Prenatal exposure to selective serotonin reuptake inhibitors and childhood overweight at 7 years of age

Sex-dependence and comorbidities of the early-life adversity induced mental and metabolic disease risks: Where are we at?

Early-life adversity (ELA) is a major risk factor for developing later-life mental and metabolic disorders. However, if and to what extent ELA contributes to the comorbidity and sex-dependent prevalence/presentation of these disorders remains unclear. We here comprehensively review and integrate human and rodent ELA (pre- and postnatal) studies examining mental or metabolic health in both sexes and discuss the role of the placenta and maternal milk, key in transferring maternal effects to the offspring. We conclude that ELA impacts mental and metabolic health with sex-specific presentations that depend on timing of exposure, and that human and rodent studies largely converge in their findings. ELA is more often reported to impact cognitive and externalizing domains in males, internalizing behaviors in both sexes and concerning the metabolic dimension, adiposity in females and insulin sensitivity in males. Thus, ELA seems to be involved in the origin of the comorbidity and sex-specific prevalence/presentation of some of the most common disorders in our society. Therefore, ELA-induced disease states deserve specific preventive and intervention strategies.

Maternal, Fetal, and Child Outcomes of Mental Health Treatments in Women: A Meta‐Analysis of Pharmacotherapy

Objective

The authors systematically reviewed evidence on pharmacotherapy for perinatal mental health disorders.

Methods

The authors searched for studies of pregnant, postpartum, or reproductive‐age women with mental health disorders treated with pharmacotherapy in MEDLINE, EMBASE, PsycINFO, the Cochrane Library, and trial registries from database inception through June 5, 2020 and surveilled literature through March 2, 2021. Outcomes included symptoms; functional capacity; quality of life; suicidal events; death; and maternal, fetal, infant, or child adverse events.

Results

164 studies were included. Regarding benefits, brexanolone for third‐trimester or postpartum depression onset may be associated with improved depressive symptoms at 30 days when compared with placebo. Sertraline for postpartum depression may be associated with improved response, remission, and depressive symptoms when compared with placebo. Discontinuing mood stabilizers during pregnancy may be associated with increased recurrence of mood episodes for bipolar disorder. Regarding adverse events, most studies were observational and unable to fully account for confounding. Evidence on congenital and cardiac anomalies for treatment compared with no treatment was inconclusive. Brexanolone for depression onset in the third trimester or the postpartum period may be associated with risk of sedation or somnolence, leading to dose interruption or reduction when compared with placebo.

Conclusions

Evidence from few studies supports the use of pharmacotherapy for perinatal mental health disorders. Although many studies report on adverse events, they could not rule out underlying disease severity as the cause of the association between exposures and adverse events. Patients and clinicians need to make informed, collaborative decisions on treatment choices.

Few studies have been conducted in pregnant and postpartum women on the benefits of pharmacotherapy; many studies report on harms but are of low quality

Brexanolone probably improves depressive symptoms; it may increase the risk of sedation or somnolence, leading to dose interruption or reduction. Sertraline may improve response, remission, and depression and anxiety symptoms. Mood stabilizers may reduce recurrence and increase time to recurrence

Although associations may exist between psychotropic medications and adverse events, causality cannot be inferred. The paucity of evidence does not mean that pharmacotherapy is not beneficial, nor that harms do not exist; rather, it underscores the absence of high‐quality research

COVID-19: can we treat the mother without harming her baby?

Medical care is predicated on 'do no harm', yet the urgency to find drugs and vaccines to treat or prevent COVID-19 has led to an extraordinary effort to develop and test new therapies. Whilst this is an essential cornerstone of a united global response to the COVID-19 pandemic, the absolute requirements for meticulous efficacy and safety data remain. This is especially pertinent to the needs of pregnant women; a group traditionally poorly represented in drug trials, yet a group at heightened risk of unintended adverse materno-fetal consequences due to the unique physiology of pregnancy and the life course implications of fetal or neonatal drug exposure. However, due to the complexities of drug trial participation when pregnant (be they vaccines or therapeutics for acute disease), many clinical drug trials will exclude them. Clinicians must determine the best course of drug treatment with a dearth of evidence from either clinical or preclinical studies, where at least in the short term they may be more focused on the outcome of the mother than of her offspring.

Antidepressants- and antipsychotics-induced hepatotoxicity

Drug-induced liver injury (DILI) is a serious health burden. It has diverse clinical presentations that can escalate to acute liver failure. The worldwide increase in the use of psychotropic drugs, their long-term use on a daily basis, common comorbidities of psychiatric and metabolic disorders, and polypharmacy in psychiatric patients increase the incidence of psychotropics-induced DILI. During the last 2 decades, hepatotoxicity of various antidepressants (ADs) and antipsychotics (APs) received much attention. Comprehensive review and discussion of accumulated literature data concerning this issue are performed in this study, as hepatotoxic effects of most commonly prescribed ADs and APs are classified, described, and discussed. The review focuses on ADs and APs characterized by the risk of causing liver damage and highlights the ones found to cause life-threatening or severe DILI cases. In parallel, an overview of hepatic oxidative stress, inflammation, and steatosis underlying DILI is provided, followed by extensive review and discussion of the pathophysiology of AD- and AP-induced DILI revealed in case reports, and animal and in vitro studies. The consequences of some ADs and APs ability to affect drug-metabolizing enzymes and therefore provoke drug–drug interactions are also addressed. Continuous collecting of data on drugs, mechanisms, and risk factors for DILI, as well as critical data reviewing, is crucial for easier DILI diagnosis and more efficient risk assessment of AD- and AP-induced DILI. Higher awareness of ADs and APs hepatotoxicity is the prerequisite for their safe use and optimal dosing.

Dose-effect of maternal serotonin reuptake inhibitor use during pregnancy on birth outcomes: A prospective cohort study

BACKGROUND

While antidepressant use during pregnancy is increasingly common, there is concern about the possible effects of in-utero antidepressant exposure on the child. Our objective was to examine whether there is a dose-effect of maternal serotonin reuptake inhibitors (SRI) during pregnancy on birth outcomes.

METHODS

Women between 12 and 16 weeks of gestation, who were using an SRI, were eligible for participation in this nation-wide prospective observational cohort study. Recruitment took place between April 2015 and February 2018 (n = 145). SRI exposure and psychopathology symptoms were assessed throughout pregnancy. Exposure was defined as SRI standardized dose at 36 weeks of gestation and mean SRI standardized dose over total pregnancy. Multivariable linear and logistic regression were used to examine the associations with birth weight, gestational age at birth, and being small for gestational age.

RESULTS

Maternal SRI dose at 36 weeks of gestation was significantly associated with birth weight (adjusted ß = -180.7, 95%CI -301.1;-60.2, p-value < 0.01) as was mean SRI standardized dose during total pregnancy (adjusted ß = -187.3, 95%CI -322.0;-52.6, p-value < 0.01). No significant associations between maternal SRI dose and gestational age or being small for gestational age were observed.

LIMITATIONS

Although prospective, we cannot make full causal inferences given that we did not randomize women to different dosages.

CONCLUSION

These findings suggest that careful dosing of SRI use during pregnancy may prevent a negative impact on birth weight and indicate the need for further investigation of causality.

Impact of Prenatal Selective Serotonin Reuptake Inhibitor Antidepressant Exposure and Maternal Mood on Physical Activity, Dietary Intake, and Markers of Adiposity at Age 6 Years

OBJECTIVE

This study assessed associations between maternal depressive symptoms, prenatal maternal antidepressant treatment, maternal estimates of child physical activity (PA), dietary total intake, and markers of adiposity.

METHODS

Mothers and their children (N = 116) were part of a longitudinal cohort study examining the effects of prenatal exposure to selective serotonin reuptake inhibitor (SSRI) antidepressants and maternal depression (SSRI exposed, n = 42; nonexposed, n = 74). Maternal depression symptoms were assessed prenatally and postnatally. At 6 years, PA was assessed using maternal report, 3-day dietary total intakes were obtained using objective records of intake, portion sizes, and product brand names, and birth weight, weight, height, and waist circumference (WC) at age 6 years were also collected. Body mass index (BMI) and WC z-scores standardized for sex and age were computed as markers of adiposity.

RESULTS

Children with SSRI exposure had lower levels of PA than children without SSRI exposure. Total dietary energy intakes did not vary between exposure groups. SSRI exposure was not associated with BMI or WC z-scores of the children. Importantly, although lower birth weight was observed in SSRI-exposed children, differences did not remain, accounting for gestational age.

CONCLUSION

Although SSRI exposure was associated with lower estimates of PA, such exposure was not associated with markers of adiposity or total diet energy intake at age 6 years. The implications across subsequent measures in childhood remain to be determined.

Improving pregnancy outcomes in humans through studies in sheep

Experimental studies that are relevant to human pregnancy rely on the selection of appropriate animal models as an important element in experimental design. Consideration of the strengths and weaknesses of any animal model of human disease is fundamental to effective and meaningful translation of preclinical research. Studies in sheep have made significant contributions to our understanding of the normal and abnormal development of the fetus. As a model of human pregnancy, studies in sheep have enabled scientists and clinicians to answer questions about the etiology and treatment of poor maternal, placental, and fetal health and to provide an evidence base for translation of interventions to the clinic. The aim of this review is to highlight the advances in perinatal human medicine that have been achieved following translation of research using the pregnant sheep and fetus.

Increased incidence of non-alcoholic fatty liver disease in male rat offspring exposed to fluoxetine during fetal and neonatal life involves the NLRP3 inflammasome and augmented de novo hepatic lipogenesis

Up to 10% of women take selective serotonin reuptake inhibitors (SSRI) during pregnancy. Children exposed to SSRIs in utero have an increased risk of being overweight suggesting that fetal exposure to SSRIs can cause permanent metabolic changes. We have previously shown in rats that fetal and neonatal exposure to the SSRI antidepressant fluoxetine results in metabolic perturbations including increased hepatic triglyceride content; a hallmark of non-alcoholic fatty liver disease (NAFLD). Therefore, the aim of this study was to identify the mechanism(s) underlying the fluoxetine-induced increase in intrahepatic triglyceride content. Female nulliparous Wistar rats were given vehicle or fluoxetine (10 mg/kg/day) orally for 2 weeks prior to mating until weaning. At 6 months of age, we assessed whether SSRI exposure altered components of the hepatic triglyceride biosynthesis pathway in the offspring and examined the molecular mechanisms underlying these changes. Male SSRI-exposed offspring had a significant increase in the steady-state mRNA levels of Elovl6 and Dgat1 and core components of the NLRP3 inflammasome (apoptosis-associated speck-like protein containing a caspase activation recruitment domain [ASC] and caspase-1). Augmented expression of Asc in the SSRI-exposed offspring coincided with increased histone acetylation in the proximal promoter region. Given that we have previously demonstrated that antenatal exposure to SSRIs can lead to fatty liver in the offspring, this raises concerns regarding the long-term metabolic sequelae of fetal SSRI exposure. Moreover, this study suggests that elevated hepatic triglyceride levels observed in the SSRI-exposed offspring may be due, in part, to activation of the NLRP3 inflammasome and augmentation of de novo lipogenesis.

The risks associated with prenatal antidepressant exposure: time for a precision medicine approach

INTRODUCTION

The prevalence of depression in pregnancy is over 10% and a significant proportion of pregnant women use antidepressant medication. The safety of antidepressants in pregnancy is controversial, partly due to methodological challenges. The conflicting results in the literature may, however, also be due to differences in risks between the study populations related to variations in e.g. degree of depression, type of antidepressant, and lifestyle. Areas covered: The literature on the safety of antidepressants in pregnancy is vast and thousands of papers have been published mainly in the last decades. This paper summarizes the evidence on important outcomes, including malformations, obstetric and neonatal outcomes, and long-term effects. It further describes results indicating that genetic variations in e.g. metabolism need to be taken into account. Expert opinion: Use of antidepressants during pregnancy must balance between the risks related to the underlying disease and the risks of antidepressant use. This balance needs to include information on a number of factors, including degree of depression and life-style. More data are required on how to include genetic information in the counseling. Overall, emerging evidence points to the need for a precision medicine approach to the treatment of pregnant women with depression.

Prenatal Depression Risk Factors, Developmental Effects and Interventions: A Review

This narrative review based on a literature search in PubMed and PsycInfo on the two terms prenatal and antenatal depression includes empirical studies, reviews and meta-analyses that have been published during the last 5 years on risk factors, developmental effects and interventions for prenatal depression. Risk factor studies that met criteria feature demographic measures (lower socioeconomic status, less education, non-marital status, non-employment, less social support and health locus of control, unintended pregnancy, partner violence and history of child abuse) and physiological variables (cortisol, amylase, and pro-inflammatory cytokines and intrauterine artery resistance). The negative effects include postpartum depression, paternal depression, and prematurity and low birth weight. Negative effects on infants include greater right frontal EEG, amygdala connectivity, cortical thinning and more difficult temperament. In childhood, externalizing and internalizing problems have been reported. The data on prenatal antidepressants (specifically SSRIs) reveal negative effects including internalizing problems as well as a greater risk for autism spectrum disorder. Prenatal interventions that have been effective include interpersonal psychotherapy, peer support, massage therapy, yoga, tai chi, and aerobic exercise. Potential underlying mechanisms are discussed as well as methodological limitations including homogeneity of samples and lack of randomization to intervention groups. Despite these limitations, the literature highlights the need for prenatal depression screening and intervention.

Effects of depression pharmacotherapy in fertility treatment on conception, birth, and neonatal health: A systematic review

OBJECTIVES

While antidepressant medications are currently used during conception, gestation and post-partum, considerable uncertainty exists regarding the benefits and harms conferred to mothers and their offspring. A significant body of evidence has focused on antidepressant use during pregnancy and post-partum. However, it is difficult to know if this translates to specific populations. Women receiving treatment for infertility are especially vulnerable to symptoms of depression and adverse perinatal outcomes. This systematic review aimed to determine the effects of antidepressants taken during the perinatal period by women receiving fertility treatment on conception, birth, and long-term maternal and child health outcomes.

METHODS

We searched MEDLINE, EMBASE, CINAHL, the Cochrane Library, PsycINFO, ProQuest Dissertation & Theses, and Pubmed databases from January 1950 to November 2015. Articles were screened for inclusion independently by two reviewers. Studies were included if they enrolled women of reproductive age exposed to pharmacotherapy for depression and infertility at any point during the perinatal period.

RESULTS

A total of 8587 unique citations, and 83 full-text articles were reviewed. Of these, two randomized controlled trials and two retrospective chart reviews were included in the narrative synthesis. While most studies reported on assisted reproduction processes and birth outcomes, none examined long-term impacts on maternal-child health. The few included studies did not find that antidepressant use by women receiving fertility therapy impacted gamete quality or pregnancy success.

CONCLUSIONS

Currently, no studies address whether pharmacotherapy for the treatment of depression in women undergoing assisted reproduction affects their health or that of their offspring long-term. It appears that much like antidepressant use in fertile women, there are risks associated with both antidepressant use and untreated depression. Decisions regarding the treatment of depression should be made taking into account clinical presentation and illness severity. Given the complexities of conducting research in this population, future research should attempt to leverage health registry data, to increase sample sizes and follow mothers and children longitudinally.

Prenatal Antidepressant Exposure and Childhood Autism Spectrum Disorders: Cause for Concern?

There is empirical evidence for a role for serotonin in autism . In experimental animals, early life exposure to serotonergic antidepressants or maternal stress affects brain development, with subsequent changes in serotonin tone in adult animals. Recently, antidepressant exposure during pregnancy has been associated with autism in epidemiological studies. At least part of the association is potentially explained by maternal depression or factors associated with depression. Importantly, even if there is no causal relation between prenatal antidepressant exposure and autism, use of antidepressants during pregnancy is a marker of potential problems later in life across five independent study populations, and exposed children may need special attention regardless of the underlying mechanism. Future studies need to disentangle the effects of maternal depression and antidepressant use during pregnancy while adjusting for the postnatal environment. One promising strategy is to use results from basic science to guide the inclusion of potential biological intermediates in advanced epidemiological studies.