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Hwang YM, Roper RT, Piekos SN, Enquobahrie DA, Hebert MF, Paquette AG, Baloni P, Price ND, Hood L, Hadlock JJ. Timing of selective serotonin reuptake inhibitor use and risk for preterm birth and related adverse events: with a consideration of the COVID-19 pandemic period. J Matern Fetal Neonatal Med 2024; 37:2313364. [PMID: 38342572 PMCID: PMC11033706 DOI: 10.1080/14767058.2024.2313364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/29/2024] [Indexed: 02/13/2024]
Abstract
OBJECTIVE There is uncertainty around the safety of SSRIs for treating depression during pregnancy. Nevertheless, the use of SSRIs has been gradually increasing, especially during the COVID-19 pandemic period. We aimed to (1) characterize maternal depression rate and use of SSRIs in a recent 10-year period, (2) address confounding by indication, as well as socioeconomic and environmental factors, and (3) evaluate associations of the timing of SSRI exposure in pregnancy with risk for preterm birth (PTB), low birthweight (LBW), and small for gestational age (SGA) infants among women with depression before pregnancy. METHODS We conducted propensity score-adjusted regression to calculate odds ratios (ORs) of PTB, LBW, and SGA. We accounted for maternal/pregnancy characteristics, comorbidity, depression severity, time of delivery, social vulnerability, and rural residence. RESULTS There were 50.3% and 40.3% increases in the prevalence rate of prenatal depression and prenatal SSRI prescription rate during the pandemic. We identified women with depression ≤180 days before pregnancy (n = 8406). Women with no SSRI order during pregnancy (n = 3760) constituted the unexposed group. The late SSRI exposure group consisted of women with an SSRI order after the first trimester (n = 3759). The early-only SSRI exposure group consisted of women with SSRI orders only in the first trimester (n = 887). The late SSRI exposure group had an increased risk of PTB of OR = 1.5 ([1.2,1.8]) and LBW of OR = 1.5 ([1.2,2.0]), relative to the unexposed group. Associations between late SSRI exposure and risk of PTB/LBW were similar among a subsample of patients who delivered during the pandemic. CONCLUSIONS These findings suggest an association between PTB/LBW and SSRI exposure is dependent on exposure timing during pregnancy. Small for gestational age is not associated with SSRI exposure.
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Affiliation(s)
- Yeon Mi Hwang
- Institute for Systems Biology; 401 Terry Ave N, Seattle, Washington, USA 98109
- Molecular Engineering and Sciences Institute, University of Washington; Seattle, Washington, USA
| | - Ryan T. Roper
- Institute for Systems Biology; 401 Terry Ave N, Seattle, Washington, USA 98109
| | - Samantha N. Piekos
- Institute for Systems Biology; 401 Terry Ave N, Seattle, Washington, USA 98109
| | - Daniel A. Enquobahrie
- Department of Epidemiology, School of Public Health, University of Washington; Seattle, Washington, USA
| | - Mary F. Hebert
- Department of Pharmacy, School of Pharmacy, University of Washington; Seattle, Washington, USA
| | - Alison G. Paquette
- Department of Pediatrics, School of Medicine, University of Washington; Seattle, Washington USA
- Center for Developmental Biology and Regenerative Medicine, Seattle Children’s Research Institute; Seattle, Washington USA
| | - Priyanka Baloni
- School of Health Sciences, Purdue University, West Lafayette, Indiana USA
| | - Nathan D. Price
- Institute for Systems Biology; 401 Terry Ave N, Seattle, Washington, USA 98109
- Thorne HealthTech, New York, New York, USA
| | - Leroy Hood
- Institute for Systems Biology; 401 Terry Ave N, Seattle, Washington, USA 98109
- Providence St. Joseph Health; Renton, Washington, USA
| | - Jennifer J. Hadlock
- Institute for Systems Biology; 401 Terry Ave N, Seattle, Washington, USA 98109
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Eleftheriou G, Zandonella Callegher R, Butera R, De Santis M, Cavaliere AF, Vecchio S, Pistelli A, Mangili G, Bondi E, Somaini L, Gallo M, Balestrieri M, Albert U. Consensus Panel Recommendations for the Pharmacological Management of Pregnant Women with Depressive Disorders. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6565. [PMID: 37623151 PMCID: PMC10454549 DOI: 10.3390/ijerph20166565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION The initiative of a consensus on the topic of antidepressant and anxiolytic drug use in pregnancy is developing in an area of clinical uncertainty. Although many studies have been published in recent years, there is still a paucity of authoritative evidence-based indications useful for guiding the prescription of these drugs during pregnancy, and the data from the literature are complex and require expert judgment to draw clear conclusions. METHODS For the elaboration of the consensus, we have involved the scientific societies of the sector, namely, the Italian Society of Toxicology, the Italian Society of Neuropsychopharmacology, the Italian Society of Psychiatry, the Italian Society of Obstetrics and Gynecology, the Italian Society of Drug Addiction and the Italian Society of Addiction Pathology. An interdisciplinary team of experts from different medical specialties (toxicologists, pharmacologists, psychiatrists, gynecologists, neonatologists) was first established to identify the needs underlying the consensus. The team, in its definitive structure, includes all the representatives of the aforementioned scientific societies; the task of the team was the evaluation of the most accredited international literature as well as using the methodology of the "Nominal Group Technique" with the help of a systematic review of the literature and with various discussion meetings, to arrive at the drafting and final approval of the document. RESULTS The following five areas of investigation were identified: (1) The importance of management of anxiety and depressive disorders in pregnancy, identifying the risks associated with untreated maternal depression in pregnancy. (2) The assessment of the overall risk of malformations with the antidepressant and anxiolytic drugs used in pregnancy. (3) The evaluation of neonatal adaptation disorders in the offspring of pregnant antidepressant/anxiolytic-treated women. (4) The long-term outcome of infants' cognitive development or behavior after in utero exposure to antidepressant/anxiolytic medicines. (5) The evaluation of pharmacological treatment of opioid-abusing pregnant women with depressive disorders. CONCLUSIONS Considering the state of the art, it is therefore necessary in the first instance to frame the issue of pharmacological choices in pregnant women who need treatment with antidepressant and anxiolytic drugs on the basis of data currently available in the literature. Particular attention must be paid to the evaluation of the risk/benefit ratio, understood both in terms of therapeutic benefit with respect to the potential risks of the treatment on the pregnancy and on the fetal outcome, and of the comparative risk between the treatment and the absence of treatment; in the choice prescription, the specialist needs to be aware of both the potential risks of pharmacological treatment and the equally important risks of an untreated or undertreated disorder.
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Affiliation(s)
- Georgios Eleftheriou
- Italian Society of Toxicology (SITOX), via Giovanni Pascoli 3, 20129 Milan, Italy
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Riccardo Zandonella Callegher
- Italian Society of Psychiatry (SIP), piazza Santa Maria della Pietà 5, 00135 Rome, Italy
- Psychiatry Unit, Department of Medicine (DAME), University of Udine, 33100 Udine, Italy
| | - Raffaella Butera
- Italian Society of Toxicology (SITOX), via Giovanni Pascoli 3, 20129 Milan, Italy
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Marco De Santis
- Italian Society of Obstetrics and Gynecology (SIGO), via di Porta Pinciana 6, 00187 Rome, Italy
- Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Anna Franca Cavaliere
- Italian Society of Obstetrics and Gynecology (SIGO), via di Porta Pinciana 6, 00187 Rome, Italy
- Department of Gynecology and Obstetrics, Fatebenefratelli Gemelli, Isola Tiberina, 00186 Rome, Italy
| | - Sarah Vecchio
- Italian Society of Toxicology (SITOX), via Giovanni Pascoli 3, 20129 Milan, Italy
- Ser.D Biella—Drug Addiction Service, 13875 Biella, Italy
| | - Alessandra Pistelli
- Italian Society of Toxicology (SITOX), via Giovanni Pascoli 3, 20129 Milan, Italy
- Division of Clinic Toxicology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy
| | - Giovanna Mangili
- Italian Society of Neonatology (SIN), Corso Venezia 8, 20121 Milan, Italy
- Department of Neonatology, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Emi Bondi
- Italian Society of Psychiatry (SIP), piazza Santa Maria della Pietà 5, 00135 Rome, Italy
- Department of Psychiatry, ASST Papa Giovanni XXIII, 24100 Bergamo, Italy
| | - Lorenzo Somaini
- Ser.D Biella—Drug Addiction Service, 13875 Biella, Italy
- Italian Society of Addiction Diseases (SIPAD), via Tagliamento 31, 00198 Rome, Italy
| | - Mariapina Gallo
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
- Italian Society for Drug Addiction (SITD), via Roma 22, 12100 Cuneo, Italy
| | - Matteo Balestrieri
- Psychiatry Unit, Department of Medicine (DAME), University of Udine, 33100 Udine, Italy
- Italian Society of Neuropsychopharmacology (SINPF), via Cernaia 35, 00158 Rome, Italy
| | - Umberto Albert
- Italian Society of Psychiatry (SIP), piazza Santa Maria della Pietà 5, 00135 Rome, Italy
- Italian Society of Neuropsychopharmacology (SINPF), via Cernaia 35, 00158 Rome, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34128 Trieste, Italy
- Division of Clinic Psychiatry, Azienda Sanitaria Universitaria Giuliano-Isontina, 34148 Trieste, Italy
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Hussain-Shamsy N, Somerton S, Stewart DE, Grigoriadis S, Metcalfe K, Oberlander TF, Schram C, Taylor VH, Dennis CL, Vigod SN. The development of a patient decision aid to reduce decisional conflict about antidepressant use in pregnancy. BMC Med Inform Decis Mak 2022; 22:130. [PMID: 35562801 PMCID: PMC9099318 DOI: 10.1186/s12911-022-01870-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/09/2022] [Indexed: 11/30/2022] Open
Abstract
Background People with moderate to severe depression in pregnancy must weigh potential risks of untreated or incompletely treated depression against the small, but uncertain risks of fetal antidepressant drug exposure. Clinical support alone appears insufficient for helping individuals with this complex decision. A patient decision aid (PDA) has the potential to be a useful tool for this population. The objective of our work was to use internationally recognized guidelines from the International Patient Decision Aids Standards Collaboration to develop an evidence-based PDA for antidepressant use in pregnancy. Methods A three-phased development process was used whereby, informed by patient and physician perspectives and evidence synthesis, a steering committee commissioned a web-based PDA for those deciding whether or not to start or continue antidepressant treatment for depression in pregnancy (Phase 1). A prototype was developed (Phase 2) and iteratively revised based on feedback during field testing based on a user-centred process (Phase 3). Results We developed a web-based PDA for people deciding whether to start or continue antidepressant use for depression in pregnancy. It has five interactive sections: (1) information on depression and treatment; (2) reasons to start/continue an antidepressant and to start/stop antidepressant medication; (3) user assessment of values regarding each issue; (4) opportunity to reflect on factors that contribute to decision making; and (5) a printable PDF that summarizes the user’s journey through the PDA. Conclusions This tool, which exclusively focuses on depression treatment with Selective Serotonin Reuptake Inhibitors and Serotonin–Norepinephrine Reuptake Inhibitors, can be used by individuals making decisions about antidepressant use to treat depression during pregnancy. Limitations of the PDA are that it is not for other conditions, nor other medications that can be used for depression, and in its pilot form cannot be used by women who do not speak English or who have a visual impairment. Pending further study, it has the potential to enhance quality of care and patient experience. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-022-01870-1.
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Affiliation(s)
- Neesha Hussain-Shamsy
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, ON, Canada
| | - Sarah Somerton
- Garry Hurvitz Centre for Brain and Mental Health, Hospital for Sick Children, 555 University Avenue, Toronto, ON, Canada
| | - Donna E Stewart
- Centre for Mental Health, University Health Network, Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON, Canada.,Temerty Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, ON, Canada
| | - Sophie Grigoriadis
- Temerty Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre and Research Institute, 2075 Bayview Avenue, Toronto, ON, Canada.,Women's College Hospital and Research Institute, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
| | - Kelly Metcalfe
- Women's College Hospital and Research Institute, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Toronto, ON, Canada
| | - Tim F Oberlander
- BC Children's Hospital, 4500 Oak Street, Vancouver, BC, Canada.,Department of Pediatrics, Faculty of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC, Canada
| | - Carrie Schram
- Women's College Hospital and Research Institute, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
| | - Valerie H Taylor
- Department of Psychiatry, University of Calgary, 2500 University Dr NW, Calgary, AB, Canada
| | - Cindy-Lee Dennis
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Toronto, ON, Canada
| | - Simone N Vigod
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, ON, Canada. .,Temerty Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, ON, Canada. .,Women's College Hospital and Research Institute, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.
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4
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Xing D, Wu R, Chen L, Wang T. Maternal use of antidepressants during pregnancy and risks for adverse perinatal outcomes: a meta-analysis. J Psychosom Res 2020; 137:110231. [PMID: 32889478 DOI: 10.1016/j.jpsychores.2020.110231] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 07/10/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To perform an updated and comprehensive meta-analysis on the risks of adverse perinatal outcomes in children whose mothers received antidepressants during pregnancy. METHODS A systematic literature search of several databases was conducted through December 2018 to identify relevant studies. Risk estimates and their corresponding 95% confidence intervals (CIs) were pooled using random-effects meta-analysis. Subgroup and sensitivity analyses were performed to explore the source of heterogeneity and test the robustness. RESULTS Forty-eight cohort and 6 case-control studies were included. In cohort studies, children whose mothers received antidepressants during pregnancy had higher risks of preterm birth (RR = 1.62, 95% CI: 1.37, 1.90), low birth weight (RR = 1.37, 95% CI: 1.04, 1.80), and admissions to neonatal intensive care unit (RR = 1.60, 95% CI: 1.38, 1.85) when compared with children born by depressed but untreated pregnant women. The risks of spontaneous abortions (RR = 1.49, 95% CI: 1.29, 1.73), large for gestational age (RR = 1.11, 95% CI: 1.03, 1.20), stillbirths (RR = 1.16, 95% CI: 1.02, 1.32), low Apgar score at 5 min (RR = 1.91, 95% CI: 1.42, 2.56), and neonatal convulsions (RR = 1.97, 95% CI: 1.56, 2.48) increased in children whose mothers received antidepressants during pregnancy when compared with children born by healthy pregnant women. CONCLUSION Compared with children whose mothers did not receive antidepressants during pregnancy, children whose mothers received antidepressants during pregnancy had increased risks of adverse perinatal outcomes. Further research on the dose of antidepressants is needed.
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Affiliation(s)
- Dexiu Xing
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Rong Wu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Lizhang Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China; Hunan Provincial Key Laboratory of Clinical Epidemiology, Hunan, China.
| | - Tingting Wang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China.
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5
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Sujan AC, Öberg AS, Quinn PD, D’Onofrio BM. Annual Research Review: Maternal antidepressant use during pregnancy and offspring neurodevelopmental problems - a critical review and recommendations for future research. J Child Psychol Psychiatry 2019; 60:356-376. [PMID: 30515808 PMCID: PMC6438736 DOI: 10.1111/jcpp.13004] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2018] [Indexed: 12/11/2022]
Abstract
Children of women treated with antidepressants during pregnancy are more likely to develop neurodevelopmental problems than are unexposed children. Associations between prenatal antidepressant exposure and neurodevelopmental problems could reflect a causal effect or could be partially or fully explained by other factors that differ between exposed and unexposed offspring, including having mothers with conditions requiring antidepressant treatment (e.g. depression), environmental risk factors, and/or genetic risk factors shared across disorders. This translational review aims to provide a brief overview of findings from rodent experiments and critically evaluate observational studies in humans to assess the extent to which associations between prenatal antidepressant exposure and neurodevelopmental problems are due to causal mechanisms versus other influences. We focus our review on two important neurodevelopmental outcomes - autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD). In general, rodent studies have reported adverse effects of perinatal antidepressant exposure on neurodevelopment. Between-species differences raise questions about the generalizability of these findings to humans. Indeed, converging evidence from studies using multiple designs and approaches suggest that observed associations between prenatal antidepressant exposure and neurodevelopmental problems in humans are largely due to confounding factors. We also provide specific recommendations for future research. Animal research should explicitly evaluate the impact of timing of exposure and dosage of medications, as well as better map outcome measures in rodents to human neurodevelopmental problems. Observational studies should investigate specific confounding factors, specific antidepressant drugs and classes, the potential impact of timing of exposure, and a wider range of other potential offspring outcomes. The findings summarized in this review may help women and their doctors make informed decisions about antidepressant use during pregnancy by providing reassurance that use of these medications during pregnancy is unlikely to substantially increase the risk of ASD and ADHD.
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Affiliation(s)
- Ayesha C. Sujan
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA
| | - A. Sara Öberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Patrick D. Quinn
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, IN, USA
| | - Brian M. D’Onofrio
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Ornoy A, Koren G. Selective serotonin reuptake inhibitor use in pregnant women; pharmacogenetics, drug-drug interactions and adverse effects. Expert Opin Drug Metab Toxicol 2018; 14:247-259. [PMID: 29345153 DOI: 10.1080/17425255.2018.1430139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Possible negative effects of selective serotonin reuptake inhibitors (SSRIs) in pregnancy relate to congenital anomalies, negative perinatal events and neurodevelopmental outcome. Many studies are confounded by the underlying maternal disease and by pharmacogenetic and pharmacokinetic differences of these drugs. Areas covered: The possible interactions of SSRIs and serotonin and norepinephrine reuptake inhibitors with other drugs and the known effects of SSRIs on congenital anomalies, perinatal and neurodevelopmental outcome. Expert opinion: SSRIs should be given with caution when combined with other drugs that are metabolized by cytochrome P450 enzymes. SSRIs apparently increase the rate of severe cardiac malformations, induce neonatal adaptation problems in up to 30% of the offspring, increase the rate of persistent pulmonary hypertension of the newborn and possibly slightly increase the rate of prematurity and low birth weight. Most neurodevelopmental follow up studies did not find significant cognitive impairments except some transient gross motor delay, slight impairment of language abilities and possibly behavioral changes. The literature on the possible association of SSRIs with autism spectrum disorder is inconsistent; if an association exists, it is apparently throughout pregnancy. The risk associated with treatment discontinuation seems to outweigh the risk of treatment, as severe maternal depression may negatively affect the child's development. If needed, treatment should continue in pregnancy with the minimal effective dose.
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Affiliation(s)
- Asher Ornoy
- a Laboratory of Teratology, Department of Medical Neurobiology , Hebrew University Hadassah Medical School , Jerusalem , Israel
| | - Gideon Koren
- b Morris Kahn- Maccabi Institute of Research and Innovation, and Tel Aviv University , TEl - AVIV , Israel
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7
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Abstract
The risks and benefits of psychopharmacological treatment in pregnancy need careful consideration. Conventional antipsychotics and tricyclic antidepressants are relatively safe for the foetus. Selective serotonin reuptake inhibitors appear to be safe, but mood stabilisers such as lithium, sodium valproate and carbamazepine are associated with increased foetal malformations. Benzodiazepines in the first trimester are teratogenic, and in high dosage can also cause withdrawal symptoms, hypotonia and agitation in the newborn. Women taking atypical antipsychotics should be switched to conventional antipsychotics before they conceive. In women with long-term mental illness necessitating psychotropic medication, effort should be made to stop polypharmacy and non-essential medication (e.g. benzodiazepines) and to decrease the dose of essential drugs, after full assessment. There is rarely a valid reason to stop essential drug treatment during pregnancy.
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8
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Ornoy A, Koren G. Selective Serotonin Reuptake Inhibitors during Pregnancy: Do We Have Now More Definite Answers Related to Prenatal Exposure? Birth Defects Res 2017; 109:898-908. [DOI: 10.1002/bdr2.1078] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 05/17/2017] [Accepted: 06/06/2017] [Indexed: 01/10/2023]
Affiliation(s)
- Asher Ornoy
- Laboratory of Teratology, Department of Medical Neurobiology; Hebrew University Hadassah Medical School Jerusalem and Maccabi Research Institute and Tel Aviv University; Tel Aviv Israel
| | - Gideon Koren
- Laboratory of Teratology, Department of Medical Neurobiology; Hebrew University Hadassah Medical School Jerusalem and Maccabi Research Institute and Tel Aviv University; Tel Aviv Israel
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Tak CR, Job KM, Schoen-Gentry K, Campbell SC, Carroll P, Costantine M, Brixner D, Birnbaum AK, Sherwin CMT. The impact of exposure to antidepressant medications during pregnancy on neonatal outcomes: a review of retrospective database cohort studies. Eur J Clin Pharmacol 2017; 73:1055-1069. [PMID: 28600701 DOI: 10.1007/s00228-017-2269-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 05/22/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Concerns with prescription antidepressant use in pregnant women have instigated the examination of potential associations between fetal exposure to antidepressant medication and outcomes including preterm delivery, congenital malformations, perinatal and post-natal adverse events, persistent pulmonary hypertension, and mortality. The retrospective cohort model is an often utilized study design. The objective of this review is to evaluate the literature on antidepressant use in pregnancy conducted as retrospective cohorts in national/regional medical, or claims databases that assess neonatal and infant outcomes for agreement between studies, ultimately providing a methodological and outcomes summary for future scientific endeavors. METHODS PubMed was searched for literature relating to antidepressant use and infant outcomes from the earliest available date through July 15, 2016. Studies with a retrospective cohort design and conducted in national/regional medical or claims databases were included. Searched outcomes included preterm delivery, congenital malformations, low birth weight, small for gestational age, persistent pulmonary hypertension of the newborn, and other select adverse events comprising low Apgar score (5 min), convulsions/seizures, respiratory distress/problems, fetal mortality, and infant mortality. RESULTS Of the 784 studies identified, 36 retrospective cohort studies met eligibility criteria. An increase in preterm delivery and respiratory distress/problems and no increase in congenital malformation or fetal and infant death were associated with prenatal use of prescription antidepressants by majority consensus (at least 2/3 [67%] of studies). CONCLUSIONS While consensus indicates that perinatal prescription antidepressant use has consequences for the fetus and infant, there are notable inconsistencies in the literature. More investigations that address prenatal exposure to depression and other important covariates are needed.
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Affiliation(s)
- Casey R Tak
- Pharmacotherapy Outcomes Research Center, Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA.,Clinical Trials Office, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Kathleen M Job
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah of Medicine, SLC, Utah 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Katie Schoen-Gentry
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Sarah C Campbell
- Nelson Laboratories, Salt Lake City, UT, USA.,Department of Pharmacology and Toxicology, College of Pharmacy, University of Utah Salt Lake City, Salt Lake City, UT, USA
| | - Patrick Carroll
- Women and Newborn Clinical Program, Department of Pediatrics, Dixie Regional Medical Center, Intermountain Healthcare, St. George, UT, USA.,Neonatal Services, Dixie Regional Medical Center, 544 East 400 South, St George, UT, 84770, USA
| | - Maged Costantine
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
| | - Diana Brixner
- Pharmacotherapy Outcomes Research Center, Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA.,Program in Personalized Health, Health Sciences Center, University of Utah, Salt Lake City, UT, USA
| | - Angela K Birnbaum
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Catherine M T Sherwin
- Clinical Trials Office, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA. .,Division of Clinical Pharmacology, Department of Pediatrics, University of Utah of Medicine, SLC, Utah 295 Chipeta Way, Salt Lake City, UT, 84108, USA. .,Department of Pharmacology and Toxicology, College of Pharmacy, University of Utah Salt Lake City, Salt Lake City, UT, USA.
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10
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Cantarutti A, Merlino L, Giaquinto C, Corrao G. Use of antidepressant medication in pregnancy and adverse neonatal outcomes: A population-based investigation. Pharmacoepidemiol Drug Saf 2017; 26:1100-1108. [DOI: 10.1002/pds.4242] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 04/19/2017] [Accepted: 05/09/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Anna Cantarutti
- Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, Laboratory of Healthcare Research and Pharmacoepidemiology; University of Milano-Bicocca; Milan Italy
| | - Luca Merlino
- Operative Unit of Territorial Health Services; Region of Lombardy; Milan Italy
| | - Carlo Giaquinto
- Department of Women's and Children's Health; University of Padova; Padova Italy
| | - Giovanni Corrao
- Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, Laboratory of Healthcare Research and Pharmacoepidemiology; University of Milano-Bicocca; Milan Italy
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11
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Braeken MA, Jones A, Otte RA, Nyklíček I, Van den Bergh BR. Potential benefits of mindfulness during pregnancy on maternal autonomic nervous system function and infant development. Psychophysiology 2016; 54:279-288. [DOI: 10.1111/psyp.12782] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 09/12/2016] [Indexed: 12/16/2022]
Affiliation(s)
- Marijke A.K.A. Braeken
- Faculty of Social and Behavioural Sciences; Tilburg University; Tilburg The Netherlands
- REVAL Rehabilitation Research Center, Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University; Hasselt Belgium
- Department of Psychology; KU Leuven Leuven Belgium
| | - Alexander Jones
- Institute of Cardiovascular Science, University College London; London UK
| | - Renée A. Otte
- Faculty of Social and Behavioural Sciences; Tilburg University; Tilburg The Netherlands
| | - Ivan Nyklíček
- Center for Research in Psychology in Somatic Diseases (CoRPS), Department of Medical and Clinical Psychology, Tilburg University; Tilburg The Netherlands
| | - Bea R.H. Van den Bergh
- Faculty of Social and Behavioural Sciences; Tilburg University; Tilburg The Netherlands
- Department of Psychology; KU Leuven Leuven Belgium
- Department of Welfare, Public Health and Family; Flemish Government; Brussels Belgium
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12
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Affiliation(s)
- Mans Rosén
- Epidemiologiskt centrum, Socialstyrelsen, S-106, Stockholm, Sweden,
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13
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Abstract
Several depressive disorders are unique to women, affecting them at various points in their life cycle. These disorders include premenstrual dysphoric disorder (PMDD), pregnancy-associated depressive disorders, and perimenopausal affective disorders. Recently, the importance of the relationship between depression and the reproductive cycle has been highlighted due to the approval of medications to treat (PMDD). The role of gender difference in the prevalence of depressive disorders has long been recognized. This article will examine whether there are differences between men and women in the clinical presentation of depression, including differences in symptom manifestation, course of illness, comorbidities, and treatment. Systematic evaluation of the role of hormonal and neuroendocrine factors may lead to more appropriate treatment of depressive disorders in women.
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Affiliation(s)
- Thea R. Moore
- Florida A&M University College of Pharmacy and Pharmaceutical Sciences, University Psychiatry Center, 3515 East Fletcher Avenue, Tampa, FL 33613
| | - Angela M. Emanuel
- Florida A&M University College of Pharmacy and Pharmaceutical Sciences, 105 Honor House, Tallahassee, FL 32308
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14
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Vigod S, Hussain-Shamsy N, Grigoriadis S, Howard LM, Metcalfe K, Oberlander TF, Schram C, Stewart DE, Taylor VH, Dennis CL. A patient decision aid for antidepressant use in pregnancy: study protocol for a randomized controlled trial. Trials 2016; 17:110. [PMID: 26923796 PMCID: PMC4770694 DOI: 10.1186/s13063-016-1233-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 02/16/2016] [Indexed: 12/28/2022] Open
Abstract
Background Many women with depression experience significant difficulty making a decision about whether or not to use antidepressant medication in pregnancy. Patient decision aids (PDAs) are tools that assist patients in making complex health decisions. PDAs can reduce decision-making difficulty and lead to better treatment outcomes. We describe the methods for a pilot randomized controlled trial of an interactive web-based PDA for women who are having difficulty deciding about antidepressant drug use in pregnancy. Methods/Design This is a pilot randomized controlled trial that aims to assess the feasibility of a larger, multi-center efficacy study. The PDA aims to help a woman: (1) understand why an antidepressant is being recommended, (2) be knowledgeable about potential benefits and risks of treatment and non-treatment with antidepressants, and (3) be clear about which benefits and risks are most important to her, with the goal of improving confidence in her decision-making. We include women aged 18 years or older who are: (1) planning a pregnancy or are pregnant (gestational age less than 30 weeks), (2) diagnosed with major depressive disorder, (3) deciding whether or not to use a selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitor (SNRI) antidepressant in pregnancy, and (4) having at least moderate decision-making difficulty as per a Decisional Conflict Scale (DCS) Score ≥25. Participants are randomized to receive the PDA or an informational resource sheet via a secure website, and have access to the stated allocation until their final study follow-up. The primary outcomes of the pilot study are feasibility of recruitment and retention, acceptability of the intervention, and adherence to the trial protocol. The primary efficacy outcome is DCS score at 4 weeks post randomization, with secondary outcomes including depressive and anxiety symptoms. Discussion Our PDA represents a key opportunity to optimize the decision-making process for women around antidepressants in pregnancy, leading to effective decision-making and optimizing improved maternal and child outcomes related to depression in pregnancy. The electronic nature of the PDA will facilitate keeping it up-to-date, and allow for widespread dissemination after efficacy is demonstrated. Trial registration This trial is registered on ClinicalTrials.Gov under the identifier NCT02308592 (first registered: 2 December 2014). Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1233-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Simone Vigod
- Women's College Hospital and Research Institute, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada. .,University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.
| | - Neesha Hussain-Shamsy
- Women's College Hospital and Research Institute, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.
| | - Sophie Grigoriadis
- University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada. .,Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
| | - Louise M Howard
- King's College London, Institute of Psychiatry, Box P031, De Crespigny Park, London, SE5 8AF, United Kingdom.
| | - Kelly Metcalfe
- Women's College Hospital and Research Institute, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada. .,University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.
| | - Tim F Oberlander
- Department of Pediatrics, University of British Columbia, Child and Family Research Institute, 4480 Oak St., Vancouver, BC, V6H 3V4, Canada.
| | - Carrie Schram
- Women's College Hospital and Research Institute, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada. .,University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.
| | - Donna E Stewart
- University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada. .,University Health Network, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
| | - Valerie H Taylor
- Women's College Hospital and Research Institute, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada. .,University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.
| | - Cindy-Lee Dennis
- Women's College Hospital and Research Institute, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada. .,University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.
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15
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Durham E, Jen S, Wang L, Nasworthy J, Elsalanty M, Weinberg S, Yu J, Cray J. Effects of Citalopram on Sutural and Calvarial Cell Processes. PLoS One 2015; 10:e0139719. [PMID: 26431045 PMCID: PMC4592261 DOI: 10.1371/journal.pone.0139719] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 09/15/2015] [Indexed: 12/31/2022] Open
Abstract
The use of selective serotonin reuptake inhibitors (SSRIs) for the treatment of depression during pregnancy is suggested to increase the incidence of craniofacial abnormalities including craniosynostosis. Little is known about this mechanism, however based on previous data we propose a mechanism that affects cell cycle. Excessive proliferation, and reduction in apoptosis may lead to hyperplasia within the suture that may allow for differentiation, bony infiltration, and fusion. Here we utilized in vivo and in vitro analysis to investigate this proposed phenomenon. For in vivo analysis we used C57BL–6 wild-type breeders treated with a clinical dose of citalopram during the third trimester of pregnancy to produce litters exposed to the SSRI citalopram in utero. At post-natal day 15 sutures were harvested from resulting pups and subjected to histomorphometric analysis for proliferation (PCNA) and apoptosis (TUNEL). For in vitro studies, we used mouse calvarial pre-osteoblast cells (MC3T3-E1) to assess proliferation (MTS), apoptosis (Caspase 3/7-activity), and gene expression after exposure to titrated doses of citalopram. In vivo analysis for PCNA suggested segregation of effect by location, with the sagittal suture, showing a statistically significant increase in proliferative response. The coronal suture was not similarly affected, however there was a decrease in apoptotic activity at the dural edge as compared to the periosteal edge. No differences in apoptosis by suture or area due to SSRI exposure were observed. In vitro results suggest citalopram exposure increased proliferation and proliferative gene expression, and decreased apoptosis of the MC3T3-E1 cells. Decreased apoptosis was not confirmed in vivo however, an increase in proliferation without a concomitant increase in apoptosis is still defined as hyperplasia. Thus prenatal SSRI exposure may exert a negative effect on post-natal growth through a hyperplasia effect at the cranial growth sites perhaps leading to clinically significant craniofacial abnormalities.
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Affiliation(s)
- Emily Durham
- Departments of Oral Health Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Serena Jen
- School of Medicine, Georgia Regents University, Augusta, Georgia, United States of America
| | - Lin Wang
- Institute for Plastic Surgery, Shanghai Jiao Tong University, Shanghai, China
| | - Joseph Nasworthy
- Department of Oral Biology, Georgia Regents University, Augusta, Georgia, United States of America
| | - Mohammed Elsalanty
- Department of Oral Biology, Georgia Regents University, Augusta, Georgia, United States of America
- Department of Cellular Biology and Anatomy, Georgia Regents University, Augusta, Georgia, United States of America
- Department of Oral Maxillofacial Surgery, Georgia Regents University, Augusta, Georgia, United States of America
- Institute for Regenerative and Reparative Medicine, Georgia Regents University, Augusta, Georgia, United States of America
| | - Seth Weinberg
- Center for Craniofacial and Dental Genetics, School of Dental Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Department of Oral Biology, School of Dental Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Jack Yu
- Institute for Regenerative and Reparative Medicine, Georgia Regents University, Augusta, Georgia, United States of America
- Department of Surgery, Division of Plastic Surgery, Georgia Regents University, Augusta, Georgia, United States of America
| | - James Cray
- Departments of Oral Health Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
- * E-mail:
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16
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Abstract
The estimate of the global burden of disease predicts that depression will be the second-leading cause of disability worldwide by 2020. Depression is widely prevalent in women in all age groups especially in India where 1.2 billion population lives. In the current scenario of underdiagnosed, untreated cases of females suffering from depression, the hurdles faced by Indian women include inadequate number of mental health professionals, lack of awareness, stigma, disadvantaged position of women, multiple roles, increased levels of stress, and domestic violence. The literature search included an electronic database, published materials, and standard textbooks. The authors have provided a brief overview of different types of depression in females. Epidemiology, etiology, clinical presentation, and management linked to the reproductive cycle of women have been covered. Awareness through public education, early detection, organized national mental health programs, comprehensive management, with judicious utilization of the limited resources would tackle the rising number of cases of female depression, in a cost effective manner, thereby preventing suicide.
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Affiliation(s)
| | - Shruti Srivastava
- Department of Psychiatry, University College of Medical Sciences, Guru Teg Bahadur Hospital, New Delhi, India
| | - M S Bhatia
- Department of Psychiatry, University College of Medical Sciences, Guru Teg Bahadur Hospital, New Delhi, India
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17
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Abstract
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.
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Affiliation(s)
- Daya Ram
- Director, Central Institute of Psychiatry, Ranchi, Jharkhand, India
| | - S. Gandotra
- Department of Psychiatry, Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India
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18
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Liu X, Olsen J, Pedersen LH, Agerbo E, Yuan W, Li J. Antidepressant use during pregnancy and asthma in the offspring. Pediatrics 2015; 135:e911-7. [PMID: 25755245 DOI: 10.1542/peds.2014-4073] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES It has been suggested that maternal depression during pregnancy is associated with asthma in the offspring, but the role of medical treatment of depression is not known. Our goal was to examine whether prenatal antidepressant use increases the risk of asthma in the offspring. METHODS A cohort study was performed among all live singletons born in Denmark between 1996 and 2007. Mothers who had a diagnosis of depressive disorder and/or who used antidepressants 1 year before or during the index pregnancy were identified. Using a Cox proportional hazards regression model, we estimated the hazard ratio (HR) for asthma in the offspring after antidepressant use during pregnancy. RESULTS Of the 733,685 children identified, 84,683 had a diagnosis of asthma. A total of 21,371 children were exposed to prenatal maternal depression (ie, a diagnosis of depressive disorder or use of antidepressants 1 year before or during pregnancy). Prenatal maternal depression was associated with childhood asthma (HR: 1.25 [95% confidence interval (CI): 1.20-1.30]). Overall, 8895 children were exposed to antidepressants in utero. Compared with children born to mothers with prenatal depression and no antidepressant use during pregnancy, the HR for asthma after any antidepressant use during pregnancy was 1.00 (95% CI: 0.93-1.08). HRs after use of selective serotonin reuptake inhibitors only, newer antidepressants only, and older antidepressants only were 0.95 (95% CI: 0.88-1.03), 1.11 (95% CI: 0.89-1.39), and 1.26 (95% CI: 1.02-1.55), respectively. CONCLUSIONS Antidepressant use during pregnancy generally did not increase the risk of asthma. Only use of older antidepressants was associated with an increased risk of asthma.
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Affiliation(s)
- Xiaoqin Liu
- Section for Epidemiology, Department of Public Health, Department of Epidemiology and Social Science on Reproductive Health, Shanghai Institute of Planned Parenthood Research, WHO Collaborating Center for Research in Human Reproduction, National Population & Family Planning Key Laboratory of Contraceptive Drugs and Devices, Shanghai, China; and
| | - Jørn Olsen
- Section for Epidemiology, Department of Public Health, Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, California
| | | | - Esben Agerbo
- National Centre for Register-Based Research, and CIRRAU-Centre for Integrated Register-based Research, Aarhus University, Aarhus, Denmark
| | - Wei Yuan
- Department of Epidemiology and Social Science on Reproductive Health, Shanghai Institute of Planned Parenthood Research, WHO Collaborating Center for Research in Human Reproduction, National Population & Family Planning Key Laboratory of Contraceptive Drugs and Devices, Shanghai, China; and
| | - Jiong Li
- Section for Epidemiology, Department of Public Health
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19
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Tuccori M, Montagnani S, Testi A, Ruggiero E, Mantarro S, Scollo C, Pergola A, Fornai M, Antonioli L, Colucci R, Corona T, Blandizzi C. Use of Selective Serotonin Reuptake Inhibitors during Pregnancy and Risk of Major and Cardiovascular Malformations: An Update. Postgrad Med 2015; 122:49-65. [DOI: 10.3810/pgm.2010.07.2175] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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20
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Vigod S, Dennis CL, Daskalakis Z, Murphy K, Ray J, Oberlander T, Somerton S, Hussain-Shamsy N, Blumberger D. Transcranial direct current stimulation (tDCS) for treatment of major depression during pregnancy: study protocol for a pilot randomized controlled trial. Trials 2014; 15:366. [PMID: 25234606 PMCID: PMC4177439 DOI: 10.1186/1745-6215-15-366] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 09/10/2014] [Indexed: 11/15/2022] Open
Abstract
Background Women with depression in pregnancy are faced with difficult treatment decisions. Untreated, antenatal depression has serious negative implications for mothers and children. While antidepressant drug treatment is likely to improve depressive symptoms, it crosses the placenta and may pose risks to the unborn child. Transcranial direct current stimulation is a focal brain stimulation treatment that improves depressive symptoms within 3 weeks of treatment by inducing changes to brain areas involved in depression, without impacting any other brain areas, and without inducing changes to heart rate, blood pressure or core body temperature. The localized nature of transcranial direct current stimulation makes it an ideal therapeutic approach for treating depression during pregnancy, although it has never previously been evaluated in this population. Methods/design We describe a pilot randomized controlled trial of transcranial direct current stimulation among women with depression in pregnancy to assess the feasibility of a larger, multicentre efficacy study. Women over 18 years of age and between 14 and 32 weeks gestation can be enrolled in the study provided they meet diagnostic criteria for a major depressive episode of at least moderate severity and have been offered but refused antidepressant medication. Participants are randomized to receive active transcranial direct current stimulation or a sham condition that is administered in 15 30-minute treatments over three weeks. Women sit upright during treatment and receive obstetrical monitoring prior to, during and after each treatment session. Depressive symptoms, treatment acceptability, and pregnancy outcomes are assessed at baseline (prior to randomization), at the end of each treatment week, every four weeks post-treatment until delivery, and at 4 and 12 weeks postpartum. Discussion Transcranial direct current stimulation is a novel therapeutic option for treating depression during pregnancy. This protocol allows for assessment of the feasibility of, acceptability of and adherence with a clinical trial protocol to administer this treatment to pregnant women with moderate to severe depression. Results from this pilot study will guide the development of a larger multicentre trial to definitively test the efficacy and safety of transcranial direct current stimulation for pregnant women with depression. Trial registration Clinical Trials Gov NCT02116127.
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Affiliation(s)
- Simone Vigod
- Women's College Hospital and Research Institute, 76 Grenville Street, Toronto, ON M5S 1B1, Canada.
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21
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Epstein RA, Moore KM, Bobo WV. Treatment of nonpsychotic major depression during pregnancy: patient safety and challenges. DRUG HEALTHCARE AND PATIENT SAFETY 2014; 6:109-29. [PMID: 25258558 PMCID: PMC4173755 DOI: 10.2147/dhps.s43308] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In pregnant women with major depression, the overarching goal of treatment is to achieve or maintain maternal euthymia, thus limiting both maternal and fetal exposure to the harmful effects of untreated or incompletely treated depression. However, the absence of uniformly effective therapies with guaranteed obstetric and fetal safety makes the treatment of major depression during pregnancy among the most formidable of clinical challenges. Clinicians and patients are still faced with conflicting data and expert opinion regarding the reproductive safety of antidepressants in pregnancy, as well as large gaps in our understanding of the effectiveness of most antidepressants and nonpharmacological alternatives for treating antenatal depression. In this paper, we provide a clinically focused review of the available information on potential maternal and fetal risks of untreated maternal depression during pregnancy, the effectiveness of interventions for maternal depression during pregnancy, and potential obstetric, fetal, and neonatal risks associated with antenatal antidepressant use.
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Affiliation(s)
- Richard A Epstein
- Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Katherine M Moore
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - William V Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
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Ornoy A, Koren G. Selective serotonin reuptake inhibitors in human pregnancy: on the way to resolving the controversy. Semin Fetal Neonatal Med 2014; 19:188-94. [PMID: 24321501 DOI: 10.1016/j.siny.2013.11.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
There has been an increase in the use of selective serotonin reuptake inhibitors (SSRIs) during pregnancy. However, in the last 10 years, in spite of a vast literature regarding use in pregnancy there seems to be some confusion as to the possible risk of these drugs, especially related to cardiovascular anomalies. In addition, there are data on developmental follow-up studies that raise the question of possible slight developmental and neurobehavioral problems. The purpose of the present review is therefore to critically summarize the current evidence for the risk/benefit analysis of SSRI use in human pregnancy. Although most studies have not shown an increase in the overall risk of major malformations, several have suggested that the use of SSRIs may be associated with a small increased risk for cardiovascular malformations. However, new compelling evidence shows that this apparent increased risk occurs also in women with untreated depression, highlighting the probable ascertainment bias involved in many of these studies. Persistent pulmonary hypertension of the newborn (PPHN) has also been described with an absolute risk of <1%; however, here too, higher rates were described among offspring of women with untreated depression. Poor neonatal adaptation has been described in up to 30% of neonates exposed to SSRIs late in pregnancy. Of the few postnatal developmental follow-up studies, there are no significant developmental problems. The literature on SSRIs in pregnancy is somewhat confusing but when analysing all prospective cohort data there seems to be no demonstrable increase in the rate of major anomalies or developmental disorders. When evaluating the risk/benefit ratio of SSRI treatment in pregnancy, the risk associated with treatment discontinuation - e.g. higher frequency of relapse, increased risk of preterm delivery and postpartum depression - appear to outweigh the potential, unproven risks of treatment. Moreover, maternal depression may negatively affect the child's development, emphasizing the importance of prevention by appropriate treatment during pregnancy with the least minimal effective dose.
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Affiliation(s)
- Asher Ornoy
- Hebrew University Hadassah Medical School, Jerusalem, Israel; Israeli Teratology Information Service, Israel Ministry of Health, Jerusalem, Israel.
| | - Gideon Koren
- Israeli Teratology Information Service, Israel Ministry of Health, Jerusalem, Israel; Motherisk Program, Division of Clinical Pharmacology/Toxicology, Department of Pediatrics, Hospital for Sick Children, Toronto, Canada
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23
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Huybrechts KF, Sanghani RS, Avorn J, Urato AC. Preterm birth and antidepressant medication use during pregnancy: a systematic review and meta-analysis. PLoS One 2014; 9:e92778. [PMID: 24671232 PMCID: PMC3966829 DOI: 10.1371/journal.pone.0092778] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 02/25/2014] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Preterm birth is a major contributor to neonatal morbidity and mortality and its rate has been increasing over the past two decades. Antidepressant medication use during pregnancy has also been rising, with rates up to 7.5% in the US. The objective was to systematically review the literature to determine the strength of the available evidence relating to a possible association between antidepressant use during pregnancy and preterm birth. METHODS We conducted a computerized search in PUBMED, MEDLINE and PsycINFO through September 2012, supplemented with a manual search of reference lists, to identify original published research on preterm birth rates in women taking antidepressants during pregnancy. Data were independently extracted by two reviewers, and absolute and relative risks abstracted or calculated. Our a priori design was to group studies by level of confounding adjustment and by timing of antidepressant use during pregnancy; we used random-effects models to calculate summary measures of effect. RESULTS Forty-one studies met inclusion criteria. Pooled adjusted odds ratios (95% CI) were 1.53 (1.40-1.66) for antidepressant use at any time and 1.96 (1.62-2.38) for 3rd trimester use. Controlling for a diagnosis of depression did not eliminate the effect. There was no increased risk [1.16 (0.92-1.45)] in studies that identified patients based on 1st trimester exposure. Sensitivity analyses demonstrated unmeasured confounding would have to be strong to account for the observed association. DISCUSSION Published evidence is consistent with an increased risk of preterm birth in women taking antidepressants during the 2nd and 3rd trimesters, although the possibility of residual confounding cannot be completely ruled out.
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Affiliation(s)
- Krista F. Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Reesha Shah Sanghani
- Department of Obstetrics and Gynecology, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Jerry Avorn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Adam C. Urato
- MetroWest Medical Center, Tufts University School of Medicine, Framingham, Massachusetts, United States of America
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24
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Bourke CH, Stowe ZN, Owens MJ. Prenatal antidepressant exposure: clinical and preclinical findings. Pharmacol Rev 2014; 66:435-65. [PMID: 24567054 DOI: 10.1124/pr.111.005207] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Pharmacological treatment of any maternal illness during pregnancy warrants consideration of the consequences of the illness and/or medication for both the mother and unborn child. In the case of major depressive disorder, which affects up to 10-20% of pregnant women, the deleterious effects of untreated depression on the offspring can be profound and long lasting. Progress has been made in our understanding of the mechanism(s) of action of antidepressants, fetal exposure to these medications, and serotonin's role in development. New technologies and careful study designs have enabled the accurate sampling of maternal serum, breast milk, umbilical cord serum, and infant serum psychotropic medication concentrations to characterize the magnitude of placental transfer and exposure through human breast milk. Despite this progress, the extant clinical literature is largely composed of case series, population-based patient registry data that are reliant on nonobjective means and retrospective recall to determine both medication and maternal depression exposure, and limited inclusion of suitable control groups for maternal depression. Conclusions drawn from such studies often fail to incorporate embryology/neurotransmitter ontogeny, appropriate gestational windows, or a critical discussion of statistically versus clinically significant. Similarly, preclinical studies have predominantly relied on dosing models, leading to exposures that may not be clinically relevant. The elucidation of a defined teratological effect or mechanism, if any, has yet to be conclusively demonstrated. The extant literature indicates that, in many cases, the benefits of antidepressant use during pregnancy for a depressed pregnant woman may outweigh potential risks.
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Huang H, Coleman S, Bridge JA, Yonkers K, Katon W. A meta-analysis of the relationship between antidepressant use in pregnancy and the risk of preterm birth and low birth weight. Gen Hosp Psychiatry 2014; 36:13-8. [PMID: 24094568 PMCID: PMC3877723 DOI: 10.1016/j.genhosppsych.2013.08.002] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 08/11/2013] [Accepted: 08/24/2013] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To examine the relationship between antidepressant use in pregnancy and low birth weight (LBW) and preterm birth (PTB). DATA SOURCES AND STUDY SELECTION We searched English and non-English language articles via PubMed, CINAHL and PsychINFO (from their start dates through December 1st, 2012). We used the following keywords and their combinations: antidepressant, selective serotonin reuptake inhibitor (SSRI), pregnancy, antenatal, prenatal, birthweight, birth weight, preterm, prematurity, gestational age, fetal growth restriction, intrauterine growth restriction, and small-for-gestational age. Published studies were considered eligible if they examined exposure to antidepressant medication use during pregnancy and reported data on at least one birth outcome of interest: PTB (<37 weeks gestation) or LBW (<2500 g). Of the 222 reviewed studies, 28 published studies met the selection criteria. DATA EXTRACTION Two authors independently extracted study characteristics from eligible studies. RESULTS Using random-effects models, antidepressant use in pregnancy was significantly associated with LBW (RR: 1.44, 95% confidence interval (CI): 1.21-1.70) and PTB (RR: 1.69, 95% CI: 1.52-1.88). Studies varied widely in design, populations, control groups and methods. There was a high level of heterogeneity as measured by I2 statistics for both outcomes examined. The relationship between antidepressant exposure in pregnancy and adverse birth outcomes did not differ significantly when taking into account drug type (SSRI vs. other or mixed) or study design (prospective vs. retrospective). There was a significant association between antidepressant exposure and PTB for different types of control status used (depressed, mixed or nondepressed). CONCLUSIONS Antidepressant use during pregnancy significantly increases the risk for LBW and PTB.
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Affiliation(s)
- Hsiang Huang
- Department of Psychiatry, Cambridge Health Alliance, Harvard Medical School, Cambridge, MA, USA.
| | - Shane Coleman
- Department of Psychiatry & Behavioral Sciences, University of Washington Medical School, Seattle, WA
| | - Jeffrey A. Bridge
- Department of Pediatrics and The Research Institute at Nationwide Children’s Hospital, The Ohio State University, Columbus, OH
| | - Kimberly Yonkers
- PMS and Perinatal Psychiatric Research Program, Yale University, New Haven, CT
| | - Wayne Katon
- Department of Psychiatry & Behavioral Sciences, University of Washington Medical School, Seattle, WA
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Engelstad HJ, Roghair RD, Calarge CA, Colaizy TT, Stuart S, Haskell SE. Perinatal outcomes of pregnancies complicated by maternal depression with or without selective serotonin reuptake inhibitor therapy. Neonatology 2014; 105:149-54. [PMID: 24356332 PMCID: PMC4054700 DOI: 10.1159/000356774] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 10/23/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed psychotropics for major depressive disorder during pregnancy and are used in up to 6.2% of pregnancies. OBJECTIVE To compare the perinatal outcomes of pregnancies complicated by maternal depression with or without SSRI therapy versus nondepressed pregnancies. METHODS International Classification of Diseases (ICD)-9 codes for depression were identified among women who delivered at the University of Iowa from April 2009 to March 2011. Data were extracted from linked maternal-neonatal records for all charts with an ICD-9 code for depression and an equal number of women without ICD-9 codes for depression. RESULTS Of the 3,695 women who delivered between 2009 and 2011, 238 had an ICD-9 code for depression. Sixteen women had depression listed in their records but did not have an ICD-9 code for depression. Their data were combined with those of the women with ICD-9 codes for depression, and it was found that 126 women (50%) in this combined depression cohort received an SSRI. Women with depression had increased alcohol and tobacco use, BMI and premature delivery rates (p < 0.01). Maternal depression was associated with an increased frequency of neonatal intensive care unit (NICU) admission (p < 0.001). In addition to depression, maternal SSRI use, obesity and smoking were univariate predictors of NICU admission. CONCLUSIONS Among women with depression, the use of an SSRI was not associated with significant differences in any of the measured maternal or neonatal parameters, but further studies are needed to evaluate the specific effects of SSRI exposure in early or late gestation. Despite SSRI utilization, women with depression continue to have increased risks during pregnancy.
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Affiliation(s)
- Holly J Engelstad
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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Ray S, Stowe ZN. The use of antidepressant medication in pregnancy. Best Pract Res Clin Obstet Gynaecol 2013; 28:71-83. [PMID: 24211026 DOI: 10.1016/j.bpobgyn.2013.09.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 09/06/2013] [Accepted: 09/27/2013] [Indexed: 01/08/2023]
Abstract
The use of antidepressant medications during pregnancy has stimulated much professional and public debate. As a consequence, considerable data on the reproductive safety of antidepressants has been generated that exceeds the available information for most, if not all, other classes of medications that may be used in the perinatal period. Despite progress to date, definitive conclusions are limited by the methodological issues inherent to clinical research involving illness versus treatment effects in pregnancy. A notable shortcoming is the limited discussion of statistically significant (a mathematical determination) versus clinically significant (incorporation of incidence and effect sizes into practical relevance). Research emphasises completing an individualised 'risk-benefit' assessment, which is a laudable goal but falls short in providing succinct practical guidelines that includes the key educational points for patients. In this chapter, we focus on areas in which the preponderance of data are consistent, and there is concordance with the preclinical literature to generate a practical approach for antidepressant use in pregnancy.
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Affiliation(s)
- Shona Ray
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Zachary N Stowe
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Department of Pediatrics and Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Psychiatric Research Institute, University of Arkansas for Medical Sciences, 4301 W. Markham Street 843, Little Rock, AR 72205-7199, USA.
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Källén B, Borg N, Reis M. The use of central nervous system active drugs during pregnancy. Pharmaceuticals (Basel) 2013; 6:1221-86. [PMID: 24275849 PMCID: PMC3817603 DOI: 10.3390/ph6101221] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 09/10/2013] [Accepted: 09/25/2013] [Indexed: 12/03/2022] Open
Abstract
CNS-active drugs are used relatively often during pregnancy. Use during early pregnancy may increase the risk of a congenital malformation; use during the later part of pregnancy may be associated with preterm birth, intrauterine growth disturbances and neonatal morbidity. There is also a possibility that drug exposure can affect brain development with long-term neuropsychological harm as a result. This paper summarizes the literature on such drugs used during pregnancy: opioids, anticonvulsants, drugs used for Parkinson's disease, neuroleptics, sedatives and hypnotics, antidepressants, psychostimulants, and some other CNS-active drugs. In addition to an overview of the literature, data from the Swedish Medical Birth Register (1996-2011) are presented. The exposure data are either based on midwife interviews towards the end of the first trimester or on linkage with a prescribed drug register. An association between malformations and maternal use of anticonvulsants and notably valproic acid is well known from the literature and also demonstrated in the present study. Some other associations between drug exposure and outcome were found.
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Affiliation(s)
- Bengt Källén
- Tornblad Institute, Lund University, Biskopsgatan 7, Lund SE-223 62, Sweden
| | - Natalia Borg
- Department of Statistics, Monitoring and Analyses, National Board of Health and Welfare, Stockholm SE-106 30, Sweden; E-Mail:
| | - Margareta Reis
- Department of Medical and Health Sciences, Clinical Pharmacology, Linköping University, Linköping SE-581 85, Sweden; E-Mail:
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van Gelder MMHJ, de Jong-van den Berg LTW, Roeleveld N. Drugs associated with teratogenic mechanisms. Part II: a literature review of the evidence on human risks. Hum Reprod 2013; 29:168-83. [DOI: 10.1093/humrep/det370] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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The effects of maternal depression and use of antidepressants during pregnancy on risk of a child small for gestational age. Psychopharmacology (Berl) 2013; 228:199-205. [PMID: 23455598 DOI: 10.1007/s00213-013-3029-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 02/04/2013] [Indexed: 10/27/2022]
Abstract
RATIONALE Use of antidepressants during pregnancy has been associated with an increased rate of children small for gestational age (SGA), but it is unclear whether this is due to an effect of the underlying depressive disorder. OBJECTIVES This study aimed to investigate the effect of antidepressants on SGA in a nationwide sample and to separate the effect of exposure to antidepressants in utero from the effect of maternal depression. METHODS A register study was conducted on all pregnant women in Denmark from 1996 to 2006 linking nationwide individualized data from the Medical Birth Register, the Psychiatric Central Register, and a prescription database. The rate of SGA (birth weight below the 10 percentile at given gestational week) was investigated for children exposed in utero to antidepressants or to a maternal psychiatric diagnosis of depression compared to children not prenatally exposed to antidepressants or maternal diagnosis. RESULTS A total of 673,853 pregnancies were included in the study of which 35.737 women had a diagnosis of depression and/or used antidepressants before end of pregnancy. Antidepressant use during pregnancy was weakly associated with SGA (hazard ratios (HR) = 1.19; 95 % confidence interval (CI), 1.11-1.28), whereas a psychiatric diagnosis before or during pregnancy was not (HR = 1.02; 95 % CI, 0.92-1.13). The association for use during pregnancy was found for selective serotonin reuptake inhibitors and newer antidepressants, but not for older antidepressants. CONCLUSIONS The use of antidepressants during pregnancy slightly increases the rate of SGA. The association seems unrelated to the underlying maternal depressive disorder.
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Riggin L, Frankel Z, Moretti M, Pupco A, Koren G. The fetal safety of fluoxetine: a systematic review and meta-analysis. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2013; 35:362-369. [PMID: 23660045 DOI: 10.1016/s1701-2163(15)30965-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Lauren Riggin
- The Motherisk Program, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto ON
| | - Zipora Frankel
- The Motherisk Program, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto ON
| | - Myla Moretti
- The Motherisk Program, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto ON
| | - Anna Pupco
- The Motherisk Program, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto ON
| | - Gideon Koren
- The Motherisk Program, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto ON
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Olivier JDA, Akerud H, Kaihola H, Pawluski JL, Skalkidou A, Högberg U, Sundström-Poromaa I. The effects of maternal depression and maternal selective serotonin reuptake inhibitor exposure on offspring. Front Cell Neurosci 2013; 7:73. [PMID: 23734100 PMCID: PMC3659337 DOI: 10.3389/fncel.2013.00073] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 05/01/2013] [Indexed: 01/05/2023] Open
Abstract
It has been estimated that 20% of pregnant women suffer from depression and it is well-documented that maternal depression can have long-lasting effects on the child. Currently, common treatment for maternal depression has been the selective serotonin reuptake inhibitor medications (SSRIs) which are used by 2–3% of pregnant women in the Nordic countries and by up to 10% of pregnant women in the United States. Antidepressants cross the placenta and are transferred to the fetus, thus, the question arises as to whether children of women taking antidepressants are at risk for altered neurodevelopmental outcomes and, if so, whether the risks are due to SSRI medication exposure or to the underlying maternal depression. This review considers the effects of maternal depression and SSRI exposure on offspring development in both clinical and preclinical populations. As it is impossible in humans to study the effects of SSRIs without taking into account the possible underlying effects of maternal depression (healthy pregnant women do not take SSRIs), animal models are of great value. For example, rodents can be used to determine the effects of maternal depression and/or perinatal SSRI exposure on offspring outcomes. Unraveling the joint (or separate) effects of maternal depression and SSRI exposure will provide more insights into the risks or benefits of SSRI exposure during gestation and will help women make informed decisions about using SSRIs during pregnancy.
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Affiliation(s)
- J D A Olivier
- Department of Women's and Children's Health, Uppsala University Uppsala, Sweden ; Center for Gender Medicine, Karolinska Institutet Stockholm, Sweden
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Jensen HM, Grøn R, Lidegaard Ø, Pedersen LH, Andersen PK, Kessing LV. Maternal depression, antidepressant use in pregnancy and Apgar scores in infants. Br J Psychiatry 2013; 202:347-51. [PMID: 23429204 DOI: 10.1192/bjp.bp.112.115931] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Use of antidepressants during pregnancy has been associated with a low Apgar score in infants but a contribution from the underlying depressive disorder might influence this association. AIMS To estimate the effects of maternal depression and use of antidepressants during pregnancy on low Apgar scores (<7) 5 min after birth. METHOD Register study on all pregnant women in Denmark from 1996 to 2006 linking nationwide individualised data from the Medical Birth Register, the Psychiatric Central Register and the National Prescription database. RESULTS Infants exposed to antidepressants during pregnancy had an increased rate of a low Apgar score (odds ratio (OR) = 1.72, 95% CI 1.34-2.20). The increased rate was only found among infants exposed to selective serotonin reuptake inhibitors (SSRIs) (OR = 1.96, 95% CI 1.52-2.54), not among those exposed to newer (OR = 0.83, 95% CI 0.40-1.74) or older antidepressants (OR = 0.53, 95% CI 0.19-1.45). Maternal depression before or during pregnancy, without prescription of antidepressants, was not associated with a low Apgar score (OR = 0.44, 95% CI 0.11-1.74). Women who had only used antidepressants prior to pregnancy had no increased rate of a low Apgar score in their subsequent pregnancy, regardless of depression status. CONCLUSIONS Use of SSRIs during pregnancy increases the risk of a low Apgar score independently of maternal depression.
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Affiliation(s)
- Hans Mørch Jensen
- Psychiatric Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
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Abstract
BACKGROUND The selective serotonin reuptake inhibitors are prescribed increasingly also during pregnancy. Although a number of studies have assessed their safety, data concerning congenital malformations and adverse perinatal outcome are conflicting. METHODS Literature search in PubMed until March 31, 2012, including original research articles, meta-analyses, and reviews. RESULTS Fluoxetine and paroxetine use in early pregnancy has been associated with a small increased risk for specific cardiovascular malformations in some studies, fluoxetine with ventricular septal defects and paroxetine with right ventricular outflow tract defects. The observed absolute risk for these specific malformations is small. Data on preterm birth, low birth weight, and being small for gestational age have been conflicting; and mother's underlying depression is obviously an important confounder. Respiratory distress and neonatal adaptation problems are common in prenatally exposed infants, and an increased risk for persistent pulmonary hypertension of the newborn has been observed in several studies. Although several studies have not confirmed an increased risk for adverse neurodevelopment, a recent study observed an increased risk for autism spectrum disorders in prenatally exposed offspring. CONCLUSIONS Causality cannot be confirmed in observational study settings. However, parallel results in individual studies regarding the cardiac malformations and pulmonary hypertension of the newborn, together with an existing biologically plausible mechanism behind these events may support causality. Considering the important role of serotonin in central nervous system development, more studies are needed to assess the possible adverse effects on long-term neurodevelopment.
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Jimenez-Solem E, Andersen JT, Petersen M, Broedbaek K, Andersen NL, Torp-Pedersen C, Poulsen HE. Prevalence of antidepressant use during pregnancy in Denmark, a nation-wide cohort study. PLoS One 2013; 8:e63034. [PMID: 23638179 PMCID: PMC3636192 DOI: 10.1371/journal.pone.0063034] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 03/27/2013] [Indexed: 11/19/2022] Open
Abstract
AIM The aim of this study was to assess the prevalence and patterns of exposure to antidepressants before, during and after pregnancy in a cohort including all pregnant women in Denmark between 1997 and 2010. METHODS We performed a retrospective cohort study including 912 322 pregnancies. Information was retrieved from the Danish Birth Registry and The Register of Medicinal Product Statistics to identify women redeeming an antidepressant prescription during pregnancy. Exposure periods were based on standard treatment doses and dispensed pack sizes. RESULTS We identified 19 740 pregnancies exposed to an antidepressant at some point during pregnancy. The rate of exposure increased from 0.2% in 1997 to 3.2% in 2010. We found that the rate of exposure was halved during the first 3 months of pregnancy. In contrast, we describe a clear increase in exposure after pregnancy among pre-delivery treatment-naïve women. CONCLUSIONS In spite of uncertainty concerning antidepressants' safety during pregnancy we find a 16-fold increase in exposure rates between 1997 and 2010. The rates describe a sharp decrease in exposure during pregnancy that is probably caused by physicians' hesitation to prescribe antidepressants and women's fear of unwanted effects on the unborn child. More studies are needed to clarify the consequences of antidepressant discontinuation during pregnancy.
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Affiliation(s)
- Espen Jimenez-Solem
- Laboratory of Clinical Pharmacology Q7642, Rigshospitalet, Copenhagen, Denmark.
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Byatt N, Deligiannidis KM, Freeman MP. Antidepressant use in pregnancy: a critical review focused on risks and controversies. Acta Psychiatr Scand 2013; 127:94-114. [PMID: 23240634 PMCID: PMC4006272 DOI: 10.1111/acps.12042] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2012] [Indexed: 01/13/2023]
Abstract
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.
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Affiliation(s)
- N Byatt
- Psychiatry and Obstetrics & Gynecology, Psychosomatic Medicine, Women's Mental Health, University of Massachusetts Medical School/UMass Memorial Medical Center, Worcester, MA 01655, USA.
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Abstract
Many women with psychiatric disorders want to become mothers and only a minority seek advise prior to becoming pregnant. In those women, in whom pregnancy can be planned, the decision, if a medication is required for stabilisation and which one to choose if this is the case, is easier to make than in women in whom pregnancy occurs unplanned. The physician has to weigh the risk that a relapse of the psychiatric disorder during pregnancy poses to the foetus against the reproductive risk of psychotropic drugs. This presentation is intended to assist in understanding the general principles of pharmacotherapy during pregnancy as well as the morphological, perinatal and neurobehavioural toxicity of antidepressants, antipsychotics, benzodiazepines and mood stabilisers.
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FETAL EFFECTS OF SELECTIVE SEROTONIN REUPTAKE INHIBITOR TREATMENT DURING PREGNANCY: IMMEDIATE AND LONGER TERM CHILD OUTCOMES. ACTA ACUST UNITED AC 2012. [DOI: 10.1017/s0965539512000095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Koren G, Nordeng H. Antidepressant use during pregnancy: the benefit-risk ratio. Am J Obstet Gynecol 2012; 207:157-63. [PMID: 22425404 DOI: 10.1016/j.ajog.2012.02.009] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Revised: 01/14/2012] [Accepted: 02/14/2012] [Indexed: 11/25/2022]
Abstract
Antidepressants are used commonly in pregnancy. Physicians who provide health care for pregnant women with depression must balance maternal well-being with potential fetal risks of these medications. Over the last decade, scores of original and review articles have discussed whether selective serotonin reuptake inhibitors-selective serotonin norepinephrine reuptake inhibitors possess risks to the fetus; however, very little has been done to integrate these potential risks, if they exist, into an overall context of a benefit:risk ratio. This review aims at presenting an updated analysis of fetal and maternal exposure to selective serotonin or norepinephrine reuptake inhibitors to allow an evidence-based benefit:risk ratio. When a psychiatric condition necessitates pharmacotherapy, the benefits of such therapy far outweigh the potential minimal risks of cardiac malformations, primary pulmonary hypertension of the newborn infant, or poor neonatal adaptation syndrome.
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Källén B. Maternal use of antidepressant drugs and twin deliveries. Eur J Obstet Gynecol Reprod Biol 2012; 164:235. [PMID: 22770631 DOI: 10.1016/j.ejogrb.2012.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 04/25/2012] [Accepted: 06/08/2012] [Indexed: 11/15/2022]
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Pregnancy outcome after exposure to antidepressants and the role of maternal depression: results from the Norwegian Mother and Child Cohort Study. J Clin Psychopharmacol 2012; 32:186-94. [PMID: 22367660 DOI: 10.1097/jcp.0b013e3182490eaf] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Results of previous studies on the safety of antidepressants during pregnancy have been conflicting. The primary objective of this study was to investigate whether first-trimester exposure to antidepressants, specifically selective serotonin reuptake inhibitors (SSRIs), was associated with increased risk of congenital malformations. The secondary objective was to examine the effects of exposure to antidepressants during pregnancy on birth weight and gestational age.We included 63,395 women from the Norwegian Mother and Child Cohort Study. The women had completed 2 self-administered questionnaires at gestational weeks 17 and 30 on medication use and medical, sociodemographic, and psychological factors. Data on pregnancy outcome were retrieved from the Medical Birth Registry of Norway.Of the 63,395 women, 699 (1.1%) reported using antidepressants during pregnancy, most frequently SSRIs (0.9%). Exposure to SSRIs during the first trimester was not associated with increased risk of congenital malformations in general (adjusted odds ratio [OR], 1.22; 95% confidence interval [CI], 0.81-1.84) or cardiovascular malformations (adjusted OR, 1.51; 95% CI, 0.67-3.43). Exposure to antidepressants during pregnancy was not associated with increased risk of preterm birth (adjusted OR, 1.21; 95% CI, 0.87-1.69) or low birth weight (adjusted OR, 0.62; 95% CI, 0.33-1.16).This study does not suggest a strongly increased risk of malformations, preterm birth, or low birth weight following prenatal exposure to antidepressants. Without adjustments for level of maternal depression and various sociodemographic and lifestyle factors, antidepressant use during pregnancy would wrongly have been associated with an increased risk of preterm birth.
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Nijenhuis CM, Horst PGJT, Berg LTWDJVD, Wilffert B. Disturbed development of the enteric nervous system after in utero exposure of selective serotonin re-uptake inhibitors and tricyclic antidepressants. Part 1: Literature review. Br J Clin Pharmacol 2012; 73:16-26. [PMID: 21815911 DOI: 10.1111/j.1365-2125.2011.04075.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The increase in selective serotonin re-uptake inhibitor (SSRI) use during pregnancy, questions concerning abnormal development of the enteric nervous system (ENS), increase in laxative use in children and the association of fluoxetine with infantile hypertrophic pyloric stenosis (IHPS) gave rise to this pharmacological literature review. The role of 5-HT and the NE uptake in ontogeny of the ENS and the effects SSRIs and TCAs might have on the development of the ENS were investigated. The literature study showed that SSRIs may influence the development of the ENS in two ways. Blockage of the serotonin re-uptake transporter (SERT) during foetal development could influence migration, differentiation and survival of cells. This could lead to abnormal development in the first trimester of pregnancy. The other way is that 5-HT seems to be a growth factor in the primitive ENS. This growth factor like action is mediated through the 5-HT(2B) receptor and stimulation of this receptor by SSRIs influences the fate of late-developing enteric neurons. This could lead to abnormal development in the second and third trimester. TCAs could influence the development of the ENS, besides through inhibition of the SERT, through inhibition of the norepinephrine transporter (NET). Expression of the NET seems to be essential for a full development of enteric neurons and especially for serotonergic neurons. In addition the NET was detected early in ontogeny and precedes neuronal differentiation, which suggests that TCAs might influence development of the ENS when exposed early in pregnancy. The insights of this study gave rise to hypotheses which will be tested in an epidemiological cohort study.
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Affiliation(s)
- Cynthia M Nijenhuis
- Department of Pharmaco-epidemiology and Pharmaco-economy, University of Groningen, Groningen, The Netherlands
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Nijenhuis CM, ter Horst PGJ, van Rein N, Wilffert B, de Jong-van den Berg LTW. Disturbed development of the enteric nervous system after in utero exposure of selective serotonin re-uptake inhibitors and tricyclic antidepressants. Part 2: Testing the hypotheses. Br J Clin Pharmacol 2012; 73:126-34. [PMID: 21848990 DOI: 10.1111/j.1365-2125.2011.04081.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
AIMS Antidepressant use has increased in the last decade. Several studies have suggested a possible association between maternal antidepressant use and teratogenic effects. METHODS The pharmacy prescription database IADB.nl was used for a cohort study in which laxative and antidiarrhoeal medication use in children after in utero exposure to antidepressants (TCA, SSRI, fluoxetine or paroxetine exposed) was compared with no antidepressant exposure. Laxatives and antidiarrhoeal medication use were applied as a proxy for constipation and diarrhoea respectively, which may be associated with disturbed enteric nervous system (ENS) development. RESULTS Children exposed in utero to SSRIs (mainly fluoxetine and paroxetine) in the second and third trimester or to TCAs in the first trimester, more often received laxatives. Combined exposure to TCAs and SSRIs in pregnancy was associated with a 10-fold increase in laxative use. In utero exposure to SSRIs is not associated with antidiarrhoeal medication use compared with non-exposed children. In contrast, antidiarrhoeal medication use was significantly higher in children exposed to TCAs anytime in pregnancy. CONCLUSIONS The increased laxative use after second and third trimester exposure to SSRIs might be explained through the inhibitory effect of the serotonin re-uptake transporter (SERT) and because of selectivity for the 5-HT(2B) receptor which affects the ENS. TCA exposure during the first trimester leads to increased laxative use probably through inhibition of the norepinephrine transporter (NET). Exposure of TCAs anytime in pregnancy leads to increase diarrhoeal use possibly through down-regulation of α₂-adrenoceptors or up-regulation of the pore forming α(1c) subunit.
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Affiliation(s)
- Cynthia M Nijenhuis
- Department of Pharmaco-epidemiology and Pharmaco-economy, University of Groningen, Groningen, The Netherlands
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Jimenez-Solem E, Andersen JT, Petersen M, Broedbaek K, Jensen JK, Afzal S, Gislason GH, Torp-Pedersen C, Poulsen HE. Exposure to selective serotonin reuptake inhibitors and the risk of congenital malformations: a nationwide cohort study. BMJ Open 2012; 2:bmjopen-2012-001148. [PMID: 22710132 PMCID: PMC3378942 DOI: 10.1136/bmjopen-2012-001148] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES To analyse the relation between selective serotonin reuptake inhibitor (SSRI) use and major congenital malformations, with focus on malformations of the heart. DESIGN Register-based retrospective nationwide cohort study, using the Danish Medical Birth Registry. SETTING Denmark. PARTICIPANTS Pregnant women in Denmark between 1997 and 2009 and their offspring. PRIMARY OUTCOME MEASURES For each SSRI, ORs for major congenital malformations were estimated using multivariable logistic regression models for women exposed to an SSRI during the first trimester and for women with paused exposure during pregnancy. RESULTS The authors identified 848 786 pregnancies; 4183 were exposed to an SSRI throughout the first trimester and 806 pregnancies paused exposure during pregnancy. Risks of congenital malformations of the heart were similar for pregnancies exposed to an SSRI throughout the first trimester, adjusted OR 2.01 (95% CI 1.60 to 2.53), and for pregnancies with paused SSRI treatment during pregnancy, adjusted OR 1.85 (95% CI 1.07 to 3.20), p value for difference: 0.94. The authors found similar increased risks of specific congenital malformations of the heart for the individual SSRIs. Furthermore, the authors found no association with dosage. CONCLUSIONS The apparent association between SSRI use and congenital malformations of the heart may be confounded by indications. The moderate absolute risk increase combined with uncertainty for causality still requires the risk versus benefit to be evaluated in each individual case.
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Affiliation(s)
- Espen Jimenez-Solem
- Laboratory of Clinical Pharmacology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Pharmacology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Jon Traerup Andersen
- Laboratory of Clinical Pharmacology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Pharmacology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Morten Petersen
- Laboratory of Clinical Pharmacology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Pharmacology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Kasper Broedbaek
- Laboratory of Clinical Pharmacology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Pharmacology, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Shoaib Afzal
- Laboratory of Clinical Pharmacology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Pharmacology, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Christian Torp-Pedersen
- Department of Cardiology, Gentofte Hospital, Copenhagen, Denmark
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Enghusen Poulsen
- Laboratory of Clinical Pharmacology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Pharmacology, Bispebjerg Hospital, Copenhagen, Denmark
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Spezielle Arzneimitteltherapie in der Schwangerschaft. ARZNEIMITTEL IN SCHWANGERSCHAFT UND STILLZEIT 2012. [PMCID: PMC7271212 DOI: 10.1016/b978-3-437-21203-1.10002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Selective serotonin reuptake inhibitors in human pregnancy: to treat or not to treat? Obstet Gynecol Int 2011; 2012:698947. [PMID: 22190957 PMCID: PMC3236415 DOI: 10.1155/2012/698947] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 10/05/2011] [Accepted: 10/07/2011] [Indexed: 11/18/2022] Open
Abstract
Selective serotonin reuptake inhibitors (SSRIs) are increasingly prescribed during pregnancy. The purpose of the present paper is to summarize and evaluate the current evidence for the risk/benefit analysis of SSRI use in human pregnancy. The literature has been inconsistent. Although most studies have not shown an increase in the overall risk of major malformations, several studies have suggested that SSRIs may be associated with a small increased risk for cardiovascular malformations. Others have noted associations between SSRIs and specific types of rare major malformations. In some studies, there appears to be a small increased risk for miscarriages, which may be associated with the underlying maternal condition. Neonatal effects have been described in up to 30% of neonates exposed to SSRIs late in pregnancy. Persistent pulmonary hypertension of the newborn has also been described with an absolute risk of <1%. The risk associated with treatment discontinuation, for example, higher frequency of relapse and increased risk of preterm delivery, should also be considered. The overall benefit of treatment seems to outweigh the potential risks.
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Okun ML, Luther JF, Wisniewski SR, Sit D, Prairie BA, Wisner KL. Disturbed sleep, a novel risk factor for preterm birth? J Womens Health (Larchmt) 2011; 21:54-60. [PMID: 21967121 DOI: 10.1089/jwh.2010.2670] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The etiology of preterm birth (PTB) is likely caused by multiple factors, which may include disturbed sleep. We evaluated whether sleep disturbance was associated with PTB and whether the association was affected by other psychosocial risk factors. METHODS Pregnant women (n=217) for whom we had depression and sleep data at 20 or 30 weeks gestation and delivery information were evaluated. Logistic models were used to test the hypotheses that disturbed sleep was associated with PTB. RESULTS Time in bed at 20 weeks was significantly associated with risk for preterm delivery (odds ratio [OR] 1.43, 95% confidence interval [CI] 1.08-1.88). However, after controlling for depression/selective serotonin reuptake inhibitors (SSRI) status, history of PTB, age, employment, and marital status, this relationship was no longer significant (OR 1.26, 95% CI .92-1.71). No other relationships were significant. CONCLUSIONS We report preliminary evidence suggesting that poor sleep may contribute to risk for PTB. Although it is speculative and additional work is needed to confirm or refute whether sleep is an independent or mediating risk factor for PTB, disturbed sleep does appear to play a role in adverse pregnancy outcomes.
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Affiliation(s)
- Michele L Okun
- Sleep Medicine Institute and Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
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Wilffert B, Altena J, Tijink L, van Gelder MMHJ, de Jong-van den Berg LTW. Pharmacogenetics of drug-induced birth defects: what is known so far? Pharmacogenomics 2011; 12:547-58. [PMID: 21521026 DOI: 10.2217/pgs.10.201] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
A literature review was performed to collect information on the role of pharmacogenetics in six proposed teratogenic mechanisms associated with drug use during pregnancy: folate antagonism, oxidative stress, angiotensin-converting enzyme inhibition and angiotensin II receptor antagonism, cyclooxygenase-1 and -2 inhibition, 5-hydroxytryptamine-reuptake inhibition and drug transporters in the placenta. Data on the direct relationship between pharmacogenetics and drug-induced birth defects were found for folate metabolism, oxidative stress caused by phenytoin exposure and drug transporters in the placenta. Although no specific data to support pharmacogenetic-related birth defects were found for the NSAIDs, paroxetine and fluoxetine, it might be expected that polymorphisms modify their teratogenic effects. The usually low prevalence of drug-induced malformations impedes the demonstration of the contribution of pharmacogenetics. Large-scale studies, preferably case-control studies, are needed.
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Affiliation(s)
- Bob Wilffert
- Unit of Pharmacoepidemiology & Pharmacoeconomics, Department of Pharmacy, University of Groningen, Groningen 9713AV, The Netherlands.
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