Pregnancy and Pre-Existing Depression

Drugs & Treatments

A woman who becomes pregnant while taking anti-depressants may have worries over the effects of a particular medicine. Luckily, there's been an explosion of effective, and for the most part safe, antidepressant drugs over the last fifteen years. Many patients will be on these newer, modern drugs. A seriously depressed patient who is still taking an older drug, however, might have to switch to a safer medicine, which could present risks of worsening her condition.

Below is a simple review of drugs used for both clinical depression and the simpler mood disorder of "feeling depressed."

Please note that The American Academy of Pediatrics feels the permanent effects of antidepressants on the nursing infant to be unknown and therefore doesn't officially sanction their safety at this time.

THE NEW STUFF: The "selective serotonin re-uptake inhibitors" (SSRIs)

These drugs keep the levels of serotonin higher in the brain. Serotonin is a neurotransmitter that rises and falls, affecting mood and well being. These medications decrease the amount of serotonin that is reabsorbed, keeping the levels higher and constant.

• Zoloft (sertraline ) FDA Class B. Probably safe.
• Prozac (fluoxetine) FDA Class B. Probably safe. There's more data on Prozac than Zoloft, prompting one to think that Prozac may be safer. But it's just that there's more data exonerating the Prozac.
• Paxil (Paroxetine) FDA Class B. Probably safe.
• Luvox (fluvoxamine) FDA Class B. Probably safe. This drug not only keeps levels of serotonin up, but also decreases the re-uptake of dopamine, another "feel good" neurotransmitter. In fact, dopamine is the neurotransmitter that is especially high in addictions, and its fall is associated with the unpleasant physical suffering called withdrawal. This is the whole idea behind using Wellbutrin (a.k.a., Zyban) (a dopamine re-uptake inhibitor) to quit smoking.
• Wellbutrin, Zyban (Bupropion) FDA Class B. Probably safe, and in fact it's safety has been well-established in that there haven't been any reports of problems with it.
• Effexor (venlafaxine). FDA Class B. Probably safe. This drug's actual mechanism is unknown, but it works probably by increasing the neurotransmitter activity as well. There have been some concerns regarding an increase in blood pressure with Effexor, and it this side effect would be particularly confusing in a pregnancy because of the usual vigilance for Pregnancy-induced Hypertension (PIH, formerly called "toxemia" or "pre-eclampsia").

ANTI-ANXIETY AGENTS

• Buspar (buspirone) FDA Class B. Probably safe. As described above, this decreases the re-uptake of dopamine.
• Atarax (or Vistaril) (Hydroxyzine) FDA Class C. There's a small possibility of abnormalities if given during the first trimester. But Vistaril is a popular anti-nausea drug that is used commonly during pregnancy. In my practice, I will just try to avoid it during the first trimester, and I don't generally use this as a first choice for anxiety, Buspar being a better choice.
• Xanax FDA Class D. See below, "The bad guys in pregnancy."

THE BAD GUYS IN PREGNANCY

• Valium (diazepam) FDA Class D. Not recommended. Quick to reach the fetus, but slow to clear, this drug has been associated with facial development abnormalities, cleft lips and palates, growth retardation...Do I need to go on? These warnings are for the chronic use or abuse of Valium. (Using it acutely in a seizure situation probably doesn't have the same dangers, not to mention that using it for dire emergencies is better than not using it.)
• Xanax (Alprazolam) FDA Class D. Not recommended. This drug is related to Valium and all of the above apply. In my practice, I've found it more addictive than the serotonin-re-uptake inhibitors. (Actually, I've never had trouble getting patients off of the serotonin-re-uptake inhibitors; but I can't say the same for Xanax. Of course, in all fairness to Xanax, it's probably used most frequently against labeling instructions.)
• Dalmane (Alprazolam) FDA Class D. Same story, it's an "-azepam" drug. In fact, it's a good idea to stay away from any drug whose generic name ends in "-azepam." Dalmane is usually used as a sleeping pill. Withdrawal in newborns is always a possibility with the "-azepams."
• Ativan (lorazepam). Lorazepam is a benzodiazepine. Lump it in with the above "bad guys." Tranxene (chlorazepate)­also an "-azepam," actually, a "-diazepine". Stay away from it, too.

THE OLDER STUFF

• Elavil (amitriptyline) FDA Class D. Probably safe, but it earns the "D" status because there have been rare reports of deformities. "Safe for most pregnancies" doesn't reassure the one person whose baby is affected adversely.
• Tofranil (Imipramine) FDA Class D. Same story as Elavil. Also, one mustn't forget the withdrawal a newborn may suffer at the hands of these drugs.