The press should treat such studies with skepticism
Another one: a worked-up panic about anti-depressants and autism. David Auerbach reports at Slate:
The alarm has been sounded: Antidepressants cause autism! Or so one could easily think based on a new study in JAMA Pediatrics. Four researchers in Quebec conclude that “the use of antidepressants, specifically selective serotonin reuptake inhibitors [SSRIs], during the second and/or third trimester increases the risk of [autism spectrum disorder] in children.” In a ResearchGate interview, study senior author and perinatal pharmacoepidemiologist Anick Bérard of the Université de Montréal and the CHU Sainte-Justine Research Centre firmly advocated avoiding antidepressant use during pregnancy: “Depression needs to be treated during pregnancy but with something other than antidepressants in the majority of cases. The risk/benefit ratio is clearly leaning towards no use.”
Risk to whom and benefit to whom? Depression can be a very serious health problem; it can be fatal.
…other researchers have stressed a note of caution about the new antidepressant study and its methods. Yet even these dissenting voices do not, I think, go far enough.
Study co-author Bérard, it turns out, has been criticized by a federal judge for cherry-picking results to link antidepressants to birth defects. The press should treat such studies with skepticism rather than leading with their findings. Sober pieces in Science, Wired, and NPR rightly questioned whether the study was significant and whether Bérard’s advocacy for stopping antidepressant usage during pregnancy was justified. In particular, Emily Underwood in Science wisely led off by writing “Many epidemiologists and psychiatrists say the study, published today in JAMA Pediatrics, is flawed and will cause unnecessary panic,” which is the most important point to make about this study. But too many journalists failed to make this point, and with autism research, such credulity is downright dangerous.
And dangerous for whom? In this case, women; pregnant women.
In response to such critiques, Bérard told NPR, “We have to be vigilant even if the risk is small,” and told me in an email: “You need to consider other treatment options such as exercise or psychotherapy,” and again emphasized the supposed risk. This is misleading, however, since treatment is a matter of balancing competing risks, and the study runs the risk of playing up one unproven danger to the exclusion of far more established dangers—such as the impact of untreated or insufficiently treated depression. Bérard’s position smacks too much of banning liquids on airplanes and making people take off their shoes in airport lines—but with far worse potential consequences if women are persuaded to stop antidepressants that they genuinely need. Exercise and psychotherapy might be effective substitutes for some, but expectant mothers should make that decision without the unjustified specter of autism hanging over them.
And is it just random that it’s women who are being told to give up anti-depressants here? Is it just random that it’s women who are being told to forget about their own health and well-being because their bodies now belong to the pregnancy?
In Science, Emily Underwood reports that Bérard “serves as a consultant for plaintiffs in litigations involving antidepressants and birth defects,” suggesting that she might not have approached the study with a disinterested attitude toward antidepressants. In 2014, she served as a plaintiffs’ expert witness in the Pennsylvania Zoloft birth defects lawsuit against Pfizer, until her testimony was excluded by Judge Cynthia M. Rufe on the grounds that Bérard’s methods were “not scientifically sound.” In her ruling, Rufe excoriates Bérard for 25 pages, writing:
The Court holds that Dr. Bérard’s opinion is not grounded in the methods and principles of science … [the report’s] methodology is not reliable or scientifically sound. … Dr. Bérard takes a position in this litigation which is contrary to the opinion she has expressed to her peers in the past, relies upon research that her peers do not recognize as supportive of her litigation opinion, and uses principles and methods which are not recognized by the relevant scientific community and are not subject to scientific verification…
Not helpful.
There is research associating increased rates of autism in children of women who lived near and downwind of agricultural areas using pesticides that are neurotoxic to insects. Problem is that insect nerves and human nerves aren’t all that different. But the minute dosage people get was supposed to be safe based on tests done on nonpregnant adults.
Of course, pregnant women are always excluded from safety studies because you wouldn’t want to harm a fetus. So instead you release the supposedly safe product and do a great big field test on them. But I digress.
Apparently what may be happening is that the minute “safe” dosages are not safe for the developing embryonic or fetal neurons, causing problems later.
That relates to the SSRI issue because the whole point with SSRIs is to interfere with certain signals between nerves. It’s not hard to make the connection that possibly a similar kind of interference with fetal nerve development ensues.
As they say, a boatload of more and better research is needed.
Meanwhile we could be realigning agriculture and industry and people’s lives so that nerve signals don’t have to be messed with.
Yes, that last is gallows humor.
This whole thing is a case of terribly irresponsible “reporting.” The other night I happened to be someplace w/a tv and I heard a local Seattle station’s revered former anchor woman now “health” reporter, Jean Enerson, seriously going on about antidepressants causing autism. Did she say “correlation is not causation”? Nope. Did she state precisely the amount of/percentage of “risk” the JAMA article reported? Nope. In short she did what news-o-tainment does – dumped a load of steaming fearful crap and left it at that.
Jesus it made me mad. And I am not surprised that the methods, analysis, and interpretations of the PI on this research are considered below par.
Among people with autism, there’s a whole lot of, “We KNOW there’s a major genetic component to autism. It runs in families. Grown women were usually missed in getting diagnosed if they have autism traits– people just didn’t suspect it in quiet girls a couple of decades ago. We also can tell you the social problems of autism often lead to depression. So, isn’t it more likely that undiagnosed autistic women are more likely to be on antidepressants, and then have autistic kids at the normal rate for people carrying the traits?”
And yes, the autistic community is angry not only that women are being told their health is less important than avoiding autistic children, but that women’s lives are being treated as less important than their pregnancies.
So let’s talk about antidepressants for a second. They are actually controversial in other contexts. There are plenty of studies (if one cares to look) showing that Prozac (and a few other SSRIs) are not much more effective than a placebo. Inevitably, when these are reported, the writer of the article will bring up pathologizing and medicating normal sadness and point to exercise and psychotherapy.
As a sufferer of chronic, severe, treatment-resistant depression, I get the immediate urge to punch the writer in the face. The thing about depression (and other mental illnesses, like schizophrenia) is that there are no lab tests for them. They are diagnosed based on observation and self-reporting of symptoms. While there are theories on how these diseases work in the body, there’s a dearth of evidence and understanding. Every once in a while a study will even pop up saying that the symptoms attributed to one specific disease (depression, schizophrenia) are actually overlapping symptoms of several different diseases (kind of like flu-like symptoms happen in response to many different infections). The point is, we don’t know much about these ailments. The treatments we have for them are very limited: they are frequently ineffective and often very dangerous and unhealthy (as in the case of ALL antipsychotics). But that’s all there is right now. These treatments came to replace lobotomies and electric shock and, before that, locking people up in insane asylums and torturing them. Just because the treatments we have today are better than the earlier options, doesn’t mean they are a good solution. On the other hand, just because they don’t help everyone and harm many doesn’t mean that either the problems they exist to fix aren’t real or that there exists another, easy and obvious, “natural” solution.
SSRIs are not the only class of antidepressant drugs out there: there are a few others, usually older, usually with more sideffects. I’ve tried several drugs from every available class, and almost all SSRIs. Only two of the multitude of drugs I tried are somewhat effective for me, and, besides not addressing all of my symptoms, they become ineffective after about a year of use, so I have to switch (this involves gradually reducing the dosage of the already ineffective drug to nothing, then gradually increasing the other to effective dose). This sucks. I wish there was something I could do, and I’ve tried just about everything (and I’m always keeping an eye out for research that this or that might help). Unfortunately, this is just reality: it’s the cards I was dealt. Frankly, I’m lucky that there are those two drugs that work — this isn’t the case for every depression sufferer. An imperfect solution is still better than nothing at all.
When people find out that I have depression and take medication for it, they often suggest the ol’ psychotherapy and exercise. Predictably, I get the urge to punch them in the face too, but instead, I take a deep breath and patiently explain that I’m seeing a psychotherapist already (nice if you can afford it, but a nice chat for an hour a week is not as helpful for symptom relief as one might imagine), and exercise does jack squat for my mood. Actually that’s not quite true: exercise is torture to me. I don’t get “runner’s high”, that jolt of endorphins that’s responsible for improved mood after exercise. I suspect I’m not the only one: if exercise felt good for everyone, everyone would do it — it can’t be just that all those people ignoring their doctor’s and the First Lady’s advice are too lazy to make themselves feel good. I do still exercise (or try to, when I can) — because I’m told it’s good for my health in many other ways. It doesn’t get better with training — it’s still torture. In fact, I need my antidepressants to be working pretty well to even contemplate putting myself through the unremitting misery of exercise for some abstract “benefits to my health” that are supposed to materialize when I’m older and, presumably, less sick than I could be.
So this bullshit aimed at pregnant women with depression is just a subset of the same old bullshit aimed at people with depression. Except even worse, because pregnant women are already under constant scrutiny about everything they put in their bodies, which become public property while they are pregnant. It’s another double bind: now that you know there’s a possibility of harm, if you still use antidepressants while pregnant, there’s more reason to prosecute you for endangering your baby, should something go wrong or if you just happen to be a conveniently vulnerable target. Of course, if you go off antidepressants and try to kill yourself while pregnant (or turn to substance abuse to take the edge off the misery you are in), there’s even better chances you’ll be prosecuted for endangering your baby (should you survive). And then there’s postpartum depression or psychosis (which you have a greater chance of developing if you already have the regular kind, and which is going to hit very hard because medication takes time to take effect, and you are not on it) — you are on your own there, but better not hurt your baby and survive, or else.
I’m also very curious about this exercise they are recommending for women in their second and third trimesters. Yoga and swimming? I guess pregnant women had better all be rich (especially if they are supposed to get psychotherapy too).
‘And is it just random that it’s women who are being told to give up anti-depressants here?’
Oh no, any non-women who might be pregnant are included too!
I’m wondering about Bérard’s ideological a prioris as well as the (apparently) unreported financial interest. There’s more than a whiff of Wakefield already. Scientologist? Fundy Xtian?
A big drawback to the study is that there is no control group. We don’t know if the increase in risk of autism is due to the meds or to the severity of depression or if there is a link between depression “genes” and autism “genes.” Granted, it is hard to have a control group because the worse the depression the higher the risk of suicide
Oh lord, this is Andrew Wakefield and the MMR all over again…
Seriously, as an ex-nurse and a science graduate (Environmental Science FYI) , this has way too many correlations with Wakefield – a single flawed paper (though Wakefield’s original publication was a case study, not a research paper) with flawed methodology identified at the outset by a researcher with a financial interest in finding a significant correlation and causation by the substance in question, picked up by a science-ignorant press and some grieving parents desperate to find someone/thing to blame for their child’s condition. Looking for reasons and assigning blame is a very human way of dealing with events you find awful.
The thing is, we knew Wakefield was full of shit within six months of the initial case study. It was the media which kept the issue alive (and some very stupid and selfish middle class parents with too little to worry about). I can see this happening in this case too…
It’s pretty clear autism has a majority genetic component. Not vaccines, not maternal SSRI intake, not poor mothering. Genes. At least for the most part.
I couldn’t get the details of the study because it is behind a paywall. So I don’t know if they broke down the numbers for each antidepressant. According to other studies, Zoloft is the least likely to pass through the placenta