Opinion | Mothers deserve better than misinformation about antidepressants

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On July 21, the Food and Drug Administration (FDA) convened a panel to discuss the safety in pregnancy of antidepressants, specifically selective serotonin reuptake inhibitors (SSRIs). Unfortunately, most speakers presented misleading and inflammatory statements about psychiatric medication and downplayed the serious adverse impact of maternal depression.

As perinatal psychiatrists who have collectively treated thousands of pregnant and postpartum patients over decades of practice, we were deeply alarmed. Maternal mental illness is common and includes not only depression but also a spectrum of mood, anxiety, trauma-related and psychotic conditions that can be devastating, life-limiting and life-threatening — not just for mothers, but for their children and families as well.

Epidemiologic studies indicate that 10% to 20% of women experience clinically significant depressive symptoms during and after pregnancy. When those conditions are untreated, the immediate risks are well documented: preterm birth, low birth weight, intrauterine growth restriction, increased neonatal intensive care admissions and suicide, which remains one of the leading causes of maternal death in the U.S.

Our decades of clinical experience have shown us something equally concerning. Maternal mental illness has a profound and lasting impact on child development — a finding confirmed by extensive research. Maternal depression can impact fetal brain development including areas critical for stress reactivity and vulnerability to mood and anxiety disorders. Untreated maternal depression leads to dysregulation of the maternal hypothalamic-pituitary-adrenal axis, exposing the developing fetus to elevated stress hormones and inflammation associated with long-standing alterations in the child’s stress response system.

In our practices, we have also witnessed how maternal depression and anxiety can compromise a mother’s ability to provide the consistent and emotionally attuned caregiving that infants and young children need for healthy brain development. Despite their love for their children, mothers with mental illness often struggle to provide the responsive nurturance, protection and delight that form the foundation of secure attachment. We also see the dramatic impact of effective treatment that makes our work as perinatal psychiatrists so rewarding. Nothing is more satisfying than helping a mother desperately fighting tears, blankly staring and unable to smile at her crying infant, to be able to access positive emotions and interact playfully with her cooing baby.

The decision to use medication during pregnancy requires careful assessment of the risks and benefits of both treatment and non-treatment. We routinely engage in this complex risk-benefit analysis, as do clinicians across all fields of medicine. Consider mothers with epilepsy. We continue anti-seizure medications during pregnancy because the risks of uncontrolled seizures far outweigh the medication risks. The same principle applies to maternal depression and other forms of mental illness.

Decades of data from large population-based studies demonstrate that SSRIs are not associated with adverse outcomes that were previously feared. Large meta-analyses have found no substantial increase in overall congenital malformations among infants with prenatal SSRI exposure. The potential risks that do exist — such as poor neonatal adaptation (affecting 25-30% of exposed newborns but typically transient with no long-term effects) — are generally mild and manageable with supportive care. Importantly, large-scale studies have found no significant increase in neurodevelopmental disorders, including autism, in children exposed to SSRIs in utero.

While antidepressants and psychotherapy can improve depression symptoms, access to any treatment is seriously limited, particularly in rural America. For many mothers — especially those with severe or recurrent depression or those who do not respond to other treatments — medication can be lifesaving.

The American College of Obstetricians and Gynecologists and American Psychiatric Association have made clear, evidence-based recommendations: Screen for depression and anxiety during and after pregnancy and ensure that women have access to the full range of treatment options including medication. The FDA should reinforce these standards, not muddy them with panelists that prioritize unfounded fears over scientific evidence.

The FDA panel sent a dangerous message to patients who may now be even more hesitant to seek help and to clinicians who may refuse to treat pregnant patients. Biased panels like this give undue weight to skepticism and fear over science and the extensive evidence base for antidepressants in pregnancy, putting both mothers and children at risk of preventable harm. The stakes are simply too high to let misinformation guide our approach to maternal mental health. Failing to identify and treat maternal mental illness causes profound harm to mothers, children and families. They deserve better.