Investigating Outcomes Following the Use of Selective Serotonin Reuptake Inhibitors for Treating Depression in Pregnancy

Quality Use of Medicines and Pharmacy Research Centre, Sansom Institute for Health Research, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, SA, Australia.
Drug Safety (Impact Factor: 2.82). 11/2011; 34(11):1027-48. DOI: 10.2165/11593130-000000000-00000
Source: PubMed


The aim of this review was to critically appraise the existing literature with a particular focus on identifying methodological issues associated with studying outcomes following the use of selective serotonin reuptake inhibitors (SSRIs) during pregnancy. Existing studies evaluating outcomes following prenatal SSRI exposure suffer from a number of important methodological limitations that should be taken into account when interpreting their results. The contradictory results obtained from prospective and retrospective cohort studies and case-control studies could be accounted for by dissimilarity between study populations, selection bias, detection bias, confounding, or differences in underlying maternal illness, data sources used, exposure classification, follow-up and statistical power/analysis. Only a small number of studies actually account for underlying maternal illness and how this may lead to adverse pregnancy outcomes. Even when such information is available, studies that include data on maternal illness have small sample sizes, limiting the statistical power to identify statistically and clinically relevant associations. Pregnancy outcomes may be confounded by the higher incidence of smoking, alcohol consumption and substance abuse frequently encountered amongst those suffering from depression, factors that are often insufficiently controlled for. While evidence of associations between prenatal SSRI exposure and adverse pregnancy outcomes are conflicting, there is an urgent need to evaluate how the particular SSRI used, the dose, timing and duration of use, genetics (maternal, paternal and/or fetal), concomitant medication use, maternal characteristics and underlying maternal illness all interact to alter pregnancy outcomes.

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    • "ADs (Lattimore et al., 2005; Grzeskowiak et al., 2011). Although the exposure to such drugs in early pregnancy has been associated, in some studies, to an increased relative risk of major malformations (MMs), perinatal complications (PCs), and miscarriage, the absolute risk of such adverse events remains very low (Kendall-Tackett and Hale, 2010; Malm et al., 2011). "
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    ABSTRACT: Objective: Escitalopram (ESC) is considered one of the most effective selective serotonin reuptake inhibitors for the treatment of major depression. However, little is known on its potential risk of inducing major malformations (MMs) and perinatal complications (PCs). Hence, aim of the present study is to provide a comprehensive review of the available literature on the safety profile of ESC during pregnancy and breastfeeding. Methods: MEDLINE and PubMed databases were searched for English language articles by using the following keywords: escitalopram, selective serotonin reuptake inhibitors, major malformations, perinatal complications, pregnancy, and breastfeeding. Results: Although some cases of MMs have been reported after maternal exposure to ESC during early pregnancy, the rate of these adverse events is substantially in the range of those reported in unexposed women. On the contrary, exposure to ESC seems to be significantly associated with some PCs. No adverse effects have been reported in the few studies evaluating its safety during breastfeeding. Conclusions: The available data seem to support the notion that ESC might be considered safe during pregnancy, in particular as far as MMs is concerned. However, similar to other selective serotonin reuptake inhibitors, it could be associated with an increased risk of PCs. Given the paucity of the studies published so far, no definitive conclusions can be drawn on its safety profile during breastfeeding.
    Human Psychopharmacology Clinical and Experimental 11/2012; 27(6). DOI:10.1002/hup.2265 · 2.19 Impact Factor
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    • "The clinical implications of the link between postpartum depression and infant - mother attachment has been discussed in several recent reviews on treatment options for prenatal and postpartum depression ( Gentile , 2011 ; Grzeskowiak , et al . , 2011 ; National Collaborating Centre for Mental Health , 2007 ; Parry , 2009 ; Stewart , 2011 ) . This prospective case series contributes to the ongoing discussion regarding SSRI use during pregnancy by examining symptoms of postpartum depression and quality of infant - mother attachment in 5 mothers who took SSRIs during pregnancy ."
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    ABSTRACT: Examine the quality of infant-mother attachment in a prospective case series of infants whose mothers took selective serotonin reuptake inhibitors (SSRIs) during pregnancy. SSRIs are prescribed to 2 to 6% of pregnant women (National Collaborating Centre for Mental Health, 2007; Stewart, 2011). Recent articles on the use of SSRIs during pregnancy note the increased risk for problematic infant-mother relationships among mothers with untreated postpartum depression (Gentile, 2011; Stewart, 2011). However, little is known about the quality of infant-mother relationships among mothers who took SSRIs during pregnancy. Five mothers who took SSRIs during pregnancy were recruited from a community study of infant development. Mothers completed ratings of postpartum depression symptoms (Beck Depression Inventory) 4 to 6 times between 1 month and 1 year following the infant's birth. At 1 year postpartum, quality of infant-mother attachment was assessed using the strange situation procedure. Four of the 5 infant-mother dyads (80%) were classified as disorganized, a rate considerably higher than in postpartum depression samples. These results are used to raise questions about the clinical implications of research on in utero exposure to SSRIs, perinatal depression, and disorganized attachment. Specifically, this case series raises questions about using research on the link between postpartum depression and infant-mother attachment as a rationale for the use of SSRIs during pregnancy. Current research indicates use of SSRIs during pregnancy may: 1) increase risk for disorganized attachment, 2) decrease risk for disorganized attachment, or 3) have no effect on disorganized attachment.
    Journal of Reproductive and Infant Psychology 07/2012; 30(3):261-277. DOI:10.1080/02646838.2012.717263 · 0.67 Impact Factor
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    ABSTRACT: ZUSAMMENFASSUNG Hintergrund: Der vorliegende Artikel gibt eine Übersicht über die aktuelle Studienlage zu Prävalenz, Risikofaktoren und Behandlung peripartaler Depression. Methode: Relevante Literatur wurde auf Medline sowie in der Cochrane Library unter "peri/pre/post", "partum/par-tal/natal", "maternal/motherhood/pregnancy" und "de-pression/affective disorder" identifiziert. Ergebnisse: Mit einer Prävalenz von 18,4 % in der Schwangerschaft und 19,2 % in der frühen Mutterschaft sind Depressionen die häufigsten Erkrankungen in der Pe-ripartalzeit. Bereits präpartal sind sie assoziiert mit erhöh-tem Frühgeburtsrisiko, geringerem Geburtsgewicht oder veränderter fötaler Herzaktivität. Langfristig werden bei den Kindern beeinträchtigte kognitive oder emotionale Fä-higkeiten beobachtet. Als Risikofaktoren gelten depressive Vorerkrankung, mangelnde partnerschaftliche wie soziale Unterstützung und belastende Lebensereignisse. Eine pe-ripartale Depression kann psychotherapeutisch wie psy-chopharmakologisch effektiv behandelt werden. Die der-zeitige Datengrundlage ermöglicht den Einsatz ausge-wählter antidepressiver Substanzen in Schwangerschaft wie Stillzeit. Niederschwellige psychosoziale Hilfen bieten vielerorts auch die Schwangerenberatungsstellen. Aller-dings werden wohl nicht mehr als 20 % der betroffenen Frauen erkannt, obwohl mit der Edinburgh Postnatal De-pression Scale (EPDS) und den beiden Whooley-Fragen ein schnelles Screening möglich ist.
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