The use of selective serotonin reuptake inhibitors during pregnancy and breast-feeding: a review and clinical aspects

Sertraline associated with gold nanoparticles reduce cellular toxicity and induce sex-specific responses in behavior and neuroinflammation biomarkers in a mouse model of anxiety

This study aimed to evaluate the effects of sertraline associated with gold nanoparticles (AuNPs) in vitro cell viability and in vivo behavior and inflammatory biomarkers in a mouse model of anxiety. Sertraline associated with AuNPs were synthesized and characterized. For the in vitro study, NIH3T3 and HT-22 cells were treated with different doses of sertraline, AuNPs, and sertraline + AuNPs and their viability was evaluated using the MTT assay. For the in vivo study, pregnant Swiss mice were administered a single dose of lipopolysaccharide (LPS) on the ninth day of gestation. The female and male offspring were divided into five treatment groups on PND 60 and administered chronic treatment for 28 days. The animals were subjected to behavioral testing and were subsequently euthanized. Their brains were collected and analyzed for inflammatory biomarkers. Sertraline associated with AuNPs exhibited significant changes in surface characteristics and increased diameters. Different doses of sertraline + AuNPs showed higher cell viability in NIH3T3 and HT-22 cells compared with sertraline alone. The offspring of LPS-treated dams exhibited anxiety-like behavior and neuroinflammatory biomarker changes during adulthood, which were ameliorated via sertraline + AuNPs treatment. The treatment response was sex-dependent and brain region-specific. These results suggest that AuNPs, which demonstrate potential to bind to other molecules, low toxicity, and reduced inflammation, can be synergistically used with sertraline to improve drug efficacy and safety by decreasing neuroinflammation and sertraline toxicity.

Modeling the transplacental transfer of small molecules using machine learning: a case study on per- and polyfluorinated substances (PFAS)

BACKGROUND

Despite their large numbers and widespread use, very little is known about the extent to which per- and polyfluoroalkyl substances (PFAS) can cross the placenta and expose the developing fetus.

OBJECTIVE

The aim of our study is to develop a computational approach that can be used to evaluate the of extend to which small molecules, and in particular PFAS, can cross to cross the placenta and partition to cord blood.

METHODS

We collected experimental values of the concentration ratio between cord and maternal blood (R_CM) for 260 chemical compounds and calculated their physicochemical descriptors using the cheminformatics package Mordred. We used the compiled database to, train and test an artificial neural network (ANN). And then applied the best performing model to predict R_CM for a large dataset of PFAS chemicals (n = 7982). We, finally, examined the calculated physicochemical descriptors of the chemicals to identify which properties correlated significantly with R_CM.

RESULTS

We determined that 7855 compounds were within the applicability domain and 127 compounds are outside the applicability domain of our model. Our predictions of R_CM for PFAS suggested that 3623 compounds had a log R_CM > 0 indicating preferable partitioning to cord blood. Some examples of these compounds were bisphenol AF, 2,2-bis(4-aminophenyl)hexafluoropropane, and nonafluoro-tert-butyl 3-methylbutyrate.

SIGNIFICANCE

These observations have important public health implications as many PFAS have been shown to interfere with fetal development. In addition, as these compounds are highly persistent and many of them can readily cross the placenta, they are expected to remain in the population for a long time as they are being passed from parent to offspring.

IMPACT

Understanding the behavior of chemicals in the human body during pregnancy is critical in preventing harmful exposures during critical periods of development. Many chemicals can cross the placenta and expose the fetus, however, the mechanism by which this transport occurs is not well understood. In our study, we developed a machine learning model that describes the transplacental transfer of chemicals as a function of their physicochemical properties. The model was then used to make predictions for a set of 7982 per- and polyfluorinated alkyl substances that are listed on EPA's CompTox Chemicals Dashboard. The model can be applied to make predictions for other chemical categories of interest, such as plasticizers and pesticides. Accurate predictions of R_CM can help scientists and regulators to prioritize chemicals that have the potential to cause harm by exposing the fetus.

Recent sample pretreatment methods for determination of selective serotonin reuptake inhibitors (SSRIs) in biological samples

Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (FLU), sertraline (SER), paroxetine (PAR), fluvoxamine (FLV) and citalopram (CIT) have been the first treatment drugs for pregnant and breastfeeding women. Quantitative analysis of SSRIs in biological samples is extremely needed in public health and clinical practice. During the analysis, sample pretreatment is an important step that can obtain an accurate quantitative analysis of SSRIs in the complex samples. The present paper discussed the recent development of sample preparation methods for SSRI analysis. Traditional sample preparation techniques such as liquid liquid extraction (LLE) and solid phase extraction (SPE), which have been widely used in the separation of SSRIs in biological samples, were extensively presented. Moreover, the new sample preparation techniques including liquid phase microextraction (LPME), solid phase microextraction (SPME), electromembrane extraction (EME) and other miniaturized extraction techniques, which are becoming highly popular in SSRI analysis, were also critically reviewed. In this review, both the advantages and disadvantages of these sample pretreatment methods were addressed. As a summary, we prospected the challenges and promising directions for the future of sample pretreatment methods in SSRI analysis.

Low barrier perinatal psychiatric care for patients with substance use disorder: meeting patients across the perinatal continuum where they are

Pregnant and postpartum patients with substance use disorders (SUD) often have other co-occurring mental health disorders. Complications of substance use and mental health conditions, such as overdose and suicide, are a significant contributor to maternal morbidity and mortality. For individuals dually diagnosed with SUD and other mental health disorders, the perinatal period can be both a motivating and a vulnerable period for care. Barriers to optimal care include, but are not limited to, lack of screening, lack of referrals for care, a limited number of psychiatric providers available to care for pregnant patients, and stigma around mental health and addiction care in pregnancy. In this review, we discuss approaches to low-barrier perinatal psychiatric care for women with SUD to promote engagement in care. We review (1) appropriate psychiatric assessment and diagnostic work-up; (2) treatment planning incorporating shared-decision making, non-punitive and culturally sensitive patient-centred care, and principles of harm reduction with a focus on psychopharmacology, and (3) the benefits of an integrated and collaborative multidisciplinary care model for this subpopulation of vulnerable patients.

Exposure of dams to fluoxetine during lactation disturbs maternal behavior but had no effect on the offspring behavior

Fluoxetine is one of the most commonly prescribed drugs for treatment of depression during pregnancy as well as postpartum. Nevertheless, fluoxetine can cross the placental barrier and/or be secreted through breastmilk and questions remain unanswered regarding safety of the unborn and/or nursing infant. Passive administration of antidepressants to infants can cause neurological developmental delay and/or dysfunction. To date, there are limited studies on neurobehavioral effects due to passive administration of fluoxetine in nursing animals. Thus, the aim of the present study was to evaluate the effects of fluoxetine exposure on the behavior of lactating dams and their offspring. Dams received either 1, 10 or 20 mg/kg fluoxetine via oral gavage (controls received water alone) from lactating day (LD) 1 to 21. Maternal behavioral studies were conducted from LD5 to LD7 and offspring studies were conducted from LD2 to LD60. Results showed dysfunction in maternal behavior, both in direct and indirect behavior, but there were no differences and/or deficiencies observed in offspring behavior. These data suggest that the impairment of dams maternal behavior combined with the amount of fluoxetine that the offspring received through breast milk during lactation did not alter their social behavior in infancy and/or adulthood, suggesting no neurodevelopmental damage associated with maternal use of fluoxetine. This study contributes to the field of human psychiatric diseases by further elucidating the effects of antidepressant medications on the health of mothers as well as children who were passively exposed to drug treatment.

Cohort study of the relationship between individual psychotherapy and pregnancy outcomes

INTRODUCTION

Antenatal depression is associated with poor obstetric outcomes, but it has not been determined if treatment improves these outcomes. We hypothesized that psychotherapy for antenatal depression would decrease rates of low Apgar score, preterm birth, low birthweight, and high maternal weight gain.

METHODS

Using longitudinal clinical data from the electronic health record (EHR) of a large academic medical center, we examined the association between exposure to psychotherapy during pregnancy among women with a history of major depressive disorder and obstetric outcomes. We compared outcomes between women with and without psychotherapy treatment during pregnancy, and included a dose response analysis.

RESULTS

Of 50,856 women with pregnancies between 1998 and 2013, 5413 had a lifetime diagnosis of depression (948 had a diagnosis of depression during pregnancy), and 536 received psychotherapy at least once during pregnancy. Women who received one or more psychotherapy sessions during pregnancy had increased odds of preterm delivery and decreased odds of high maternal weight gain (more than 40 pounds). Individuals who received four or more psychotherapy sessions during pregnancy had increased odds of preterm birth and low infant birth weight and decreased odds of high maternal weight gain.

LIMITATIONS

Patients may have pursued treatment outside of this hospital's EHR data, and we cannot control for the quality of treatment or type of psychotherapy.

DISCUSSION

Psychotherapy was associated with negative obstetric outcomes. While treatment of depression in pregnant women has been shown to benefit the mother, the absence of benefit in terms of pregnancy outcomes merits further investigation.

Using sertraline in postpartum and breastfeeding: balancing risks and benefits

INTRODUCTION

The World Health Organization recommends newborns to be breastfed but this may be challenging if the mother needs to be treated for depression, since strong evidence to inform treatment choice is missing.

AREAS COVERED

We provide a critical review of the literature to guide clinicians who are considering sertraline for the management of depression during postpartum.

EXPERT OPINION

Sertraline is one of the safest antidepressants during breastfeeding. In most cases, women already taking sertraline should be advised to breastfeed and continue the medication. We recommend to begin with low doses and to slowly increase the dose up, with careful monitoring of the newborn for adverse effects (irritability, poor feeding, or uneasy sleep, especially if the child was born premature or had low weight at birth). The target dose should be the lowest effective. When feasible, child exposure to the medication may be reduced by avoiding breastfeeding at the time when the antidepressant milk concentration is at its peak. A decision to switch to sertraline from ongoing and effective treatment should be taken only after a scrupulous evaluation of the potential risks and benefits of switching versus continuing the ongoing medication while monitoring the infant carefully.

Efficient genome-wide association in biobanks using topic modeling identifies multiple novel disease loci

Biobanks and national registries represent a powerful tool for genomic discovery, but rely on diagnostic codes that may be unreliable and fail to capture the relationship between related diagnoses. We developed an efficient means of conducting genome-wide association studies using combinations of diagnostic codes from electronic health records (EHR) for 10845 participants in a biobanking program at two large academic medical centers. Specifically, we applied latent Dirichilet allocation to fit 50 disease topics based on diagnostic codes, then conducted genome-wide common-variant association for each topic. In sensitivity analysis, these results were contrasted with those obtained from traditional single-diagnosis phenome-wide association analysis, as well as those in which only a subset of diagnostic codes are included per topic. In meta-analysis across three biobank cohorts, we identified 23 disease-associated loci with p<1e-15, including previously associated autoimmune disease loci. In all cases, observed significant associations were of greater magnitude than for single phenome-wide diagnostic codes, and incorporation of less strongly-loading diagnostic codes enhanced association. This strategy provides a more efficient means of phenome-wide association in biobanks with coded clinical data.

Antidepressants, anxiolytics, and hypnotics in pregnancy and lactation

AIMS

Untreated perinatal depression and anxiety disorders are known to have significant negative impact on both maternal and fetal health. Dilemmas still remain regarding the use and safety of psychotropics in pregnant and lactating women suffering from perinatal depression and anxiety disorders. The aim of the current paper was to review the existing evidence base on the exposure and consequences of antidepressants, anxiolytics, and hypnotics in women during pregnancy and lactation and to make recommendations for clinical decision making in management of these cases.

MATERIALS AND METHODS

We undertook a bibliographic search of Medline/PubMed (1972 through 2014), Science Direct (1972 through 2014), Archives of Indian Journal of Psychiatry databases was done. References of retrieved articles, reference books, and dedicated websites were also checked.

RESULTS AND CONCLUSIONS

The existing evidence base is extensive in studying multiple outcomes of the antidepressant or anxiolytic exposure in neonates, and some of the findings appear conflicting. Selective serotonin reuptake inhibitors are the most researched antidepressants in pregnancy and lactation. The available literature is criticized mostly on the lack of rigorous well designed controlled studies as well as lacunae in the methodologies, interpretation of statistical information, knowledge transfer, and translation of information. Research in this area in the Indian context is strikingly scarce. Appropriate risk-benefit analysis of untreated mental illness versus medication exposure, tailor-made to each patient's past response and preference within in the context of the available evidence should guide clinical decision making.

The safety of serotonin-noradrenaline reuptake inhibitors (SNRIs) in pregnancy and breastfeeding: a comprehensive review

OBJECTIVE

The present study provides a comprehensive review of the existing literature on the safety of serotonin-noradrenaline reuptake inhibitors (SNRIs) in pregnancy and lactation.

METHODS

Studies published in English, reporting the use of SNRIs in pregnant and/or breastfeeding women, were identified by searching MEDLINE/Pubmed, PsycINFO, and EMBASE.

RESULTS

Twenty-nine studies were included in the review. Altogether, the initial evidence coming from the reviewed studies suggests a lack of association between SNRIs and an increased risk of major congenital malformations. Conversely, exposure to SNRIs seems to be significantly associated with an increased risk of some perinatal complications. No neonatal adverse events emerged, so far, in the few studies concerning the safety of SNRIs during breastfeeding.

CONCLUSIONS

Available data suggest that venlafaxine is relatively safe during pregnancy, in particular as far as major malformations are concerned, whereas considering the small number of studies published, no definitive conclusions can be drawn on its safety during breastfeeding. Because of the few studies so far published, the safety of duloxetine during pregnancy and breastfeeding remains to be well established.

Culturally relevant treatment services for perinatal depression in socio-economically disadvantaged women: the design of the MOMCare study

BACKGROUND

Depression during pregnancy has been demonstrated to be predictive of low birthweight, prematurity, and postpartum depression. These adverse outcomes potentially have lasting effects on maternal and child well-being. Socio-economically disadvantaged women are twice as likely as middle-class women to meet diagnostic criteria for antenatal major depression (MDD), but have proven difficult to engage and retain in treatment. Collaborative care treatment models for depression have not been evaluated for racially/ethnically diverse, pregnant women on Medicaid receiving care in a public health system. This paper describes the design, methodology, culturally relevant enhancements, and implementation of a randomized controlled trial of depression care management compared to public health Maternity Support Services (MSS).

METHODS

Pregnant, public health patients, >18 years with a likely diagnosis of MDD or dysthymia, measured respectively by the Patient Health Questionnaire-9 (PHQ-9) or the Mini-International Neuropsychiatric Interview (MINI), were randomized to the intervention or to public health MSS. The primary outcome was reduction in depression severity from baseline during pregnancy to 18-months post-baseline (one-year postpartum).

BASELINE RESULTS

168 women with likely MDD (96.4%) and/or dysthymia (24.4%) were randomized. Average age was 27.6 years and gestational age was 22.4 weeks; 58.3% racial/ethnic minority; 71.4% unmarried; 22% no high school degree/GED; 65.3% unemployed; 42.1% making <$10,000 annually; 80.4% having recurrent depression; 64.6% PTSD, and 72% unplanned pregnancy.

CONCLUSIONS

A collaborative care team, including a psychiatrist, psychologist, project manager, and 3 social workers, met weekly, collaborated with the patients' obstetrics providers, and monitored depression severity using an electronic tracking system. Potential sustainability of the intervention within a public health system requires further study.

The role of clomipramine in potentiating the teratogenic effects of caffeine in pregnant rats: a histopathological study

Since little is known about the teratogenic effects of clomipramine used concurrently with caffeine during the organogenesis period, the aim of this study was to test the teratogenic effects of a coadministration of caffeine and clomipramine on rat fetuses. We divided 42 pregnant rats into seven groups, randomly. The first group (control) received 0.5 mL of normal saline. Clomipramine was injected at 40 mg/kg and 80 mg/kg to the second and third groups, respectively. The fourth and fifth groups received caffeine in doses of 60 mg/kg and 120 mg/kg, respectively. The sixth group received a combination of 40 mg/kg clomipramine and 60 mg/kg caffeine, and the seventh group was given clomipramine and caffeine at 80 mg/kg and 120 mg/kg, respectively. The fetuses were removed on the 17th day of pregnancy and studied in terms of microscopic and macroscopic morphological features. Fetuses of rats receiving high doses of caffeine or combinations of caffeine and clomipramine showed a significant rate of cleft palate development, open eyelids, mortality, torsion anomalies, shrinkage of skin, and subcutaneous haemorrhage (P ≤ 0.001). This study concludes that caffeine in high doses or the simultaneous administration of caffeine and clomipramine leads to teratogenicity.

The fetal safety of fluoxetine: a systematic review and meta-analysis

OBJECTIVE

Fluoxetine is the selective serotonin reuptake inhibitor (SSRI) with the longest clinical use. Published reports regarding its fetal safety are contradictory. We aimed to establish the fetal safety of the drug.

METHODS

We performed a systematic review of the literature, searching PubMed, Medline, and Embase from inception to August 31, 2012, for cohort and case-control studies in which women were exposed to fluoxetine during the first trimester and compared outcomes with those of unexposed control subjects.

RESULTS

Twenty-one studies met the inclusion criteria. The odds ratio for major malformations associated with maternal fluoxetine use in cohort studies was 1.12 (95% CI 0.98 to 1.28). The studies included were homogeneous. Fifteen cohort studies evaluated cardiac malformations and yielded an overall odds ratio of 1.6 (95% CI 1.31 to 1.95). These studies also were homogeneous. In contrast, two case-control studies assessing cardiac malformations yielded a combined odds ratio of 0.63 (95% CI 0.39 to 1.03).

CONCLUSION

The apparent increased risk of fetal cardiac malformations associated with maternal use of fluoxetine has recently been shown also in depressed women who deferred SSRI therapy in pregnancy, and therefore most probably reflects an ascertainment bias. Overall, women who are treated with fluoxetine during the first trimester of pregnancy do not appear to have an increased risk of major fetal malformations.

The association of psychosocial factors and obstetric history with depression in pregnant women: focus on the role of emotional support

OBJECTIVE

Depression during pregnancy can negatively affect both maternal and fetal health. The benefits of early detection and treatment for antenatal depression have been emphasized. Therefore, we investigated risk factors for antenatal depression with a focus on emotional support.

METHODS

We conducted a cross-sectional study of pregnant women (n=1262) enrolled from the local division of a community mental health center. All subjects completed self-report questionnaires that assessed depressive mood, emotional support and other risk factors. Associations between antenatal depression and potential risk factors including emotional support were analyzed by logistic regression analysis.

RESULTS

Antenatal depression was associated with various biopsychosocial correlates: unmarried state, low education, cigarette smoking, low income, familial history of depression, past history of depression, physical abuse history, sexual abuse history, premenstrual syndrome, primiparity and unplanned pregnancy. When the associations of emotional support with antenatal depression were specified by its resources, current emotional support from partner [odds ratio (OR)=2.26, 95% confidence interval (CI)=1.94-2.64] and mother (OR=1.43, 95% CI=1.26-1.62) and past experience for emotional support from mother (OR=1.52, 95% CI=1.32-1.74), but not from father significantly influenced depression during pregnancy.

CONCLUSIONS

The multidimensional biopsychosocial approach would be needed to identify and assess antenatal depression. Promoting emotional support from the partner, family member and, possibly, the health provider could be a protective effect against the development of antenatal depression.

Antidepressant use in pregnancy: a critical review focused on risks and controversies

OBJECTIVE

Conflicting data have led to controversy regarding antidepressant use during pregnancy. The objectives of this study are to i) review the risks of untreated depression and anxiety, ii) review the literature on risks of exposure to antidepressants during pregnancy, iii) discuss the strengths and weaknesses of the different study designs used to evaluate those risks, and iv) provide clinical recommendations.

METHOD

MEDLINE/PubMed was searched for reports and studies on the risk of first-trimester teratogenicity, postnatal adaptation syndrome (PNAS), and persistent pulmonary hypertension (PPHN) with in utero antidepressant exposure.

RESULTS

While some individual studies suggest associations between some specific major malformations, the findings are inconsistent. Therefore, the absolute risks appear small. PNAS occurs in up to 30% of neonates exposed to antidepressants. In some studies, PPHN has been weakly associated with in utero antidepressant exposure, while in other studies, there has been no association.

CONCLUSION

Exposures of concern include that of untreated maternal illness as well as medication exposure. It is vital to have a careful discussion, tailored to each patient, which incorporates the evidence to date and considers methodological and statistical limitations. Past medication trials, previous success with symptom remission, and women's preference should guide treatment decisions.

Postpartum depression: diagnostic and treatment issues

Postpartum depression is the most common psychiatric complication of child-bearing. Despite the potentially deleterious effects of postpartum depression on the mother and her infant, the disorder is often unrecognized and untreated. Women may be reluctant to seek professional help because of the stigma of mental illness, or they may be unwilling to try medication because of concerns about safety during lactation. In this review of postpartum depression, we discuss its clinical presentation, diagnosis, differential diagnosis, and treatment.

Neonatal outcomes after late-gestation exposure to selective serotonin reuptake inhibitors

OBJECTIVE

This study aimed to investigate neonatal outcomes after prenatal exposure to selective serotonin reuptake inhibitors (SSRIs) during late-gestation.

METHODS

A retrospective cohort study was conducted using linked records from the Women's and Children's Health Network in South Australia, Australia, including the Perinatal Statistics Collection and the Hospital Pharmacy Dispensing Records. Women were eligible to participate if they gave birth to singleton, live-born infants between September 2000 and December 2008 (n = 33,965). Women were excluded if they received a dispensing for antidepressants other than SSRIs (n = 93) or an antipsychotic (n = 81). We estimated odds ratios (ORs) and 95% confidence intervals (CIs) for preterm delivery, low birth weight, small-for-gestational age, neonatal hospitalization and length of hospital admission, adjusting for sociodemographic, lifestyle, and medical factors.

RESULTS

Two hundred twenty-one women received a dispensing for an SSRI during pregnancy, 1566 had a psychiatric illness but did not receive a dispensing for an SSRI, and 32,004 did not have a psychiatric illness and did not receive a dispensing for an SSRI. Compared to infants of women with a psychiatric illness but no SSRI use, infants of women exposed to SSRIs had an increased risk of preterm delivery (adjusted OR, 2.68; 95% CI, 1.83-3.93), low birth weight (adjusted OR, 2.26; 95% CI, 1.31-3.91), admission to hospital (adjusted OR, 1.92; 95% CI, 1.39-2.65), and length of hospital stay longer than 3 days (adjusted OR, 1.93; 95% CI, 1.11-3.36) but not small-for-gestational age (adjusted OR, 1.13; 95% CI, 0.65-1.94). Psychiatric illness but no SSRI use during pregnancy was only associated with an increased likelihood of neonatal hospital admission (adjusted OR, 1.21; 95% CI, 1.07-1.38).

CONCLUSIONS

These results add to the growing body of evidence of an association between SSRI exposure during pregnancy and a range of adverse neonatal outcomes, but the potential for confounding according to severity of underlying maternal psychiatric illness requires further investigation.

Pharmacological treatment of unipolar depression during pregnancy and breast-feeding--a clinical overview

BACKGROUND

This overview is aimed at clinicians working with patients in the fertile age who suffer from depressive disorders. The study of adverse effects of antidepressants on the foetus is hampered by difficulty in distinguishing between the behavioural changes that are related to the disorder itself and changes that accompany its treatment with antidepressants. The current lack of solid scientific knowledge and the implications, mainly emotional, of treating pregnant or breast-feeding women often raise anxiety and cause concern among patients and clinicians.

METHODS

Currently available data are evaluated and clinical recommendations given.

RESULTS AND CONCLUSIONS

Citalopram and sertraline can be used during pregnancy, while some controversy remains over in utero exposure to paroxetine and fluoxetine, which might be associated with an increased risk of foetal cardiovascular malformation. Less data is available concerning fluvoxamine and escitalopram use but current data does not indicate a specific risk. Citalopram, paroxetine and sertraline can be used during breast-feeding, while fluoxetine probably should be avoided. Nortriptyline, amitriptyline and clomipramine can be used during pregnancy and lactation, although data are more abundant for SSRI treatment. Venlafaxine can be used during pregnancy, while caution is advised during breast-feeding. Other antidepressants should be avoided because of lack of data on their effect. A strongly indicated lithium therapy should be continued. Close monitoring of lithium levels throughout pregnancy is mandatory, as is detailed foetal echocardiography in weeks 18-22 of gestation. Lithium should not be used during breast-feeding. Electroconvulsive therapy (ECT) is a valid option if indicated, both during pregnancy and breast-feeding.

Possible prenatal impact of sertraline on human placental glutathione S-transferase-π

Sertraline (SER), a tricyclic antidepressant, is considered to belong to the group of selective amine reuptake inhibitors. Its ability to cross the blood–brain barrier and transplacental transport has been reported previously. It is widely distributed in the brain and is bound to human glutathione S-transferase-π (GST-π). If SER is taken during pregnancy, it gets accumulated in the embryo and fetus, and some studies have suggested it may cause congenital malformations, thus the study of the interaction of GST-π with antidepressants is crucial. In this study, the interaction of human placental GST-π with SER in the presence of the natural ligand, reduced glutathione (GSH) and a xenobiotic ligand, 1-chloro-2,4-dinitrobenzene (CDNB) was investigated. The Vm values obtained at variable [CDNB] and variable [GSH] were 61.3 ± 2.3 and 46.4 ± 1.7 U/mg protein, respectively. The kcat and kcat/ Km values for GSH and CDNB were 3.63 × 106 s−1, 2.59 × 1010 M−1 s−1 and 4.79 × 106 s−1, 1.29 × 1010 M−1 s−1, respectively. The half maximal inhibitory concentration value for SER was 4.60 mM. At constant [CDNB] and variable [GSH] the inhibition type was linear mixed-type, with Ks, α, and Ki values of 0.14 ± 0.02, 2.90 ± 1.64, and 2.18 ± 0.80 mM, respectively. On the other hand, at fixed [GSH] and at variable [CDNB], the inhibition type was competitive, with Ki value of 0.96 ± 0.10 mM. Thus, these findings weaken the importance of the protective role of GST against toxic electrophiles in vivo in adults, but due to its immature enterohepatic system SER may accumulate in the fetus and cause congenital malformations.

Delivery outcome after maternal use of antidepressant drugs in pregnancy: an update using Swedish data

BACKGROUND

Concerns have been expressed about possible adverse effects of the use of antidepressant medication during pregnancy, including risk for neonatal pathology and the presence of congenital malformations.

METHOD

Data from the Swedish Medical Birth Register (MBR) from 1 July 1995 up to 2007 were used to identify women who reported the use of antidepressants in early pregnancy or were prescribed antidepressants during pregnancy by antenatal care: a total of 14 821 women with 15 017 infants. Maternal characteristics, maternal delivery diagnoses, infant neonatal diagnoses and the presence of congenital malformations were compared with all other women who gave birth, using the Mantel-Haenszel technique and with adjustments for certain characteristics.

RESULTS

There was an association between antidepressant treatment and pre-existing diabetes and chronic hypertension but also with many pregnancy complications. Rates of induced delivery and caesarean section were increased. The preterm birth rate was increased but not that of intrauterine growth retardation. Neonatal complications were common, notably after tricyclic antidepressant (TCA) use. An increased risk of persistent pulmonary hypertension of the newborn (PPHN) was verified. The congenital malformation rate was increased after TCAs. An association between use of paroxetine and congenital heart defects was verified and a similar effect on hypospadias was seen.

CONCLUSIONS

Women using antidepressants during pregnancy and their newborns have increased pathology. It is not clear how much of this is due to drug use or underlying pathology. Use of TCAs was found to carry a higher risk than other antidepressants and paroxetine seems to be associated with a specific teratogenic property.

Breastfeeding rates among mothers of infants with neonatal abstinence syndrome

BACKGROUND

Woman who struggle with drug addiction during pregnancy are perhaps the most vulnerable of new mothers. The opioid substitution medications methadone and buprenorphine are both compatible with breastfeeding. The objective of this study is to determine breastfeeding rates among opioid-dependent women giving birth in a Baby-Friendly Hospital.

METHODS

We performed a retrospective chart review of all infants born at Boston Medical Center (Boston, MA) between July 2003 and January 2009 with a diagnosis of neonatal abstinence syndrome. Feeding information was obtained, as well as baseline medical information about the mother-infant pairs. Breastfeeding eligibility was determined by a negative urine toxicology screen on admission, no illicit drug use in the third trimester, and a negative human immunodeficiency virus status.

RESULTS

Two hundred seventy-six mother-infant pairs were identified. Forty percent of the mothers carried one or more psychiatric diagnoses; 24% were taking two or more psychiatric medications. Sixty-eight percent of the mothers were eligible to breastfeed; of those, 24% breastfed to some extent during their infant's hospitalization. Sixty-percent of those who initiated stopped breastfeeding after an average of 5.88 days (SD 6.51).

CONCLUSIONS

Breastfeeding rates among opioid-dependent women were low, with three-quarters of those eligible electing not to breastfeed. Of the minority of women who did choose to breastfeed, more than half stopped within 1 week.

Treatment of mood disorders during pregnancy and postpartum

Studies suggest that pregnancy does not protect women from the emergence or persistence of mood disorders. Mood and anxiety disorders are prevalent in women during the childbearing years and, for many women, these mood disorders are chronic or recurrent. Maintenance antidepressant therapy is often indicated during the reproductive years and women face difficult treatment decisions regarding psychotropic medications and pregnancy. Treatment of psychiatric disorders during pregnancy involves a thoughtful weighing of the risks and benefits of proposed interventions and the documented and theoretical risks associated with untreated psychiatric disorders such as depression. Collaborative decision-making that incorporates patient treatment preferences is optimal for women trying to conceive or who are pregnant. This article reviews the diagnosis and treatment guidelines of mood disorders during pregnancy and postpartum, with specific reference to the use of psychotropic medications during this critical time.

Safety of selective serotonin reuptake inhibitors in pregnancy

Selective serotonin reuptake inhibitors (SSRIs) are among the most commonly used medications, with a prescription frequency of 2.3% in pregnant women. Although most babies born to women who take SSRIs during pregnancy are normal, there is accumulating evidence that maternal SSRI treatment during pregnancy may cause adverse reproductive outcomes. Maternal SSRI treatment during the first trimester has been implicated in increased risks of birth defects, specifically cardiac abnormalities, in the infant, whereas third-trimester treatment has been linked to various neonatal complications, including symptoms of neonatal withdrawal and toxicity, prematurity, low birth weight and persistent pulmonary hypertension of the newborn. Although data on neurobehavioural and long-term cognitive problems among children of women who were treated with SSRIs during pregnancy remain limited, the possibility of such functional abnormalities is an additional concern. On the other hand, untreated maternal depression also carries serious risks for both the mother and the baby, and SSRIs are one of the best available treatments. Thus, pregnant women who require treatment for depression and their physicians often face a difficult choice regarding the use of SSRIs.

Postpartum depression

Postpartum depression (PPD) affects up to 15% of mothers. Recent research has identified several psychosocial and biologic risk factors for PPD. The negative short-term and long-term effects on child development are well-established. PPD is under recognized and under treated. The obstetrician and pediatrician can serve important roles in screening for and treating PPD. Treatment options include psychotherapy and antidepressant medication. Obstacles to compliance with treatment recommendations include access to psychotherapists and concerns of breastfeeding mothers about exposure of the infant to antidepressant medication. Further research is needed to examine systematically the short-term and long-term effect of medication exposure through breastmilk on infant and child development.

Selective serotonin reuptake inhibitor use and risk of gestational hypertension

OBJECTIVE

The purpose of this study was to assess the effects of treatment with selective serotonin reuptake inhibitors (SSRIs) on the risks of gestational hypertension and preeclampsia.

METHOD

The authors analyzed data from 5,731 women with nonmalformed infants and no underlying hypertension who participated in the Slone Epidemiology Center Birth Defects Study from 1998 to 2007. Gestational hypertension was defined as incident hypertension diagnosed after 20 weeks of pregnancy, with and without proteinuria (i.e., with and without preeclampsia). The risks of gestational hypertension and preeclampsia were compared between women who did and did not receive SSRI treatment during pregnancy. Relative risks and 95% confidence intervals (CIs) were estimated using the Cox proportional hazards model, adjusting for prepregnancy sociodemographic, lifestyle, reproductive, and medical factors.

RESULTS

Gestational hypertension was present in 9.0% of the 5,532 women who were not treated with SSRIs and 19.1% of the 199 women who were treated with SSRIs. Among women who received treatment, gestational hypertension was present in 13.1% of the 107 women who received treatment only during the first trimester and in 26.1% of the 92 women who continued treatment beyond the first trimester. The occurrence of preeclampsia was 2.4% among women who were not treated with SSRIs, 3.7% among women who were exposed to SSRIs only during the first trimester, and 15.2% among women who continued SSRI treatment beyond the first trimester. Relative to women who did not receive treatment, the adjusted relative risk of preeclampsia was 1.4 for women who discontinued treatment and 4.9 for women who continued treatment.

CONCLUSION

SSRI exposure during late pregnancy-whether a causal factor or not-might identify women who are at an increased risk for gestational hypertension and preeclampsia. Further investigation is needed in order to separate the effects of treatment with SSRIs from those of underlying mood disorders.

Cognitive Behavioral Treatment of Postpartum Onset

This case study describes the application of cognitive behavioral therapy (CBT) for obsessive compulsive disorder (OCD) with postpartum onset. Sara, a 29-year-old woman, presented with aggressive obsessions of strangling and drowning her 5-month-old son. When she presented at the clinic, Sara had recently begun pharmacological treatment and was highly motivated to supplement this treatment with CBT. She showed marked improvement over the course of 8 CBT sessions using exposure and ritual prevention. This case study highlights cognitive and behavioral risk factors for OCD with postpartum onset, key considerations in differential diagnosis, and the utility of CBT for OCD with this population.

Pharmacokinetics of duloxetine in breast milk and plasma of healthy postpartum women

OBJECTIVE

The purpose of this study was to characterize duloxetine pharmacokinetics in the breast milk and plasma of lactating women and to estimate the duloxetine dose that an infant might consume if breastfed.

METHODS

This open-label study included six healthy women aged 22-35 years who stopped nursing during and after the study. Duloxetine 40 mg was given orally every 12 hours for 3.5 days; seven plasma and milk samples over 12 hours were obtained after the seventh dose. Plasma and milk samples were analysed using validated liquid chromatography-tandem mass spectrometry methods. Safety measures included vital signs, ECGs, laboratory tests, adverse event monitoring and depression rating scales.

RESULTS

The mean steady-state milk-to-plasma duloxetine exposure ratio was 0.25 (90% CI 0.18, 0.35). The amount of duloxetine in the breast milk was 7 microg/day (range 4-15 microg/day). The estimated infant dose was 2 microg/kg/day (range 0.6-3 microg/kg/day), which is 0.14% of the maternal dose. Dizziness, nausea and fatigue were commonly reported adverse events. No clinically important changes in safety measures occurred.

CONCLUSION

Duloxetine is detected in breast milk, and steady-state concentrations in breast milk are about one-fourth of those in maternal plasma. As the safety of duloxetine in infants is unknown, prescribers should carefully assess, on an individual basis, the potential risks of duloxetine exposure to infants and the benefits of nursing an infant when the mother is on duloxetine therapy.

Stepped care treatment of postpartum depression: a primary care-based management model

BACKGROUND AND PURPOSE

Postpartum depression (PPD), the most prevalent serious postpartum complication, is a devastating illness that negatively impacts not only the mother, but also her infant, other family members, and work performance. There is an extensive body of research addressing systems-based quality improvement efforts for treatment of depression in primary care populations; however, little of this research has been directed toward postpartum populations. This paper presents a health care systems-based quality improvement model for the treatment of PPD derived from research outcomes in general primary care populations.

METHODS

OVID/MEDLINE and PsychINFO searches were performed using the following terms: depression, postpartum depression, mass screening, collaborative care, stepped care, psychotherapy, cognitive-behavioral therapy, interpersonal therapy, and education as keywords.

MAIN FINDINGS

The PPD management model described herein includes screening and diagnosis, initiation of active treatment, and use of collaborative care, which includes primary care visits, case manager follow-up, and more intensive care, through specialty consultation or referral, for complicated or difficult cases.

CONCLUSION

Stepped care, a form of collaborative depression treatment, is proposed as a practical, cost-effective method for improving PPD diagnosis and clinical outcomes.

Depressive Störungen

Das Spektrum depressiver Erkrankungen macht den Hauptteil affektiver Störungen aus und gehört mit einer Inzidenz von ca. 8–20% zu den häufigsten psychischen Erkrankungen. Depressionen werden nach wie vor zu selten einer adäquaten Therapie (Antidepressiva, störungsspezifische Psychotherapie wie z. B. kognitive Verhaltenstherapie) zugeführt.

Paroxetine in the first trimester and the prevalence of congenital malformations

PURPOSE

To refine a preliminary analysis identifying a possibly increased prevalence of malformations among infants born to women exposed to paroxetine in the first trimester.

METHODS

This study used data from UnitedHealthcare, a large U.S. insurer, using datasets originally for a study of bupropion in pregnancy. We identified women with a live-born delivery between January 1995 and September 2004. We classified women according to their first trimester mono- or mono/polytherapy exposure to paroxetine and other antidepressants. We confirmed malformation cases by medical record abstraction. We calculated the adjusted odds ratios (AORs) through logistic regression.

RESULTS

For paroxetine, there were 815 infants among 791 women exposed as monotherapy, and 1020 infants among 989 women exposed as mono- or polytherapy. For other antidepressants, there were 4198 infants among 4072 women exposed as monotherapy, and 4936 infants among 4767 women exposed as mono- or polytherapy. AORs for all congenital malformations associated with paroxetine were 1.89 (95%CI 1.20-2.98) for monotherapy, and 1.76 (95%CI 1.18-2.64) for mono- or polytherapy. AORs for cardiovascular malformations associated with paroxetine were 1.46 (95%CI 0.74-2.88) for monotherapy, and 1.68 (95%CI 0.95-2.97) for mono- or polytherapy.

CONCLUSIONS

These more detailed paroxetine findings confirm previous findings of analyses of these data among women exposed to all types of antidepressants. The present findings are consistent with other recent results suggesting the possibility of a modestly increased occurrence of congenital malformations following first trimester exposure to paroxetine compared to other antidepressants.

Thérapeutique des troubles anxieux et dépressifs de la grossesse et du post-partum. Revue et synthèse

The aim of this article is to review the main methods of treatment of anxious and depressive disorders during pregnancy and the postpartum. To this end, we analyse recent publications about the use and efficacy of psychotherapy and psychosocial interventions (cognitive behavioural therapy, interpersonal psychotherapy, psychoanalytical therapy) in the perinatal period. We also review recent papers about the use of psychotropic medication during pregnancy and breast-feeding, with special emphasis on clinical trials. We particularly focus on the risk/benefit assessment of antidepressants, mood stabilisers, antipsychotics and benzodiazepines, in terms of teratogenicity, and impact on neonatal adaptation and neuropsychological development. Various treatment modalities are presented and discussed. It appears that psychotherapies have proved their efficiency on most pre- and postpartum anxious and depressive disorders and represent a first line treatment in most cases. Psychopharmacological treatment is indicated for severe anxious and depressive disorders. The risks of such medication, especially antidepressants, may have been overestimated in the past. Provided reasonable precautions are taken and mothers and future mothers receive clear information on the potential risks and benefits, psychotropic medication could be more broadly prescribed during pregnancy and the breast-feeding period.

Neonatal outcome following pregnancy exposure to antidepressants: a prospective controlled cohort study

OBJECTIVE

To determine the incidence of early adverse effects associated with antidepressant drug use during pregnancy.

DESIGN

Prospective, controlled cohort study.

SETTING

A Drug and Health Information Centre in Milan, Italy.

POPULATION

A total of 200 neonates exposed to antidepressants in utero and 1200 controls.

METHODS

Women who took antidepressants during pregnancy and delivered liveborn children between 1995 and 2003 were selected. Each case was matched for maternal age and gravidity to six randomly selected controls (not exposed to teratogenic drugs or drugs known to cause neonatal side effects). Odds ratio was estimated for attributable risks.

MAIN OUTCOME MEASURES

Neonatal adverse events and Special Care Unit admission rate, assessed through an interview with the mothers.

RESULTS

Of the 200 neonates exposed to antidepressants in utero, 14 had adverse events and 3 required Special Care Unit admission. Jaundice (n = 5), agitation (n = 3) and respiratory distress (n = 2) were the most common symptoms. In the control group, 50 newborns had side effects and no statistically significant differences in the prevalence rate compared to the exposed group were found, even after stratification for drugs and pregnancy period of exposure. Only the prematurity rate was significantly higher in exposed compared to non-exposed newborns (OR = 2.31; 95% CI 1.14-4.63).

CONCLUSIONS

These results do not support an association between antidepressant exposure and unsafe fetal and neonatal outcomes in newborns. However, a collaborative international multicentre epidemiological monitoring of the use of psychotropic drugs during pregnancy is needed in order to guarantee pregnant women and their children safe and effective treatments, both at brief and long time from exposure.

The safety of antidepressant drugs during pregnancy

This article discusses known or suspected effects of maternal use of antidepressants during pregnancy on pregnancy outcome. It is unlikely that any marked teratogenic effect occurs with the possible exception of an increased risk for cardiovascular defects after maternal use of clomipramine or paroxetine. An increased risk for preterm birth is seen. Transient neonatal symptoms are common after the use of antidepressants in late pregnancy. Few firm data are available on the possible impact on the long-term neuropsychological development of the infants. The magnitude of the actual contribution from drug therapy is unclear; it is likely that the underlying pathology of the mother explains part of the anomalies. Selective serotonin re-uptake inhibitor drugs seem to represent a smaller hazard than tricyclic antidepressants. Further research to separate the effects of the drug and underlying pathology is urgently needed as are large-scale studies on long-term development. When a pregnant woman has a major depressive disease and non-pharmacological treatments are not enough, the relatively small risk with drug therapy has to be weighed against the considerable risk for a relapse of the disease if therapy is interrupted.

Treatment of perinatal mood and anxiety disorders: a review

OBJECTIVES

To review the nonpharmacologic and pharmacologic treatment modalities for perinatal mood and anxiety disorders and to discuss the importance of weighing the risks and the benefits of exposing the fetus or baby to maternal mental illness as opposed to exposure to antidepressant medications.

METHODS

We conducted a literature search of the PubMed and MEDLINE databases. Key words included the following: perinatal, pregnancy, postpartum, depression, anxiety, pharmacologic, nonpharmacologic, psychotherapy, and treatment.

RESULTS

Recent literature reflects that both pharmacologic and nonpharmacologic treatments for perinatal women are associated with positive and negative outcomes. No treatment decision was found to be risk-free. The detrimental effects of untreated mental illness on the mother, as well as on the baby, highlight the need for treatment intervention. The long-term effects of exposure to either medications or maternal mental illness are unknown, as yet.

CONCLUSION

Women with perinatal depression and anxiety disorders require timely and efficient management with a goal of providing symptom relief for the suffering mother while simultaneously ensuring the baby's safety. Although knowledge in the area of appropriate intervention is constantly evolving, rigorous and scientifically sound research in the future is critical.

Maternal use of selective serotonin re-uptake inhibitors in early pregnancy and infant congenital malformations

BACKGROUND

Maternal use of selective serotonin re-uptake inhibitors (SSRIs) has recently been associated with an increased risk for certain malformations.

METHODS

Using the Swedish Medical Birth Register, we identified women who had reported the use of SSRIs in early pregnancy and studied their infants, born between July 1, 1995 and the end of 2004. Congenital malformations were identified from that register, from the Register of Congenital Malformations, and from the Hospital Discharge Register. The effect of drug exposure was studied after adjustment for a number of identified maternal characteristics that could act as confounders.

RESULTS

We identified 6,481 women who reported the use of SSRIs in early pregnancy and their 6,555 infants. There was no general increase in malformation risk. An increased risk for cystic kidneys was seen, but this was based on only nine malformed infants, and the pathology varied between these cases. An in-depth study of cardiovascular defects identified an association between such defects and notably ventricular and atrial septum defects and maternal use of paroxetine but not other SSRIs. No support for a postulated association between SSRI use and infant craniostenosis or omphalocele was found.

CONCLUSIONS

Use of SSRIs in early pregnancy does not seem to be a major risk factor for infant malformations. The association between paroxetine use and infant cardiovascular defects may be a result of multiple testing, but is supported by other studies.

[What our patients want and need to know about generalized anxiety disorder]

Persons with generalized anxiety disorder often do not seek treatment, and if they do, it is more often for the somatic symptoms (muscle tension, insomnia) or for a secondary depression than because of the cardinal feature of generalized anxiety disorder: worry. The worry aspect becomes apparent when the patient is proposed to try anxiolytic medication. The physician will then need to be prepared to answer many questions regarding the potential hazards and benefits of such medication. These patients tend to have a sceptical attitude, having informed themselves on websites that display claims that are based on anything from evidence-based scientific guidelines to distorted, erroneous and unfounded allegations. Which are the frequent questions that worried patients pose to the physician before accepting anxiolytic pharmacotherapy? Having seen anxious patients in my practice during 25 years, and having conducted several clinical trials of anxiolytics I have put together evidence-based answers in plain language to these questions in this paper.

Paroxetine and congenital malformations: Meta-Analysis and consideration of potential confounding factors

BACKGROUND

Antidepressants have been commonly used by women of childbearing age. Recent studies suggest that paroxetine, a selective serotonin reuptake inhibitor (SSRI), might specifically increase teratogenic risk.

OBJECTIVES

The purpose of this study was to quantify first-trimester exposure to paroxetine and birth defects and examine potential sources of bias in the in utero or postnatal detection of more congenital malformations among women with depression. We also sought to examine whether paroxetine was used for the same indications as other SSRIs among pregnant women.

METHODS

This meta-analysis was designed to quantify malformation rates associated with the use of paroxetine. A search of the literature from 1985 to 2006 (English language) found in MEDLINE, EMBASE, REPROTOX, Scopus, and Biological Abstracts was conducted using the following terms: pregnancy outcome, congenital or fetal AND anomalies, malformations, cardiac/heart defects, AND selective serotonin reuptake inhibitors, paroxetine, and Paxil. Administrative databases of medication and medical services use in the Province of Quebec, Canada, were used to calculate the rates of ultrasound and echocardiogram in pregnancy and infancy in women/infants exposed to SSRIs and to compare the indications for general SSRI use versus paroxetine use.

RESULTS

Based on the studies analyzed, first-trimester paroxetine exposure was associated with a significant increase in the risk for cardiac malformation (odds ratio [OR], 1.72; 95% CI, 1.22-2.42). Women using antidepressants in pregnancy had a 30% higher rate of utilization of ultrasound in pregnancy. Infants of women who received SSRIs underwent approximately twice as many echocardiograms in the first year of life compared with children of women who used nothing. Significantly more women receiving paroxetine used the drug for anxiety or panic than women receiving other SSRIs (OR, 4.11; 95% CI, 2.39-7.08).

CONCLUSIONS

Based on the results of this metaanalysis, first-trimester exposure to paroxetine appears to be associated with a significant increase in the risk for cardiac malformation. However, a detection bias cannot be ruled out as contributing to the apparent increased detection of cardiovascular malformation of children exposed in utero to paroxetine. A significantly greater number of women were using paroxetine for anxiety or panic when compared with women using other SSRIs.