Preliminary Research Sparks Concerns that In Utero Exposure May Increase Risk of Autism Spectrum Disorder: Evaluating the Report

Recently a case-controlled study was published online associating selective serotonin reuptake inhibitor (SSRI) antidepressant exposure during pregnancy with a modest increase in the risk of exposed offspring developing an autism spectrum disorder (ASD).  The research data was gathered from medical records at a Kaiser Permanente Medical Care Program based in Northern California.  The study shows that approximately 2.3% of children with autism spectrum disorder  may be linked to first trimester maternal use of SSRIs such as fluoxetine (Prozac), citalopram (Celexa), ecitalopram (Lexapro), and sertraline (Zoloft).  Further, it suggests that there is an increased risk of autism spectrum disorder , although slightly less than in the first trimester, for children exposed in-utero to maternal SSRI use during the second and third trimesters.  Because other research suggests that abnormal serotonin regulation may contribute to the development of autism spectrum disorder , this study raises valid concerns about SSRI use in pregnancy and its long-term risks for offspring.

AUTISM?  NOT SO FAST….

While the conclusions reached by the article’s authors are valid and the research appears to be a well-done case-controlled study; there are some limitations that would suggest we view its results as preliminary in nature, due to:

1. There were no clinical assessments of the severity of maternal depression and anxiety during pregnancies, as these conditions alone may contribute to neuro-developmental difficulties in offspring.
2. The study participant group was small and only represented a specific geographical location.
3. The data relies solely on documentation of prescriptions written, and does not validate actual maternal use of antidepressants.
4. The offspring were not clinically evaluated to confirm a diagnosis of autism spectrum disorder.
5. The exclusion of some control offspring whose medical records contained an autism spectrum disorder diagnosis after initial group selection.

“……Very Unlikely to be a Major Risk Factor for Autism…”

Thus, it must be stressed that the results of this study do not establish unequivocably that SSRIs increase the risk for autistic spectrum disease in prenatally exposed offspring.   As the authors themselves admit, “..it is reasonable to conclude that prenatal SSRI exposure is very unlikely to be a major risk factor for autism spectrum disorder .”  Because clinical depression causes significant risk to both the mother and her unborn child; a potential increase in autism spectrum disorder needs to be weighed carefully with any additional risks and benefits antidepressant medication poses.

A new alternative to psychopharmacological treatment of depression during pregnancy and breastfeeding is Transcranial Magnetic Stimulation (TMS). TMS is an FDA-approved outpatient application of MRI-strength magnetic pulses to the head, which has been proven effective in the treatment of depression and depression-related anxiety.  Unlike medications, TMS does not enter the blood stream, eliminating the direct exposure risk to in-utero or breastfeeding babies.

As a psychiatrist sub-specializing in reproductive psychiatry, I have treated patients, both pregnant and breastfeeding, for years with psychiatric medications and have witnessed the benefits of SSRI antidepressants. Nevertheless, medications are sometimes ineffective or require the addition of more drugs, which leads to further exposures. Therefore, I offer TMS for consideration as an alternative to medication treatment for depression.  In my opinion, TMS is a viable option for treatment of clinical depression in pregnant or breastfeeding women.

Croen LA et al.  Antidepressant use during pregnancy and childhood autism spectrum disorders.  Arch Gen Psychiatry.  2011 Nov;68(11):1104-12. Epub 2011 Jul 4.

Kim DR et al.  An open label pilot study of transcrnial magnetic stimulation for pregnant women with major depressive disorder.  Journal of Women’s Health.  Nov 2011;20:2:255-261.

Zhang D and Hu Zeqing.  rTMS may be a good choice for pregnant women with depression.  Arch Womens Mental Health.  Published online 24 Feb 2009

Nahas ZN et al.  Safety and feasibility of repetitive transcranial magnetic stimulation in the treatment of anxious depression in pregnancy: a case report.  J Clin Psychiatry 60:1. Jan 1999;60:50-52.

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