A recent publication in the British Journal of Clinical Pharmacology has again raised concerns regarding an increase in the risk of birth defects ( heart defects, spina bifida and extra ureter) in babies exposed to taking  fluoxetine ( prozac)  in the first trimester of pregnancy. The findings were the results of a meta-analysis of 16 observational studies, not a new study. ( no randomised controlled trials in pregnancy and breastfeeding can occur due to ethical considerations) . The women observed will have many differences, which can also be risk factors and it is not known whether  one of the other factors resulted in a higher risk, or the medication. The risk increase was small, but real. Heart defects are relatively common in the population, approximately 1 in 100 babies will be born with one . These results are not new, fluoxetine( prozac) and paroxetine ( aropax) have previously been linked to a small increase in the risk of birth defects, neither of these SSRI medications are amongst the most commonly prescribed in Australia.

At present, there is little evidence that exposure to antidepressants through breast milk has any serious adverse effects in infants. Some adverse events have been reported as case reports and case series, these have been subtle, nonspecific symptoms such as irritability, decreased feeding and sleep problems and may not be caused by the medication. As little as 1-5% of antidepressant medication passes into the breast milk, there are many benefits of treating postpartum depression and advantages of breastfeeding for both the mother and the baby.

Mental health conditions affects the mother, her relationships, her baby and the baby's development. Research has demonstrated that perinatal mental illness affects the child directly and indirectly. During pregnancy, maternal anxiety exposes the developing baby to higher levels of the stress hormone, cortisol, which continues to be present in higher levels throughout the child's life and may be a marker for the higher rates of anxiety, mood and behavioural problems measured in these children.

Women with mental illness are at risk of self-harm and suicide and more likely to use alcohol and illicit drugs.

Postpartum depression has been shown to have a significant effect on the mother-baby relationship if left untreated, and adverse effects on cognitive and behavioural development in the children of untreated mothers.  

Not treating with medications and using psychological means alone needs to be balanced against the risks of medications during pregnancy and lactation. 

There is no straightforward answer for the best  management of mental illness in pregnancy. Each woman and her partner must weigh up the risk-benefit with the help of their health provider and may even consider seeking a second opinion. The risk to the mother of being off the medication and the effects of her being unwell on the baby, against the risk of medication to the baby.  Australian Guidelines suggest women who have had serious, recurrent illness have no risk-free options, women who have been well for a year or more, who have had one episode of anxiety or depression and kept functioning when unwell, may consider stopping their antidepressants before pregnancy

Managing stress with a healthy lifestyle, diet, exercise, sleep, ceasing smoking and minimising alcohol remains an important foundation for good mental health. Many women will benefit from emotional and practical support, online forums and support groups and psychological therapy, but medication or even a brief hospital admission may be included in a treatment plan for those with severe symptoms.

Mental health conditions can be a common complication of pregnancy, like high blood pressure or diabetes and in the same way, require understanding and management with the help of health professionals, family and friends

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