the consequences for mother and fetus of not treating the mother’s underlying disease.2 For example, depressive symptoms and antidepressant exposure are associated with fetal growth changes and shorter gestation, but most studies have not been able to control for the possible effects of depression.3 Major depressive disorders, bipolar disorder, panic disorder, social anxiety, generalized anxiety disorder, and any substance misuse “tend to be chronic and relapsing disorders . . . For many women medications [for these disorders] are not optional,” Yonkers said.

If a woman stopped taking antidepressants she may self medicate with alcohol or cigarettes. Furthermore, it is difficult to disentangle the effects of other prescription, over the counter drugs, or illicit drugs a woman may be taking.

“We don’t have a systematic way of collecting outcomes,” said Chambers, who noted that serotonin reuptake inhibitors were among the top 10 medications used by pregnant women. Seventeen studies showed that their use during pregnancy increased the risk of major birth defects, while 17 other studies showed no risk.


Cite this as: BMJ 2013;346:f3852