Are GPs putting mothers-to-be in danger by telling them to ditch the antidepressants?
As hospitals are reprimanded for pushing ‘natural’ births, a new potential scandal...
SOME doctors’ reluctance to continue to prescribe antidepressants to women when they become pregnant is putting new mothers at risk of mental health problems, experts warn. Their caution is linked to fears that the medications – taken by about six million people in the UK, and one in ten women – increase the risk of heart defects, autism and serious lung conditions in unborn children.
Studies have also linked some of the pills to severe postnatal bleeding in women, low birth weight in infants and premature delivery.
But a growing number of health professionals say these dangers are minimal and are being overstated by over-cautious GPs and other healthcare professionals.
Coming off the drugs, they warn, can trigger a mental health relapse – risking far greater harm to the health of both mother and child.
Dr Stephanie DeGiorgio, a GP specialising in women’s health who has spent four years educating thousands of GPs on the subject, tells The Mail on Sunday: ‘This has been a problem for a long time.
‘For many years, we didn’t have safe antidepressants that can be taken in pregnancy, which we do now, and the risk of suicide was underestimated. Today we know suicide is the leading cause of death in the perinatal [during pregnancy and the first year after birth] period, and 20 per cent of women suffer from mental health problems during this time. This can be avoided.
‘While there is a very small increased risk to the foetus from antidepressants, this isn’t being explained to women properly. It means some come off their medication with often disastrous consequences.’
DR DeGIORGIO added that she believes women are, in general, being ‘infantilised’ about what is safe in pregnancy ‘from being told one paracetamol is too much to avoiding alcohol completely’. This has led to scepticism about taking any drugs, including antidepressants, she said.
While knowledge was improving, ‘change isn’t happening fast enough’, Dr DeGiorgio adds.
After the GP tweeted about the issue, one specialist midwife working in perinatal mental health agreed the ‘dangerous message’ that antidepressants were bad put ‘the seed of fear’ in women’s minds.
‘I have seen it directly cause harm to families time and time again,’ she adds.
A hospital pharmacist says: ‘I see this all the time on antenatal wards, and there are rarely safety nets in place if the patient has a really hard time off [their medication]. And the risk is relatively high given that they most often go cold-turkey and are more likely to experience postnatal depression.’
One perinatal psychiatrist also reported that her team received ‘weekly’ referrals for pregnant women whose mental health had deteriorated after doctors had advised them to stop taking their medication.
Ruth Rowland became one of them when, at nine weeks pregnant with her second child, she was told by her GP in rural West Wales to come off her antidepressants immediately. With a history of bipolar disorder and post-natal depression after the birth of her first child 15 years previously, Ruth had only just lost her mother to cancer.
Without her medication, her mood spiralled so rapidly that she began planning how to take her own life, meticulously calculating how she could do it without her loved ones finding her. There was debilitating insomnia, uncontrollable facial tics and spasms that made her whole body feel ‘as if it was vibrating’.
She felt ‘absolutely terrified – everything was overwhelming, and I was completely out of control’, she says. Thanks to the support of a desperately worried friend and advice from her old GP, Ruth went to her local A&E – and she was immediately referred for an emergency psychiatric assessment.
Her medication was reinstated, and she was given ongoing mental health support until after her son Oscar, now nine, was born.
Ruth, 47, who runs a reflexology clinic in Carmarthenshire and has another daughter, Olivia, six, was left shaken by her experience. It led to a review of the way pregnant women were supported by mental health teams in the community.
‘I honestly believe if my friend and old GP hadn’t been there, my sisters would have been planning a second funeral, having just buried our mother two months earlier,’ she says. ‘It’s incredibly sad this is still going on, that nothing has changed. It should never happen to anyone.’
Speaking on The Mail on Sunday’s Medical Minefield podcast, Ruth adds that if she ever saw the GP who instructed her to stop taking her medication, ‘I’d tell him to go back to school’.
Gail Parker, 29, has a similar tale. She had been taking antidepressants for five years when she found herself unexpectedly pregnant with her first child in June 2021. Her GP advised it wasn’t safe to continue, and gradually reduced the dose over three weeks.
But soon afterwards, she was forced to self-isolate for ten days in her fourth-floor flat near Salisbury after coming into contact with a Covid case. ‘That’s when everything went wrong,’ says Gail. ‘I became very emotional. I wanted to jump out of the window, and terminate the pregnancy.
‘I was tearful, didn’t want to eat. Life didn’t feel worth living, despite being pregnant.’
During her 16-week appointment with a midwife, Gail, a senior healthcare assistant, admitted she was struggling.
‘I said something like “I don’t want to do this any more”, and she was brilliant. It took another month because the GP was so reluctant, but I was finally put back on a low dose of the pills and referred for therapy. I had to be selfish for myself, because I couldn’t have gone on like that.’
Her daughter, Kallie, was born healthy in February and Gail is now back on her normal dose.
Doctors’ concerns about antidepressants stem from the fact that none is officially licensed for use in pregnant women in the UK.
This is simply because, in common with clinical trials for any drugs, pregnant women can’t take part. That means GPs themselves take on responsibility for prescribing them.
The fears relate particularly to the newer class of antidepressants called selective serotonin reuptake inhibitors, or SSRIs. These boost levels of the brain chemical serotonin, which is linked to mood.
Most people are prescribed these drugs, which include citalopram,
and fluoxetine, before other kinds of antidepressant are offered. It’s SSRIs, and particularly one called paroxetine, that research has linked to an increased risk of heart defects, pulmonary hypertension, autism and other issues.
‘Some studies have shown small increased risks associated with SSRIs, but it’s important we put these into perspective,’ adds Ian Jones, Professor of Psychiatry at Cardiff University.
‘According to these studies, there’s a 1.5 per cent risk of heart defects in babies born to mothers on SSRIs. But the risk is one per cent in the general population, regardless of what medication is taken.’
There is also an increased risk of pulmonary hypertension – a high blood pressure problem that affects babies’ lungs. About one in every 1,000 babies is born with the condition.
In those exposed to SSRIs beyond 20 weeks, it’s two in 1,000, according to some research.
There are a handful of studies that suggest the risk could be higher – up to one in 100. However, Prof Jones urges caution when interpreting all research in this area. He says: ‘The findings for all of these potential effects are in observational studies, which can only ever flag up an association or link – not a definitive cause and effect. It’s possible, and perhaps even likely, there are other causes, not linked to the SSRI, which the researchers haven’t taken into account.
‘For example, we know mothers being overweight increases the risk of heart problems in babies by about the same amount – and people who are overweight are more likely to take antidepressants.
‘Studies that take account of these other factors generally find no increased risk from antidepressants alone. If you think about the risk [to babies from SSRIs] being about the same as being overweight, that puts it in context.’
Current guidance from health watchdog NICE, published in 2014, recommends doctors discuss gradually withdrawing pregnant women from the drugs, and that in some cases talking therapies are preferable.
However, some experts argue that this advice is outdated and harks back to a time when less was known about potential side effects of SSRIs in pregnancy.
Professor Irene Petersen, epidemiologist at University College London, says the evidence for adverse outcomes ‘is not strong’. ‘My research shows women who’ve taken antidepressants during pregnancy are more likely to have an alcohol problem, to smoke and to take drugs,’ she says. ‘They’re also more likely to be obese. All of these issues are also a risk for congenital abnormalities. ‘The one thing that could be associated with antidepressants is post-partum haemorrhage if taken a month before giving birth because these drugs can stop clotting, but that’s something which can be managed with the right care.’
She adds GPs are practising ‘defensive medicine’ and ‘covering their own backs’ by not prescribing to pregnant women because of a misplaced fear that the pills will cause problems and they could be held accountable.
The other side of this, explains Carmine Pariante, Professor of Biological Psychiatry at King’s College London, is that depression itself, if left untreated, is a huge risk for mothers and their babies.
Mothers with depression have higher levels of the stress hormone cortisol, he says, and studies have shown levels of oxytocin, known as the ‘love’ hormone, are also dissertraline rupted. ‘This has a biological effect that possibly impairs the mother’s ability to fully bond and engage with the child, and might also affect the baby’s development in utero. It increases the risk of premature birth and lower birth weight.
‘If you measure the behaviour of newborns, it can be less responsive, or hyper-responsive, which makes them harder to soothe.
‘We even have long-term data that shows children born to mothers who are depressed in pregnancy are more at risk of developing depression or mental health disorders in later life. It seems being exposed to stress in the womb makes them hyperresponsive to stress themselves.’ He adds: ‘Overall, the risk [of taking antidepressants] is very small compared to what we know is a real increased risk of untreated depression.’ There are those who disagree. Some clinicians say the extent of potential side effects in pregnancy still aren’t fully understood. Joanna Moncrieff, Professor of Critical Psychiatry at University College London, disputes the idea that depression is bad for the baby. She says: ‘I don’t think we have evidence for that. Underlying reasons for depression, such as poverty, are likely to be more relevant. But there is evidence linking antidepressants to foetal abnormalities.
‘Aside from foetal abnormalities, some animal research shows if we give antidepressants during pregnancy, the offspring show reduced sexual function when they reach puberty and less social.’
John Reed, Professor of Psychiatry at the University of East London, added that doctors are ‘working in the dark’ because of the lack of research in this area.
‘There are very real concerns, and it’s good that GPs are being cautious,’ he said.
‘What if these mums in the first few weeks [after birth] are closed down emotionally, which is essentially what antidepressants do?
‘I am really concerned about that, because you really need to be tuned in to your emotions, to be a good parent in those first few weeks of life.’
What most do agree on is that pregnancy is a really good time for GPs to discuss with women whether their antidepressants are still necessary, and to make sure women understand the risks – and the benefits – of continuing.
Dr Philippa Kaye, a GP with a special interest in women’s health, agreed that the risks from SSRIs are there, but very small, and that ‘it needs to be a conversation between a doctor who knows about women’s health, and their patient, helping them weigh it all up before making a decision’.
She agreed it was vital pregnant women weren’t frightened into stopping taking vital medications.
Ruth Rowland points out: ‘Of course there’s an element of risk in taking any drug while pregnant. But in some cases, the alternative is a woman in crisis who might need to be pumped full of drugs to manage that. If you don’t have healthy mothers, you don’t have healthy children.’