Sasha Aslanian: It's only been in the past decade that doctors identified and began studying depression during pregnancy. Dr. Lee Cohen is a Perinatal Psychiatrist at Massachusetts General Hospital in Boston.

Lee Cohen: When I trained, clinical lore went along the lines that women did fine during pregnancy, that they were protected because of the reproductive hormones.

Aslanian: Nearly twenty years later, Cohen runs one of the leading centers in the country specializing in mood disorders during pregnancy. He says women in this situation haven't always found good information to guide them.

[Mother talking to child]

Seven years ago, when she was considering becoming pregnant and wondering what to do about her medication, Lisa Kirshenbaum of Providence, Rhode Island, says her psychiatrist told her to stop taking the drugs for the sake of the baby, and not to worry.

Lisa Kirshenbaum: He said most women, when they're pregnant, don't suffer from depression. Most women have this sort of natural high when they're pregnant.

Aslanian: That worked for her first pregnancy. But for her second, going off her antidepressant during pregnancy brought on a swift and debilitating relapse. She and her husband Evan struggled to find help.

Evan Kirshenbaum: They were pushing for us non-medication alternatives, like exercise and yoga and -

Lisa: Kirshenbaum: Acupuncture.

Evan Kirshenbaum: Meditation tapes.

Lisa Kirshenbaum: I had needles put in my toes and I'm laying there thinking - I felt like I was dying and someone had to help me. I remember saying to him, 'Please help me, please help me, please help me.' I was just so desperate.

Aslanian: The couple turned to Lisa's OB-GYN and other psychiatrists, but they say no one was equipped to deal with their problem.

Evan Kirshenbaum: I mean, at one particular doctor's appointment, you know, he handed us a medical journal article. You know, I'm not a doctor. It was just kinda dumped in our lap.

Lisa Kirshenbaum: Basically, 'These are the risks you're going to take. I'm very hesitant to prescribe but if you insist on taking medications these are the risks and they're pretty high.' I mean we were - we were really scared.

Aslanian: The Kirshenbaums were warned about the risk of organ malformation during the early weeks of pregnancy, something that Lee Cohen, the perinatal psychiatrist, says has not been borne out by almost two decades worth of international surveillance by the drug makers and by independent registries. With her third pregnancy, Lisa Kirshenbaum came to Dr. Cohen for help. He switched her to an antidepressant he considered safer and she had a healthy baby.

Prozac is the oldest SSRI. It went on the market in the U.S. in 1987. SSRI stands for Selective Serotonin Reuptake Inhibitor. Although the FDA has never approved any SSRIs for use during pregnancy, they are so widely prescribed in the general population that Cohen says there's a lot of data about them, even during pregnancy.

Cohen: We know much more about the SSRIs in terms of their reproductive safety than most of the medications that women actually take during pregnancy.

Aslanian: And so far, Cohen says, the news is pretty good.

Cohen: There are essentially no reports that suggest that using SSRIs during the first trimester of pregnancy increases the risk for organ malformations. And that's a very reassuring message.

Aslanian: Cohen says while the information about SSRIs isn't perfect, it's his sense that if there were some serious negative outcome, it would have surfaced by now.

Dr. Sandy Zeskind views the safety data in a different light.

Sandy Zeskind: Studies that have found no effects, no adverse effects of moms taking SSRIs during pregnancy, are really based on such outcomes as the baby is low-birthweight, or premature, or if there are gross physical anomalies. And those are the kinds of measures that, quite honestly, are the same ones that ancient Sparta used to determine whether a baby was healthy or not.

Aslanian: Zeskind directs neurodevelopmental research at Carolinas Medical Center in Charlotte. He testified before the FDA advisory panel that, although SSRI-exposed babies may look like healthy full-term babies, when closely observed right after birth, they display subtle neurological problems.

Zeskind: Babies whose moms used SSRIs during pregnancy were significantly more tremulous. They had these nervous shakes, much more than other babies. They also startled more.

Aslanian: But, Dr. Cohen, of Mass General, sent a letter to the FDA as a consultant for Prozac-maker Eli Lilly, pointing out these symptoms in newborns also show up in babies whose mothers were depressed and not on medication.

Cohen: And until we have better studies, it'll be very hard to tease out the effects of being on those medications and the effects of being exposed to depression.

Aslanian: In the face of this uncertainty, pregnant women need to make choices.

Psychiatrist Helen Kim counsels patients daily at Hennepin Women's Mental Health Program in Minneapolis. She tries to put the FDA warning in the context of the woman's own history of depression.

Helen Kim: Ultimately, when you are face-to-face with a woman struggling with depression or anxiety during or after her pregnancy, her experience of illness is, I think, the most important determinant of the right thing to do. And I can have the same conversation with a room full of women and that room full of women as individuals will make very different decisions based on their own perception of risk.

Aslanian: Women must also decide what do to about medication in the post-partum period, particularly if they want to breastfeed. The American Academy of Pediatrics says the effects of antidepressants on nursing babies are unknown, but may be of concern.

But forgoing treatment could mean exposing a baby to depression in his or her first crucial relationship.

Ed Tronick, a developmental psychologist at Harvard University, has spent 30 years filming the moment-by-moment interactions between depressed mothers and their babies.

[Videotape sound]

Ed Tronick: The mother is reaching to take the baby's hand and the baby's pulling her hand away. Now, here's a smile, but when she smiles, the baby's looking away so she goes flat again. It's almost like she gives up on the interaction.

Aslanian: Over time, the missteps add up. Tronick says the baby displays sadness and irritability and starts to take on the mother's depressed affect. Tronick says he's come to see depression as a communicable disease, transferred through a mother's communication to her baby.

[Baby sounds]

Aslanian: Amy Newell, a 29-year-old mother in Brookline, Massachusetts is trying to spare her one-year old son Ari her history of depression. She's concerned about his vulnerability to what she calls "the black hole of depression," so she's vigilant about taking care of her own mental health.

Amy Newell: Every mood that I have, Ari gets to share. I don't think that means that I have to be happy all the time, but it means that I have to model good management of my moods. And I try to plan for what would I do if I had a major depressive episode again. Obviously, my first priority would be to insulate Ari as much as possible from the effects of that.

Aslanian: Since ten-percent of pregnant women suffer from depression, experts in the field of perinatal psychiatry say finding better ways to insulate children from depression, as well as medication, is a top priority.

For NPR News and American Radio Works, I'm Sasha Aslanian.

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