We thank David Zitner and Angela Bischoff for their interest in our commentary.1 Unfortunately, they do not consider an increasing body of evidence on the serious risks of untreated depression in pregnancy, including the risks of suicidal ideation, suicide attempts and perinatal complications. In addition, gestational depression is the strongest predictor of postpartum depression.2 The results of our risk–benefit analysis have been confirmed by similar expert reviews.3,4
We agree that the cause of depression is often multifactorial and that an abnormality of serotonin levels or serotonin metabolism is often not demonstrated. However, it is not practical to use a specific test to confirm such an abnormality in the clinical setting.
The suggestion by Zitner and Bischoff that pregnant women and women of childbearing age should avoid taking antidepressants because of a lack of well-controlled studies showing a benefit over placebo is analogous to not treating meningitis in pregnancy because there are no randomized trials to demonstrate that penicillin is better than placebo in pregnancy.
Zitner and Bischoff quote one of us as having said, elsewhere, that “What we found was that [among] pregnant women who use Paxil through pregnancy until birth, their offspring are more likely to have several stormy weeks at infancy.” This was taken out of context, as they omitted the accompanying statement that “Many of these babies have to stay in the hospital for two to three weeks after they're born, but they suffer no long-term health effects.”5
Although it may be possible for some women to avoid taking antidepressants as Zitner and Bischoff suggest, they do not offer an alternative approach for the substantial number of women who have major depressive symptoms during pregnancy. Antidepressants continue to be prescribed and it is important that pregnant women and their health care providers have accurate information upon which to base an informed decision regarding therapy.
Gideon Koren Motherisk Program Hospital for Sick Children Toronto, Ont. Doreen Matsui Department of Pediatrics University of Western Ontario London, Ont. Adrienne Einarson Motherisk Program Hospital for Sick Children Toronto, Ont. David Knopper Department of Pediatrics University of Western Ontario London, Ont. Meir Steiner Department of Psychiatry and Behavioural Neurosciences McMaster University Hamilton, Ont.
REFERENCES
- 1.Koren G, Matsui D, Einarson A, et al. Is maternal use of selective serotonin reuptake inhibitors in the third trimester of pregnancy harmful to neonates? CMAJ 2005;172(11):1457-9. [DOI] [PMC free article] [PubMed]
- 2.Huot RL, Brennan PA, Stowe ZN, et al. Negative effect in offspring of depressed mothers is predicted by infant cortisol levels at 6 months and maternal depression during pregnancy, but not postpartum. Ann NY Acad Sci 2004;1032:234-6. [DOI] [PubMed]
- 3.Nordeng H, Spigset O. Treatment with selective serotonin reuptake inhibitors in the third trimester of pregnancy: effects on the infant. Drug Saf 2005;28:565-81. [DOI] [PubMed]
- 4.Ruchkin V, Martin A. SSRIs and the developing brain. Lancet 2005;365(9458):451-3. [DOI] [PubMed]
- 5.Paxil in late pregnancy may cause problems. Available: www.healthyplace.com/communities/depression/treatment/antidepressants/articles/004.asp (accessed 2005 Oct 12).