This week’s Clinical Problems in Consultation Psychiatry (CPCP) is about antidepressants in pregnancy. It’s an excellent summary of the cutting edge in research on this often confusing issue. Are they safe or not?
As we listened to Dr. Laura Gibbons’ presentation, the answer is not clearly “yes” or “no” but “it depends.” It depends on how the data was collected, who was in the control group, which antidepressant we’re talking about, and more.
Certainly the media fuels some of the head scratching about it. I remember a presentation at an Academy of Psychosomatic Medicine (APM) meeting in 2015 which highlighted that. This was a slide from “2015 Updates in Psychosomatic Medicine: Women’s Mental Health by Dr. Christina L. Wichman, D.O., F.A.P.M., who, at the time, was Associate Professor of Psychiatry and Behavioral Medicine, Associate Professor of Obstetrics and Gynecology, Director of the Psychiatric Consultation-Liaison Service, and Director of Women’s Mental Health at the Medical College of Wisconsin.
Dr. Wichman pointed out the controversial nature of the reportedly poor pregnancy outcomes. The most common effect of selective serotonin reuptake inhibitors (SSRIs) was poor neonatal adaptation. It may be marked by jitteriness, constant crying, feeding and sleeping problems, autonomic instability, tachypnea, hyperreflexia/hypertonia, or seizures. It may last from 1-4 days, can happen with any antidepressant, isn’t dose dependent, and requires supportive treatment only.
Like Dr. Gibbons, Dr. Wichman covered the topic of whether one SSRI is safer than another. The study by Furu et al (see reference below) involved a nation-wide health register including 5 Nordic countries involving 2.3 million births. The number of babies exposed to SSRIs was 36, 772. There was no association with increased risk of any malformations. The authors were able to adjust results for confounding factors including genetics and family-related concerns.
The Reefhuis et al study (see reference below) used an expanded dataset from the National Birth Defects Prevention Study and it was a case/control study. There were 17,952 with defects, 9,857 without defects, and 1,285 exposed to SSRIs. There was increased risk of malformation in children exposed to fluoxetine and paroxetine.
Furu K, Kieler H, Haglund B, Engeland A, et al. Selective serotonin reuptake inhibitors and venlafaxine in early pregnancyand risk of birth defects: population based cohort study and sibling design. BMJ. 2015 Apr 17;350:h1798.
Reefhuis J, Devine O, Friedman JM, Louik C, et al. Specific SSRIs and birth defects: bayesian analysis to interpret new data in the context of previous reports. BMJ June 2015.
Interestingly, when all is said and done, that’s pretty similar to what Dr. Gibbons found. Further, Dr. Wichman and Dr. Gibbons remind us that exposure to untreated severe maternal depression in utero and during early childhood is linked to worse cognitive and behavioral outcomes than with antidepressants.
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