Infant developmental outcomes following prenatal exposure to antidepressants, and maternal depressed mood and positive affect

Bidirectional Relations Among Maternal Positive Emotion, Infant Positive Emotionality, and Infant Physiological Regulation Across the First 18 Months of Life

Respiratory sinus arrhythmia (RSA), a marker of self-regulation, has been linked to developmental outcomes in young children. Although positive emotions may have the potential to facilitate physiological self-regulation, and enhanced self-regulation could underlie the development of positive emotions in early childhood, the relation between positive emotions and physiological self-regulation in infancy has been relatively overlooked. The current study examined the bidirectional associations among maternal positive emotion, infant positive emotionality, and infant resting RSA across the first 18 months of life. We used data from the Longitudinal Attention and Temperament Study (LanTs; N = 309 in the current analysis) to test the within- and between-person relations of study variables over time using a random-intercepts cross-lagged panel model. We found that infants with higher overall levels of positive emotionality also displayed greater resting RSA, and their mothers exhibited higher levels of positive emotion. However, there were negative cross-lagged associations within-person; higher than average infant positive emotionality predicted lower levels of infant resting RSA at the subsequent timepoint during early infancy, whereas higher than average infant RSA subsequently predicted decreased levels of infant positive emotionality later in infancy. Results highlight the importance of considering transactional relations between positive emotion and physiological self-regulation in infancy.

Combination of taking neuropsychiatric medications and psychological distress in pregnant women, with behavioral problems in children at 2 years of age: The Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study

Aim

To examine the association of the combination of taking neuropsychiatric medications from the onset of pregnancy to mid-pregnancy and maternal psychological distress at mid-pregnancy, with children's behavioral problems.

Methods

Neuropsychiatric medication use from the onset of pregnancy to mid-pregnancy was defined by the self-reported name of the neuropsychiatric medication in the questionnaire in early and mid-pregnancy. Maternal psychological distress was defined by the Kessler Psychological Distress Scale (K6) ≥13 on the questionnaire in mid-pregnancy. We classified the participants into four categories based on the combination of taking neuropsychiatric medications and psychological distress: "None," "Medications only," "K6 ≥ 13 only," and "Both." Children's behavioral problems were assessed using the Child Behavior Checklist for Ages 1½-5 (CBCL) at 2 years of age. The clinical ranges of the internalizing and externalizing scales of the CBCL were defined as behavioral problems. We conducted a multivariable logistic regression analysis to examine the associations between the four categories of maternal exposure and children's behavioral problems.

Results

Compared with the "None" category (n = 9873), the "K6 ≥ 13 only" category (n = 308) was statistically significantly associated with internalizing and externalizing problems. In contrast, the "Medications only" (n = 93) and "Both" (n = 22) categories were not statistically significantly associated with internalizing and externalizing problems, although the point estimates of the odds ratio in the "Both" category were relatively high (1.58 for the internalizing problem and 2.50 for the externalizing problem).

Conclusion

The category of mothers taking neuropsychiatric medications and having no psychological distress during pregnancy was not associated with children's behavioral problems in the present population.

Infants of mothers with early remitted clinical depression and mothers with no postpartum depression: Adaptive functioning in the second year of life

Whether and how remitted clinical depression in postpartum motherhood contributes to poor infant adaptive functioning is inconclusive. The present longitudinal study examines adaptive functioning in infants of mothers diagnosed as clinically depressed at 5 months but remitted at 15 and 24 months. Fifty-five U. S. mothers with early, remitted clinical depression and 132 mothers without postpartum depression completed the Vineland Adaptive Behavior Scales about their infants at 15 and 24 months. Between groups, mothers were equivalent in age, ethnicity, marital status, and receptive vocabulary (a proxy for verbal intelligence), and infants were equivalent in age and distribution of gender. Controlling for maternal education and parity, mothers with early, remitted clinical depression and mothers with no postpartum depression rated their infants similarly on communication, daily living skills, and socialization. Mothers with early, remitted clinical depression rated their infants poorer in motor skills. Girls were rated more advanced than boys in communication at 24 months and daily living skills at 15 and 24 months. Rated infant adaptive behavior skills increased from 15 to 24 months. With exceptions, adaptive functioning in infants may be robust to early, remitted maternal depression, and adaptive functioning presents a domain to promote positive development in this otherwise vulnerable population.

Behavioural outcomes of children exposed to antidepressants and unmedicated depression during pregnancy

BACKGROUND

Antenatal exposure to both antidepressants and maternal depression has been associated with child behavioural difficulties. However, previous research has not adequately distinguished between the effects of the antidepressants and the underlying maternal depression.

METHODS

Child behavioural difficulties were assessed using the Strengths and Difficulties Questionnaire at 2-, 4.5-, and 8-years of age by mothers in the Growing Up in New Zealand study (N = 6233 at 2-years; N = 6066 at 4.5-years; N = 4632 at 8-years). Mothers were classified as either on antidepressants, unmedicated depression, or neither based on self-reported antidepressant intake during pregnancy and the Edinburgh Postnatal Depression Scale. Hierarchical multiple logistic regressions were used to examine whether antenatal exposure to antidepressants and unmedicated depression had a differential association with child behavioural outcomes relative to no exposure.

RESULTS

When later life depression in the mother and a range of birth and sociodemographic variables were accounted for, neither antenatal exposure to unmedicated depression or antidepressants remained associated with an increased risk of behavioural difficulties at the ages investigated. However, maternal later life depression was associated with behavioural difficulties in the fully adjusted analyses at all three ages investigated.

LIMITATIONS

The current study relied on mother-report of child behaviour which may be susceptible to bias due to maternal mental health problems.

CONCLUSIONS

Adjusted results did not show an adverse association between antenatal antidepressant exposure or unmedicated depression in relation to child behaviour. Findings also suggest that efforts to improve child behaviour need to include more family-based approaches that support maternal wellbeing.

Positive maternal mental health attenuates the associations between prenatal stress and children's internalizing and externalizing symptoms

Positive maternal mental health can improve perceptions of stressful situations and promote the use of adaptive coping strategies. However, few studies have examined how positive maternal mental health affects children's development. The aims of this study were to examine the associations between positive maternal mental health and children's internalizing and externalizing symptoms, and to ascertain whether positive maternal mental health moderated the associations between prenatal stress and children's internalizing and externalizing symptoms. This study is based on the Norwegian Mother, Father, and Child Cohort Study (MoBa), and comprised 36,584 mother-child dyads. Prenatal stress was assessed using 41 self-reported items measured during pregnancy. Positive maternal mental health (self-efficacy, self-esteem, and enjoyment) was assessed by maternal report during pregnancy and postpartum. Child internalizing and externalizing symptoms were assessed by maternal report at age 5. Structural equation modeling was used for analysis. Maternal self-efficacy, self-esteem, and enjoyment were negatively associated with internalizing and externalizing symptoms in males and females. The association between prenatal stress and internalizing symptoms in males was stronger at low than at high levels of maternal self-esteem and enjoyment, whereas for females, the association was stronger at low than at high levels of maternal self-esteem and self-efficacy. This study provides evidence of associations between positive maternal mental health and children's mental health, and suggests that higher positive maternal mental health may buffer against the impacts of prenatal stress. Positive maternal mental health may represent an important intervention target to improve maternal-child well-being and foster intergenerational resilience.

Positive affect improves a transdiagnostic model of perinatal depression symptoms

INTRODUCTION

Accurate measurement of perinatal depression is vital. We aimed to 1) test whether a factor that measured positive affect (PA) bettered a transdiagnostic model of depression symptoms and 2) replicate the model in a second sample.

METHODS

We conducted secondary analyses from two samples (n's = 657 and 142) of women in treatment at perinatal psychiatric clinics. Data were derived from items from seven commonly used measures. We compared fit indices from our original factor model-one general and six specific factors derived from the Research Domain Criteria (Loss, Potential Threat, Frustrative Nonreward, and Sleep-Wakefulness) and depression literatures (Somatic and Coping)-to our novel factor model with a PA factor. The PA factor was created by recategorizing items that measured affective states with a positive valence into a new factor. Sample 1 data were split into six perinatal periods.

RESULTS

In both samples, the addition of a PA factor improved model fit. At least partial metric invariance was found between perinatal periods, with the exception of trimester 3 - postpartum period 1.

LIMITATIONS

Our measures did not operationalize PA in the same way as in the positive valence system in RDoC and we were unable to perform longitudinal analyses on our cross-validation sample.

CONCLUSIONS

Clinicians and researchers are encouraged to consider these findings as a template for understanding symptoms of depression in perinatal patients, which can be used to guide treatment planning and the development of more effective screening, prevention, and intervention tools to prevent deleterious outcomes.

Effect of Musical Stimulation on Placental Programming and Neurodevelopment Outcome of Preterm Infants: A Systematic Review

BACKGROUND

The fetal environment is modulated by the placenta, which integrates and transduces information from the maternal environment to the fetal developmental program and adapts rapidly to changes through epigenetic mechanisms that respond to internal (hereditary) and external (environmental and social) signals. Consequently, the fetus corrects the trajectory of own development. During the last trimester of gestation, plasticity shapes the fetal brain, and prematurity can alter the typical developmental trajectories. In this period, prevention through activity-inducing (e.g., music stimulation) interventions are currently tested. The purpose of this review is to describe the potentialities of music exposure on fetus, and on preterm newborns in the Neonatal Intensive Care Unit evaluating its influence on neurobehavioral development.

METHODS

Databases were searched from 2010 to 2022 for studies investigating mechanisms of placental epigenetic regulation and effects of music exposure on the fetus and pre-term neonates.

RESULTS

In this case, 28 selected papers were distributed into three research lines: studies on placental epigenetic regulation (13 papers), experimental studies of music stimulation on fetus or newborns (6 papers), and clinical studies on premature babies (9 papers). Placental epigenetic changes of the genes involved in the cortisol and serotonin response resulted associated with different neurobehavioral phenotypes in newborns. Prenatal music stimulation had positive effects on fetus, newborn, and pregnant mother while post-natal exposure affected the neurodevelopment of the preterm infants and parental interaction.

CONCLUSIONS

The results testify the relevance of environmental stimuli for brain development during the pre- and perinatal periods and the beneficial effects of musical stimulation that can handle the fetal programming and the main neurobehavioral disorders.

Association of Antidepressant Use During Pregnancy With Risk of Neurodevelopmental Disorders in Children

Importance

Antidepressant use during pregnancy has been associated with neurodevelopmental disorders in children in some studies. However, results may be explained by uncontrolled confounding by parental mental health status, genetics, and environmental factors.

Objective

To evaluate the association between antidepressant use in pregnancy and neurodevelopmental outcomes in children.

Design, Setting, and Participants

This cohort study of health care utilization data was separated into cohorts of publicly and privately insured pregnant individuals and their children nested in the Medicaid Analytic eXtract (MAX; 2000-2014) and the IBM MarketScan Research Database (MarketScan; 2003-2015). A total of 1.93 million pregnancies in MAX and 1.25 million pregnancies in MarketScan were recorded. Children were followed from birth until outcome diagnosis, disenrollment, death, or end of study (maximum 14 years). Analyses were conducted between August 2020 and July 2021.

Exposures

Dispensing of antidepressant medication from gestational week 19 until delivery, the period of synaptogenesis.

Main Outcomes and Measures

Neurodevelopmental disorders in children defined using validated algorithms. Early pregnancy exposure was considered in sensitivity analyses, and approaches to confounding adjustment included propensity score fine stratification, discontinuers comparison, and sibling analyses.

Results

Among the individuals included in the analysis, there were 145 702 antidepressant-exposed and 3 032 745 unexposed pregnancies; the mean (SD) age among the antidepressant exposed and unexposed was 26.2 (5.7) and 24.3 (5.8) years in MAX and 32.7 (4.6) and 31.9 (4.6) years in MarketScan, respectively; and in MAX, which collected information on race and ethnicity, 72.4% of the antidepressant-exposed and 37.1% of the unexposed individuals were White. Crude results suggested up to a doubling in risk of neurodevelopmental outcomes associated with antidepressant exposure; however, no association was observed in the most fully adjusted analyses. When comparing antidepressant-exposed and unexposed siblings, hazard ratios were 0.97 (95% CI, 0.88-1.06) for any neurodevelopmental disorder, 0.86 (95% CI, 0.60-1.23) for autism spectrum disorder, 0.94 (95% CI, 0.81-1.08) for attention-deficit/hyperactivity disorder, 0.77 (95% CI, 0.42-1.39) for specific learning disorders, 1.01 (95% CI, 0.88-1.16) for developmental speech/language disorder, 0.79 (95% CI, 0.54-1.17) for developmental coordination disorder, 1.00 (95% CI, 0.45-2.22) for intellectual disability, and 0.95 (95% CI, 0.80-1.12) for behavioral disorders. Results were generally consistent for antidepressant classes and drugs and across exposure windows.

Conclusions and Relevance

The results of this cohort study suggest that antidepressant use in pregnancy itself does not increase the risk of neurodevelopmental disorders in children. However, given strong crude associations, antidepressant exposure in pregnancy may be an important marker for the need of early screening and intervention.

Perinatal exposure to fluoxetine and maternal adversity affect myelin-related gene expression and epigenetic regulation in the corticolimbic circuit of juvenile rats

Many pregnant women experience symptoms of depression, and are often treated with selective serotonin reuptake inhibitor (SSRI) antidepressants, such as fluoxetine. In utero exposure to SSRIs and maternal depressive symptoms is associated with sex-specific effects on the brain and behavior. However, knowledge about the neurobiological mechanisms underlying these sex differences is limited. In addition, most animal research into developmental SSRI exposure neglects the influence of maternal adversity. Therefore, we used a rat model relevant to depression to investigate the molecular effects of perinatal fluoxetine exposure in male and female juvenile offspring. We performed RNA sequencing and targeted DNA methylation analyses on the prefrontal cortex and basolateral amygdala; key regions of the corticolimbic circuit. Perinatal fluoxetine enhanced myelin-related gene expression in the prefrontal cortex, while inhibiting it in the basolateral amygdala. SSRI exposure and maternal adversity interacted to affect expression of genes such as myelin-associated glycoprotein (Mag) and myelin basic protein (Mbp). We speculate that altered myelination reflects altered brain maturation. In addition, these effects are stronger in males than in females, resembling known behavioral outcomes. Finally, Mag and Mbp expression correlated with DNA methylation, highlighting epigenetic regulation as a potential mechanism for developmental fluoxetine-induced changes in myelination.

A cross-sectional study of the relationship between CYP2D6 and CYP2C19 variations and depression symptoms, for women taking SSRIs during pregnancy

Depression during pregnancy affects 10-15% of women, and 5% of women take antidepressants during pregnancy. Clinical guidelines provide recommendations for selective serotonin reuptake inhibitor (SSRI) drug choice and dose based on CYP2D6 and CYP2C19 genotype; however, they are based on evidence from non-pregnant cohorts. This study aimed to test the hypothesis that women with function-altering variants (increased, decreased, or no function) in these pharmacogenes, taking SSRIs prenatally, would have more depression symptoms than women whose pharmacogenetic variants are associated with normal SSRI metabolism. Comprehensive CYP2D6 and CYP2C19 genotyping using a range of methods, including gene copy number analysis, was performed as secondary analyses on two longitudinal cohorts of pregnant women (N = 83) taking the SSRIs paroxetine, citalopram, escitalopram, or sertraline. The Kruskal-Wallis test compared mean depression scores across four predicted metabolizer groups: poor (n = 5), intermediate (n = 10), normal (n = 53), and ultrarapid (n = 15). There were no significant differences between mean depression scores across the four metabolizer groups (H(3) = .73, p = .87, eta-squared = .029, epsilon-squared = .0089). This is the first study of the relationship in pregnancy between CYP2C19 pharmacogenetic variations and depression symptoms in the context of SSRI use. Findings from this initial study do not support the clinical use of pharmacogenetic testing for SSRI use during the second or third trimesters of pregnancy, but these findings should be confirmed in larger cohorts. There is an urgent need for further research to clarify the utility of pharmacogenetic testing for pregnant women, especially as companies offering direct-to-consumer genetic testing expand their marketing efforts.

Perinatal fluoxetine dose-dependently affects prenatal stress-induced neurobehavioural abnormalities, HPA-axis functioning and underlying brain alterations in rat dams and their offspring

Both untreated and SSRI antidepressant treated maternal depression during the perinatal period can pose both short-and long-term health risks to the offspring. Therefore, it is essential to have an effective SSRI treatment consisting of the lowest effective dose beneficial to the mother, without causing adverse effects on offspring development. The effects of prenatal stress on neurobehavioral outcomes were studied in the pregnant and lactating rat dam, and her offspring. Furthermore, stressed dams were treated with different doses of fluoxetine (FLX; 5, 10and 25 mg/kg) during pregnancy and the postpartum period. We found that prenatal stress-induced anxiety-and depressive-like behaviour and increased HPA-axis function in pregnant and postpartum dams, and in offspring. Maternal stress impaired object recognition but did not affect spatial memory in offspring. Prenatal stress decreased whole-brain serotonin and brain-derived-neurotrophic-factor, and increased interleukin-17 and malondialdehyde, but did not affect oxytocin and interleukin-6 in the brains of offspring. Maternal treatment with 5 mg/kg FLX during the perinatal period did not rescue any stress-induced anxiety/depressive-like behaviour in the pregnant and postpartum dam and had only a few rescuing effects in offspring. Maternal FLX treatment with 10 mg/kg did rescue most stress-induced anxiety-and depressive-like behaviour or HPA-axis-function in dams and offspring. The highest dose tested, 25 mg/kg FLX, had the rescuing properties in dams while having the same, or an even greater, detrimental effect as prenatal stress on offspring behaviour and molecular alterations in the brain. Our results show prenatal stress rescuing properties for FLX treatment in the pregnant and postpartum dam, with dose-dependent effects on the offspring.

Prenatal antidepressant exposure and sex differences in neonatal corpus callosum microstructure

Prenatal exposure to selective serotonin reuptake inhibitor (SSRI) antidepressants may influence white matter (WM) development, as previous studies report widespread microstructural alterations and reduced interhemispheric connectivity in SSRI-exposed infants. In rodents, perinatal SSRIs had sex-specific disruptions in corpus callosum (CC) axon architecture and connectivity; yet it is unknown whether SSRI-related brain outcomes in humans are sex specific. In this study, the neonate CC was selected as a region-of-interest to investigate whether prenatal SSRI exposure has sex-specific effects on early WM microstructure. On postnatal day 7, diffusion tensor imaging was used to assess WM microstructure in SSRI-exposed (n = 24; 12 male) and nonexposed (n = 48; 28 male) term-born neonates. Fractional anisotropy was extracted from CC voxels and a multivariate discriminant analysis was used to identify latent patterns differing between neonates grouped by SSRI-exposure and sex. Analysis revealed localized variations in CC fractional anisotropy that significantly discriminated neonate groups and correctly predicted group membership with an 82% accuracy. Such effects were identified across three dimensions, representing sex differences in SSRI-exposed neonates (genu, splenium), SSRI-related effects independent of sex (genu-to-rostral body), and sex differences in nonexposed neonates (isthmus-splenium, posterior midbody). Our findings suggest that CC microstructure may have a sex-specific, localized, developmental sensitivity to prenatal SSRI exposure.

Prenatal antidepressant exposure and child development at kindergarten age: a population-based study

BACKGROUND

Though prenatal antidepressant exposure has been associated with adverse developmental outcomes, the extent to which the effects are due to prenatal drug exposure or underlying maternal mood disturbances is unclear.

METHODS

This was a population-based retrospective cohort study using administrative data from British Columbia, Canada (n = 94,712). Analyses were designed to remove confounding effects of prenatal antidepressant exposure from maternal mood. First, children prenatally exposed to antidepressants were matched to unexposed children using high-dimensional propensity scores (HDPS). Second, children whose mothers had used antidepressants throughout pregnancy were compared against those whose mothers discontinued treatment.

RESULTS

In all, 3.87% (n = 3661) of children in the overall study population were prenatally exposed to antidepressants. In both analyses, we report increased odds for lower levels of physical independence (HDPS: OR, 1.14; 95% CI, 1.00-1.30; continuers/discontinuers: OR, 1.14; 95% CI, 0.99-1.32), and higher levels of anxious behaviors (HDPS: OR, 1.30; 95% CI, 1.01-1.66; continuers/discontinuers: OR, 1.32; 95% CI, 1.01-1.72) associated with antidepressant use in pregnancy. All other relationships were not significant using these methods.

CONCLUSIONS

Prenatal antidepressant exposure was selectively associated with worse anxious behaviors and physical independence at kindergarten age, with no effects on other developmental domains. Effects are also likely attributable to maternal mental illness severity or other unmeasured confounding factors.

IMPACT

Selective associations between prenatal antidepressant exposure and children's anxiety and physical independence at kindergarten were identified, with no impact on other developmental domains. Contradictory reports have emerged regarding the association of adverse child outcomes with prenatal antidepressant exposure. These inconsistencies may be due to differences in control for confounding. Effects of prenatal antidepressant exposure on anxious behaviors and physical independence are likely also attributable to severity of underlying maternal mood disorders, highlighting the importance of maternal mental health for developmental health.

The combination of fluoxetine and environmental enrichment reduces postpartum stress-related behaviors through the oxytocinergic system and HPA axis in mice

Gestational stress can increase postpartum depression in women. To treat maternal depression, fluoxetine (FLX) is most commonly prescribed. While FLX may be effective for the mother, at high doses it may have adverse effects on the fetus. As environmental enrichment (EE) can reduce maternal stress effects, we hypothesized that a subthreshold dose of FLX increases the impact of EE to reduce anxiety and depression-like behavior in postpartum dams exposed to gestational stress. We evaluated this hypothesis in mice and to assess underlying mechanisms we additionally measured hypothalamic-pituitary-adrenal (HPA) axis function and brain levels of the hormone oxytocin, which are thought to be implicated in postpartum depression. Gestational stress increased anxiety- and depression-like behavior in postpartum dams. This was accompanied by an increase in HPA axis function and a decrease in whole-brain oxytocin levels in dams. A combination of FLX and EE remediated the behavioral, HPA axis and oxytocin changes induced by gestational stress. Central administration of an oxytocin receptor antagonist prevented the remediating effect of FLX + EE, indicating that brain oxytocin contributes to the effect of FLX + EE. These findings suggest that oxytocin is causally involved in FLX + EE mediated remediation of postpartum stress-related behaviors, and HPA axis function in postpartum dams.

Antidepressant Use During Pregnancy and the Potential Risks of Motor Outcomes and Intellectual Disabilities in Offspring: A Systematic Review

Background

There is a risk of adverse neurodevelopmental outcomes in offspring from exposure to antidepressants during pregnancy.

Objective

This study was performed to systematically review the available evidence regarding the impact of in utero exposure to antidepressants on motor and intellectual disability outcomes in children.

Patients and Methods

A systematic literature search for published observational studies examining the effects of antidepressants on motor development or intellectual disabilities in children was conducted using the Cochrane Central Register of Controlled Trials, PubMed/Medline, and Google Scholar.

Results

A total of 14 studies were included in this review. Studies have reported conflicting effects on motor development in infants with maternal exposure to antidepressants. Furthermore, not all of the studies included that assessed intellectual disabilities in infants found an association between maternal exposure to antidepressants and intellectual disabilities. However, methodological flaws existed in the studies, such as the use of scales with inadequate reliability or validity, a lack of statistical power, or confounding by indication or disease severity.

Conclusion

The available literature provides inconclusive evidence on the relationship between in utero exposure to antidepressants and adverse effects on motor development outcomes or neurocognitive skills. Further observational studies with robust methodologies are needed to comprehensively evaluate the potential risks of prescribing antidepressants during pregnancy.

Maternal Serotonin Reuptake Inhibitor Antidepressants Have Acute Effects on Fetal Heart Rate Variability in Late Gestation

Background: Prenatal exposure to serotonin reuptake inhibitor (SRI) antidepressants increases risk for adverse neurodevelopmental outcomes, yet little is known about whether effects are present before birth. In relation to maternal SRI pharmacokinetics, this study investigated chronic and acute effects of prenatal SRI exposure on third-trimester fetal heart rate variability (HRV), while evaluating confounding effects of maternal depressed mood. Methods: At 36-weeks' gestation, cardiotocograph measures of fetal HR and HRV were obtained from 148 pregnant women [four groups: SRI-Depressed (n = 31), SRI-Non-Depressed (n = 18), Depressed (unmedicated; n = 42), and Control (n = 57)] before, and ~5-h after, typical SRI dose. Maternal plasma drug concentrations were quantified at baseline (pre-dose) and four time-points post-dose. Mixed effects modeling investigated group differences between baseline/pre-dose and post-dose fetal HR outcomes. Post hoc analyses investigated sex differences and dose-dependent SRI effects. Results: Maternal SRI plasma concentrations were lowest during the baseline/pre-dose fetal assessment (trough) and increased to a peak at the post-dose assessment; concentration-time curves varied widely between individuals. No group differences in fetal HR or HRV were observed at baseline/pre-dose; however, following maternal SRI dose, short-term HRV decreased in both SRI-exposed fetal groups. In the SRI-Depressed group, these post-dose decreases were displayed by male fetuses, but not females. Further, episodes of high HRV decreased post-dose relative to baseline, but only among SRI-Non-Depressed group fetuses. Higher maternal SRI doses also predicted a greater number of fetal HR decelerations. Fetuses exposed to unmedicated maternal depressed mood did not differ from Controls. Conclusions: Prenatal SRI exposure had acute post-dose effects on fetal HRV in late gestation, which differed depending on maternal mood response to SRI pharmacotherapy. Importantly, fetal SRI effects were sex-specific among mothers with persistent depressive symptoms, as only male fetuses displayed acute HRV decreases. At trough (pre-dose), chronic fetal SRI effects were not identified; however, concurrent changes in maternal SRI plasma levels suggest that fetal drug exposure is inconsistent. Acute SRI-related changes in fetal HRV may reflect a pharmacologic mechanism, a transient impairment in autonomic functioning, or an early adaption to altered serotonergic signaling, which may differ between males and females. Replication is needed to determine significance with postnatal development.

Maternal Depressive Symptoms and Developmental Delay at Age 2: A Diverse Population-Based Longitudinal Study

OBJECTIVES

Children raised by depressed mothers perform lower on measures of cognitive, emotional, and behavioral skills, compared to children of non-depressed mothers. It is unclear how maternal depressive symptoms (MDS), which persist and accrue over time, impact child development. The purpose of this study was to determine whether cumulative MDS from pre-pregnancy to postpartum influences child development in children by age 2.5.

METHODS

Using a longitudinal population-based study design, 2679 racially and ethnically diverse mothers completed the 2014 Los Angeles Mommy and Baby (LAMB) and 2016 Follow-Up surveys. A total MDS score was created based on responses to standardized questions, including the Patient Health Questionnaire-2 (PHQ-2). Data was collected for before pregnancy, during pregnancy, and 4 months postpartum in the 2014 survey, and at 2.5 years postpartum in the 2016 survey. Child development was measured using the CDC's Learn the Signs. Act Early Milestones Checklist. Bivariate and multivariate logistic regressions were conducted.

RESULTS

The prevalence of any cumulative MDS was 45.2%. Language, cognitive/adaptive, motor, and social-emotional delays for surveyed toddlers were 7.7%, 4.0%, 1.2%, and 14.2%. After adjusting for covariates, mothers reporting depressive symptoms at all four time points were significantly more likely to report a social-emotional delay in their child (aOR = 4.39, 95% CI - 1.72 to 11.18).

CONCLUSIONS FOR PRACTICE

Mothers with cumulative depressive symptoms are at-risk of reporting social-emotional delays by age 2.5. Understanding these effects may help direct resources to target interventions that support mothers with depressive symptoms early-on and promote positive developmental outcomes among their children.

Association Between Maternal Perinatal Depression and Anxiety and Child and Adolescent Development: A Meta-analysis

IMPORTANCE

There is widespread interest in associations between maternal perinatal depression and anxiety and offspring development; however, to date, there has been no systematic, meta-analytic review on the long-term developmental outcomes spanning infancy through adolescence.

OBJECTIVE

To provide a comprehensive systematic review and meta-analysis of the extant literature on associations between maternal perinatal depression and anxiety and social-emotional, cognitive, language, motor, and adaptability outcomes in offspring during the first 18 years of life.

DATA SOURCES

Six databases were searched (CINAHL Complete, Cochrane Library, Embase, Informit, MEDLINE Complete, and PsycInfo) for all extant studies reporting associations between perinatal maternal mental health problems and offspring development to March 1, 2020.

STUDY SELECTION

Studies were included if they were published in English; had a human sample, quantitative data, a longitudinal design, and measures of perinatal depression and/or anxiety and social-emotional, cognitive, language, motor, and/or adaptability development in offspring; and investigated an association between perinatal depression or anxiety and childhood development.

DATA EXTRACTION AND SYNTHESIS

Of 27 212 articles identified, 191 were eligible for meta-analysis. Data were extracted by multiple independent observers and pooled using a fixed- or a random-effects model. A series of meta-regressions were also conducted. Data were analyzed from January 1, 2019, to March 15, 2020.

MAIN OUTCOMES AND MEASURES

Primary outcomes included social-emotional, cognitive, language, motor, and adaptability development in offspring during the first 18 years of life.

RESULTS

After screening, 191 unique studies were eligible for meta-analysis, with a combined sample of 195 751 unique mother-child dyads. Maternal perinatal depression and anxiety were associated with poorer offspring social-emotional (antenatal period, r = 0.21 [95% CI, 0.16-0.27]; postnatal period, r = 0.24 [95% CI, 0.19-0.28]), cognitive (antenatal period, r = -0.12 [95% CI, -0.19 to -0.05]; postnatal period, r = -0.25 [95% CI, -0.39 to -0.09]), language (antenatal period, r = -0.11 [95% CI, -0.20 to 0.02]; postnatal period, r = -0.22 [95% CI, -0.40 to 0.03]), motor (antenatal period, r = -0.07 [95% CI, -0.18 to 0.03]; postnatal period, r = -0.07 [95% CI, -0.16 to 0.03]), and adaptive behavior (antenatal period, r = -0.26 [95% CI, -0.39 to -0.12]) development. Findings extended beyond infancy, into childhood and adolescence. Meta-regressions confirmed the robustness of the results.

CONCLUSIONS AND RELEVANCE

Evidence suggests that perinatal depression and anxiety in mothers are adversely associated with offspring development and therefore are important targets for prevention and early intervention to support mothers transitioning into parenthood and the health and well-being of next-generation offspring.

Can broad-spectrum multinutrients treat symptoms of antenatal depression and anxiety and improve infant development? Study protocol of a double blind, randomized, controlled trial (the 'NUTRIMUM' trial)

BACKGROUND

Untreated antenatal depression and anxiety can be associated with short and long term health impacts on the pregnant woman, her infant and the rest of the family. Alternative interventions to those currently available are needed. This clinical trial aims to investigate the efficacy and safety of a broad-spectrum multinutrient formula as a treatment for symptoms of depression and anxiety in pregnant women and to determine the impact supplementation has on the general health and development of the infant.

METHODS

This randomised, controlled trial will be conducted in Canterbury, New Zealand between April 2017 and June 2022. One hundred and twenty women aged over 16 years, between 12 and 24 weeks gestation and who score ≥ 13 on the Edinburgh Postnatal Depression Scale (EPDS) will be randomly assigned to take the intervention (n = 60) or an active control formula containing iodine and riboflavin (n = 60) for 12 weeks. After 12 weeks, participants can enter an open-label phase until the birth of their infant and naturalistically followed for the first 12 months postpartum. Infants will be followed until 12 months of age. Randomisation will be computer-generated, with allocation concealment by opaque sequentially numbered envelopes. Participants and the research team including data analysts will be blinded to group assignment. The EPDS and the Clinical Global Impressions Scale of Improvement (CGI-I) will be the maternal primary outcome measures of this study and will assess the incidence of depression and anxiety and the improvement of symptomatology respectively. Generalized linear mixed effects regression models will analyse statistical differences between the multinutrient and active control group on an intent-to-treat basis. A minimum of a three-point difference in EPDS scores between the groups will identify clinical significance. Pregnancy outcomes, adverse events and side effects will also be monitored and reported.

DISCUSSION

Should the multinutrient formula be shown to be beneficial for both the mother and the infant, then an alternative treatment option that may also improve the biopsychosocial development of their infants can be provided for pregnant women experiencing symptoms of depression and anxiety.

TRIAL REGISTRATION

Trial ID: ACTRN12617000354381 ; prospectively registered at Australian New Zealand Clinical Trials Registry on 08/03/2017.

Intra-uterine exposure to selective serotonin reuptake inhibitors (SSRIs), maternal psychopathology, and neurodevelopment at age 2.5years - Results from the prospective cohort SMOK study

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) are prescribed in 2-8% during pregnancy. Whether prenatal exposure to SSRIs has long-term effects on the children's development is unknown.

AIM

The aim of this study was to determine the effect of prenatal exposure to SSRIs on children's cognitive, motor, and behavioral outcomes at 2.5 years, adjusted for maternal depression and anxiety.

METHODS

In a prospective, longitudinal cohort-study we included 111 pregnant women treated either or not with an SSRI. We examined cognitive and motor development of their children at 2.5 years, using the Bayley Scale of Infant and Toddler Development, 3rd Edition, and measured emotional and behavioral problems using the parent-rated Child Behavior Checklist (CBCL). Maternal depression and anxiety was determined during pregnancy and at the children's assessment. Differences of normed cognitive, motor, and behavioral scores between SSRI-exposed and non-SSRI-exposed children were tested using multiple linear regression analyses.

RESULTS

We examined 102 children. SSRI-exposed children had lower scaled scores on cognition and gross motor development than non-SSRI-exposed children: 9.0 ± 1.4 (mean ± SD) versus 9.9 ± 1.7 [P = 0.004], and 7.9 ± 2.2 versus 9.0 ± 2.5 [P = 0.01], respectively. Differences remained significant after adjusting for maternal depression and anxiety and other confounders in various models (mean difference for cognition 0.8 to 0.9 points, for gross motor 1.1 to 1.2 points). Only after adjusting for severity of maternal anxiety, differences in gross motor scores lost significance.

CONCLUSIONS

Prenatal exposure to SSRIs is associated with poorer cognitive and gross motor development of the children at 2.5 years. Effects on gross motor development disappeared after correction for severity of maternal anxiety.

Maternal prenatal depression and epigenetic age deceleration: testing potentially confounding effects of prenatal stress and SSRI use

Previous studies suggest epigenetic alterations may contribute to the association between maternal prenatal depression and adverse offspring outcomes. Developmental researchers have recently begun to examine these associations in relation to epigenetic age acceleration/deceleration, a biomarker of developmental risk that reflects the deviation between epigenetic age and chronological age. In the perinatal period, preliminary studies indicate that maternal prenatal depression may lead to epigenetic age deceleration in newborns, which may predict adverse developmental outcomes. The present study examined the relationship between maternal prenatal exposures (i.e., depression, stress, and SSRI use) and offspring epigenetic age deceleration in 303 mother-offspring dyads. Women were recruited in the first trimester of pregnancy and followed longitudinally until delivery. Maternal depression, perceived stress, and SSRI use were assessed at each prenatal visit. Newborn epigenetic age was determined via cord blood samples. Results indicated maternal prenatal stress was not associated with newborn epigenetic age deceleration (ΔR² = 0.002; p = 0.37). Maternal prenatal depression was associated with decelerated epigenetic age (ΔR² = 0.01, p = 0.04), but this relationship did not hold when accounting for maternal use of SSRIs (ΔR² = 0.002, p = 0.43). Conversely, maternal SSRI use significantly predicted newborn epigenetic age deceleration over and above the influence of maternal depression (ΔR² = 0.03, p = 0.001). These findings suggest maternal prenatal SSRI use may significantly contribute to the previously documented association between maternal prenatal depression and epigenetic age deceleration. Further studies are needed to examine how these epigenetic differences at birth may contribute to adverse outcomes in later development.

A common clinical conundrum: Antidepressant treatment of depression in pregnant women

Depression during pregnancy is associated with adverse maternal, pregnancy, and infant outcomes. Treatment during pregnancy requires a balanced discussion of the risks of both drug exposure and untreated depression. An updated review of the epidemiology, outcomes, and management of maternal depression is presented. Adverse outcomes are associated with both maternal depression and antidepressants. Research gaps include data on the longitudinal developmental trajectory of offspring exposed to antidepressants compared to depression, with assessment of in utero symptom exposure and environmental exposures. Additionally, neonatal syndrome associated with antidepressant use during pregnancy has no consensus definition or mechanistic explanation. With sophisticated large-scale epidemiologic studies, there has been progress in distinguishing the impact of depression processes from medication used for treatment. Optimal treatment of perinatal depression includes close symptom monitoring and medication adjustments to maintain symptom remission. This evolving field requires frequent consultation with reproductive data sources included in this article.

Advanced neuroimaging: A window into the neural correlates of fetal programming related to prenatal exposure to maternal depression and SSRIs

Fetal programming is a conceptual framework whereby the in utero environment shapes the offspring's neurodevelopment. Maternal depression and treatment with selective serotonin reuptake inhibitor (SSRI) antidepressants during pregnancy are common prenatal exposures that affect critical early life developmental programming processes. Prenatal depression and SSRIs both have been reported to increase the risks for preterm birth, low birth weight, and are associated with behavioral disturbances across the early life span. However, not all exposures lead to adverse developmental outcomes and distinguishing how each exposure contributes to variations in development remains challenging. Advances in neuroimaging, using MR and EEG, offer novel insights into central processes that might reveal the neural correlates of fetal programming. This review focuses on emerging findings from neuroimaging studies reflecting early brain functional and structural development associated with prenatal exposure to maternal depression and SSRI antidepressants. Suggestions for future research directions that use neuroimaging as a tool to advancing our understanding of the early origins of developmental plasticity are offered.

A Cohort Study of Psychotropic Prescription Drug Use in Pregnancy in British Columbia, Canada from 1997 to 2010

Background: Psychiatric conditions are relatively common during pregnancy, and many of these conditions are treated with psychotropic medications. In this article, we aim to quantify the rate of pregnancy-related exposures and describe how psychotropic medications are being used in pregnancy. Materials and Methods: We conducted a retrospective cohort study of all pregnancies ending in a live birth in the Canadian province of British Columbia between January 1, 1997 and December 31, 2010. We examined antipsychotic, anxiolytic, antidepressant, and stimulants use during pregnancy. We describe use of these medications across the pregnancy period, in terms of incident and prevalent use in pregnancy and whether women had corresponding diagnoses for mental health conditions. Results: We included 424,307 pregnancies, of whom 7.1% were dispensed a psychotropic medication. The most commonly used psychotropic medications were antidepressants (4.2%) followed by anxiolytics (3.4%). Among psychotropic medication users, the most commonly associated psychiatric diagnosis was major depressive disorder (43.2%) followed by anxiety (15.8%) and adjustment reaction and/or acute stress (15.8%). The majority of antidepressant use was prevalent (continued from preconception period), whereas most anxiolytic use was incident (no prescriptions in the 6 months before conception). Conclusions: The relatively high rate of use of psychotropic drugs in this cohort, and the existence of effective alternative treatments for the commonly treated conditions suggests a need to improve access to nondrug options before and during pregnancy. The finding that fewer women are discontinuing their antidepressants during pregnancy should be further investigated.

Consistency in maternal affect and positive vocalization over the first year of life

Consistency in parenting infants has positive developmental outcomes. Yet, the role of socioeconomic status (SES) in consistency of maternal behaviors is not well understood. We investigated individual-order continuity of maternal smile and laughter and positive vocalization from 6 to 12 months of age in 82 mother-infant dyads. Overall, individual differences in maternal smile and laughter, and positive vocalization were consistent across time. A multidimensional measure of SES moderated the association of maternal smile and laughter from 6 to 12 months, such that infants from lower SES families were vulnerable to unpredictable parenting - experiencing a lack of consistency in maternal smiles and laughter.

Perinatal fluoxetine exposure disrupts the circadian response to a phase-shifting challenge in female rats

RATIONALE

Selective serotonin reuptake inhibitor (SSRI) antidepressants are increasingly prescribed during pregnancy. Changes in serotonergic signaling during human fetal development have been associated with changes in brain development and with changes in affective behavior in adulthood. The suprachiasmatic nucleus (SCN) is known to be modulated by serotonin and it is therefore assumed that SSRIs may affect circadian rhythms. However, effects of perinatal SSRI treatment on circadian system functioning in the offspring are largely unknown.

OBJECTIVE

Our aim was to investigate the effects of perinatal exposure to the SSRI fluoxetine (FLX) on circadian behavior, affective behavior, and 5-HT_1A receptor sensitivity in female rats. In addition, we studied the expression of clock genes and the 5-HT_1A receptor in the SCN, as they are potentially involved in underlying mechanisms contributing to changes in circadian rhythms.

RESULTS

Perinatal FLX exposure shortened the free-running tau in response to the 5-HT_1A/7 agonist 8-OH-DPAT. However, FLX exposure did not alter anxiety, stress coping, and 5-HT_1A receptor sensitivity. No differences were found in 5-HT_1A receptor and clock genes Per1, Per2, Cry1, and Cry2 SCN gene expression.

CONCLUSIONS

Perinatal FLX exposure altered the response to a phase-shifting challenge in female rats, whether this may pose health risks remains to be investigated.

Antenatal exposure to antidepressant drugs and the risk of neurodevelopmental and psychiatric disorders: a systematic review

Abstract: This study investigated whether antenatal exposure to antidepressants (ADs) increases the risks of autism spectrum disorders (ASD), attention deficit/hyperactivity disorders (ADHD), schizophrenia and other mental illnesses, and cognitive and developmental deficits in infants or preschool children. PubMed, EMBASE, BIREME/BVS databases were searched to identify studies examining associations of ADs in pregnancy with neurodevelopmental and psychiatric disorders. Twenty studies addressed ASD and/or ADHD risks while 30 focused on developmental and cognitive deficits in infants or preschool children. Most studies detected no association of antenatal AD with ASD after adjustment of risk ratios for maternal depression or psychiatric disorders. Some studies showed that maternal depression, regardless of whether it is treated or untreated, increased ASD risks. Seven out of 8 studies found no increase in ADHD risk associated with antenatal exposure to selective serotonin reuptake inhibitors, the most commonly used AD. No consistent evidence was found linking AD in pregnancy to neurocognitive developmental deficits in infants or preschool children. A residual confounding by indication (depression severity) remained in almost all studies. This systematic review found no consistent evidence suggesting that ADs in pregnancy increase risks of ASD, ADHD, and neurocognitive development deficits. Some studies, however, found evidence that maternal depression increases ASD risks.

Prenatal SSRI antidepressant use and maternal internalizing symptoms during pregnancy and postpartum: Exploring effects on infant temperament trajectories for boys and girls

BACKGROUND

The severity and treatment of depression/anxiety during pregnancy and postpartum has important implications for maternal and child well-being. Yet, little is known about prenatal SSRI use and early child socioemotional development. This study explores effects of prenatal SSRI exposure, and pre- and postnatal internalizing symptoms on trajectories of infant temperament, identifying potential differences for boys and girls.

METHODS

Using latent growth models, sex differences in infant temperament trajectories from 3- to 10-months were examined in relation to prenatal and postpartum internalizing symptoms and prenatal SSRI exposure among 185 mother-infant dyads.

RESULTS

For girls, prenatal internalizing symptoms were associated with greater initial distress to limitations, and lower duration of orienting, smiling/laughter, and soothability. Postnatal symptoms predicted slower decreases in girls' duration of orienting. SSRI exposure predicted decreases in distress to limitations and slower increases in smiling and laughter. For boys, maternal internalizing symptoms did not generally affect temperament profiles. SSRI exposure was associated with higher initial activity level and slower declines in distress to limitations.

LIMITATIONS

Only parent-report indicators of infant temperament across 10 months of infancy were provided. Maternal internalizing symptoms were measured at discrete times during pregnancy and postpartum, with no analysis of changes in symptoms across time.

CONCLUSIONS

Prenatal SSRI treatment, and both prenatal and postpartum internalizing symptoms, exert unique effects on infant temperament. Overall, the present study suggests sex-dependent fetal programming effects that should be further evaluated in future research. Results have implications for perinatal mental health treatment and perceived impacts on child socioemotional development.

Hub distribution of the brain functional networks of newborns prenatally exposed to maternal depression and SSRI antidepressants

BACKGROUND

Prenatal maternal depression (PMD) and selective serotonin reuptake inhibitor (SSRI) antidepressants are associated with increased developmental risk in infants. Reports suggest that PMD is associated with hyperconnectivity of the insula and the amygdala, while SSRI exposure is associated with hyperconnectivity of the auditory network in the infant brain. However, associations between functional brain organization and PMD and/or SSRI exposure are not well understood.

METHODS

We examined the relation between PMD or SSRI exposure and neonatal brain functional organization. Infants of control (n = 17), depressed SSRI-treated (n = 20) and depressed-only (HAM-D ≥ 8) (n = 16) women, underwent resting-state functional magnetic resonance imaging at postnatal Day 6. At 6 months, temperament was assessed using Infant Behavioral Questionnaire (IBQ). We applied GTA and partial least square regression (PLSR) to the resting-state time series to assess group differences in modularity, and connector and provincial hubs.

RESULTS

Modularity was similar across all groups. The depressed-only group showed higher connector hub values in the left anterior cingulate, insula, and caudate as well as higher provincial hub values in the amygdala compared to the control group. The SSRI group showed higher provincial hub values in Heschl's gyrus relative to the depressed-only group. PLSR showed that newborns' hub values predicted 10% of the variability in infant temperament at 6 months, suggesting different developmental patterns between groups.

CONCLUSIONS

Prenatal exposures to maternal depression and SSRIs have differential impacts on neonatal functional brain organization. Hub values at 6 days predict variance in temperament between infant groups at 6 months of age.

Perinatal exposure to venlafaxine leads to lower anxiety and depression-like behavior in the adult rat offspring

Depression during pregnancy and in the post-partum period is a growing health issue. Venlafaxine, a representative of serotonin and noradrenaline reuptake inhibitors, is used to treat a wide spectrum of mood disorders. However, the limited number of prenatal and perinatal studies raises the question about the long-term consequences of venlafaxine therapy. The aim of this study was to investigate the effect of venlafaxine exposure during pregnancy and lactation on anxiety-like and depression-like behaviors, as well as adrenocortical hormone concentrations in the adult rat offspring. For this purpose, rat dams were treated orally with venlafaxine from day 15 of gestation to postnatal day 20 at doses of 7.5, 37.5, and 75 mg/kg. Administration of venlafaxine during gestation and lactation affected anxiety-like and depression-like behaviors in adult rat offspring of both sexes. The animals exposed through their mothers to venlafaxine, particularly at the lowest and middle doses, were less anxious and less depressive in several relevant behavioral tests, which can be considered a deviation from the normal state. At clinically relevant doses, venlafaxine did not alter circulating level of corticosterone and aldosterone in the adult offspring. In general, the consequences of venlafaxine were dose dependent and more apparent in females. Together, these results suggest that prenatal and early postnatal exposure to venlafaxine may interfere with functional development of the brain, though not necessarily in a negative way.

Use and validity of child neurodevelopment outcome measures in studies on prenatal exposure to psychotropic and analgesic medications - A systematic review

In recent years there has been increased attention to child neurodevelopment in studies on medication safety in pregnancy. Neurodevelopment is a multifactorial outcome that can be assessed by various assessors, using different measures. This has given rise to a debate on the validity of various measures of neurodevelopment. The aim of this review was twofold. Firstly we aimed to give an overview of studies on child neurodevelopment after prenatal exposure to central nervous system acting medications using psychotropics and analgesics as examples, giving special focus on the use and validity of outcome measures. Secondly, we aimed to give guidance on how to conduct and interpret medication safety studies with neurodevelopment outcomes. We conducted a systematic review in the MEDLINE, Embase, PsycINFO, Web of Science, Scopus, and Cochrane databases from inception to April 2019, including controlled studies on prenatal exposure to psychotropics or analgesics and child neurodevelopment, measured with standardised psychometric instruments or by diagnosis of neurodevelopmental disorder. The review management tool Covidence was used for data-extraction. Outcomes were grouped as motor skills, cognition, behaviour, emotionality, or "other". We identified 110 eligible papers (psychotropics, 82 papers, analgesics, 29 papers). A variety of neurodevelopmental outcome measures were used, including 27 different psychometric instruments administered by health care professionals, 15 different instruments completed by parents, and 13 different diagnostic categories. In 23 papers, no comments were made on the validity of the outcome measure. In conclusion, establishing neurodevelopmental safety includes assessing a wide variety of outcomes important for the child's daily functioning including motor skills, cognition, behaviour, and emotionality, with valid and reliable measures from infancy through to adolescence. Consensus is needed in the scientific community on how neurodevelopment should be assessed in medication safety in pregnancy studies. Review registration number: CRD42018086101 in the PROSPERO database.

SSRIs and SNRIs (SRI) in Pregnancy: Effects on the Course of Pregnancy and the Offspring: How Far Are We from Having All the Answers?

Serotonin has important roles in the development of the brain and other organs. Manipulations of synaptic serotonin by drugs such as serotonin reuptake inhibitors (SRI) or serotonin norepinephrine reuptake inhibitors (SNRI) might alter their development and function. Of interest, most studies on the outcome of prenatal exposure to SRI in human have not found significant embryonic or fetal damage, except for a possible, slight increase in cardiac malformations. In up to a third of newborns exposed to SRI, exposure may induce transient neonatal behavioral changes (poor neonatal adaptation) and increased rate of persistent pulmonary hypertension. Prenatal SRI may also cause slight motor delay and language impairment but these are transient. The data on the possible association of prenatal SRIs with autism spectrum disorder (ASD) are inconsistent, and seem to be related to pre-pregnancy treatment or to maternal depression. Prenatal SRIs also appear to affect the hypothalamic hypophyseal adrenal (HPA) axis inducing epigenetic changes, but the long-term consequences of these effects on humans are as yet unknown. SRIs are metabolized in the liver by several cytochrome P450 (CYP) enzymes. Faster metabolism of most SRIs in late pregnancy leads to lower maternal concentrations, and thus potentially to decreased efficacy which is more prominent in women that are rapid metabolizers. Studies suggest that the serotonin transporter SLC6A4 promoter is associated with adverse neonatal outcomes after SRI exposure. Since maternal depression may adversely affect the child's development, one has to consider the risk of SRI discontinuation on the fetus and the child. As with any drug treatment in pregnancy, the benefits to the mother should be considered versus the possible hazards to the developing embryo/fetus.

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.

Infants born to women with substance use: Exploring early neurobehavior with the Dubowitz neurological examination

BACKGROUND

There is a special concern regarding substance using pregnant women due to the possible adverse effects on the infant. While the immediate effects of prenatal substance exposure are well known, the long-term data on the infants' neurodevelopment is inconclusive.

AIMS

The purpose of this study was to assess early neurobehavior of infants of mothers with substance use using the Dubowitz examination and to follow their neuromotor development until one year of age.

STUDY DESIGN AND SUBJECTS

Ninety-five pregnant women with a recent history of substance use were recruited and followed up at the maternity outpatient clinic. Follow-up data was collected from hospital records and maternal interviews. The Dubowitz neurological examination was performed to the 54 clinically healthy term infants. The results were converted into optimality scores and compared to normative values from clinically healthy term infants derived from a separate normative population. The infant's neuromotor development was followed up to one year of age.

RESULTS

Only 7% of the infants born to women with recent or current substance use reached optimal scores (<30.5) in the Dubowitz neurological examination compared to 95% reported in normative population. Sixty-three percent of the newborns needed follow-up based on physiotherapeutic assessment of neurobehavior. By 12 months of age, the neuromotor status of 88% (n = 30) of these infants was found normal.

CONCLUSIONS

A high percentage of infants of mothers who were referred prenatally to hospital due to substance use showed suboptimal neurological findings during their first days of life.

Cognitive Performance in First-Degree Relatives of Individuals With vs Without Major Depressive Disorder: A Meta-analysis

IMPORTANCE

Findings of cognitive impairment in major depressive disorder (MDD), including remitted MDD, raise the question whether impaired cognition is part of preexisting vulnerability rather than a consequence of MDD or its treatment. To our knowledge, no meta-analyses have been published on cognitive impairment in first-degree relatives of individuals with MDD.

OBJECTIVE

To compare cognitive performance between individuals with and without family history of MDD.

DATA SOURCES

Medline/PubMed, PsycINFO, and Embase using combinations of search terms for depression, first-degree relatives, and cognition from January 1, 1980, to July 15, 2018.

STUDY SELECTION

Original articles that reported data on cognition in first-degree relatives of individuals with MDD compared with controls with no family history of major mental illness.

DATA EXTRACTION AND SYNTHESIS

Means and SDs were extracted, and standardized mean differences (SMD) between relatives and controls were calculated for each measure of cognitive performance. The relative-control differences in overall cognition and in specific cognitive domains were synthesized in random-effects meta-analyses with robust variance estimation that allows including multiple correlated measures of cognition within each study. Heterogeneity was quantified with τ2. Publication bias was assessed with funnel plots and Egger intercept.

MAIN OUTCOMES AND MEASURES

Performance on cognitive tests.

RESULTS

Across 284 measures of cognition in 54 nonoverlapping samples including 3246 relatives of people with MDD (mean age 15.38 years, 57.68% females) and 5222 controls (mean age 14.70 years, 55.93% females), relatives of people with MDD performed worse than controls across all measures of cognition (SMD = -0.19; 95% CI, -0.27 to -0.11; P < .001). Domain-specific meta-analyses showed similar size of relative-control difference in most domains of cognition, including Full-Scale IQ (SMD = -0.19), verbal intelligence (SMD = -0.29), perceptual intelligence (SMD = -0.23), memory (SMD = -0.20), academic performance (SMD = -0.40), and language (SMD = -0.29). Study characteristics were not significantly associated with observed between-group differences. There was no evidence of publication bias.

CONCLUSIONS AND RELEVANCE

A general impairment in cognition is a feature of familial disposition for MDD. Cognition may contribute to early identification of risk for depression and may be examined as potential target for early intervention.

Transgenerational hypocortisolism and behavioral disruption are induced by the antidepressant fluoxetine in male zebrafish Danio rerio

The global prevalence of depression is high during childbearing. Due to the associated risks to the mother and baby, the selective serotonin reuptake inhibitor fluoxetine (FLX) is often the first line of treatment. Given that FLX readily crosses the placenta, a fetus may be susceptible to the disruptive effects of FLX during this highly plastic stage of development. Here, we demonstrate that a 6-day FLX exposure to a fetus-relevant concentration at a critical developmental stage suppresses cortisol levels in the adult zebrafish (F₀). This effect persists for three consecutive generations in the unexposed descendants (F₁ to F₃) without diminution and is more pronounced in males. We also show that the in vivo cortisol response of the interrenal (fish "adrenal") to an i.p. injection of adrenocorticotropic hormone was also reduced in the males from the F₀ and F₃ FLX lineages. Transcriptomic profiling of the whole kidney containing the interrenal cells revealed that early FLX exposure significantly modified numerous pathways closely associated with cortisol synthesis in the male adults from the F₀ and F₃ generations. We also show that the low cortisol levels are linked to significantly reduced exploratory behaviors in adult males from the F₀ to F₂ FLX lineages. This may be a cause for concern given the high prescription rates of FLX to pregnant women and the potential long-term negative impacts on humans exposed to these therapeutic drugs.

Major depressive disorder during pregnancy: Psychiatric medications have minimal effects on the fetus and infant yet development is compromised

Psychotropic medication use and psychiatric symptoms during pregnancy each are associated with adverse neurodevelopmental outcomes in offspring. Commonly, studies considering medication effects do not adequately assess symptoms, nor evaluate children when the effects are believed to occur, the fetal period. This study examined maternal serotonin reuptake inhibitor and polypharmacy use in relation to serial assessments of five indices of fetal neurobehavior and Bayley Scales of Infant Development at 12 months in N = 161 socioeconomically advantaged, non-Hispanic White women with a shared risk phenotype, diagnosed major depressive disorder. On average fetuses showed the expected development over gestation. In contrast, infant average Bayley psychomotor and mental development scores were low (M = 84.10 and M = 89.92, range of normal limits 85-114) with rates of delay more than 2-3 times what would be expected based on this measure's normative data. Controlling for prenatal and postnatal depressive symptoms, prenatal medication effects on neurobehavioral development were largely undetected in the fetus and infant. Mental health care directed primarily at symptoms may not address the additional psychosocial needs of women parenting infants. Speculatively, prenatal serotonin reuptake inhibitor exposure may act as a plasticity rather than risk factor, potentially enhancing receptivity to a nonoptimal postnatal environment in some mother-infant dyads.

Perinatal fluoxetine has enduring sexually differentiated effects on neurobehavioral outcomes related to social behaviors

Selective serotonin reuptake inhibitor medications (SSRIs) are prescribed to up to 10% of pregnant women to treat maternal mood disorders. Exposure to these medications in-utero has raised concerns about altered neurobehavioral outcomes; most recently those related to peer-to-peer social interactions and play. While clinical data show that both perinatal SSRIs (pSSRI) and maternal stress can contribute to social behavioral changes in children, minimal animal work has investigated the effects of pSSRIs in relevant models of maternal stress or the long-term implications of these effects. Therefore the aim of this work was to investigate the long-term effects of pSSRI exposure to fluoxetine on social behaviors, the hypothalamic pituitary adrenal system (HPA) and hippocampal plasticity in adult male and female rat offspring using a model of pre-gestational maternal stress. Adult Sprague-Dawley female and male rat offspring from the following four groups were utilized: 1. Control + Vehicle, 2. Control + Fluoxetine, 3. Pre-gestational Stress + Vehicle, 4. Pre-gestational Stress + Fluoxetine (n = 8-16/female/age groups, n = 8-14/male/age groups). Main findings show pSSRIs increased social investigation in adult females and increased social play (pouncing, nape attacks) in adult males. Perinatal SSRIs also had sexually differentiated effects on hippocampal neurogenesis and GR density. Pre-gestational stress had enduring effects by decreasing social investigation and hippocampal neurogenesis in adult males. Thus pSSRIs, as well as pre-gestational maternal stress, have significant long-term effects on social neurobehavioral outcomes which differ in males and females. This suggests that it would be valuable to consider fetal-sex specific treatments for maternal mental illness.

Prenatal influences on temperament development: The role of environmental epigenetics

This review summarizes current knowledge and outlines future directions relevant to questions concerning environmental epigenetics and the processes that contribute to temperament development. Links between prenatal adversity, epigenetic programming, and early manifestations of temperament are important in their own right, also informing our understanding of biological foundations for social-emotional development. In addition, infant temperament attributes represent key etiological factors in the onset of developmental psychopathology, and studies elucidating their prenatal foundations expand our understanding of developmental origins of health and disease. Prenatal adversity can take many forms, and this overview is focused on the environmental effects of stress, toxicants, substance use/psychotropic medication, and nutrition. Dysregulation associated with attention-deficit/hyperactivity-disruptive disorders was noted in the context of maternal substance use and toxicant exposures during gestation, as well as stress. Although these links can be made based on the existing literature, currently few studies directly connect environmental influences, epigenetic programming, and changes in brain development/behavior. The chain of events starting with environmental inputs and resulting in alterations to gene expression, physiology, and behavior of the organism is driven by epigenetics. Epigenetics provides the molecular mechanism of how environmental factors impact development and subsequent health and disease, including early brain and temperament development.

A Meta-Analysis of Maternal Prenatal Depression and Anxiety on Child Socioemotional Development

OBJECTIVE

Observed associations between maternal prenatal stress and children's socioemotional development have varied widely in the literature. The objective of the current study was to provide a synthesis of studies examining maternal prenatal anxiety and depression and the socioemotional development of their children.

METHOD

Eligible studies through to February 2018 were identified using a comprehensive search strategy. Included studies examined the association between maternal prenatal depression or anxiety and the future development of their children's socioemotional development (eg, difficult temperament, behavioral dysregulation) up to 18 years later. Two independent coders extracted all relevant data. Random-effects meta-analyses were used to derive mean effect sizes and test for potential moderators.

RESULTS

A total of 71 studies met full inclusion criteria for data analysis. The weighted average effect size for the association between prenatal stress and child socioemotional problems was as follows: odds ratio (OR) = 1.66 (95% CI = 1.54-1.79). Effect sizes were stronger for depression (OR = 1.79; 95% CI = 1.61-1.99) compared to anxiety (OR = 1.50; 95% CI = 1.36-1.64). Moderator analyses indicated that effect sizes were stronger when depression was more severe and when socio-demographic risk was heightened.

CONCLUSION

Findings suggest that maternal prenatal stress is associated with offspring socioemotional development, with the effect size for prenatal depression being more robust than for anxiety. Mitigating stress and mental health difficulties in mothers during pregnancy may be an effective strategy for reducing offspring behavioral difficulties, especially in groups with social disadvantage and greater severity of mental health difficulties.

Resources for Psychiatric Clinicians Working With Breastfeeding Mothers

In today's health care-focused climate, in which encouraging breastfeeding is part of national and international health care initiatives, clinicians in any field should have resources available for breastfeeding mothers. The current article provides information for psychiatric clinicians on how breastfeeding may affect women with psychiatric conditions, the type of lactation counselor likely to be best prepared to collaborate with psychiatric clinicians, and resources available regarding maternal psychiatric medications safe for breastfeeding infants. These resources can assist informed choices that support the mother's breastfeeding goals while providing the psychological care the nursing mother requires. [Journal of Psychosocial Nursing and Mental Health Services, 56(8),37-46.].

Prenatal Antidepressant Exposure and Child Motor Development: A Meta-analysis

CONTEXT

There is increasing use of antidepressants in pregnancy and hence children exposed in utero. Contradictory studies exist in the literature in which researchers report on the potential impact of antenatal antidepressant exposure on subsequent child motor development.

OBJECTIVE

Our objective in this systematic review and meta-analysis was to determine whether antenatal antidepressant exposure increases the risk of impaired motor development in children.

DATA SOURCES

We searched PsychINFO, Embase, Medline, PubMed, and Scopus up to July 24, 2017.

STUDY SELECTION

English-language cohort and case control studies in which researchers report primary data from a motor assessment of infants or children after any antidepressant exposure in pregnancy were included.

DATA EXTRACTION

Of the 329 studies identified, there were 160 articles screened, 24 were included in the systematic review, and 18 met inclusion criteria for the meta-analysis.

RESULTS

The total pooled results were based on random effects models and revealed a significant association between exposure to antidepressants during pregnancy and overall occurrence of poorer motor outcomes in children (effect size = 0.22; 95% confidence interval = 0.07 to 0.37) with a moderate degree of heterogeneity (I² = 56.6%).

LIMITATIONS

There was variation in the measurement both of exposure and motor development across the identified study, and few followed up to later childhood or beyond.

CONCLUSIONS

A small increased risk of poorer motor development may exist for children who are exposed to antidepressant medications during pregnancy. However, the marked methodological variation among studies and the limited control for possible confounds warrants cautious interpretation of these findings.

New Insights into How Serotonin Selective Reuptake Inhibitors Shape the Developing Brain

Development passes through sensitive periods, during which plasticity allows for genetic and environmental factors to exert indelible influence on the maturation of the organism. In the context of central nervous system (CNS) development, such sensitive periods shape the formation of neuro-circuits that mediate, regulate, and control behavior. This general mechanism allows for development to be guided by both the genetic blueprint, as well as the environmental context. While allowing for adaptation, such sensitive periods are also windows of vulnerability during which external and internal factors can confer risk to brain disorders by derailing adaptive developmental programs. Our group has been particularly interested in developmental periods that are sensitive to serotonin (5-HT) signaling, and impact behavior and cognition relevant to psychiatry. Specifically, we review a 5-HT-sensitive period that impacts fronto-limbic system development, resulting in cognitive, anxiety, and depression-related behaviors. We discuss preclinical data to establish biological plausibility and mechanistic insights. We also summarize epidemiological findings that underscore the potential public health implications resulting from the current practice of prescribing 5-HT reuptake inhibiting antidepressants during pregnancy. These medications enter the fetal circulation, likely perturb 5-HT signaling in the brain, and may be affecting circuit maturation in ways that parallel our findings in the developing rodent brain. More research is needed to better disambiguate the dual effects of maternal symptoms on fetal and child development from the effects of 5-HT reuptake inhibitors on clinical outcomes in the offspring. Birth Defects Research 109:924-932, 2017. © 2017 Wiley Periodicals, Inc.

Effect of Time-Dependent Selective Serotonin Reuptake Inhibitor Antidepressants During Pregnancy on Behavioral, Emotional, and Social Development in Preschool-Aged Children

OBJECTIVE

To evaluate the effect of prenatal exposure to selective serotonin reuptake inhibitors (SSRIs) on children's behavioral, emotional, and social development by age 5 years, and over time since age 1.5 years.

METHOD

The prospective Norwegian Mother and Child Cohort Study was linked to the Medical Birth Registry of Norway. We included women who reported depressive/anxiety disorders before and/or during pregnancy. Children born to women who used SSRIs in early (weeks 0-16), mid- (weeks 17-28), or late (> week 29) pregnancy were compared to those who were unexposed. Children's internalizing and externalizing behaviors (Child Behavior Checklist) and temperament traits (Emotionality, Activity and Shyness Temperament Questionnaire) were measured at 1.5, 3, and 5 years. Mean scores were calculated and standardized. General linear marginal structural models were fitted to account for time-varying exposure and confounders, and censoring; 3-level growth-curve models were used.

RESULTS

A total of 8,359 mother-child dyads were included, and 4,128 children had complete outcome data at age 5 years. Children exposed to SSRIs in late pregnancy had an increased risk of anxious/depressed behaviors by age 5 years compared with unexposed children (adjusted β = 0.50, 95% CI = 0.04, 0.96). Such risk was not evident for earlier timings of exposure. There was no evidence for a substantial prenatal SSRI effect on externalizing, social, and emotional problems.

CONCLUSION

These findings suggest no substantial increased risk for externalizing, emotional, or social problems in preschool-aged children following prenatal SSRI exposure. Although the role of chance and potential unmeasured confounding cannot be ruled out, late-pregnancy SSRI exposure was associated with greater anxious/depressed behaviors in the offspring.

Selective serotonin reuptake inhibitor use in pregnant women; pharmacogenetics, drug-drug interactions and adverse effects

INTRODUCTION

Possible negative effects of selective serotonin reuptake inhibitors (SSRIs) in pregnancy relate to congenital anomalies, negative perinatal events and neurodevelopmental outcome. Many studies are confounded by the underlying maternal disease and by pharmacogenetic and pharmacokinetic differences of these drugs. Areas covered: The possible interactions of SSRIs and serotonin and norepinephrine reuptake inhibitors with other drugs and the known effects of SSRIs on congenital anomalies, perinatal and neurodevelopmental outcome. Expert opinion: SSRIs should be given with caution when combined with other drugs that are metabolized by cytochrome P450 enzymes. SSRIs apparently increase the rate of severe cardiac malformations, induce neonatal adaptation problems in up to 30% of the offspring, increase the rate of persistent pulmonary hypertension of the newborn and possibly slightly increase the rate of prematurity and low birth weight. Most neurodevelopmental follow up studies did not find significant cognitive impairments except some transient gross motor delay, slight impairment of language abilities and possibly behavioral changes. The literature on the possible association of SSRIs with autism spectrum disorder is inconsistent; if an association exists, it is apparently throughout pregnancy. The risk associated with treatment discontinuation seems to outweigh the risk of treatment, as severe maternal depression may negatively affect the child's development. If needed, treatment should continue in pregnancy with the minimal effective dose.