Depressing observations on the use of selective serotonin-reuptake inhibitors during pregnancy

The management of mood disorders in pregnancy: alternatives to antidepressants

The management of mood disorders during pregnancy is complex due to risks associated with medication use and risks associated with untreated depression. Antidepressant use during pregnancy is an exposure for the unborn child, and it currently remains unclear what long-term repercussions there might be from this exposure, though available data are reassuring. On the other hand, there are risks for both the mother and child of untreated depression during pregnancy. There is a real need for research into nonpharmacological strategies for the prevention of relapse of mood disorders in pregnant women who are off medications. We have reviewed a number of potential candidate interventions including psychotherapies, exercise, light box therapy (LBT), repetitive transcranial magnetic stimulation (rTMS), electroconvulsive therapy (ECT), holistic strategies, and nutritional and herbal supplements. Currently there is a lack of evidence supporting the use of such strategies in the prevention of depressive relapse during pregnancy, though most of these strategies have at least some support for their use in the treatment of a major depressive episode. Carefully conducted research using one or more of these strategies in women who want to discontinue antidepressants for pregnancy is sorely needed.

Antidepressant use during pregnancy: current controversies and treatment strategies

The treatment of depression during pregnancy is both a common and complex clinical challenge. The decision to expose the fetus to antidepressant medication during pregnancy must be weighed against the risks of untreated maternal depression to both mother and fetus. Maternal depression during pregnancy has been associated with increased rates of preterm birth and maternal substance use. The safety of antidepressant use during pregnancy seems to be largely reassuring but there remain 2 areas of controversy including neonatal withdrawal syndrome and primary pulmonary hypertension of the newborn. Individualized treatment recommendations based on the patient's history are essential to optimize outcomes.

Increasing use of antidepressants in pregnancy

OBJECTIVE

The purpose of this study was to quantify the rate of exposures to antidepressants during pregnancy in a large cohort of women.

STUDY DESIGN

This was a retrospective cohort study of 105,335 pregnancies among women enrolled in Tennessee Medicaid from 1999-2003. Pregnancies were classified according to antidepressant exposures during pregnancy using previously validated computerized pharmacy records linked with birth certificates.

RESULTS

During the study period, 8.7% of women giving birth had exposure to any antidepressant; 6.2% had exposure to a selective serotonin reuptake inhibitor. Maternal age > 25 years (P < .0001), white race (P < .0001), and education > 12 years (P = .008) were significant predictors of antidepressant exposure. The proportion of pregnancies with antidepressant use increased from 5.7% of pregnancies in 1999 to 13.4% of pregnancies in 2003 (p < .0001). The increase was mostly accounted for by increases in selective serotonin reuptake inhibitor exposures.

CONCLUSION

There is an urgent need for further studies that better quantify the fetal consequences of exposure to antidepressants.

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