Antidepressant use in pregnancy: A critical review focused on risks and controversies

Psychiatry and Obstetrics & Gynecology, Psychosomatic Medicine, Women's Mental Health, University of Massachusetts Medical School/UMass Memorial Medical Center, Worcester, MA, USA.
Acta Psychiatrica Scandinavica (Impact Factor: 5.61). 12/2012; 127(2). DOI: 10.1111/acps.12042
Source: PubMed

ABSTRACT Objective:
Conflicting data have led to controversy regarding antidepressant use during pregnancy. The objectives of this study are to i) review the risks of untreated depression and anxiety, ii) review the literature on risks of exposure to antidepressants during pregnancy, iii) discuss the strengths and weaknesses of the different study designs used to evaluate those risks, and iv) provide clinical recommendations.

MEDLINE/PubMed was searched for reports and studies on the risk of first-trimester teratogenicity, postnatal adaptation syndrome (PNAS), and persistent pulmonary hypertension (PPHN) with in utero antidepressant exposure.

While some individual studies suggest associations between some specific major malformations, the findings are inconsistent. Therefore, the absolute risks appear small. PNAS occurs in up to 30% of neonates exposed to antidepressants. In some studies, PPHN has been weakly associated with in utero antidepressant exposure, while in other studies, there has been no association.

Exposures of concern include that of untreated maternal illness as well as medication exposure. It is vital to have a careful discussion, tailored to each patient, which incorporates the evidence to date and considers methodological and statistical limitations. Past medication trials, previous success with symptom remission, and women's preference should guide treatment decisions.

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Available from: Kristina M Deligiannidis, May 05, 2014
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    • "Dr Robinson's conclusion that " any risks found do not exceed the risks of congenital problems found in 1–3% of the general population " does not apply to the postnatal adjustment problems of newborns prenatally exposed to SSRIs. Lower Apgar scores and a postnatal adaptation syndrome are well documented with signs of jitteriness, tremors, feeding difficulty, abnormal sleep, rigidity, hypertonia, or hypotonia, and these have been observed in up to 30% of SSRI-exposed newborns (Byatt et al., 2013; Casper et al., 2003; Jensen et al., 2013; Klinger et al., 2011; Laine et al., 2003; Oberlander et al., 2004; Smith et al., 2013). Genetic variation might play a role because the serotonin transporter promoter genotype (Oberlander et al., 2007a) and the monoamine oxidase-A and catechol-O-methyltransferase genotypes (Hilli et al., 2009) have been associated with adverse neonatal outcomes. "
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    ABSTRACT: The paper by Robinson posits that risks from prenatal exposure to selective serotonin reuptake inhibitor (SSRI) antidepressants are not different from the risks encountered in the general population and that untoward effects of SSRIs are difficult to distinguish from those of the mood disorder. Indeed, maternal depression and anxiety can have negative consequences for fetal and postnatal development. Fortunately, experimental evidence suggests that mood and anxiety disorder symptoms often respond to psychosocial interventions. If pharmacotherapy becomes necessary, it is, however, important to know that even if SSRI drugs have been shown to be safe overall, research has shown that fetal development can be adversely affected by in utero exposure to SSRIs in a subgroup of neonates. Examples would be the transient neonatal adaptation syndrome, an increased risk of persistent pulmonary hypertension of the newborn, and small, albeit measurable, changes in motor and social adaptability in infancy and childhood.
    Journal of Nervous & Mental Disease 03/2015; 203(3):167-9. DOI:10.1097/NMD.0000000000000258 · 1.69 Impact Factor
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    • "Algorithms are available to guide clinical decision making on treatment for maternal mental illness for mothers who are planning to conceive, and for those who are already pregnant (see Yonkers et al. [109] in their work with the American Psychiatric Association and the American College of Obstetricians and Gynecologists). The absence of evidence of specific teratogenic outcome in all exposed neonates does not equate to evidence of absence of risk [8]. It is critical to recognise that, although we continue to seek answers to explain who is at risk and why, we consider a spectrum of risks that arise from a variety of sources and extend over developmentally sensitive periods and well into childhood. "
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    ABSTRACT: Depression, anxiety, or both, during pregnancy are common complications during the perinatal period, with 15-20% of women experiencing depression at some point during their pregnancy. Considerable evidence suggests that untreated or undertreated maternal Axis I mood disorders can increase the risk for preterm birth, low birth weight, and alter neurobehavioral development in utero. Serotonin reuptake inhibitor antidepressants are often considered for antenatal therapy, with the goal of improving maternal mental health during pregnancy. Treatment with a serotonin-reuptake inhibitor, however, does not guarantee remission of depression, and in-utero serotonin reuptake inhibitor exposure has also been linked to increased risks for adverse infant outcomes. In this chapter, evidence linking serotonin reuptake inhibitor use with an increased risk for postnatal adaptation syndrome, congenital heart defects, and neonatal persistent pulmonary hypertension is reviewed. Management decisions should include attention to the continuum of depression symptoms, from subclinical to severe major depressive disorder and the long-term developmental risks that might also be associated with pre- and postnatal exposure.
    Best practice & research. Clinical obstetrics & gynaecology 09/2013; 28(1). DOI:10.1016/j.bpobgyn.2013.09.001 · 1.92 Impact Factor
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    Acta Psychiatrica Scandinavica 02/2013; 127(2):115-6. DOI:10.1111/acps.12046 · 5.61 Impact Factor
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