Use of psychotropic medications in treating mood disorders during lactation : practical recommendations

Fluoxetine-induced proliferation and differentiation of neural progenitor cells isolated from rat postnatal cerebellum

Previous studies have shown that the serotonin-reuptake inhibitor (SSRI) fluoxetine affects neural progenitors derived from postnatal cerebellum or adult hippocampus and stimulates their proliferation. In the human cerebellum, the proliferation of cerebellar granule cells (CGC) continues until the 11th postnatal month and could be influenced in infants by breastfeeding-delivered SSRIs. Current information about fluoxetine effects on postnatal cerebellar neural progenitors is limited. Here we report the characterization of fluoxetine actions on rat postnatal cerebellar neural progenitors. RT-PCR and immunostaining revealed the expression of serotonin transporter (SERT), 5HT(1A) receptors, tryptophan hydroxylase (TPH), and serotonin (5HT). Protracted in vitro fluoxetine treatment increased cell proliferation and differentiation. The proliferative effects of fluoxetine, 5HT, and the selective agonist of 5HT(1A) receptors trans-8-hydroxy-2-(N-n-propyl-N-3'-iodo-2'-propenyl)aminotetralin (8-OH-PIPAT) were abolished by the selective antagonist of 5HT(1A) receptors, N-[2-[4-(2-methoxyphenyl)-1-piperazinyl]ethyl]-N-(2-pyridinyl)cyclohexanecarboxamide trihydrochloride (WAY-100635). Furthermore, fluoxetine-induced activation of both the cAMP-response element-binding (CREB) protein and extracellular signal-regulated protein kinases (ERK1/2), which was abolished by the selective inhibitor of MAP kinase kinase (MEK) 1,4-diamino-2,3-dicyano-1,4-bis(2-aminophenylthio)butadiene (U0126), and increased cyclin D1 expression. All these effects were prevented by WAY-100635. Collectively, our results demonstrate that rat postnatal cerebellum contains neural progenitors capable of proliferating and differentiating in response to fluoxetine exposure, possibly through the activation of 5HT(1A) receptors. The relevance of these findings for possible SSRI effects on the developing postnatal/infant human cerebellum should be explored.

Breastfeeding and antidepressants

Although a large literature supports the benefits of breastfeeding, this review suggests that breastfeeding is less common among postpartum depressed women, even though their infants benefit from the breastfeeding. Depressed mothers, in part, do not breastfeed because of their concern about potentially negative effects of antidepressants on their infants. Although sertraline (Zoloft) and paroxetine (Paxol) concentrations are not detectable in infants' sera, fluoxetine (Prozac) and citalopram (Celexa) do have detectable levels. Unfortunately these findings are not definitive because they are based on very small sample, uncontrolled studies. As in the literature on prenatal antidepressant effects, the question still remains whether the antidepressants or the untreated depression itself has more negative effects on the infant. It is possible that the positive effects of breastfeeding may outweigh the positive effects of the antidepressants for both the mother and the infant. In addition, some alternative therapies may substitute or attenuate the effects of antidepressants, such as vagal stimulation or massage therapy, both therapies being noted to reduce depression. Further studies of this kind are needed to determine the optimal course of therapy for the benefit of the depressed, breastfeeding mother and the breastfed infant.

Pharmacological management of panic disorder

Panic disorder (PD) is a disabling condition which appears in late adolescence or early adulthood and affects more frequently women than men. PD is frequently characterized by recurrences and sometimes by a chronic course and, therefore, most patients require long-term treatments to achieve remission, to prevent relapse and to reduce the risks associated with comorbidity. Pharmacotherapy is one of the most effective treatments of PD. In this paper, the pharmacological management of PD is reviewed. Many questions about this effective treatment need to be answered by the clinician and discussed with the patients to improve her/his collaboration to the treatment plan: which is the drug of choice; when does the drug become active; which is the effective dose; how to manage the side effects; how to manage nonresponse; and how long does the treatment last. Moreover, the clinical use of medication in women during pregnancy and breastfeeding or in children and adolescents was reviewed and its risk-benefit balance discussed.

Depressive Störungen

Das Spektrum depressiver Erkrankungen macht den Hauptteil affektiver Störungen aus und gehört mit einer Inzidenz von ca. 8–20% zu den häufigsten psychischen Erkrankungen. Depressionen werden nach wie vor zu selten einer adäquaten Therapie (Antidepressiva, störungsspezifische Psychotherapie wie z. B. kognitive Verhaltenstherapie) zugeführt.

Mammary gland homeostasis employs serotonergic regulation of epithelial tight junctions

Homeostatic control of volume within the alveolar spaces of the mammary gland has been proposed to involve a feedback system mediated by serotonin signaling. In this article, we describe some of the mechanisms underlying this feedback based on studies of a human normal mammary epithelial cell line (MCF10A) and mouse mammary epithelium. Mammary serotonin was elevated during lactation and after injection of 5-hydroxytryptophan (5-HTP). The genes encoding the serotonin reuptake transporter (SERT) and the type 7 serotonin receptor (5-HT(7)) were expressed in human and mouse mammary epithelial cells, and serotonin caused a concentration-dependent increase of cAMP in MCF10A cells. Mouse and human mammary epithelial cells formed polarized membranes, in which tight junction activity was monitored. Treatment of mammary epithelial membranes with serotonin receptor antagonists increased their transepithelial electrical resistance (TEER). Antagonist and agonist effects on TEER were mediated by receptors on the basolateral face of the membranes. Our results suggest a process in which serotonin accumulates in the interstitial fluid surrounding the mammary secretory epithelium and is detected by 5-HT(7) receptors, whereupon milk secretion is inhibited. One mechanism responsible for this process is serotonin-mediated opening of tight junctions, which dissipates the transepithelial gradients necessary for milk secretion.

The use of electroconvulsive therapy in postpartum affective disorders

Postpartum affective disorders continue to be a major health issue for women. There is a general belief that electroconvulsive therapy (ECT) is effective in treating severe or treatment-refractory postpartum affective illnesses, but evidence to support this assertion is lacking. In this case series, we present 5 cases of women with postpartum depression and psychosis, all of whom had failed prior pharmacological therapy. All 5 women had a significant response within 3 to 6 treatments with ECT. Our findings suggest that ECT is overall an effective treatment of postpartum illnesses. In addition to being an excellent choice for women who have failed prior medication trials, ECT may also be considered for women whose severity of illness necessitates rapid symptom resolution.

SSRIs during breastfeeding: spotlight on milk-to-plasma ratio

OBJECTIVE

To investigate the usefulness of the milk-to-plasma (M/P) ratio for assessing the risks for the breastfed infant associated with the maternal use of SSRIs.

DATA SOURCES

Medline, Toxnet, Embase, Current Contents, and PsycInfo indexed articles from 1980 to September 2006.

STUDY SELECTION AND DATA EXTRACTION

All studies reporting the M/P ratio in mothers taking SSRIs while breastfeeding or studies which such an information could be calculated from data reported in the article.

DATA SYNTHESIS

Higher M/P ratios were rarely associated with a clinically significant impact on the babies during the early phases of breastfeeding.

CONCLUSIONS

So far no evidence-based information seems to support the hypothesis that SSRIs characterized by a M/P ratio <1.0 should be preferred. Hence, physicians should consider different parameters when attempting to choose the safest SSRI for the breastfeeding woman. These parameters might be represented by the number of well-documented published adverse event reports and the tendency of each SSRI of inducing in the infants serum concentrations that are elevated above 10% of average maternal serum levels. In any case, if the mother wishes to breastfeed her infant while taking a SSRI, the baby should be closely monitored in order to promptly detect any iatrogenic event.

Use of contemporary antidepressants during breastfeeding: a proposal for a specific safety index

Despite the well known severe repercussions of maternal depression on infants' well being, women are often reluctant to seek pharmacological treatment for postnatal depression. The fear of adverse events for the suckling infant plays an important role in such maternal considerations. However, the pharmacological approach to mood disorders at postpartum onset often represents one of the most realistic options in a number of clinical conditions. Therefore, the necessity exists to establish the safety of antidepressant treatment in the breastfed infant. For this reason, the aim of this article is to propose a specific safety index that assesses the frequency and degree of severity of adverse events in infants associated with maternal treatment with second-generation antidepressants during puerperium. The index is derived from a simple formula that uses the number of reports of adverse events in infants exposed to antidepressants as the numerator and the combined total of reports of healthy outcomes and reports of adverse events as the denominator. The sum is then multiplied by 100. A value of < or =2 indicates that the drug should be relatively safe for use during breastfeeding, a value of 2.1-10 indicates that the drug should be used with great caution and a value >10 indicates that the drug should be contraindicated in breastfeeding mothers. In addition to the figure created by this calculation, each drug will also be assigned a letter or the combination of a letter and a subscripted number to symbolise, respectively, the type and clinical management of the most serious recorded event. At this early developmental stage of the index, a complete classification of contemporary antidepressants regarding their safety in infants nursed to the breast is unfeasible. Indeed, because of the lack of suitable published data, so far the index has been limited to the evaluation of four antidepressants. In accordance with the index classification for these four antidepressants, sertraline and paroxetine should be considered as first-line medications in women who need to start antidepressant treatment during the postpartum period and wish to continue breastfeeding. The utilisation of fluoxetine and citalopram seems conversely to be associated with a relatively higher risk of adverse events (with a low degree of severity, however). For the other newer antidepressant drugs, the index is still of no assistance to the patient or physician in deciding on the safety of their use in lactation.