**Cohen, L. S., Altshuler, L. L., Harlow, B. L., Nonacs, R., Newport, D. J., Viguera, A. C. et al. (2006). JAMA, 295, 499-507.

Although one article is usually cited in each section of this Evidence-Based Practice column, in this instance, the body of work supporting the evidence is not coherent, but contradictory, and it seemed appropriate to comment on both of these new studies on depression treatment. These studies underscore the quandary facing healthcare providers and pregnant women about taking antidepressants in pregnancy. Cohen et al. (2006) report findings that dispute the widely held belief that pregnancy is a time of well being, protective against emotional and psychiatric problems. They suggest that stopping antidepressant medication may be dangerous for mother and child. On the other hand, Levinson-Castiel, Merlob, Linder, Sirota, and Klinger (2006) report that 30% of women who take selective serotonin reuptake inhibitors (SSRIs) during pregnancy have babies who have symptoms of drug withdrawal (crying, tremors, sleep problems, and gastrointestinal disturbances) for upto 48 hours. The long-term effects of in utero exposure to SSRIs was not examined in either study.

In the Cohen study, 201 women who had a history of major depression before pregnancy and were currently receiving antidepressant medication were studied in pregnancy. The majority of the women (92%) received predominantly SSRIs or dual-action antidepressants. Some continued to take their medication, others discontinued it. Forty-three percent of the women experienced a relapse of major depression in pregnancy. Of those who kept taking their medication, only 26% relapsed, compared to 68% of those who discontinued their medication.

In the second study, 18 of 60 infants exposed to SSRIs in pregnancy suffered neonatal abstinence syndrome (30%). None of a matched group of 60 infants whose mothers did not take SSRIs in pregnancy had the problem.

So what are we to conclude from these studies? Depression in pregnancy poses its own risks. Depressed pregnant women do not eat properly and may engage in behaviors harmful to themselves and the fetus, that is, smoking, alcohol, and drugs. But prolonged SSRI exposure has at least a short-term effect on the newborn. Dr. Cohen concluded: "My hope is that it will be less of a reflex to stop the medicine and more a collaborative decision that weighs all the risks."

Linda Beth Tiedje

^**After the publication of the Cohen study, it was discovered that most of the 13 authors had financial ties with drug companies including antidepressant makers, but only two of the authors revealed their ties when the study was published. The authors defended their research in a letter to the editor published on July 12, 2006. The lead author who is in the speakers bureau for eight drug companies, disputed that such ties could influence findings. This further adds to the complexities of interpreting this research. [Context Link]