A woman who is depressed in pregnancy faces the difficult process of weighting the pros and cons of starting antidepressant treatment, but unfortunately the evidence regarding the effects of antidepressants in pregnancy on offspring outcomes remains far from conclusive. At the same time, more studies are showing that untreated depression per se has negative consequences on offspring outcomes. Weighing the pros and cons in this context is by no means an easy process.

A number of population-based studies using prescriptions registers have found that treatment with antidepressants in pregnancy, especially with selective serotonin reuptake inhibitors, is associated with an increased risk of cardiac malformations (for exposure in the first trimester) and of pulmonary hypertension in the newborn (for exposure in the third trimester) (Pedersen et al, 2009; Grigoriadis et al, 2014). However, there is one main caveat: it is very difficult to distinguish the effects of antidepressants from the effects of untreated depression, as prescriptions registers often lack clinical information, and treatment allocation is not randomized. Even comparing the naturalistic cohorts of treated and untreated depressed women cannot adjust for the fact that treated women are likely to be more complex and more severely depressed—and therefore more likely to smoke, to drink alcohol, and to have less regular antenatal care. Indeed, one very recent study that has attempted to adjust for such variables using the US Medicaid database has found no substantial increase in the risk of cardiac malformations attributable to antidepressants (Huybrechts et al, 2014). Even the (small) increase in pulmonary hypertension attributable to antidepressants could be explained by the higher risk of prematurity described in women who are depressed (Grigoriadis et al, 2014).

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