Using sertraline in postpartum and breastfeeding: balancing risks and benefits

The real-world safety profile of sertraline: Pharmacovigilance analysis of the FAERS database

OBJECTIVE

Sertraline is a widely used antidepressant, and its safety characteristics in elderly and adolescent patients have not been fully clarified. The purpose of this study was to comprehensively evaluate the characteristics of adverse effects of sertraline through a large-scale analysis of real-world data and to add to the evidence in the elderly and adolescent populations.

METHODS

The data were extracted from the Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database from the first quarter (Q1) 2004 to Q1 2024 for data cleaning and analysis. Adverse drug events were analyzed using the Reporting Odds Ratio (ROR), Bayesian Confidence Propagation Neural Network (BCPNN), Proportional Reporting Ratio (PRR), and Multi-Item Gamma Poisson Shrinker (MGPS) methods.

RESULTS

A total of 49,359 sertraline-related adverse event reports were included in this study. In addition to known adverse events (AEs), the study identified new potential safety signals for bruxism, microscopic colitis and genital anaesthesia. Intentional self-injury was the common adverse event in patients under 18 years of age and hyponatremia in patients 65 years of age and older. 26.77 % of adverse reactions occurred within one week of administration.

CONCLUSION

Sertraline requires special attention to the risks associated with neurologic, psychiatric, and congenital disorders in clinical use. In addition to common AEs such as nausea, and tremor, newly identified adverse reactions such as genital anaesthesia, bruxism, and microscopic colitis should be guarded against. For adolescents, suicide risk monitoring should be strengthened. In elderly patients, the risk of falls and electrolyte disturbances should be emphasized.

Meta-analysis of Xiaoyao formula as an adjuvant therapy for treating postpartum depression

Background

Xiaoyao Powder/Pill, as a classical Chinese herbal formula, has been widely used for treating depression. This meta-analysis aims to evaluate the effectiveness of Xiaoyao formula (XYF) as an adjuvant therapy for treating postpartum depression.

Methods

We searched studies indexed in international databases (Cochrane Library, Embase, and PubMed) and Chinese databases (SinoMed, CNKI, and Wanfang). Randomized controlled trials (RCTs) assessing the efficacy of XYF in combination with Western therapy compared to Western therapy alone for treating postpartum depression were eligible. The total response rate was defined as a reduction of more than 25% in depression scores, while clinical recovery was defined as a reduction of more than 75% in depression scores.

Results

Our analysis included ten RCTs comprising 810 women. The combination of XYF and Western therapy led to a significant improvement in the total response rate (risk ratios [RR] 1.17; confidence intervals [CI] 1.08-1.26) and the clinical recovery rate (RR 1.56; 95% CI 1.27-1.91) compared to Western therapy alone. Additionally, XYF as an adjuvant therapy also significantly decreased Hamilton Depression Scale scores (standard mean difference [SMD] -1.69; 95% CI -2.37 to -1.01).

Conclusions

Adjuvant treatment with XYF can effectively alleviate depression in postpartum women. However, further well-designed RCTs are necessary to validate these findings, as the current evidence remains uncertain.

A pooled analysis of the efficacy of sertraline in women, with a focus on those of childbearing age

INTRODUCTION

Gender- and age-specific research on medications is essential for personalizing treatment plans, optimizing dosing, minimizing adverse effects and improving outcomes. Women are twice as likely to be diagnosed with major depressive disorder (MDD), and it is commonly reported during their reproductive years. This post-hoc pooled analysis evaluated the efficacy of sertraline (one of the most studied medications in women) in women of reproductive age (18-44 years).

METHODS

Data was pooled from nine clinical trials of sertraline that included 1832 subjects with MDD. The analysis set included 1097 women, 651 of those were of reproductive age. Sertraline was compared with placebo for changes in total HAM-D17 and CGI scores measured over time through MMRM analysis. The change from baseline to the end of study (-week 8) was assessed using ANCOVA.

RESULTS

The changes from baseline in total HAM-D17 and CGI scores were significantly higher for sertraline than for placebo at the end of 8 weeks for all women (LS Mean difference, 95% CI: -1.81(-3.01,-0.62), P = 0.0029; -0.38(-0.55,-0.20), P < 0.0001, respectively). For women of reproductive age these changes (LS Mean difference, 95% CI: -2.08(-3.52,-0.64), P = 0.0047; -0.44(-0.66,-0.22), P < 0.0001, respectively), were significant from week 2 (HAM-D17) and week 1 (CGI) till the end of study.

LIMITATIONS

Only sertraline and placebo arms were included in the analysis. The dosing varied between studies, and the effect of dose was not addressed.

CONCLUSIONS

Sertraline is an effective option for treatment of MDD in women, including those in the childbearing age.

Study protocol: perinatal mood treatment study

Perinatal depression (PND) affects up to 20% of women and is associated with significant impairment and disability in affected women. In addition, perinatal depression is associated with broader public health and multigenerational consequences. Innovative approaches are needed to reduce the burden of perinatal depression through identification, tracking, and treatment of depressive symptoms during the perinatal period. This study is a randomized clinical trial comparing the relative efficacy of a multi-tiered system of care, Screening and Treatment of Anxiety and Depression (STAND) to perinatal care delivered by a reproductive psychiatrist in reducing symptoms of depression and anxiety. A sample of 167 individuals was randomized between week 28 of pregnancy and 6 months postpartum. A secondary aim compares the original online therapy intervention used in the first half of the study to a newer online therapy program used in the second half of the study for individuals assigned to the STAND treatment. The study measures, intervention groups, and analysis methods are described, as well as expected implications. The findings from this study may improve the methods for tracking symptom changes over time, monitoring treatment response, and providing personalized care for individuals with PND. As such, this study may improve the lives of patients with PND and their families and lower the related health care costs to society.Trial registration NCT: 9/24/2021NCT direct link: https://www.clinicaltrials.gov/study/NCT05056454?term=NCT05056454&rank=1&a=1 .

Efficacy and safety of electroacupuncture in patients with postpartum depression: a meta-analysis

Objective

This study aimed to assess the clinical effectiveness and safety of electroacupuncture (EA) for the treatment of postpartum depression (PPD).

Methods

We systematically retrieved relevant randomized controlled trials (RCTs) from electronic databases, including PubMed, Cochrane Library, China National Knowledge Infrastructure, EMBASE, China Science and Technology Journal Database, Chinese Biological Medical Database, and the Wanfang database from their inception to November 2023. The outcomes measured were the Hamilton Depression Rating Scale (HAMD) scores, Edinburgh Postnatal Depression Scale (EPDS) scores, adverse events (AEs), and the total response rate. The study aimed to estimate heterogeneity, publication bias, mean difference (MD), and risk ratios (RR) with 95% confidence intervals (CIs).

Results

This study included 12 RCTs with a total of 1364 participants (571 in the treatment group and 793 in the control group) for analysis. The results of the meta-analysis indicated that EA did not significantly reduce HAMD (MD = 1.49, 95% CI = [-0.30, 3.27], P = 0.1, I2 = 0%) and EPDS (MD = 1.12, 95% CI = [-1.62, 3.85], P = 0.42, I2 = 32%) scores compared to sham EA among patients with PPD, resulting in low heterogeneity. In terms of the total response rate, the EA group exhibited superior results compared to the placebo group (RR = 1.77, 95% CI = [1.15, 2.74], P = 0.01, I2 = 0%) and the sham EA group (RR = 1.2, 95% CI = [1.02, 4.4], P = 0.02, I2 = 0%), with statistical significance and low heterogeneity. The incidence of AEs was lower, also with low heterogeneity (RR = 0.9, 95% CI = [0.57, 1.43], P = 0.66, I2 = 12%).

Conclusion

The current evidence indicates that the effectiveness and safety of EA in the treatment of PPD warrant affirmation. However, EA does not demonstrate superiority over sham EA in reducing HAMD and EPDS scores in patients with PPD. Due to the limited quantity and quality of curent research, the above conclusion should be further validated through high-quality studies to confirm the efectiveness of EA in PPD management.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=318917, identifier CRD42023318917.

Psychiatric Treatment in Pregnancy: A Narrative Review

Pregnancy, childbirth and the puerperium are a series of transformations and huge changes in a woman's life, which may also be accompanied by various mental problems. Very often, women experiencing mental disorders during this period and their doctors face a decision on safety of treatment. The purpose of the following review was to assess the safety of treatment during pregnancy. Internet scientific database PubMed was searched. There are groups of psychiatric medications contraindicated during pregnancy such as valproates as well as relatively safe ones such as selective serotonin reuptake inhibitors (SSRIs) or antipsychotics. However, in every clinical situation, a decision should be made with caution, based on individual characteristics of patient, severity of disorder and clinical picture.

Is lactational sertraline exposure safe for maternal health and the reproductive/neurobehavioral development of the descendants? A study in rats

Although sertraline is considered one of the safest antidepressants in the lactation period, there are still few studies that assess its impact on child development. Therefore, this experimental study aimed to clarify the effect of sertraline on the neurobehavioral and reproductive development of male rats. Thus, 30 lactating rats were divided into 3 experimental groups (n = 10/group): CO- received filtered water, S10 and S20 groups that received, respectively, 10 and 20 mg/kg/day of sertraline. Treatment was performed by gavage, from postnatal days (PND) 1-20. During this period, the reflex and somatic development of rats were observed, as well as maternal behavior. On PND 21, mothers were euthanized and the organs were weighed. On PND 21, 45, and 100, one male from each litter was euthanized for histological and immunohistochemical (PCNA and WT1) analysis of the reproductive organs. The growth of body weight, the anogenital distance (AGD), the time to puberty, sperm quality, sexual behavior, neurobehavior, and natural fertility were also verified. Statistical analysis: One-way ANOVA or Kruskal-Wallis test (p ≤ 0.05). The results showed that mothers in the S20 group had an increase in thyroid weight. The male offspring exposed to sertraline had lower body weight (PND 7), lower AGD (PND 7 and 14), and delay in reflex development, in addition to histological alterations in the testis (PND 21). In adulthood, sperm quality was altered, without compromising natural fertility. Therefore, the present study found important alterations in the reflex and reproductive development of male rats exposed to sertraline during lactation.

Inflammatory pathophysiological mechanisms implicated in postpartum depression

Postpartum Depression (PPD) is a serious psychiatric disorder of women within the first year after delivery. It grievously damages women's physical and mental health. Inflammatory reaction theory is well-established in depression, and also has been reported associated with PPD. This review summarized the inflammatory pathophysiological mechanisms implicated in PPD, including decreased T cell activation, increased proinflammatory cytokines secretion, active kynurenine pathway, and initiated NLRP3 inflammasome. Clinical and preclinical research are both gathered. Potential therapeutical alternatives targeting the inflammatory mechanisms of PPD were introduced. In addition, this review briefly discussed the differences of inflammatory mechanisms between PPD and depression. The research of inflammation in PPD is limited and seems just embarking, which indicates the direction we can further study. As a variety of risky factors contribute to PPD collectively, therapy for women with PPD should be comprehensive, and clinical heterogeneity should be taken into consideration. As PPD has a predictability, early clinical screening and interventions are also needed. This review aims to help readers better understand the inflammatory pathological mechanisms in PPD, so as to identify biomarkers and potential therapeutic targets in the future.

Reproductive development of male rats exposed in utero to stress and/or sertraline

Despite increased prescription of sertraline during pregnancy, little is known about its action on reproductive development. Therefore, the present study aimed to investigate the impact that stress, associated or not with sertraline, causes on the reproductive development of male rats. Pregnant Wistar rats were divided into 4 groups (n = 16/group): CO - received filtered water; SE - received 20 mg/kg sertraline; ST - submitted to restraint stress and received filtered water; SS - submitted to restraint stress and received sertraline. The treatment was carried out from gestational days (GD) 13 to 20. The animals were euthanized on GD 20 (n = 8/group), postnatal day (PND) 45 (n = 8/group) and PND 110 (n = 8/group). The testes and epididymis were analyzed histologically, and immunohistochemistry was performed on the testes by proliferating cell nuclear antigen (PCNA) and the Wilms tumor protein (Wt1). Sperm quality was also analyzed on PND 110. The evolution of body weight, anogenital distance (AGD), and puberty installation day were also verified. Statistical analysis: Two-way ANOVA or Kruskal-Wallis test (p ≤ 0.05). Fetal testes presented a large number of acidophilic cells in the sertraline-exposed groups. The SS group also showed a decrease in the nuclear volume of Leydig cells. This same group showed low expression of PCNA and Wt1, decreased weight of the testes and epididymis, lower AGD, and delayed puberty installation. The adulthood groups exposed to sertraline presented alterations in sperm morphology and motility. The results demonstrated that prenatal exposure to sertraline compromises the development of the rat reproductive system.

Exposure of pregnant rats to stress and/or sertraline: Side effects on maternal health and neurobehavioral development of male offspring

AIMS

Sertraline (SE) is one of the most prescribed medications for treating gestational depression, anxiety and stress. However, little is known about its effects on nervous-system development in offspring. Therefore, this study investigated the somatic, reflex and neurobehavioral development of rats exposed to SE during pregnancy, associated or not with stress.

MAIN METHODS

Pregnant Wistar rats were assigned to the following groups (n = 10-8 rats/group): CO - control animals administered filtered water by gavage; SE - animals administered 20 mg/kg SE by gavage; ST - animals subjected to restraining stress and administered filtered water; ST/SE - animals subjected to restraining stress and administered 20 mg/kg SE. The treatment was administered between gestational days (GD) 13 to 20. Somatic and reflex developments were investigated in the male offspring from postnatal day (PND) 1 to 21. The elevated plus maze was performed on PND 25 and 80. The open field and light/dark box test were performed on PND 90 and 100, respectively.

KEY FINDINGS

Body weight reduction and vaginal bleeding were observed in pregnant rats exposed to SE. The male offspring of the SE group showed delay in incisor eruption, fur development and negative geotaxis. In addition, the SE group was less exploratory (anxious personality) compared to the CO and ST groups.

SIGNIFICANCE

The results obtained in the present study demonstrate that sertraline not only impairs maternal health, but also, associated or not with stress, can compromise the somatic, reflex and neurobehavioral development of male rats.

Effectiveness of Telehealth Interventions for Women With Postpartum Depression: Systematic Review and Meta-analysis

BACKGROUND

Postpartum depression (PPD) is a prevalent mental health problem with serious adverse consequences for affected women and their infants. Clinical trials have found that telehealth interventions for women with PPD result in increased accessibility and improved treatment effectiveness. However, no comprehensive synthesis of evidence from clinical trials by systematic review has been conducted.

OBJECTIVE

The aim of this study is to evaluate the effectiveness of telehealth interventions in reducing depressive symptoms and anxiety in women with PPD. To enhance the homogeneity and interpretability of the findings, this systematic review focuses on PPD measured by the Edinburgh Postnatal Depression Scale (EPDS).

METHODS

PubMed, The Cochrane Library, CINAHL, PsycINFO, CNKI, and Wanfang were electronically searched to identify randomized controlled trials (RCTs) on the effectiveness of telehealth interventions for women with PPD from inception to February 28, 2021. Data extraction and quality assessment were performed independently by two researchers. The quality of included studies was assessed using the Cochrane risk-of-bias tool, and meta-analysis was performed using RevMan 5.4 software.

RESULTS

Following the search, 9 RCTs with a total of 1958 women with PPD were included. The EPDS (mean difference=-2.99, 95% CI -4.52 to -1.46; P<.001) and anxiety (standardized mean difference=-0.39, 95% CI -0.67 to -0.12; P=.005) scores were significantly lower in the telehealth group compared with the control group. Significant subgroup differences were found in depressive symptoms according to the severity of PPD, telehealth technology, specific therapy, and follow-up time (P<.001).

CONCLUSIONS

Telehealth interventions could effectively reduce the symptoms of depression and anxiety in women with PPD. However, better designed and more rigorous large-scale RCTs targeting specific therapies are needed to further explore the potential of telehealth interventions for PPD.

TRIAL REGISTRATION

PROSPERO CRD42021258541; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=258541.

Postpartum Depression: Are You Listening?

Postpartum depression (PPD) affects10% to 20% of women within the first year after birth and 25% beyond the first year. PPD, despite advances in diagnosis and treatment, remains underdiagnosed and misunderstood. Women do not always display signs of PPD while in care for delivery of the infant and may not discuss mood changes to their primary care provider at discharge and first post-delivery appointment. Identifying screening and treatment options for non-mental health providers was the purpose of this article.