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Damer EA, van Kampen D, Edens MA, Hemels MAC, Bijvank BSWAN, Ter Horst PGJ. A pilot study on in-utero exposure to psychotropic drugs: A comparison of pharmacological classes on neonatal and maternal outcomes. Gen Hosp Psychiatry 2024; 90:76-83. [PMID: 39029257 DOI: 10.1016/j.genhosppsych.2024.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 06/25/2024] [Accepted: 06/29/2024] [Indexed: 07/21/2024]
Abstract
OBJECTIVE In this retrospective cohort study, we compared neonatal and maternal outcomes after exposure of different psychopharmacological classes of drugs. Both psychiatric diseases and pharmacological treatment of these are associated with lower birth weights, lower APGAR scores, and NICU admission. Therefore, we tried to rule out the role of psychotropics as if no differences were found between pharmacological classes, the lower birthweights might not be attributable to these. METHOD We divided our groups in exposed to atypical antipsychotic drugs, Selective Serotonin Reuptake Inhibitors (SSRI), Tricyclic Antidepressants (TCA), benzodiazepines, and different combinations of psychotropic drugs. The last group included SSRIs combined with benzodiazepines, methylphenidate, lithium, and classic antipsychotic drugs. RESULTS We used univariate regression analysis to see which factors from our rich dataset including pharmacological class, are associated with birth weight, APGAR scores, gestational age, and NICU admission. The significant associations from univariate analyses were further analyzed using ancova analysis or logistic regression where applicable. CONCLUSION We found no clinically relevant differences in neonatal and maternal outcomes between the different exposed pharmacological classes. However, our dataset may have been too small to draw firm conclusions.
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Affiliation(s)
- Elvera A Damer
- Department of Psychiatry, Isala, Dr van Heesweg 2, 8025 AB Zwolle, the Netherlands.
| | - Demi van Kampen
- Department of Clinical Pharmacy, Isala, Dr van Heesweg 2, 8025 AB Zwolle, the Netherlands
| | - Mireille A Edens
- Academy of Isala, Isala, Dr van Heesweg 2, 8025 AB Zwolle, the Netherlands.
| | - Marieke A C Hemels
- Department of Neonatology, Isala, Dr van Heesweg 2, 8025 AB Zwolle, the Netherlands.
| | - Bas S W A Nij Bijvank
- Department of Obstetrics and Gynecology, Isala, Dr van Heesweg 2, 8025 AB Zwolle, the Netherlands
| | - Peter G J Ter Horst
- Department of Clinical Pharmacy, Isala, Dr van Heesweg 2, 8025 AB Zwolle, the Netherlands.
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Oude Weernink M, Damer EA, Edens MA, Bijvank BSWAN, Hemels MAC, Ter Horst PGJ. Risks associated with antidepressants in patients with hypertension during pregnancy: a retrospective cohort study. Arch Gynecol Obstet 2024; 310:161-170. [PMID: 38286817 DOI: 10.1007/s00404-023-07350-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 12/17/2023] [Indexed: 01/31/2024]
Abstract
PURPOSE In a cohort of pregnant women using antihypertensive drugs, we compared exposure to antidepressants versus no exposure and the possible association with birth weight, APGAR scores, NICU admission, and maternal admission to an obstetrical intensive care unit (OHC). It was hypothesized that pregnant women with hypertensive disorders using antidepressants are at greater risk of complications. METHODS A retrospective cohort study in a general teaching hospital in Zwolle, in the Middle-Northern part of The Netherlands. Finally, 58 pregnancies in the exposed group and 273 pregnancies in the reference group met all inclusion and exclusion criteria. We compared the neonate's birthweight between the exposed to antidepressants group and the reference group as the primary outcome. Secondary outcomes were the APGAR score at 1 and 5 min and obstetric high care (OHC) admission of the mother and neonatal intensive care unit (NICU) admission of the child. RESULTS We found no differences in birth weight in neonates of mothers with hypertensive disorders and whether or not to use antidepressants. Besides a possible higher risk of admission to an OHC in women with hypertension-complicated pregnancies using antidepressants, we found no other maternal or neonatal risks in this population. CONCLUSION We found no additional maternal or neonatal risks of using antidepressants prescribed to women with hypertension disorders during pregnancy.
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Affiliation(s)
- Marlieke Oude Weernink
- Department of Clinical Pharmacy, Isala Klinieken, dr van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - Elvera A Damer
- Department of Psychiatry, Isala, Zwolle, The Netherlands
| | | | | | | | - Peter G J Ter Horst
- Department of Clinical Pharmacy, Isala Klinieken, dr van Heesweg 2, 8025 AB, Zwolle, The Netherlands.
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Campbell SA, Dys SP, Henderson JMT, Bradley HA, Rucklidge JJ. Exploring the impact of antenatal micronutrients used as a treatment for maternal depression on infant temperament in the first year of life. Front Nutr 2024; 11:1307701. [PMID: 38711532 PMCID: PMC11073451 DOI: 10.3389/fnut.2024.1307701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 03/25/2024] [Indexed: 05/08/2024] Open
Abstract
Antenatal depression and maternal nutrition can influence infant temperament. Although broad-spectrum-micronutrients (BSM: vitamins and minerals) given above Recommended Dietary Allowances during pregnancy can mitigate symptoms of antenatal depression, their associated effects on infant temperament are unknown. One hundred and fourteen New Zealand mother-infant dyads (45 infants exposed to BSM during pregnancy (range of exposure during pregnancy: 12-182 days) to treat antenatal depressive symptoms (measured by Edinburgh Postnatal Depression Scale) and 69 non-exposed infants) were followed antenatally and for 12 months postpartum to determine the influence of in utero BSM exposure on infant temperament. The Infant Behavior Questionnaire-Revised: Very Short-Form assessed temperament at 4 (T1), 6 (T2) and 12 (T3) months postpartum via online questionnaire. Latent growth curve modeling showed BSM exposure, antenatal depression and infant sex did not statistically significantly predict initial levels or longitudinal changes in orienting/regulatory capacity (ORC), positive affectivity/surgency (PAS) or negative affectivity (NEG). Higher gestational age was positively associated with initial PAS, and smaller increases between T1 and T3. Breastfeeding occurrence was positively associated with initial NEG. Although not significant, BSM exposure exerted small, positive effects on initial NEG (β = -0.116) and longitudinal changes in ORC (β = 0.266) and NEG (β = -0.235). While BSM exposure did not significantly predict infant temperament, it may mitigate risks associated with antenatal depression. BSM-exposed infants displayed temperamental characteristics on par with typical pregnancies, supporting the safety of BSM treatment for antenatal depression.
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Affiliation(s)
- S. A. Campbell
- School of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand
| | - S. P. Dys
- Department of Psychology, Simon Fraser University, Burnaby, BC, Canada
| | - J. M. T. Henderson
- School of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand
| | - H. A. Bradley
- School of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand
| | - J. J. Rucklidge
- School of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand
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Vickery PB. Concepts for selection and utilization of psychiatric medications in pregnancy. Ment Health Clin 2023; 13:255-267. [PMID: 38058594 PMCID: PMC10696173 DOI: 10.9740/mhc.2023.12.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/14/2023] [Indexed: 12/08/2023] Open
Abstract
Psychiatric illness may develop or relapse during pregnancy, and understanding best practices is paramount. In 2017, the British Association for Psychopharmacology (BAP) consensus guidance on the use of psychotropic medication preconception, in pregnancy, and postpartum was released. The BAP guidelines provide concise evidence and additional insight and flexibility for use of psychiatric medication. Key takeaways of these guidelines are highlighted serving as a concise reference for practitioners. Additionally, practice points, such as recommendations for rapid tranquilization and the role of long-acting injectable antipsychotic medications as well as additional insights to the growing body of literature associated with psychiatric medications in pregnancy since 2017 are summarized. Providers are strongly encouraged to stay up to date to provide optimal care for pregnant patients and their babies.
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Eleftheriou G, Zandonella Callegher R, Butera R, De Santis M, Cavaliere AF, Vecchio S, Pistelli A, Mangili G, Bondi E, Somaini L, Gallo M, Balestrieri M, Albert U. Consensus Panel Recommendations for the Pharmacological Management of Pregnant Women with Depressive Disorders. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6565. [PMID: 37623151 PMCID: PMC10454549 DOI: 10.3390/ijerph20166565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION The initiative of a consensus on the topic of antidepressant and anxiolytic drug use in pregnancy is developing in an area of clinical uncertainty. Although many studies have been published in recent years, there is still a paucity of authoritative evidence-based indications useful for guiding the prescription of these drugs during pregnancy, and the data from the literature are complex and require expert judgment to draw clear conclusions. METHODS For the elaboration of the consensus, we have involved the scientific societies of the sector, namely, the Italian Society of Toxicology, the Italian Society of Neuropsychopharmacology, the Italian Society of Psychiatry, the Italian Society of Obstetrics and Gynecology, the Italian Society of Drug Addiction and the Italian Society of Addiction Pathology. An interdisciplinary team of experts from different medical specialties (toxicologists, pharmacologists, psychiatrists, gynecologists, neonatologists) was first established to identify the needs underlying the consensus. The team, in its definitive structure, includes all the representatives of the aforementioned scientific societies; the task of the team was the evaluation of the most accredited international literature as well as using the methodology of the "Nominal Group Technique" with the help of a systematic review of the literature and with various discussion meetings, to arrive at the drafting and final approval of the document. RESULTS The following five areas of investigation were identified: (1) The importance of management of anxiety and depressive disorders in pregnancy, identifying the risks associated with untreated maternal depression in pregnancy. (2) The assessment of the overall risk of malformations with the antidepressant and anxiolytic drugs used in pregnancy. (3) The evaluation of neonatal adaptation disorders in the offspring of pregnant antidepressant/anxiolytic-treated women. (4) The long-term outcome of infants' cognitive development or behavior after in utero exposure to antidepressant/anxiolytic medicines. (5) The evaluation of pharmacological treatment of opioid-abusing pregnant women with depressive disorders. CONCLUSIONS Considering the state of the art, it is therefore necessary in the first instance to frame the issue of pharmacological choices in pregnant women who need treatment with antidepressant and anxiolytic drugs on the basis of data currently available in the literature. Particular attention must be paid to the evaluation of the risk/benefit ratio, understood both in terms of therapeutic benefit with respect to the potential risks of the treatment on the pregnancy and on the fetal outcome, and of the comparative risk between the treatment and the absence of treatment; in the choice prescription, the specialist needs to be aware of both the potential risks of pharmacological treatment and the equally important risks of an untreated or undertreated disorder.
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Affiliation(s)
- Georgios Eleftheriou
- Italian Society of Toxicology (SITOX), via Giovanni Pascoli 3, 20129 Milan, Italy
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Riccardo Zandonella Callegher
- Italian Society of Psychiatry (SIP), piazza Santa Maria della Pietà 5, 00135 Rome, Italy
- Psychiatry Unit, Department of Medicine (DAME), University of Udine, 33100 Udine, Italy
| | - Raffaella Butera
- Italian Society of Toxicology (SITOX), via Giovanni Pascoli 3, 20129 Milan, Italy
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Marco De Santis
- Italian Society of Obstetrics and Gynecology (SIGO), via di Porta Pinciana 6, 00187 Rome, Italy
- Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Anna Franca Cavaliere
- Italian Society of Obstetrics and Gynecology (SIGO), via di Porta Pinciana 6, 00187 Rome, Italy
- Department of Gynecology and Obstetrics, Fatebenefratelli Gemelli, Isola Tiberina, 00186 Rome, Italy
| | - Sarah Vecchio
- Italian Society of Toxicology (SITOX), via Giovanni Pascoli 3, 20129 Milan, Italy
- Ser.D Biella—Drug Addiction Service, 13875 Biella, Italy
| | - Alessandra Pistelli
- Italian Society of Toxicology (SITOX), via Giovanni Pascoli 3, 20129 Milan, Italy
- Division of Clinic Toxicology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy
| | - Giovanna Mangili
- Italian Society of Neonatology (SIN), Corso Venezia 8, 20121 Milan, Italy
- Department of Neonatology, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Emi Bondi
- Italian Society of Psychiatry (SIP), piazza Santa Maria della Pietà 5, 00135 Rome, Italy
- Department of Psychiatry, ASST Papa Giovanni XXIII, 24100 Bergamo, Italy
| | - Lorenzo Somaini
- Ser.D Biella—Drug Addiction Service, 13875 Biella, Italy
- Italian Society of Addiction Diseases (SIPAD), via Tagliamento 31, 00198 Rome, Italy
| | - Mariapina Gallo
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
- Italian Society for Drug Addiction (SITD), via Roma 22, 12100 Cuneo, Italy
| | - Matteo Balestrieri
- Psychiatry Unit, Department of Medicine (DAME), University of Udine, 33100 Udine, Italy
- Italian Society of Neuropsychopharmacology (SINPF), via Cernaia 35, 00158 Rome, Italy
| | - Umberto Albert
- Italian Society of Psychiatry (SIP), piazza Santa Maria della Pietà 5, 00135 Rome, Italy
- Italian Society of Neuropsychopharmacology (SINPF), via Cernaia 35, 00158 Rome, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34128 Trieste, Italy
- Division of Clinic Psychiatry, Azienda Sanitaria Universitaria Giuliano-Isontina, 34148 Trieste, Italy
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Lugo-Candelas C, Talati A, Glickman C, Hernandez M, Scorza P, Monk C, Kubo A, Wei C, Sourander A, Duarte CS. Maternal Mental Health and Offspring Brain Development: An Umbrella Review of Prenatal Interventions. Biol Psychiatry 2023; 93:934-941. [PMID: 36754341 PMCID: PMC10512172 DOI: 10.1016/j.biopsych.2023.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 01/20/2023] [Accepted: 01/31/2023] [Indexed: 02/08/2023]
Abstract
The idea that risk for psychiatric disorders may be transmitted intergenerationally via prenatal programming places interest in the prenatal period as a critical moment during which intervention efforts may have a strong impact, yet studies testing whether prenatal interventions also protect offspring are limited. The present umbrella review of systematic reviews and meta-analyses (SRMAs) of randomized controlled trials aimed to synthesize the available evidence and highlight promising avenues for intervention. Overall, the literature provides mixed and limited evidence in support of prenatal interventions. Thirty SRMAs were included. Of the 23 SRMAs that reported on prenatal depression interventions, 16 found a significant effect (average standard mean difference = -0.45, SD = 0.25). Similarly, 13 of the 20 SRMAs that reported on anxiety outcomes documented significant reductions (average standard mean difference = -0.76, SD = 0.95 or -0.53/0.53 excluding one outlier). Only 4 SRMAs reported child outcomes, and only 2 (of 10) analyses showed significant effects of prenatal interventions (massage and telephone support on neonatal resuscitation [relative risk = 0.43] and neonatal intensive care unit admissions [relative risk = 0.91]). Notably missing, perhaps due to our strict inclusion criteria (inclusion of randomized controlled trials only), were interventions focusing on key facets of prenatal health (e.g., whole diet, sleep). Structural interventions (housing, access to health care, economic security) were not included, although initial success has been documented in non-SRMAs. Most notably, none of the SRMAs focused on offspring mental health or neurodevelopmental outcomes. Given the possibility that interventions deployed in this period will positively impact the next generation, randomized trials that focus on offspring outcomes are urgently needed.
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Affiliation(s)
- Claudia Lugo-Candelas
- New York State Psychiatric Institute, New York, New York; Department of Psychiatry, Columbia University Irving Medical Center, New York, New York
| | - Ardesheer Talati
- New York State Psychiatric Institute, New York, New York; Department of Psychiatry, Columbia University Irving Medical Center, New York, New York
| | - Caila Glickman
- New York State Psychiatric Institute, New York, New York
| | - Mariely Hernandez
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York
| | - Pamela Scorza
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York
| | - Catherine Monk
- New York State Psychiatric Institute, New York, New York; Department of Psychiatry, Columbia University Irving Medical Center, New York, New York
| | - Ai Kubo
- Division of Research, Kaiser Permanente, Oakland, California
| | - Chiaying Wei
- New York State Psychiatric Institute, New York, New York; Department of Psychiatry, Columbia University Irving Medical Center, New York, New York
| | - Andre Sourander
- Department of Child Psychiatry, Turku University Hospital, Turku University, Turku, Finland
| | - Cristiane S Duarte
- New York State Psychiatric Institute, New York, New York; Department of Psychiatry, Columbia University Irving Medical Center, New York, New York.
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Gover A, Endrawes K, Molad M, Lavie-Nevo K, Riskin A. The Effect of SSRI Exposure in Pregnancy on Early Respiratory and Metabolic Adaptation in Infants Born Preterm. CHILDREN 2023; 10:children10030508. [PMID: 36980066 PMCID: PMC10046952 DOI: 10.3390/children10030508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 02/25/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023]
Abstract
Selective serotonin reuptake inhibitors (SSRIs) are increasingly used for maternal depression during pregnancy; however, their use has been linked to adverse effects in newborns. Respiratory and feeding problems, jaundice, metabolic and temperature dysregulation and hypoglycemia have been described in term infants. However, scarce data exists on early neonatal adaptation in exposed infants born prematurely. We aimed to assess the effects of SSRI exposure on early neonatal adaptation measures in infants born prematurely. Data from preterm infants exposed to maternal SSRIs during pregnancy and from matched controls were retrospectively collected. Forty-two infants comprised the final cohort: 21 infants with SSRI exposure and 21 matched controls. 1 min Apgar score was significantly lower in the exposed group compared to the non-exposed group (p = 0.043). No differences were found in 5 min Apgar scores, cord pH, need for delivery room resuscitation, rate of hypoglycemia, hyponatremia, hyperbilirubinemia, need for phototherapy, temperature stability and maximal oxygen requirements. No differences were found in the total time of respiratory support, time to reaching full enteral feeds, length of stay and complications of prematurity. Unlike studies in term infants, no significant differences were found in adaptation and short-term outcomes between preterm infants with and without SSRI exposure in pregnancy.
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Affiliation(s)
- Ayala Gover
- Neonatal Intensive Care Unit, Bnai-Zion Medical Center, Haifa 3339419, Israel
- Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa 3525433, Israel
| | - Kareen Endrawes
- Neonatal Intensive Care Unit, Lady Davis Carmel Medical Center, Haifa 3436212, Israel
| | - Michal Molad
- Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa 3525433, Israel
- Neonatal Intensive Care Unit, Lady Davis Carmel Medical Center, Haifa 3436212, Israel
| | - Karen Lavie-Nevo
- Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa 3525433, Israel
- Neonatal Intensive Care Unit, Lady Davis Carmel Medical Center, Haifa 3436212, Israel
| | - Arieh Riskin
- Neonatal Intensive Care Unit, Bnai-Zion Medical Center, Haifa 3339419, Israel
- Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa 3525433, Israel
- Correspondence: ; Tel.: +972-506267330
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Benefits and Risks of Antidepressant Drugs During Pregnancy: A Systematic Review of Meta-analyses. Paediatr Drugs 2023; 25:247-265. [PMID: 36853497 DOI: 10.1007/s40272-023-00561-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND The prescription of antidepressant drugs during pregnancy has been steadily increasing for several decades. Meta-analyses (MAs), which increase the statistical power and precision of results, have gained interest for assessing the safety of antidepressant drugs during pregnancy. OBJECTIVE We aimed to provide a meta-review of MAs assessing the benefits and risks of antidepressant drug use during pregnancy. METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature search on PubMed and Web of Science databases was conducted on 25 October, 2021, on MAs assessing the association between antidepressant drug use during pregnancy and health outcomes for the pregnant women, embryo, fetus, newborn, and developing child. Study selection and data extraction were carried out independently and in duplicate by two authors. The methodological quality of included studies was evaluated with the AMSTAR-2 tool. Overlap among MAs was assessed by calculating the corrected covered area. Data were presented in a narrative synthesis, using four levels of evidence. RESULTS Fifty-one MAs were included, all but one assessing risks. These provided evidence for a significant increase in the risks for major congenital malformations (selective serotonin reuptake inhibitors, paroxetine, fluoxetine, no evidence for sertraline; eight MAs), congenital heart defects (paroxetine, fluoxetine, sertraline; 11 MAs), preterm birth (eight MAs), neonatal adaptation symptoms (eight MAs), and persistent pulmonary hypertension of the newborn (three MAs). There was limited evidence (only one MA for each outcome) for a significant increase in the risks for postpartum hemorrhage, and with a high risk of bias, for stillbirth, impaired motor development, and intellectual disability. There was inconclusive evidence, i.e., discrepant results, for an increase in the risks for spontaneous abortion, small for gestational age and low birthweight, respiratory distress, convulsions, feeding problems, and for a subsequent risk for autism with an early antidepressant drug exposure. Finally, MAs provided no evidence for an increase in the risks for gestational hypertension, preeclampsia, and for a subsequent risk for attention-deficit/hyperactivity disorder. Only one MA assessed benefits, providing limited evidence for preventing relapse in severe or recurrent depression. Effect sizes were small, except for neonatal symptoms (small to large). Results were based on MAs in which overall methodological quality was low (AMSTAR-2 score = 54.8% ± 12.9%, [19-81%]), with a high risk of bias, notably indication bias. The corrected covered area was 3.27%, which corresponds to a slight overlap. CONCLUSIONS This meta-review has implications for clinical practice and future research. First, these results suggest that antidepressant drugs should be used as a second-line treatment during pregnancy (after first-line psychotherapy, according to the guidelines). The risk of major congenital malformations could be prevented by observing guidelines that discourage the use of paroxetine and fluoxetine. Second, to decrease heterogeneity and bias, future MAs should adjust for maternal psychiatric disorders and antidepressant drug dosage, and perform analyses by timing of exposure.
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Lebin LG, Novick AM. Selective Serotonin Reuptake Inhibitors (SSRIs) in Pregnancy: An Updated Review on Risks to Mother, Fetus, and Child. Curr Psychiatry Rep 2022; 24:687-695. [PMID: 36181572 PMCID: PMC10590209 DOI: 10.1007/s11920-022-01372-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2022] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW To provide an updated summary and appraisal of work from 2019 to 2022 examining risks of selective serotonin reuptake inhibitor (SSRI) use in pregnancy. RECENT FINDINGS Perinatal SSRI exposure does not increase risk of major malformations or gestational diabetes after accounting for underlying maternal illness. SSRIs are associated with small increase in risk of pre-eclampsia, postpartum hemorrhage, preterm delivery, persistent pulmonary hypertension of the newborn, and neonatal intensive care unit admissions, though absolute risk of these outcomes is low. While data suggests no increased risk of neurodevelopmental disorders in offspring, mixed evidence indicates increased risk of adverse cognitive outcomes and affective disorders. Recent evidence suggest low absolute risk of clinically relevant negative outcomes with perinatal SSRI exposure when compared to untreated perinatal depression. However, study design and ability to control for confounding remains an ongoing research challenge, highlighting need for ongoing rigorous study design and analysis.
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Affiliation(s)
- Lindsay G Lebin
- Department of Psychiatry, University of Colorado School of Medicine, Anschutz Medical Campus, 1890 N Revere Court, Suite 5003, Aurora, CO, 80045, USA.
| | - Andrew M Novick
- Department of Psychiatry, University of Colorado School of Medicine, Anschutz Medical Campus, 1890 N Revere Court, Suite 5003, Aurora, CO, 80045, USA
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Rommel AS, Momen NC, Molenaar NM, Agerbo E, Bergink V, Munk-Olsen T, Liu X. Antidepressant use during pregnancy and risk of adverse neonatal outcomes: A comprehensive investigation of previously identified associations. Acta Psychiatr Scand 2022; 145:544-556. [PMID: 35152413 PMCID: PMC9117424 DOI: 10.1111/acps.13409] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/25/2022] [Accepted: 01/30/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Prenatal antidepressant use is widespread. Observational studies have investigated the neonatal effects of prenatal antidepressant exposure with inconclusive results. We aimed to comprehensively investigate the associations between prenatal antidepressant exposure and the most commonly studied adverse neonatal outcomes: preterm birth, birthweight, poor neonatal adaptation, persistent pulmonary hypertension of the neonate (PPHN), neonatal admission and congenital malformations. METHODS We included 45,590 singletons (born 1997-2015) whose mothers used antidepressants within one year before pregnancy. Children were categorised into two groups: continuation (antidepressant use before and during pregnancy) or discontinuation (antidepressant use before but not during pregnancy). We applied random-effects logistic and linear regressions, adjusting for covariates. RESULTS After adjusting for confounders, prenatal antidepressant exposure was associated with a 2.3 day (95% CI -2.9; -2.0) decrease in gestational age and a 51 g (95% CI -62g; -41 g) decrease in birthweight. The continuation group was at increased risk for moderate-to-late preterm birth (32-37 weeks) (aOR = 1.43; 95%CI 1.33; 1.55), moderately low birthweight (1500-2499 g) (aOR = 1.28; 95%CI 1.17; 1.41), postnatal adaptation syndrome (aOR = 2.59; 95%CI 1.87; 3.59) and neonatal admission (aOR = 1.52; 95%CI 1.44; 1.60) compared to the discontinuation group. CONCLUSION Prenatal antidepressant exposure was associated with small decreases in gestational age and birthweight, as well as higher risk for moderate-to-late preterm birth, moderately low birthweight, neonatal admission and postnatal adaptation syndrome. No differences in risk were found for PPHN, or congenital malformations. The causality of the observed associations cannot be established due to the potential for unmeasured residual confounding linked to the underlying disease.
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Affiliation(s)
- Anna-Sophie Rommel
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York City, New York, 10029, USA.,Corresponding author: Anna-Sophie Rommel, Icahn (East) Building Floor 4, 1425 Madison Ave, New York, NY 10029,
| | - Natalie C. Momen
- NCRR-The National Centre for Register-based Research, Aarhus University, 8210 Aarhus, Denmark
| | - Nina Maren Molenaar
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York City, New York, 10029, USA
| | - Esben Agerbo
- NCRR-The National Centre for Register-based Research, Aarhus University, 8210 Aarhus, Denmark,CIRRAU - Centre for Integrated Register-Based Research at Aarhus University, 8210 Aarhus, Denmark,iPSYCH-Lundbeck Foundation Initiative for Integrative Psychiatric Research, 8210 Aarhus, Denmark
| | - Veerle Bergink
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York City, New York, 10029, USA.,Department of Psychiatry, Erasmus Medical Centre Rotterdam, 3015 Rotterdam, The Netherlands.,Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York City, New York, 10029, USA
| | - Trine Munk-Olsen
- NCRR-The National Centre for Register-based Research, Aarhus University, 8210 Aarhus, Denmark,Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
| | - Xiaoqin Liu
- NCRR-The National Centre for Register-based Research, Aarhus University, 8210 Aarhus, Denmark
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11
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Lorenzo LS. Beyond the ‘normal’ worries: detection and treatment of perinatal anxiety and anxiety disorders. BJPSYCH ADVANCES 2022. [DOI: 10.1192/bja.2022.9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SUMMARY
In clinical psychiatry, it is common to see pregnant and postpartum patients who express excessive anxiety and concerns about pregnancy or childbearing. This implies the need to distinguish between symptoms that could be considered to be an expected reaction to the situation, the diagnosis of an anxiety disorder or the presence of pregnancy-related (pregnancy-specific) anxiety. The last presents as a specific clinical phenomenon, identified in the literature as concerns exclusively linked to the situation of pregnancy or childbirth. In this article I review key points in the differential diagnosis of perinatal anxiety and its impact on both the pregnancy and the baby, as well as aspects of detection and diagnosis. I also give a brief summary of possible management approaches and treatments.
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12
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Nozari A, Gagné R, Lu C, Yauk C, Trudeau VL. Brief Developmental Exposure to Fluoxetine Causes Life-Long Alteration of the Brain Transcriptome in Zebrafish. Front Endocrinol (Lausanne) 2022; 13:847322. [PMID: 35573988 PMCID: PMC9097470 DOI: 10.3389/fendo.2022.847322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 03/23/2022] [Indexed: 11/25/2022] Open
Abstract
Fluoxetine (FLX) and other selective serotonin reuptake inhibitors are widely used to treat depressive disorders during pregnancy. Early-life exposure to FLX is known to disrupt the normal function of the stress axis in humans, rodents, and teleosts. We used a zebrafish line with a cortisol-inducible fluorescent transgene to study the effects of developmental daily exposure to FLX (54 µg/L) on the transcriptomic profile of brain tissues in exposed larvae and later as 6-month-old adults. High throughput RNA sequencing was conducted on brain tissues in unstressed and stressed conditions. Long-lasting effects of FLX were observed in telencephalon (Tel) and hypothalamus (Hyp) of adult zebrafish with 1927 and 5055 genes significantly (≥1.2 fold-change, false-discovery p-value < 0.05) dysregulated in unstressed condition, respectively. Similar findings were observed in Hyp with 1245 and 723 genes being significantly dysregulated in stressed adults, respectively. Differentially expressed genes converted to Homo sapiens orthologues were used for Ingenuity Pathway Analysis. The results showed alteration of pathways involved in neuroendocrine signaling, cholesterol metabolism and synaptogenesis. Enriched networks included lipid metabolism, molecular transport, and nervous system development. Analysis of putative upstream transcription regulators showed potential dysregulation of clocka and nr3c1 which control circadian rhythm, stress response, cholesterol metabolism and histone modifications. Several genes involved in epigenetic regulation were also affected by FLX, including dnmt3a, adarb1, adarb2, hdac4, hdac5, hdac8, and atf2. We report life-long disruptive effects of FLX on pathways associated with neuroendocrine signaling, stress response and the circadian rhythm, and all of which are implicated in the development of depressive disorders in humans. Our results raise concern for the persistent endocrine-disrupting potential of brief antidepressant exposure during embryonic development.
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Affiliation(s)
- Amin Nozari
- Department of Biology, University of Ottawa, Ottawa, ON, Canada
| | - Remi Gagné
- Environmental Health Science and Research Bureau, Health Canada, Ottawa, ON, Canada
| | - Chunyu Lu
- Department of Biology, University of Ottawa, Ottawa, ON, Canada
| | - Carole Yauk
- Department of Biology, University of Ottawa, Ottawa, ON, Canada
- Environmental Health Science and Research Bureau, Health Canada, Ottawa, ON, Canada
| | - Vance L. Trudeau
- Department of Biology, University of Ottawa, Ottawa, ON, Canada
- *Correspondence: Vance L. Trudeau,
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13
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Brown HK, Vigod SN. Making Decisions About Antidepressant Treatment in Pregnancy. JAMA 2021; 326:1687-1689. [PMID: 34726726 DOI: 10.1001/jama.2021.16216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Hilary K Brown
- Department of Health & Society, University of Toronto Scarborough, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Simone N Vigod
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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14
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Janiaud P, Agarwal A, Tzoulaki I, Theodoratou E, Tsilidis KK, Evangelou E, Ioannidis JPA. Validity of observational evidence on putative risk and protective factors: appraisal of 3744 meta-analyses on 57 topics. BMC Med 2021; 19:157. [PMID: 34225716 PMCID: PMC8259334 DOI: 10.1186/s12916-021-02020-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 05/28/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The validity of observational studies and their meta-analyses is contested. Here, we aimed to appraise thousands of meta-analyses of observational studies using a pre-specified set of quantitative criteria that assess the significance, amount, consistency, and bias of the evidence. We also aimed to compare results from meta-analyses of observational studies against meta-analyses of randomized controlled trials (RCTs) and Mendelian randomization (MR) studies. METHODS We retrieved from PubMed (last update, November 19, 2020) umbrella reviews including meta-analyses of observational studies assessing putative risk or protective factors, regardless of the nature of the exposure and health outcome. We extracted information on 7 quantitative criteria that reflect the level of statistical support, the amount of data, the consistency across different studies, and hints pointing to potential bias. These criteria were level of statistical significance (pre-categorized according to 10-6, 0.001, and 0.05 p-value thresholds), sample size, statistical significance for the largest study, 95% prediction intervals, between-study heterogeneity, and the results of tests for small study effects and for excess significance. RESULTS 3744 associations (in 57 umbrella reviews) assessed by a median number of 7 (interquartile range 4 to 11) observational studies were eligible. Most associations were statistically significant at P < 0.05 (61.1%, 2289/3744). Only 2.6% of associations had P < 10-6, ≥1000 cases (or ≥20,000 participants for continuous factors), P < 0.05 in the largest study, 95% prediction interval excluding the null, and no large between-study heterogeneity, small study effects, or excess significance. Across the 57 topics, large heterogeneity was observed in the proportion of associations fulfilling various quantitative criteria. The quantitative criteria were mostly independent from one another. Across 62 associations assessed in both RCTs and in observational studies, 37.1% had effect estimates in opposite directions and 43.5% had effect estimates differing beyond chance in the two designs. Across 94 comparisons assessed in both MR and observational studies, such discrepancies occurred in 30.8% and 54.7%, respectively. CONCLUSIONS Acknowledging that no gold-standard exists to judge whether an observational association is genuine, statistically significant results are common in observational studies, but they are rarely convincing or corroborated by randomized evidence.
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Affiliation(s)
- Perrine Janiaud
- Meta-Research Innovation Center at Stanford (METRICS), Stanford, CA, 94305, USA.,Department of Clinical Research, University Hospital Basel, University of Basel, CH-4056, Basel, Switzerland
| | - Arnav Agarwal
- Department of Medicine, University of Toronto, 1 King's College Circle #3172, Toronto, ON, M5S 1A8, Canada
| | - Ioanna Tzoulaki
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, University Campus, 45110, Ioannina, Greece.,Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, W2 1PG, UK
| | - Evropi Theodoratou
- Centre for Global Health, The University of Edinburgh, Edinburgh, EH8 9AG, UK.,Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, Western General Hospital, The University of Edinburgh, Edinburgh, EH4 2XU, UK
| | - Konstantinos K Tsilidis
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, University Campus, 45110, Ioannina, Greece.,Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, W2 1PG, UK
| | - Evangelos Evangelou
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, University Campus, 45110, Ioannina, Greece.,Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, W2 1PG, UK
| | - John P A Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford, CA, 94305, USA. .,Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, 94305, USA. .,Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA. .,Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA, 94305, USA. .,Department of Statistics, Stanford University School of Humanities and Sciences, Stanford, CA, 94305, USA.
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15
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Schäfer W, Wentzell N, Schink T, Haug U. Characterization of pregnancies exposed to St. John's wort and their outcomes: A claims data analysis. Reprod Toxicol 2021; 102:90-97. [PMID: 33961968 DOI: 10.1016/j.reprotox.2021.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/01/2021] [Accepted: 04/29/2021] [Indexed: 10/21/2022]
Abstract
Little is known about the utilization of St. John's wort (Hypericum perforatum L.) during pregnancy. In Germany, certain preparations of St. John's wort can be reimbursed by statutory health insurances, facilitating to investigate exposure to St. John's wort based on claims data. We therefore aimed to characterize pregnancies exposed to St. John's wort and to explore potential malformations in the babies. Using claims data from the German Pharmacoepidemiological Research Database (GePaRD), pregnancies exposed to St. John's wort during at least one trimester between 2006 and 2016 and the corresponding babies were identified. Exposure was identified via outpatient dispensations. Pregnancies were characterized regarding timing of exposure, use of other antidepressants, pregnancy outcomes and the occurrence of major malformations in the babies (not considering codes for musculoskeletal and other malformations due to low data quality in this regard). Out of 496 pregnancies with a dispensation of St. John's wort during pregnancy, 420 (85 %) had a dispensation during the first trimester. There was a dispensation of other antidepressants before pregnancy in 21 % (during pregnancy: 12 %). Eleven percent of pregnancies ended in non-live births. In 312 babies linked to 305 pregnancies, major malformations were coded in 18 babies (5.8 %), of which 17 were exposed in the first trimester. The crude relative risk of major malformations for babies exposed during the first vs. the second or third trimester only was 3.56 (0.48-26.17). Our results suggest that only in a minority of pregnancies, St. John's wort is used as an alternative to other antidepressants. Even though the relatively high rates of non-live births and major malformations after exposure to St. John's wort during the first trimester need to be interpreted with caution, the findings are striking and generate hypotheses that merit further investigation.
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Affiliation(s)
- Wiebke Schäfer
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany.
| | - Nadine Wentzell
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Tania Schink
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany; Faculty of Human and Life Sciences, University of Bremen, Bremen, Germany
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16
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Colombo A, Giordano F, Giorgetti F, Di Bernardo I, Bosi MF, Varinelli A, Cafaro R, Pileri P, Cetin I, Clementi E, Viganò CA, Dell'Osso B. Correlation between pharmacokinetics and pharmacogenetics of Selective Serotonin Reuptake Inhibitors and Selective Serotonin and Noradrenaline Reuptake Inhibitors and maternal and neonatal outcomes: Results from a naturalistic study in patients with affective disorders. Hum Psychopharmacol 2021; 36:e2772. [PMID: 33253437 DOI: 10.1002/hup.2772] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 11/03/2020] [Accepted: 11/13/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Some studies have linked the use of selective serotonin reuptake inhibitors and selective serotonin and noradrenaline reuptake inhibitors (SSRIs/SNRIs) to the risk of perinatal complications. This study explored the relationship between pharmacokinetics and pharmacogenetics, SSRIs/SNRIs tolerability and effectiveness and maternal and newborn outcomes. METHODS Fifty-five pregnant women with Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) diagnoses of affective disorders, treated with SSRIs/SNRIs, were recruited and, during the third trimester, their blood samples were collected for pharmacokinetic and pharmacogenetic analyses. Plasma levels and metabolic phenotypes were then related to different obstetrical and maternal outcomes. RESULTS The pharmacokinetic data were more stable for Sertraline, Citalopram, and Escitalopram compared to other molecules (p = 0.009). The occurrence of postnatal adaptation syndrome onset was associated with higher plasma levels for Sertraline (median at delivery: 16.7 vs. 10.5 ng/ml), but not for fluoxetine and venlafaxine. Finally, the subgroup within range plasma concentrations had less blood loss than the below range subgroup (p = 0.030). CONCLUSIONS Plasma levels of Sertraline, Citalopram and Escitalopram were more frequently in range in late pregnancy when compared to other drugs. Drug plasma concentrations do not strictly correlate with worse perinatal outcomes, but with possible differences between the different drugs.
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Affiliation(s)
- Anna Colombo
- Psychiatry Unit 2, ASST Fatebenefratelli Sacco, L. Sacco University Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | | | - Federica Giorgetti
- Psychiatry Unit 2, ASST Fatebenefratelli Sacco, L. Sacco University Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Ilaria Di Bernardo
- Psychiatry Unit 2, ASST Fatebenefratelli Sacco, L. Sacco University Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Monica F Bosi
- Psychiatry Unit 2, ASST Fatebenefratelli Sacco, L. Sacco University Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Alberto Varinelli
- Psychiatry Unit 2, ASST Fatebenefratelli Sacco, L. Sacco University Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Rita Cafaro
- Psychiatry Unit 2, ASST Fatebenefratelli Sacco, L. Sacco University Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Paola Pileri
- Unit of Obstetrics and Gynecology, ASST Fatebenefratelli Sacco, V. Buzzi Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Irene Cetin
- Unit of Obstetrics and Gynecology, ASST Fatebenefratelli Sacco, V. Buzzi Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Emilio Clementi
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco, L. Sacco University Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy.,E. Medea Scientific Institute, Bosisio Parini, Milan, Italy
| | - Caterina A Viganò
- Psychiatry Unit 2, ASST Fatebenefratelli Sacco, L. Sacco University Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Bernardo Dell'Osso
- Psychiatry Unit 2, ASST Fatebenefratelli Sacco, L. Sacco University Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy.,Department of Health Sciences, 'Aldo Ravelli' Research Center for Neurotechnology and Experimental Brain Therapeutics, University of Milan, Milan, Italy.,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA
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17
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Shenassa ED, Widemann LG, Hunt CD. Antepartum Depression and Preterm Birth: Pathophysiology, Epidemiology, and Disparities due to structural racism. Curr Psychiatry Rep 2021; 23:14. [PMID: 33630175 DOI: 10.1007/s11920-021-01223-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Informed by the evidence of links between physiology of stress and parturition, we review recent epidemiologic evidence (2015-2020) of antenatal depression as a risk factor for preterm birth (PTB). We also explain racial/ethnic disparities in depression and preterm birth as a consequence of structural racism. RECENT FINDINGS Epidemiologic evidence is consistent in linking antepartum depression with an elevated risk of PTB. Antidepressant usage has been linked with an elevated risk of PTB. However, recent evidence suggests that severity of depression is the underlying driver of the elevated risk attributed to antidepressant usage. The number of depressive symptoms, as a proxy for severity of maternal stress, may be a more informative predictor of PTB than criterion based predictors. Across various study designs, measurement modalities, and populations, antenatal depression predicts an elevated risk of delivering preterm. The physiology of stress provides a plausible explanation for this observation. Excessive stress-induced elevations in maternal and then fetal HPA hormones can alter maternal and fetal homeostasis and hasten the timing of parturition. Antenatal depression and exposure to structural racism are two stressors that can trigger the maternal stress response. Chronically elevated levels of stress hormones among women of color in the USA provide a likely physiologic explanation for Black-White disparities in the risk of PTB. Focusing on the number of depressive symptoms as the more informative predictor of PTB raises several questions. We consider these questions as well as directions for future research in the context of recent advances in the field.
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Affiliation(s)
- Edmond D Shenassa
- Maternal & Child Health Program, Department of Family Science; and Department of Epidemiology and Biostatistics, School of Public Health, University of Maryland, College Park, MD, USA. .,Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA. .,Department of Epidemiology & Biostatistics, School of Medicine, University of Maryland, Baltimore, MD, USA.
| | - Lea G Widemann
- Maternal & Child Health Program, Department of Family Science; and Department of Epidemiology and Biostatistics, School of Public Health, University of Maryland, College Park, MD, USA
| | - Cole D Hunt
- Maternal & Child Health Program, Department of Family Science; and Department of Epidemiology and Biostatistics, School of Public Health, University of Maryland, College Park, MD, USA
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18
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Schoretsanitis G, Westin AA, Stingl JC, Deligiannidis KM, Paulzen M, Spigset O. Antidepressant transfer into amniotic fluid, umbilical cord blood & breast milk: A systematic review & combined analysis. Prog Neuropsychopharmacol Biol Psychiatry 2021; 107:110228. [PMID: 33358964 PMCID: PMC7882033 DOI: 10.1016/j.pnpbp.2020.110228] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 11/22/2020] [Accepted: 12/16/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Data regarding the ability of antidepressants to enter fetal, newborn and infant fluids have become gradually available, but mechanisms of antidepressant transfer remain poorly understood. Here we calculated penetration ratios in an array of matrices from combined samples of pregnant/breastfeeding women taking antidepressants. METHOD We performed a systematic literature search of PubMed and EMBASE to identify studies with concentrations of antidepressants from maternal blood, amniotic fluid, umbilical cord blood and/or breast milk. Penetration ratios were calculated by dividing the concentrations in amniotic fluid, umbilical cord plasma or breast milk by the maternal plasma concentration. When data from multiple studies were available, we calculated combined penetration ratios, weighting the study mean by study size. RESULTS Eighty-five eligible studies were identified. For amniotic fluid, the highest penetration ratios were estimated for venlafaxine (mean 2.77, range 0.43-4.70 for the active moiety) and citalopram (mean 2.03, range 0.35-6.97), while the lowest ratios were for fluvoxamine (mean 0.10) and fluoxetine (mean 0.11, range 0.02-0.20 for the active moiety). For umbilical cord plasma, nortriptyline had the highest ratio (mean 2.97, range 0.25-26.43) followed by bupropion (mean 1.14, range 0.3-5.08). For breast milk, the highest ratios were observed for venlafaxine (mean 2.59, range 0.85-4.85), mianserin (mean 2.22, range 0.80-3.64) and escitalopram (mean 2.19, range 1.68-3.00). CONCLUSION We observed considerable variability across antidepressants regarding their ability to enter fetal, newborn and infant fluids. Measuring antidepressant concentrations in a maternal blood sample can provide a reliable estimate of fetal/infant exposure, although further evidence for concentration-dependent effects is required.
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Affiliation(s)
- Georgios Schoretsanitis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA.
| | - Andreas A. Westin
- Department of Clinical Pharmacology, St Olav University Hospital, Trondheim, Norway
| | - Julia C. Stingl
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, Aachen, Germany
| | - Kristina M. Deligiannidis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, USA,Zucker School of Medicine, Hempstead, New York and The Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Michael Paulzen
- Alexianer Hospital Aachen, Aachen, Germany and Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany,JARA - Translational Brain Medicine, Aachen, Germany
| | - Olav Spigset
- Department of Clinical Pharmacology, St Olav University Hospital, Trondheim, Norway,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
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Antenatal Antidepressant Prescription Associated With Reduced Fetal Femur Length but Not Estimated Fetal Weight: A Retrospective Ultrasonographic Study. J Clin Psychopharmacol 2021; 41:571-578. [PMID: 34412105 PMCID: PMC8440368 DOI: 10.1097/jcp.0000000000001446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE/BACKGROUND Antidepressants are among the most frequently prescribed medications during pregnancy and may affect fetal weight. Associations between antenatal antidepressant use and ultrasonographic measures of fetal development have rarely been examined. We hypothesized that the prescription of an antenatal antidepressant would be associated with lower estimated fetal weight (EFW). METHODS/PROCEDURES A retrospective analysis of routine ultrasonographic data extracted from electronic medical records was performed on a cohort of pregnant women with psychiatric diagnoses and grouped according to the presence of an antenatal antidepressant prescription (n = 32 antidepressant-prescribed and n = 44 antidepressant prescription-free). After stratifying for gestational age, comparisons included 13 ultrasonographic parameters, frequency of oligohydramnios and polyhydramnios and growth deceleration, and maternal serum protein markers assessed per routine care, including α-fetoprotein, free β-human chorionic gonadotropin, and unconjugated estriol levels, using t tests, nonparametric and Fisher tests, and effect sizes (ESs) were computed. FINDINGS/RESULTS No statistically significant EFW differences between groups at any time point were detected (P > 0.05). Antenatal antidepressant prescription was associated with lower femur length at weeks 33 to 40 (P = 0.046, ES = 0.75) and greater left ventricular diameter at weeks 25 to 32 (P = 0.04, ES = 1.18). No differences for frequency of oligohydramnios or polyhydramnios or growth deceleration were observed (P > 0.05). We did not detect group differences for maternal proteins (P > 0.05). IMPLICATIONS/CONCLUSIONS Our evidence suggested a lack of association between antenatal antidepressant prescription and lower EFW but indicated an association with lower femur length and greater left ventricular diameter in mid-late gestation. Future research should examine the clinical implications of these findings.
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20
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A novel murine model to study the impact of maternal depression and antidepressant treatment on biobehavioral functions in the offspring. Mol Psychiatry 2021; 26:6756-6772. [PMID: 34002019 PMCID: PMC8760069 DOI: 10.1038/s41380-021-01145-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 04/15/2021] [Accepted: 04/21/2021] [Indexed: 12/19/2022]
Abstract
Antenatal psychopathology negatively affects obstetric outcomes and exerts long-term consequences on the offspring's wellbeing and mental health. However, the precise mechanisms underlying these associations remain largely unknown. Here, we present a novel model system in mice that allows for experimental investigations into the effects of antenatal depression-like psychopathology and for evaluating the influence of maternal pharmacological treatments on long-term outcomes in the offspring. This model system in based on rearing nulliparous female mice in social isolation prior to mating, leading to a depressive-like state that is initiated before and continued throughout pregnancy. Using this model, we show that the maternal depressive-like state induced by social isolation can be partially rescued by chronic treatment with the selective serotonin reuptake inhibitor, fluoxetine (FLX). Moreover, we identify numerous and partly sex-dependent behavioral and molecular abnormalities, including increased anxiety-like behavior, cognitive impairments and alterations of the amygdalar transcriptome, in offspring born to socially isolated mothers relative to offspring born to mothers that were maintained in social groups prior to conception. We also found that maternal FLX treatment was effective in preventing some of the behavioral and molecular abnormalities emerging in offspring born to socially isolated mothers. Taken together, our findings suggest that the presence of a depressive-like state during preconception and pregnancy has sex-dependent consequences on brain and behavioral functions in the offspring. At the same time, our study highlights that FLX treatment in dams with a depression-like state can prevent abnormal behavioral development in the offspring.
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21
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Shea AK, Wang DY, Snelgrove JW, Dalfen A, Hewko S, Murphy KE. Do Maternal Pharmacogenetics Impact the Neonatal Abstinence Syndrome Following In Utero Exposure to Antidepressant Medications? JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 43:726-732. [PMID: 33303407 DOI: 10.1016/j.jogc.2020.09.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are the most commonly used medications for mood and anxiety disorders in women. Many women need to continue or initiate these medications during pregnancy, but there is concern about potential withdrawal effects in the newborn, referred to as neonatal abstinence syndrome (NAS). The reason why some infants remain asymptomatic while others are affected has not been elucidated. The objective of this study was to examine whether genetic differences in maternal drug metabolism influence the incidence of NAS. METHODS Women who took Selective serotonin reuptake inhibitors s/SNRIs during pregnancy were recruited from obstetrical clinics. DNA was extracted from saliva samples for genetic analyses of cytochrome P450 (CYP) enzyme polymorphisms. Delivery and NAS data were collected from electronic medical records. RESULTS Ninety-five women participated. The overall NAS rate was 16.2%. Mild NAS was seen in 13.8% of neonates and severe NAS, in 2%. One-quarter (25%) of the neonates with mild withdrawal symptoms were born to mothers with polymorphisms associated with slower metabolism of their particular antidepressant, but this association was not statistically significant. CONCLUSION Importantly, the overall rate of NAS in our study was lower than previously reported. Maternal CYP polymorphisms did not affect the rate of NAS in neonates exposed to SSRIs/SNRIs in utero. This study lends added assurance to patients requiring SSRIs or SNRIs during pregnancy.
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Affiliation(s)
- Alison K Shea
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON.
| | - Dong Yao Wang
- Undergraduate Medical Education Program, University of Toronto, Toronto, ON
| | - John W Snelgrove
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, ON
| | - Ariel Dalfen
- Department of Psychiatry, Mount Sinai Hospital, Toronto, ON
| | | | - Kellie E Murphy
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, ON
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