Implementation of Advanced Methods for Reproductive Pharmacovigilance in Autism: A Meta-Analysis of the Effects of Prenatal Antidepressant Exposure

Prenatal Antidepressant Exposures and Autism Spectrum Disorder or Traits: A Retrospective, Multi-Cohort Study

Prenatal antidepressant exposure has been associated with increased risk for neurodevelopmental disorders in childhood, including autism spectrum disorder (ASD). The current study utilized multi-cohort data from the Environmental influences on Child Health Outcomes (ECHO) program (N = 3129) to test for this association, and determine whether the association remained after adjusting for maternal prenatal depression and other potential confounders. Antidepressants and a subset of selective serotonin reuptake inhibitors (SSRIs) were examined in relation to binary (e.g., diagnostic) and continuous measures of ASD and ASD related traits (e.g., social difficulties, behavior problems) in children 1.5 to 12 years of age. Child sex was tested as an effect modifier. While prenatal antidepressant exposure was associated with ASD related traits in univariate analyses, these associations were statistically non-significant in models that adjusted for prenatal maternal depression and other maternal and child characteristics. Sex assigned at birth was not an effect modifier for the prenatal antidepressant and child ASD relationship. Overall, we found no association between prenatal antidepressant exposures and ASD diagnoses or traits. Discontinuation of antidepressants in pregnancy does not appear to be warranted on the basis of increased risk for offspring ASD.

Benefits and Risks of Antidepressant Drugs During Pregnancy: A Systematic Review of Meta-analyses

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.

Should Antidepressants be Avoided in Pregnancy?

Many (> 40%) women discontinue antidepressants during pregnancy because of concerns about effects on the foetus, based on information from inadequately-controlled studies. The sibling-control study design provides the best control for confounding factors, notably maternal depression. The purpose of this review was to investigate the evidence from sibling-control analyses for adverse outcomes in offspring associated with antidepressant exposure during pregnancy. Fourteen sibling-control studies were identified through searches of PubMed and Embase. Outcomes included preterm birth, small for gestational age, neonatal size, birth defects, autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), behavioural problems, neurodevelopmental deficits, and scholastic attainment. For the majority of these outcomes, no statistically significant associations were found when comparing exposed and unexposed siblings. Single studies reported associations with preterm birth, reduced gestational age, ADHD, anxiety at 36 months, and lower mathematics test scores, which persisted in the sibling-control analyses. However, differences were small and possibly not clinically significant. Moreover, effects of residual confounding could not be excluded. These findings provide evidence that many of the previously reported associations between prenatal antidepressant exposure and adverse outcomes in offspring are no longer statistically significant when exposed offspring are compared with unexposed siblings. The few statistically significant differences in sibling-control analyses were generally small with doubtful clinical significance. Decisions on antidepressant treatment during pregnancy should be made individually, based on evidence from properly controlled studies, not on misleading information based on studies that have not controlled adequately for confounding factors.

Mechanisms of action of fluvoxamine for COVID-19: a historical review

The ongoing coronavirus disease 2019 (COVID-19) pandemic caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) accelerates the discovery of prophylactic and therapeutic drugs for persons infected with the virus. Drug repurposing for the COVID-19 pandemic has received particular attention. Increasing clinical data suggest that antidepressant use in early-stage subjects with COVID-19 might be associated with a reduced risk of intubation or death. Among the antidepressants, fluvoxamine is the most attractive drug for mild to moderate subjects with COVID-19. In this article, we review the mechanisms of action (i.e., serotonin transporter, sigma-1 receptor, and acid sphingomyelinase) of fluvoxamine for COVID-19. Furthermore, we discuss a possible link between maternal COVID-19 infection and a risk for neuropsychiatric disorders (i.e., autism spectrum disorder and schizophrenia) in offspring.

Pregnant Mothers' Medical Claims and Associated Risk of Their Children being Diagnosed with Autism Spectrum Disorder

A retrospective analysis of administrative claims containing a diverse mixture of ages, ethnicities, and geographical regions across the United States was conducted in order to identify medical events that occur during pregnancy and are associated with autism spectrum disorder (ASD). The dataset used in this study is comprised of 123,824 pregnancies of which 1265 resulted in the child being diagnosed with ASD during the first five years of life. Logistic regression analysis revealed significant relationships between several maternal medical claims, made during her pregnancy and segmented by trimester, and the child's diagnosis of ASD. Having a biological sibling with ASD, maternal use of antidepressant medication and psychiatry services as well as non-pregnancy related claims such hospital visits, surgical procedures, and radiology exposure were related to an increased risk of ASD regardless of trimester. Urinary tract infections during the first trimester and preterm delivery during the second trimester were also related to an increased risk of ASD. Preventative and obstetrical care were associated with a decreased risk for ASD. A better understanding of the medical factors that increase the risk of having a child with ASD can lead to strategies to decrease risk or identify those children who require increased surveillance for the development of ASD to promote early diagnosis and intervention.

Mental disorder in pregnancy and the early postpartum

Perinatal mental illness is common, affecting up to 20% of women, but remains under-recognised and under-diagnosed. It may have adverse effects on pregnancy and neonatal outcomes, and mental disorder remains one of the leading causes of maternal death in the UK. Women with mental ill health face difficult decisions in balancing risks and benefits of treatment. Stigma related to mental disorder may lead to non-engagement with maternity care. Some disorders bring specific challenges for anaesthetists working in maternity settings and it is vital that anaesthetists have knowledge of these disorders so they may offer care which is sensitive and appropriate.

An Array of Studies Addressing Cognition and Cognitively Defined Neuropsychiatric Conditions: Many More Connections Than You Might Think

Six articles in the June 2020 issue of the American Journal of Psychiatry address the overall construct of cognition. These articles have a broad connection to cognition, which is itself a broad concept. From the experimental psychology perspective, cognition is the set of processes associated with attending, learning, knowing, and remembering. From the clinical perspective, a number of neuropsychiatric conditions are defined by the presence of cognitive impairment, with onset ranging from childhood, such as attention deficit hyperactivity disorder and intellectual disability, to later life, such as dementia. Other conditions have notable cognitive impairments even if specific cognitive impairments are not an explicit part of their formal diagnostic criteria, including autism spectrum disorder and schizophrenia. Thus, the array of articles in this issue are related to each other and also may make important points about the role of cognition in everyday functioning and the connections between cognitive impairments in neuropsychiatric conditions and in the human population in general. Further, these articles address the neurobiological substrates that have an impact on cognition, with important implications in other domains, such as genomics. Finally, through sophisticated research methods, they clarify the results of previous studies that were affected by a variety of methodological challenges.