The Use of Tricyclic Antidepressants and Selective Serotonin Reuptake Inhibitors in Women Who Are Breastfeeding

Transfer of anticonvulsants and lithium into amniotic fluid, umbilical cord blood & breast milk: A systematic review & combined analysis

OBJECTIVE

Data on the ability of anticonvulsants and lithium to enter fetal and newborn circulation has become increasingly available; here we estimated penetration ratios in a series of matrices from combined samples of pregnant/breastfeeding women treated with anticonvulsants or lithium.

METHODS

We conducted a systematic literature search in PubMed/EMBASE for studies with concentrations of anticonvulsants/lithium 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 concentrations. When data from multiple studies were available, we calculated combined penetration ratios, weighting studies' mean by study size.

RESULTS

Ninety-one eligible studies for brivaracetam, carbamazepine, clonazepam, ethosuximide, gabapentin, lacosamide, lamotrigine, levetiracetam, lithium, oxcarbazepine, perampanel, phenobarbital, phenytoin, pregabalin, primidone, topiramate, valproate, vigabatrin and zonisamide were identified. For amniotic fluid, the highest penetration ratios were estimated for levetiracetam (mean 3.56, range 1.27-5.85, n = 2) and lowest for valproate (mean 0.11, range 0.02-1.02, n = 57). For umbilical cord plasma, oxcarbazepine had the highest ratio (mean 1.59, range 0.11-4.33, n = 12) with clonazepam having the lowest (mean 0.55, range 0.52-0.59, n = 2). For breast milk, the highest ratios were observed for oxcarbazepine (mean 3.75, range 0.5-7.0, n = 2), whereas the lowest were observed for valproate (mean 0.04, range 0.01-0.22, n = 121).

DISCUSSION

We observed substantial variability between anticonvulsants and lithium regarding their ability to enter fetal/newborn circulation. Assessing concentrations of anticonvulsants and lithium in maternal samples can provide a surrogate of fetal/infant exposure, although patterns of concentration-dependent effects for maternal/neonatal safety are lacking.

Review article: Functional dyspepsia and pregnancy-Effects and management in a special population

BACKGROUND

Around 10% of Americans meet the Rome IV criteria for functional dyspepsia (FD), with a significantly higher rate in women. FD also has a higher prevalence in women below the age of 50, suggesting that women who are affected are likely to be of reproductive age. Unfortunately, there is a lack of research or evidence-based guidelines on managing FD in pregnancy.

AIMS AND METHODS

To address this issue, we aimed to perform a systematic review of the interactions between FD and pregnancy and managing pre-existing FD in the peripartum and post-partum phases using current lifestyle, pharmacological, non-pharmacological and alternative medicine interventions.

RESULTS

Due to the lack of Rome IV FD-specific data in pregnancy, we instead performed a narrative review on how existing FD interventions could be extrapolated to the pregnant population. Where possible we use the highest level of available evidence or official guidelines to answer these questions, which often involves synthesising treatment and safety evidence of these interventions in other diseases during pregnancy. Finally, we highlight current substantial knowledge gaps requiring further research for the safe management of a pregnant patient with pre-existing FD.

CONCLUSIONS

Overall, despite the paucity of knowledge of treating FD during pregnancy, providers can mitigate this uncertainty by planning ahead with the patient. Patients should ideally minimise treatment until after breastfeeding. However, interdisciplinary resources are available to ensure that minimal-risk interventions are maximised, while interventions with more risks, if necessary, are justifiable by both the patient and the care team. Future investigations should continue to elicit the mechanistic relationship between FD and pregnancy while cautiously expanding prospective research on promising and safe therapies in pregnant patients with pre-existing FD.

Efficacy and Safety of Shuganjieyu Capsule Alone or in Combination with Other Antidepressants in the Treatment of Postpartum Depression: A Meta-Analysis

Objective

To evaluate the efficacy and safety of Shuganjieyu capsule alone or in combination with other antidepressants in the treatment of postpartum depression.

Methods

Related control and randomized studies till August 1, 2021, were retrieved from the following databases: PubMed, Cochrane, CNKI, CMB, Wan-Fang, and VIP. Outcomes included HAMD reduction from baseline, response rate, and adverse events rate. Review Manager 5.3 was used in the present meta-analysis.

Results

16 studies including 1409 participants were included in the present study. In comparison of single Shuganjieyu capsule versus regular antidepressant, 8, 6, and 4-week HAMD reduction of the Shuganjieyu group were significantly higher (8-week MD: 3.1 (1.54, 4.66), p < 0.0001; 6-week MD: 0.71 (0.10, 1.31), p=0.02; and 4-week MD: 0.82 (0.34, 1.30), p=0.0008), response rates were comparable for the two groups (OR: 1.51 (0.87, 2.63), p=0.014), and the adverse event rate of the Shuganjieyu group was significantly lower (OR: 0.22 (0.15, 0.32), p < 0.00001). In comparison of combination of Shuganjieyu capsule with regular antidepressant versus regular antidepressant alone, the 8, 6, 4, 2, and 1-week HAMD reduction and response rate of combination of Shuganjieyu with the regular antidepressant group were significantly larger (8-week MD: 3.2 (1.34, 5.06), p=0.0007; 6-week MD: 4.00 (2.72, 5.28), p < 0.00001; 4-week MD: 3.33 (1.94,4.73), p < 0.00001; 2-week MD: 2.69 (1.34, 4.03), p < 0.0001; 1-week MD: 2.27 (0.69, 3.86), p=0.005; and response rate OR: 4.69 (2.27, 9.68), p < 0.0001) and the adverse event rate was comparable for the two groups (OR: 1.26 (0.73, 2.17), p=0.41).

Conclusion

Compared with regular antidepressants, single Shuganjieyu capsule has similar efficacy and better safety profile; when Shuganjieyu capsule is combined with regular antidepressants, the efficacy is improved significantly without increasing adverse events. Therefore, Shuganjieyu capsule was effective and safe for postpartum, making it worth further investigation and popularization.

Antidepressant transfer into amniotic fluid, umbilical cord blood & breast milk: A systematic review & combined analysis

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.

Antidepressants in breast milk; comparative analysis of excretion ratios

Despite increasing prescription rates of antidepressants in pregnant and breastfeeding women over the past decades, evidence of drug exposure for neonates through lactation is very sparse. Concentrations of three antidepressants citalopram, sertraline, and venlafaxine were measured in maternal blood and breast milk in 17 women receiving antidepressant therapy during breastfeeding period. We also computed concentration-by-dose-ratios (C/D) and milk to serum (plasma) penetration ratios (M/P). Non-parametric tests were applied. Serum concentration of citalopram and daily dosage correlated positively while daily dosage and mother milk concentration did not (rho = 0.939, p = 0.005, and rho = 0.772, p > 0.05 respectively). A significant correlation was also found between serum and milk concentrations (rho = 0.812, p = 0.05). Venlafaxine daily dosage correlated positively with the active moiety milk concentration (rho = 0.949, p = 0.014). No significant correlations were reported for sertraline. The amount of antidepressant concentrations to which neonates may be exposed, assessed as absolute infant dose (AID), was particularly low with the highest median AID being 0.16 mg/kg/day for venlafaxine. No significant difference was detected for the M/P ratios between different drugs (p > 0.05), whereas the comparison of C/D ratios revealed lower values in the sertraline group, with the highest values reported for citalopram group (p = 0.007 for serum concentrations and p = 0.008 for mother milk). Findings suggest that breastfeeding under antidepressant treatment constantly exposes children with measurable drug concentrations. As daily dosage and serum concentration of the antidepressants did not predict drug concentrations in mother milk, measuring of drug concentrations in milk helps to quantify drug exposure during breastfeeding. More data-even data of drug concentrations in breastfed children-are needed to better assess the effects of drug exposure on children's development.

The impact of mood disorders and their treatment on the pregnant woman, the fetus, and the infant

Treatment of mood disorders in pregnant or nursing women can carry significant risks for the mother and the developing infant. For patients and physicians, it may be difficult to obtain current information to make the proper decisions regarding pharmacologic and alternative treatments. Thus, this paper discusses the risks and benefits of pharmacologic treatment and the risks of not treating depression and bipolar disorder in the pregnant woman. The safety of treatment options is reviewed. Alternative treatment options are also discussed.

Antidepressant medication use during breastfeeding

We performed an electronic search by using MEDLINE, PreMEDLINE, Current Contents, Biological Abstracts, and PsycINFO from June 2002 to December 2008 using the following terms: "antidepressant drugs", "antidepressive agents", "human milk", "lactation", and "breastfeeding" and the generic name of each antidepressant. Articles in the English language with reports of antidepressants in maternal serum or breast milk, infant serum, and short-term and long-term clinical outcomes in the infants were obtained. The search yielded a total of 31 empirical papers. Breastfeeding and antidepressant treatments are not mutually exclusive. Sertraline, paroxetine, nortriptyline, and imipramine are the most evidence-based medications for use during breastfeeding.

Breastfeeding and antidepressants

Although a large literature supports the benefits of breastfeeding, this review suggests that breastfeeding is less common among postpartum depressed women, even though their infants benefit from the breastfeeding. Depressed mothers, in part, do not breastfeed because of their concern about potentially negative effects of antidepressants on their infants. Although sertraline (Zoloft) and paroxetine (Paxol) concentrations are not detectable in infants' sera, fluoxetine (Prozac) and citalopram (Celexa) do have detectable levels. Unfortunately these findings are not definitive because they are based on very small sample, uncontrolled studies. As in the literature on prenatal antidepressant effects, the question still remains whether the antidepressants or the untreated depression itself has more negative effects on the infant. It is possible that the positive effects of breastfeeding may outweigh the positive effects of the antidepressants for both the mother and the infant. In addition, some alternative therapies may substitute or attenuate the effects of antidepressants, such as vagal stimulation or massage therapy, both therapies being noted to reduce depression. Further studies of this kind are needed to determine the optimal course of therapy for the benefit of the depressed, breastfeeding mother and the breastfed infant.

The expectant brain: adapting for motherhood

A successful pregnancy requires multiple adaptations of the mother's physiology to optimize fetal growth and development, to protect the fetus from adverse programming, to provide impetus for timely parturition and to ensure that adequate maternal care is provided after parturition. Many of these adaptations are organized by the mother's brain, predominantly through changes in neuroendocrine systems, and these changes are primarily driven by the hormones of pregnancy. By contrast, adaptations in the mother's brain during lactation are maintained by external stimuli from the young. The changes in pregnancy are not necessarily innocuous: they may predispose the mother to post-partum mood disorders.

SSRIs during breastfeeding: spotlight on milk-to-plasma ratio

OBJECTIVE

To investigate the usefulness of the milk-to-plasma (M/P) ratio for assessing the risks for the breastfed infant associated with the maternal use of SSRIs.

DATA SOURCES

Medline, Toxnet, Embase, Current Contents, and PsycInfo indexed articles from 1980 to September 2006.

STUDY SELECTION AND DATA EXTRACTION

All studies reporting the M/P ratio in mothers taking SSRIs while breastfeeding or studies which such an information could be calculated from data reported in the article.

DATA SYNTHESIS

Higher M/P ratios were rarely associated with a clinically significant impact on the babies during the early phases of breastfeeding.

CONCLUSIONS

So far no evidence-based information seems to support the hypothesis that SSRIs characterized by a M/P ratio <1.0 should be preferred. Hence, physicians should consider different parameters when attempting to choose the safest SSRI for the breastfeeding woman. These parameters might be represented by the number of well-documented published adverse event reports and the tendency of each SSRI of inducing in the infants serum concentrations that are elevated above 10% of average maternal serum levels. In any case, if the mother wishes to breastfeed her infant while taking a SSRI, the baby should be closely monitored in order to promptly detect any iatrogenic event.

Use of contemporary antidepressants during breastfeeding: a proposal for a specific safety index

Despite the well known severe repercussions of maternal depression on infants' well being, women are often reluctant to seek pharmacological treatment for postnatal depression. The fear of adverse events for the suckling infant plays an important role in such maternal considerations. However, the pharmacological approach to mood disorders at postpartum onset often represents one of the most realistic options in a number of clinical conditions. Therefore, the necessity exists to establish the safety of antidepressant treatment in the breastfed infant. For this reason, the aim of this article is to propose a specific safety index that assesses the frequency and degree of severity of adverse events in infants associated with maternal treatment with second-generation antidepressants during puerperium. The index is derived from a simple formula that uses the number of reports of adverse events in infants exposed to antidepressants as the numerator and the combined total of reports of healthy outcomes and reports of adverse events as the denominator. The sum is then multiplied by 100. A value of < or =2 indicates that the drug should be relatively safe for use during breastfeeding, a value of 2.1-10 indicates that the drug should be used with great caution and a value >10 indicates that the drug should be contraindicated in breastfeeding mothers. In addition to the figure created by this calculation, each drug will also be assigned a letter or the combination of a letter and a subscripted number to symbolise, respectively, the type and clinical management of the most serious recorded event. At this early developmental stage of the index, a complete classification of contemporary antidepressants regarding their safety in infants nursed to the breast is unfeasible. Indeed, because of the lack of suitable published data, so far the index has been limited to the evaluation of four antidepressants. In accordance with the index classification for these four antidepressants, sertraline and paroxetine should be considered as first-line medications in women who need to start antidepressant treatment during the postpartum period and wish to continue breastfeeding. The utilisation of fluoxetine and citalopram seems conversely to be associated with a relatively higher risk of adverse events (with a low degree of severity, however). For the other newer antidepressant drugs, the index is still of no assistance to the patient or physician in deciding on the safety of their use in lactation.

Gender differences in depression and response to psychotropic medication

BACKGROUND

In the United States, depression is approximately twice as common among women as among men, across all age groups.

OBJECTIVE

This review examines gender differences in the epidemiology and clinical presentation of depression, and explores whether women respond differently than men to antidepressant medications.

METHODS

This is a selective review focusing on current issues in the management of depression, with particular attention to gender differences in the epidemiology, diagnosis, and treatment of the disease.

RESULTS

Women are more likely than men to have atypical symptoms of depression (eg, hypersomnia, hyperphagia), to have comorbid anxiety disorders, and to attempt suicide. Women are also more likely to have seasonal affective disorder. Mood and anxiety symptoms that seem to be related to the menstrual cycle do not often represent genuine premenstrual dysphoria, but when premenstrual dysphoric disorder does occur, its impact on quality of life is similar to that of major depressive disorder. There is ongoing controversy about whether men and women respond equally well to antidepressant medications, and preliminary evidence suggests that selective serotonin reuptake inhibitors (SSRIs) are more effective in the presence of estrogen. Depression affects about 10% of pregnant women. Antidepressant medication should be considered during pregnancy if depression is moderate or severe, or if withdrawal of maintenance medication is likely to result in recurrent depression. The potential benefits of using antidepressant medications in a pregnant or breastfeeding woman should be balanced against the potential risks to the newborn. Because of the risk of neonatal withdrawal syndrome, SSRIs should be used at the lowest effective dose during the third trimester of pregnancy and should be tapered before delivery.

CONCLUSIONS

Continuing research is needed to determine how gender influences the risk, clinical presentation, and response to treatment of depression. Exploration of sex differences in animals and humans should aid in efforts to treat depression as an organic disorder rather than a psychological maladaptation.

Neural regulation of bone and the skeletal effects of serotonin (5-hydroxytryptamine)

There is increasing evidence for a contribution of the neural system to the regulation of bone metabolism. The skeleton is richly innervated by both sympathetic and sensory neurons. While these nerves serve sensory and vascular functions, they are also being found to influence bone cell activities. The most convincing evidence for this has been provided by studies into the skeletal effects of the hormone leptin, which has been shown to centrally regulate bone mass, and through studies into the skeletal effects of hypothalamic neuropeptide Y2 and Y4 receptors. This paper discusses recent evidence for the neural regulation of bone metabolism and, in particular, the potential role of the neurotransmitter serotonin (5-hydroxytryptamine, 5-HT). Recent studies have demonstrated the presence of functional pathways in bone for both responding to and regulating the uptake of 5-HT. This is of high clinical relevance given the role of the serotonergic system in affective disorders, and the wide use of pharmacological agents that target the 5-HT system to manage these disorders. Initial data suggest that exposure to these agents at different stages during the lifespan may have significant effects on the skeleton.