Antidepressant Medication Use in Pregnancy

Effects of M-DEPTH Model of Depression Care on Maternal Functioning and Infant Developmental Outcomes in the Six Months Post Delivery: Results from a Cluster Randomized Controlled Trial

Perinatal depression has been shown to have deleterious effects on maternal post-partum functioning, as well as early child development. However, few studies have documented whether depression care helps to mitigate these effects. We examined the effects of the M-DEPTH (Maternal Depression Treatment in HIV) depression care model (including antidepressants and individual Problem Solving Therapy) on maternal functioning and infant development in the first 6 months post-delivery in an ongoing cluster randomized controlled trial of 391 HIV-infected women with at least mild depressive symptoms enrolled across eight antenatal care clinics in Uganda. A subsample of 354 (177 in each of the intervention and control groups) had a live birth delivery and comprised the analytic sample, of whom 69% had clinical depression at enrollment; 70% of women in the intervention group (including 96% of those with clinical depression) received depression treatment. Repeated-measures multivariable regression models found that the intervention group reported better infant care, lower parental burden, and greater perceived adequacy of parental support, compared to the control group. These findings suggest that depression care for pregnant women living with HIV is important not only for maternal mental health, but it also helps women to better manage parenting and care for their infant.

Effects of M-DEPTH Model of Depression Care on Maternal HIV Viral Suppression and Adherence to the PMTCT Care Continuum Among HIV-Infected Pregnant Women in Uganda: Results from a Cluster Randomized Controlled Trial at Pregnancy Completion

Perinatal depression has been shown to impede adherence to antiretroviral therapy (ART) and the prevention of mother-to-child transmission (PMTCT) care continuum; therefore, treating perinatal depression may result in increased viral suppression and PMTCT adherence. We examined the effects of the M-DEPTH (Maternal Depression Treatment in HIV) depression care model (including antidepressants and individual Problem Solving Therapy) on depression, maternal viral suppression and adherence to PMTCT care processes in an ongoing cluster-randomized controlled trial of 391 HIV-infected pregnant women (200 usual care; 191 intervention) with at least mild depressive symptoms enrolled across 8 antenatal care clinics in Uganda. At baseline, 68.3% had clinical depression and 41.7% had detectable HIV viral load. Adjusted repeated-measures multivariable regression models found that the intervention group was nearly 80% less likely to be clinically depressed [Adjusted OR (95% CI) 0.22 (0.05, 0.89)] at the 2-month post-pregnancy assessment, compared to the control group. However, the intervention and control groups did not differ meaningfully on maternal viral suppression, ART adherence, and other PMTCT care processes and outcomes. In this sample of women who were mostly virally suppressed and ART adherent at baseline, the depression care model had a strong effect on depression alleviation, but no downstream effects on viral suppression or other PMTCT care processes.Trial Registration NIH Clinical Trial Registry NCT03892915 (clinicaltrials.gov).

Prenatal Venlafaxine Exposure-Induced Neurocytoarchitectural and Neuroapoptotic Degeneration in Striatum and Hippocampus of Developing Fetal Brain, Manifesting Long-term Neurocognitive Impairments in Rat Offspring

Depression is a leading cause of disability which at its worst leads to suicide. Its treatment relies on psychotherapy in combination with certain antidepressants (AD_(s)) from various classes such as tricyclics, selective serotonin reuptake inhibitors, or serotonin and norepinephrine reuptake inhibitors (SNRIs). Among SNRIs, venlafaxine (VEN) is one such most commonly prescribed AD which is recently reported to be in the top 50 most prescribed drugs in the USA. Depression during pregnancy is a common condition, where prescribing an AD becomes necessary as untreated depression during pregnancy has its own complications for both mother and the child. This, probably, is why an incredible rise has been reported in prescribing ADs like VEN to pregnant women in the recent past, despite some studies, including the one from our own group, having reported the in-utero VEN-induced apoptotic neurodegeneration in the fetal neocortex and the consequent neurobehavioral anomalies in adulthood. However, there still exists a lack of insight into the effects of intrauterine exposures of VEN on other fetal brain regions like the hippocampus (HPC) and striatum (STR) and the consequent effects on their cognitive and emotional wellbeing in later life. Hence, this study has been conducted where pregnant Charles-Foster (CF) rats were oral gavaged with VEN (25, 40, and 50 mg/kg bw) from gestation day (GD) 05-19. On GD-19, half of the control and treated dams were euthanized to collect their fetuses. Fetal brains were dissected and processed for reactive oxygen species (ROS) estimation neurohistopathology and confocal microscopic studies. The remaining dams were allowed to deliver naturally, and litters were reared for up to 8 weeks then tested for their cognitive abilities by the Morris water maze test and for their emotionality by the Forced swimming test. Our results showed substantial neurocytoarchitectural deficits in both HPC and STR, along with enhanced ROS levels and apoptotic neurodegenerations. Furthermore, VEN-treated young rat offsprings displayed cognitive impairments and depressive behavior as the long-lasting impact of VEN in a dose-dependent manner. So it may be inferred that prenatal VEN-induced oxidative stress causes apoptotic neurodegeneration leading to neuronal loss in HPC and STR which consequently affects the development of the said brain areas resulting in impaired cognitive and emotional abilities of young adult offsprings. Therefore, extrapolating these findings in animal models, caution may be taken before prescribing VEN to pregnant women, especially during the sensitive phase of pregnancy.

Maternal depression treatment in HIV (M-DEPTH): Study protocol for a cluster randomized controlled trial

INTRODUCTION

Over one-third of human immunodeficiency virus (HIV)-infected pregnant women are clinically depressed, increasing the risk of mother-to-child transmission (MTCT) of HIV, as well as negative birth and child development outcomes. This study will evaluate the efficacy and cost-effectiveness of an evidence-based stepped care treatment model for perinatal depression (maternal depression treatment in HIV [M-DEPTH]) to improve adherence to prevention of MTCT care among HIV+ women in Uganda.

METHODS

Eight antenatal care (ANC) clinics in Uganda will be randomized to implement either M-DEPTH (n=4) or usual care (n=4) for perinatal depression among 400 pregnant women (n=50 per clinic) between June 2019 and August 2022. At each site, women who screen positive for potential depression will be enrolled and followed for 18 months post-delivery, assessed in 6-month intervals: baseline, within 1 month of child delivery or pregnancy termination, and months 6, 12, and 18 following delivery. Primary outcomes include adherence to the prevention of mother-to-child transmission (PMTCT) care continuum-including maternal antiretroviral therapy and infant antiretrovial prophylaxis, and maternal virologic suppression; while secondary outcomes will include infant HIV status, post-natal maternal and child health outcomes, and depression treatment uptake and response. Repeated-measures multivariable regression analyses will be conducted to compare outcomes between M-DEPTH and usual care, using 2-tailed tests and an alpha cut-off of P <.05. Using a micro-costing approach, the research team will relate costs to outcomes, examining the incremental cost-effectiveness ration (ICER) of M-DEPTH relative to care as usual.

DISCUSSION

This cluster randomized controlled trial will be one of the first to compare the effects of an evidence-based depression care model versus usual care on adherence to each step of the PMTCT care continuum. If determined to be efficacious and cost-effective, this study will provide a model for integrating depression care into ANC clinics and promoting adherence to PMTCT.

TRIAL REGISTRATION

NIH Clinical Trial Registry NCT03892915 (clinicaltrials.gov).

Use of Antidepressants During Pregnancy?: What to Consider when Weighing Treatment with Antidepressants Against Untreated Depression

Introduction Mood disorders impact many pregnant women, particularly those who have experienced symptoms prior to conception, and there are significant barriers, including stigma and access, to seeking and receiving appropriate treatments. Antidepressants are a helpful option in treating perinatal depression, but research on risks and benefits of antidepressant use in pregnancy is difficult given lack of "gold standard" comparative trials. Methods This paper summarizes current state of knowledge on the safety of antidepressants during pregnancy by providing a summary of the literature published in the past 3 years (January 2013-October 2015). We identified 21 reviews and meta-analyses that were included in this summary report. This report is meant to provide a user-friendly, yet comprehensive guide summarizing the abundant, and in part contradicting, literature on risks and benefits of antidepressants during pregnancy, in order to assist busy primary care prescribers in educating their patients. Our goal is also to contrast the risks/benefits of untreated depression in pregnancy versus treatment with antidepressant medication in pregnancy, and in such support prescribers in their decision-making. Results The past 3 years have yielded an abundance of publications on the topic, in part, with conflicting findings adding to confusion and concern among providers, patients, and their families. Many reported studies have methodological problems limiting their impact. Data on adverse effects of medications on pregnancy and fetal outcomes have to be weighed against the impact of untreated illness and poor health habits associated with untreated illness on the same outcomes. Discussion Medical-decision making is often complex and seldom free of risks. Obviously, as providers we cannot guarantee that fetal exposure to antidepressants is totally free of risk, yet this is true for any medicine taken in pregnancy. However, to date, perinatal psychiatry has collected enough evidence to suggest that, if the clinical picture warrants it, the use of many antidepressants, especially the SSRIs, is favorable compared to exposing mother and child to untreated depressive illness.

Spectrum of anxiety disorders: diagnosis and pharmacologic treatment

Nearly 30% of women experience an anxiety disorder at some time during their lives, and there is increasing evidence that anxiety disorders are associated with adverse pregnancy outcomes. Despite increased media coverage regarding anxiety disorders, women are reluctant to discuss signs and symptoms of anxiety with family or health care providers. Additionally, despite ongoing research and improved educational curricula, primary care and women's health care providers find diagnosis and treatment of mental health disorders challenging. This article reviews the diagnostic features and pharmacologic treatment options for the most common anxiety disorders including generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, and posttraumatic stress disorder. The impact of anxiety disorders on pregnancy and guidelines for management are presented.