Can pregnant women shake off depression?

For her baby's sake, Lisa Kirshenbaum's psychiatrist advised, she should stop taking her antidepressant when she became pregnant. Besides, he told her, "you have a natural high when you're pregnant."

That seemed to be true with her first pregnancy. Even off her medication, "I was feeling pretty good," says Kirshenbaum, 36, a Cranston, R.I., communications consultant who had been on an antidepressant since college. "I had some anxiety, but it was manageable."

When her son was 2 1/2, she and her husband decided to try for another child. Kirshenbaum got pregnant almost immediately and went off her antidepressant. This time, she fell into a severe depression.

Her experience is not uncommon. Doctors have always shied away from prescribing medications to pregnant women because of concerns about harming the fetus. And they believed pregnancy protected against depression.

New area of concern

"You hear about postpartum depression," notes new mother Cassie Paredes, who turns 20 this month. "I didn't know that depression occurred during pregnancy."

Paredes, of Springfield, Ore., has a family history of depression. Until her pregnancy, she hadn't suffered from it herself. But, she says, she became so depressed when pregnant with her now 9-month-old son that she hoped vaginal bleeding meant she'd miscarry. "I thought I was a freak, that I must be a horrible person if I'm happy at the thought of miscarrying," she says.

Only recently have doctors begun to recognize that pregnant women are just as likely to get depressed as their non-pregnant peers. Studies suggest that more than 10% of pregnant women experience depression, or hundreds of thousands each year.

A study published last month of 201 pregnant women with a history of major depression found that 68% of those who stopped their antidepressants relapsed, compared with only 26% of those who stayed on their drugs. Lead author Lee Cohen, a Harvard psychiatrist, says his team is trying to figure out why some women did not relapse after quitting their antidepressants.

Though doctors worried about antidepressants' effects on a fetus, little consideration was given to untreated depression's effect on mother and child.

"Going off a medication during pregnancy may be for some women a far greater risk than staying on," says psychologist Margaret Howard of Women & Infants Hospital in Providence.

Recent research suggests that depressed pregnant women are more likely to deliver too early or develop preeclampsia. "There are potentially risks on both sides of the fence," says University of Michigan psychiatrist Sheila Marcus. "You really have to look at the severity of the maternal illness, the desire of the mother, the medicine you're thinking about using."

For some pregnant women, talk therapy and exercise can relieve depression without drugs, she says.

Research about the safety of selective serotonin reuptake inhibitors (SSRIs) such as Prozac and Paxil during pregnancy has come to mixed conclusions. A study out last month concluded that women who took Prozac, Paxil, Zoloft or Celexa during the second half of pregnancy were six times more likely to deliver a baby with a rare but potentially fatal heart and lung condition.

At a press conference about the findings, Food and Drug Administration official Sandra Kweder said the agency might ask SSRI manufacturers to add a new warning to their labels. But Kweder emphasized that the risk of the condition is still only about 1% in women who take SSRIs later in pregnancy.

Preliminary data from two other studies suggests that babies whose mothers took Paxil early in pregnancy are 1 1/2 to 2 times more likely to be born with a heart defect than babies in the general population, where the risk of such defects is about 1%. That finding spurred the FDA in December to reclassify Paxil from pregnancy category C, meaning pregnant women should be cautious about taking it, to category D, meaning there is evidence of human fetal risk.

And some research suggests that babies born to mothers who took SSRIs while pregnant may have temporary withdrawal symptoms.

'A crisis for my family'

Kirshenbaum tried several non-drug treatments for depression during her second pregnancy, such as yoga and light therapy, which some research suggests might help depressed pregnant women.

Nothing worked, and she miscarried at nine weeks. She says she can't be sure whether depression played a role. But she is certain about one thing. Her untreated depression during that pregnancy "was a crisis for my family. My son was 3. I couldn't interact with him. I couldn't get out of bed."

After her miscarriage, Kirshenbaum resumed taking an antidepressant. Within a few weeks, she was back at work. She and her husband were still desperate for another child, but she didn't see how she could stop taking her medication.

Then she learned about Cohen at Harvard. He advised that she switch to Prozac, with the longest track record in pregnancy, before trying to conceive. Prozac alleviated her depression, and Kirshenbaum quickly became pregnant. As her pregnancy progressed, Cohen raised her dosage to compensate for her increased fluid volume.

"I had the most wonderful pregnancy. There wasn't a doubt in my mind that she was going to be perfect," she says of her daughter, now 2 1/2. "And of course, she is."

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