December 17, 2015
We write on behalf of Postpartum Support International (PSI), the leading organization dedicated to helping women suffering from perinatal mood disorders, and its clinical member group, the Reproductive Psychiatry Group. As a group, we are deeply concerned by the possible harmful repercussions of Boukhris et al.’s study ‘Antidepressant Use During Pregnancy and the Risk of Autism Spectrum Disorder in Children’, just published in JAMA Pediatrics. (Boukhris 2015) (1). This study and the resulting media fervor may frighten women who may previously, currently or in the future need antidepressants during pregnancy for their mental health and wellbeing.
We hope to highlight serious methodological errors in this study. First, epidemiological studies such as this one fall short of identifying unique risks related to antidepressants during pregnancy. There is already strong evidence that mothers with untreated depression are more likely to have a child with autism. (2) The genetic heritability of autism was found to be more than 90%, and the genes found to be involved in depression overlap with those playing a role in autism. (3) Despite these clear genetic links, the authors failed to control for family history of both parents when designing this recent study.
In terms of results, the findings of an association between prenatal exposure to antidepressants and offspring with autism were no longer significant once autism diagnosis was made only by a neurologist or by a psychiatrist. Furthermore, the risk of autism was significantly decreased after controlling for maternal history of depression.
Finally, the authors frame the main finding as an ‘87% increase’ in offspring of mothers who took antidepressants during pregnancy, while in fact the absolute risk increase was less than 1%.
Many studies have explored this topic, yet unfortunately the media focuses on papers with positive findings, regardless of the veracity of the work. Two larger, well-controlled epidemiological studies in 2013, one including up to 630 000 Danish children, failed to find an association between prenatal exposure to antidepressant medication and autism spectrum disorders. (4) We implore the mainstream media to present the negative studies to help women feel more secure, not just the positive studies that feed into their greatest fears.
A risk versus benefit analysis occurs daily among women, their partners, and clinicians involved in reproductive psychiatry. Alarmist headlines, such as those we are seeing worldwide in response to this study, cause many women with a history of depression to stop their antidepressant medication, increasing their chance of relapsing to more than 50%. Both antenatal and postnatal depression have known and quantifiable risks to mother and child, and every treatment decision for a pregnant woman must balance those known risks against any risks of medication. As a society, we must be very cautious about understanding the risks and benefits associated with psychiatric treatment. PSI, the Reproductive Psychiatry Group, and its members support well-designed research and thoughtful publication to help families and providers make well-informed decisions regarding the use of psychotropic medication during pregnancy.
Carla Atkinson MD, FRCPC, Department of Psychiatry, University of Calgary, Calgary, AB, Canada
Gisèle Apter, MD, PhD, University of Paris 7 Denis Diderot, Perinatal Psychiatry Emergency Mobile Unit, France
Nazan Aydin, MD and the Bakirkoy Women’s Mental Health Center, İstanbul, Turkey
Beth Bassett, MS LPC, Portland Oregon
Catherine A. Birndorf, MD, Clinical Associate Professor of Psychiatry, Founding Director, Payne Whitney Women’s Program, NY Presbyterian Hospital – Weill Cornell Medical Center
Angela Bowen, RN PhD, University of Saskatchewan, Canada
Nancy Byatt, DO, MS, MBA, FAPM, Medical Director, Massachusetts Child Psychiatry Access Project for Moms (MCPAP for Moms), Assistant Professor of Psychiatry and Obstetrics & Gynecology, UMass Memorial Medical Center/UMass Medical School
Jessica Chaudhary, MD, Danbury, CT
Nicole Harrington Cirino MD, Assistant Professor Psychiatry and Obstetrics and Gynecology, Division Chief, Women’s Mental Health and Wellness, Oregon Health and Sciences University (OHSU) Center for Women’s Health, Portland OR
Shelly Cohen, MD, JD, New York, NY
Ariel K. Dalfen, MD, FRCP(C), Perinatal Mental Health Program, Dept of Psychiatry, Mount Sinai Hospital, Assistant Professor, Department of Psychiatry, University of Toronto, Canada
Emily C Dossett, MD and the Women’s Mental Health Program at Los Angeles County + University of Southern California, Los Angeles, CA, USA
Gregg A. Eichenfield, PhD, LP, St Paul, MN
Adrienne Einarson, RN, PhD, founder of Reproductive Psychiatry Group, former assistant director at The Motherisk Program, Hospital for Sick Children, Toronto Canada
Noreen Esposito EdD, PMHNP-BC, WHNP-BC, FAANP, Associate Professor, School of Nursing, University of North Carolina at Chapel Hill
Elizabeth M. Fitelson, M.D. , Assistant Professor of Psychiatry at CUMC, Director, The Women’s Program, Columbia University Department of Psychiatry, New York, NY
Dr. Alicja Fishell, MD, Department of Psychiatry, Women’s College Hospital, Toronto, Canada
Julia Frew, MD, Director, Women’s Mental Health Service, Dartmouth-Hitchcock Medical Center. Assistant Professor of Psychiatry, Geisel School of Medicine at Dartmouth, New Hampshire
Lisa Gagnon, MD, Chair of the Perinatal Mental Health Network and lead Quality Assurance for the Department of Psychiatry in Calgary, University of Calgary, Calgary, Alberta, Canada
Priya Gopalan, MD, University of Pittsburgh Medical Center; Western Psychiatric, Institute and Clinic, Pittsburgh PA
Judy A. Greene MD, Director of Women’s Mental Health, Bellevue Hospital Center, Training Director, Reproductive Psychiatry Fellowship, NYU School of Medicine
Adrienne Griffen, Executive Director, Postpartum Support Virginia; Christine Truman, MD, Board Member, Postpartum Support Virginia; Natasha K. Sriraman, MD, MPH, FAAP, FABM, Associate Professor of Pediatrics, Children’s Hospital of The King’s Daughters/Eastern Virginia Medical School
Sophie Grigoriadis, MD, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
Catherine Harrison-Restelli, MD, Assistant Professor, Division of Consultation Liaison Psychiatry, University of Maryland School of Medicine, Baltimore, MD
Alison Hermann MD, Clinical Director of the Payne Whitney Women’s Program, Weill Cornell Medicine
Margaret Howard, PhD, Women’s behavioral health at Women & Infants Hospital, Brown University, Women & Infants Hospital, Providence, Rhode Island
Pec Indman, EdD, MFT, San Jose, CA
Helen Kim, MD, Mother-Baby Program and Hennepin Women’s Mental Health Program, Hennepin County Medical Center, Minneapolis, MN
Elizabeth M. LaRusso, MD and the Mother Baby Mental Health Program, Allina Health, Minneapolis, MN
Shari I. Lusskin, MD, Clinical Professor of Psychiatry, Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, NY
Judy S. McKay, M.D., M.P.H., Asheville, N.C.
Samantha Meltzer-Brody, MD, and Chris Raines, RN MSN APRN-BC, University of North Carolina Perinatal Psychiatry Program, Chapel Hill, NC
Leena Mittal, MD and Women’s Mental Health at Brigham and Women’s Hospital, Boston, Massachusetts
Maria Muzik, MD, MS for the Women and Infants Mental Health Program, Department of Psychiatry, University of Michigan
Irena Nulman MD, MSc, FRCPC Neurology, PhD, Professor of Pediatrics and Pharmacology, Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, University of Toronto
Izu Nwachukwu MD, FRCPC, DCP, M.Sc, MRCPsych(UK), University of Calgary, Alberta Canada
Oguz Omay M.D., Perinatal Psychiatry Unit, La Teppe Medical Center, 26600 Tain l’Hermitage, France
Lauren M. Osborne, MD and Jennifer Payne, MD, Women’s Mood Disorders Center, The Johns Hopkins University School of Medicine, Baltimore MD
Vivian Polak, MD, FRCPC, Wellington Reproductive Psychiatry Telemedicine Program, Ontario, Canada
Gail Erlick Robinson, MD, DPsych, FRCPC, Professor of Psychiatry, University of Toronto, Director, Women’s Mental Health Program, University Health Network, Toronto, Ontario
Miriam Schultz, M.D., Berkeley, CA
Rachel Shmuts, D.O., Women’s Mental Health Program, Department of Psychiatry, Rowan University School of Osteopathic Medicine, New Jersey
Ann D.S. Smith, MSN, CNM, WHNP, President, Postpartum Support International
Milena Hruby Smith, M.D., Ph.D., Annapolis, MD
Carly Snyder, MD, PSI Research Chair, PSI Executive Board PSI, Director, Women’s Health Program, Family Health Associates, Program Director, Women’s Mental Health Elective, Mount Sinai Beth Israel Medical Center, New York, NY
Diane N. Solomon, CNM, PMHNP, PhD Candidate, Oregon Health & Science University, Portland Oregon
Margaret Spinelli MD, Clinical Professor of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY
Amanda Tinkelman, MD, Tina Walch, MD, Pauline Walfisch, LCSW, Perinatal Psychiatry Services at The Zucker Hillside Hospital and South Oaks Hospital- North Shore-LIJ, NY
Christine Titus, PMHNP, Portland Oregon
Simone Vigod, MD, MSc, FRCPC, Lori Wasserman, MD, FRCPC; Renu Gupta, MD, FRCPC from Reproductive Life Stages Program, Women’s College Hospital, Toronto, Canada
Tricia Wright, MD MS FACOG Diplomate ABAM, Assistant Professor Department of Obstetrics, Gynecology and Women’s Health Clinical Assistant Professor, Department of Psychiatry, University of Hawaii John A. Burns School of Medicine