Tuesday, May 11, 2010

Pregnancy Depression Antidepressants

The May issue of the Archives of Pediatrics and Adolescent Medicine had an interesting study titled Prenatal Effects of Selective Serotonin Reuptake Inhibitor Antidepressants, Serotonin Transporter Genotype (SLC6A4) and Maternal Mood on Child Behavior at 3 Years of Age. Although depression is common in pregnant women there is so much that is unknown about the use of antidepressants in pregnancy that I am always interested in new information. For this study I went to review the original article rather than just a summary of the findings. Fortunately it was available for free.

Depression in pregnant women is common. Between 14-23% (depending on the study) of pregnant women experience significant depressive symptoms and up to 13 % are taking antidepressant medication. We know surprisingly little about the effects of antidepressant medication in pregnancy despite this being a common problem. One of the difficulties has been that it really would be unethical to conduct randomized placebo controlled trials so the information we have is gathered from a variety of different studies all with significant limitations in design and ability to tease out all the important factors from one another. When we look at this question we must look at a number of areas of concern which include:

What is the effect of untreated depression on the fetus?

Are there any congenital abnormalities associated with antidepressant medication?

Are antidepressants associated with preterm birth?

Are antidepressants associated with any maternal complications?

Are antidepressants associated with low birth weight?

Are antidepressant medications associated with any neonatal problems?

Are antidepressants safe for nursing?

Are there any long term effects on children who have been exposed to antidepressants in utero?

There have been no studies that have been able to look at all these factors. Each published study has focused on one or two of these areas. Some of the studies give conflicting results but there are things we do know. Most of the studies have been focused on the class of antidepressants referred to as the selective serotonin reuptake inhibitors ( Prozac, Zoloft, Paxil, Celexa, Lexapro) as they are the most common antidepressants used during pregnancy.

What we do know is this:

Untreated depression and anxiety is associated with adverse fetal effects including preterm birth, low birth weight, and neonatal difficulties of increased irritability, poorer attention and more difficulty with soothing. The selective serotonin reuptake inhibitors (SSRI's) are generally not associated with any congenital abnormalities except for one study that showed that first trimester use of Paxil may increase the risk of cardiac defects although the actual risk is quite small. A recent review of the studies published in the New England Journal of Medicine concluded that there is no association between maternal use of SSRI's and birth defects. Antidepressants are associated with an increased risk of preterm birth (23%) compared to the general population (6%) although depression itself regardless of whether or not antidepressants use resulted in the same higher rate. Antidepressants are associated with an increased risk of gestational hypertension and preeclampsia. There have been conflicting studies regarding the issue of low birth weight. There clearly is an association between SSRI use during pregnancy and neonatal difficulties including lower Apgar scores, irritability, and increased risk of persistent pulmonary hypertension and seizures. There is clearly a neonatal withdrawal syndrome in some infants who have SSRI withdrawal symptoms in the first week of life. Floxetine (Prozac) is safe while nursing. Several small studies (too small I think to really tell us anything)have not found any long term behavioral effects for SSRI exposed children although this recent study (which is a much larger study) appears to indicate that there can be some problems. So, that is about what we know.

From the limited information we have in August 0f 2009 the American Psychiatric Association and the American College of Obstetricians and Gynecologists issued a joint statement with treatment recommendations. For women who are thinking of becoming pregnant and have had no depressive symptoms for 6 months or greater it may be appropriate to taper and discontinue the medication. This does not apply to women with a history of severe recurrent depression or those that have bipolar depression, psychosis or a history of suicide attempts. For pregnant women who are already on antidepressant medication it is generally appropriate to consider tapering and discontinuing the medication if those other above factors don't apply. For pregnant women who are not on medication and develop depression psychotherapy may be the best initial option although women who prefer to take medication should be clearly informed about the potential risks.

With this as a background I would like to spend the next several days discussing the study itself.

Thought for the day

"All joy in this world comes from wanting others to be happy, and all suffering in this world comes from wanting only oneself to be happy".

Shantideva

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