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No easy answers for physicians caring for pregnant women with depression.

PROMPTED BY GROWING EVIDENCE that pregnant women face a higher risk of fetal problems both with the use of selective serotonin reuptake inhibitors (SSRIs) and with untreated depression, experts from the American College of Obstetricians and Gynecologists (ACOG) and the American Psychiatric Association (APA) are offering physicians a nuanced set of guidelines that emphasize an individualized approach. Between 10% and 20% of women experience depression during pregnancy, according to the March of Dimes, and the use of antidepressant medications in this population for at least some period during pregnancy more than doubled in recent years, from 5.7% of pregnancies in 1993 to 13.4% in 2003 (Cooper WO et al. Am J Obstet Gynecol. 2007;196[6]:544e). Yet even as more women and their physicians recognize the importance of treating depression for the wellbeing of both mother and child, they face difficult choices when considering whether medicat ion use is appropriate. Recent data suggest that use of SSRIs, which are now the most commonly used antidepressants, during pregnancy may contribute to an increased risk of such outcomes as septal heart defects, preterm delivery, low 5-minute Apgar score, and admission to a neonatal intensive care unit. These new findings add to a complex body of evidence that has linked both antidepressant use and gestational depression with poor fetal growth, premature delivery, and short-term behavioral changes in the neonate, according to a recent review and guidelines by the APA and ACOG (Yonkers KA et al. Gen Hosp Psychiatry. 2009;31[5]:403-413). Other studies have suggested that SSRI use during early pregnancy is associated