Controversies about the use of antidepressants in pregnancy

Investigation of Hypothalamic Pituitary Adrenal Axis and Oxytocinergic System Changes in a Pragmatic Randomized Controlled Feasibility Trial of Acupuncture for Antenatal Depression

Background: Antenatal depression is common and associated with detrimental impacts on women and their families. Disrupted neuroendocrine functioning is reported in women experiencing perinatal mental health disturbances. Preliminary randomized controlled trial (RCT) evidence suggests acupuncture may provide a safe and effective adjunct treatment; however, underlying mechanisms of effect are unclear. We conducted an RCT examination of acupuncture for the management of antenatal depressive symptomologies, which included oxytocinergic and hypothalamic pituitary adrenal (HPA) axis system evaluations. This article reports postintervention changes to cortisol: dehydroepiandrosterone (DHEA) ratios, and oxytocin (OT) hormone concentrations. Methods: Fifty-seven women with Edinburgh Postnatal Depression Scale (EPDS) scores ≥13 were randomized to receive individually tailored depressed specific acupuncture, progressive muscle relaxation (PMR) attention comparator, or treatment as usual (TAU). Weekly 1-h sessions were conducted for 8 weeks (24-31 of pregnancy). Preintervention and postintervention saliva samples were collected. Results: Postintervention mean cortisol: DHEA ratio differences were not significantly predicted by group allocation (n = 46, p = 0.065). Two-group comparisons demonstrated cortisol: DHEA ratios were significantly increased and predicted by group allocation when acupuncture was compared to TAU (p = 0.039); however, not between acupuncture and PMR (p = 0.179), or PMR and TAU (p = 0.421). Postintervention OT concentrations were not significantly predicted by group allocation. Limitations: Small sample size and posthoc analysis Conclusion: Findings suggest positive regulation of the HPA axis may be an underlying mechanism by which acupuncture provided the significant improvements to antenatal depression, stress, and distress observed in this cohort. Trial Registration: Registered on March 19, 2015, with the Australian New Zealand Clinical Trials Registry (ACTRN12615000250538).

Effect of Parenting Interventions on Perinatal Depression and Implications for Infant Developmental Outcomes: A Systematic Review and Meta-Analysis

Considering the significant impact of perinatal depression on both maternal wellbeing and infant development, it is important to examine the effectiveness of interventions designed to prevent or reduce these risks. This systematic review and meta-analysis synthesised evidence on parenting intervention in relation to how such programs affect symptoms of perinatal depression and infant outcomes within 12 months of postpartum. We followed the Cochrane Collaboration guidelines on conducting systematic reviews and meta-analyses. A total of five electronic databases were searched for controlled trials that met pre-determined eligibility criteria. Outcomes of interest were maternal depressive symptoms and infants' language, motor and socioemotional development. Seventeen studies involving 1665 participants were included in the systematic review. Estimates from a random effects model of 15 studies in the final meta-analysis revealed statistically significant reductions in maternal depressive symptoms at post-intervention for mothers allocated to receive parenting interventions (SMD = - 0.34, 95%CI   - 0.44,  - 0.24; z = 5.97, p < 0.001; I² = 0%). Data on infant development outcomes from the included studies were scarce, and therefore, infant outcomes were not analysed in this review. For individual study outcomes, the majority of studies reported a general trend for reductions in maternal depressive symptoms from pre- to post-intervention. Although parenting interventions are frequently considered preventive strategies that are designed to offer support to parents and impart skills that promote their physical and psychological wellbeing, our findings suggest that these interventions have a positive effect on perinatal depressive symptoms. Implications and recommendations for future research are addressed. The systematic review protocol was registered with PROSPERO 2020 CRD42020184491.

Addressing Crises in Teenage Pregnancy

Background:

Adolescent pregnancy is a major public health concern with medical, psychiatric, and social implications. Within this population, there is an elevated rate of co-occurring psychiatric conditions including mood disorders, anxiety disorders, suicidality, and substance use. However, little is known about the assessment and treatment of adolescent pregnancy within the context of these co-occurring psychiatric conditions, particularly in an emergency situation.

Objective:

This article utilizes a case report to illustrate the challenges faced in consultative psychiatry in the assessment and treatment of a pregnant suicidal youth with a complex psychosocial history. Topics addressed include: 1) The role of childhood trauma and suicidality in adolescent pregnancy 2) A consideration of the risks and benefits of treating adolescents with psychotropics during pregnancy.

Method:

A literature search was performed with the key words of adolescent, pregnancy, child sexual abuse and psychiatric illness. In addition, expert opinions of a reproductive psychiatrist and a psychiatrist who had specialized in addiction and adolescents were enlisted on key aspects of the case formulation and treatment.

Results:

Several studies were found that focused on depression, substance abuse and trauma in adolescent pregnancy. There were more studies that looked at psychopharmacological treatment in adult pregnant women and a few that focused on adolescents.

Conclusion:

Addressing the crisis of psychiatric illness in adolescent pregnancy requires a thorough approach in understanding the severity of the illness and the contribution of child abuse and suicidality. Psychotherapeutic interventions are most certainly always necessary and beneficial when dealing with this population. Deciding when to start and maintain medication during pregnancy should be individualized, with considerations of the risks of untreated illness and of medication exposure.

Maternal depression treatment in HIV (M-DEPTH): Study protocol for a cluster randomized controlled trial

INTRODUCTION

Over one-third of human immunodeficiency virus (HIV)-infected pregnant women are clinically depressed, increasing the risk of mother-to-child transmission (MTCT) of HIV, as well as negative birth and child development outcomes. This study will evaluate the efficacy and cost-effectiveness of an evidence-based stepped care treatment model for perinatal depression (maternal depression treatment in HIV [M-DEPTH]) to improve adherence to prevention of MTCT care among HIV+ women in Uganda.

METHODS

Eight antenatal care (ANC) clinics in Uganda will be randomized to implement either M-DEPTH (n=4) or usual care (n=4) for perinatal depression among 400 pregnant women (n=50 per clinic) between June 2019 and August 2022. At each site, women who screen positive for potential depression will be enrolled and followed for 18 months post-delivery, assessed in 6-month intervals: baseline, within 1 month of child delivery or pregnancy termination, and months 6, 12, and 18 following delivery. Primary outcomes include adherence to the prevention of mother-to-child transmission (PMTCT) care continuum-including maternal antiretroviral therapy and infant antiretrovial prophylaxis, and maternal virologic suppression; while secondary outcomes will include infant HIV status, post-natal maternal and child health outcomes, and depression treatment uptake and response. Repeated-measures multivariable regression analyses will be conducted to compare outcomes between M-DEPTH and usual care, using 2-tailed tests and an alpha cut-off of P <.05. Using a micro-costing approach, the research team will relate costs to outcomes, examining the incremental cost-effectiveness ration (ICER) of M-DEPTH relative to care as usual.

DISCUSSION

This cluster randomized controlled trial will be one of the first to compare the effects of an evidence-based depression care model versus usual care on adherence to each step of the PMTCT care continuum. If determined to be efficacious and cost-effective, this study will provide a model for integrating depression care into ANC clinics and promoting adherence to PMTCT.

TRIAL REGISTRATION

NIH Clinical Trial Registry NCT03892915 (clinicaltrials.gov).

Antidepressant use in pregnancy: are we closer to consensus?

We specify and summarize significant data from recent large studies in a tool with which to aim at consensus on the question of whether and how serotonin-reuptake antidepressants should be used in pregnancy, on the basis that concern for the mental health of the mother should not vie for primacy with concern for the short-, medium-, and long-term health of the child, but must be best served together. Side effects are small but significant over the majority of 11 categories, perinatal and into adolescence. In clinical practice, alternatives for serotonin-reuptake medication in pregnancy should be more actively pursued.

Comparative effects of antidepressant medications and untreated major depression on pregnancy outcomes: a systematic review

Psychopharmacological treatment of pregnant women is an area of continued controversy; extensive observational research on the use of antidepressant medications in pregnancy has found these medications to be associated with increased risk of spontaneous abortion, preterm delivery, and low birth weight. However, depression itself has also been associated with increased risk of those same outcomes, and only recently have researchers begun trying to compare treated with untreated depression. The purpose of this study was to conduct a systematic review of the literature to integrate those comparative studies and compare risks and benefits. PubMed, PsycInfo, and CINAHL searches; study selection; and data extraction were carried out using PRISMA guidelines. Eleven prospective observational and case-control studies were selected for final inclusion. Risk of low birth weight and related outcomes do not differ between antidepressant-treated pregnant women and untreated depressed women. Average gestational lengths tend to be slightly shorter with antidepressant use but it is unclear whether these differences are clinically meaningful or extend to preterm delivery. Very limited research on spontaneous abortion did not allow conclusions to be drawn regarding that outcome. The low number of studies meeting criteria highlights the need for further research to aid in risk-benefit analysis for women considering antidepressant use in pregnancy. While further research is necessary, discontinuing antidepressant treatment of major depression in pregnancy due to concerns about length of gestation, birth weight, or spontaneous abortion is not supported by the evidence available at this time.

Perinatal depression: A clinical update

Perinatal depression is a common condition with significant adverse maternal, fetal, neonatal, and early childhood outcomes. The perinatal period is an opportune time to screen, diagnose, and treat depression. Improved recognition of perinatal depression, particularly among low-income women, can lead to improved perinatal health outcomes.

Use of Antidepressants During Pregnancy?: What to Consider when Weighing Treatment with Antidepressants Against Untreated Depression

Introduction Mood disorders impact many pregnant women, particularly those who have experienced symptoms prior to conception, and there are significant barriers, including stigma and access, to seeking and receiving appropriate treatments. Antidepressants are a helpful option in treating perinatal depression, but research on risks and benefits of antidepressant use in pregnancy is difficult given lack of "gold standard" comparative trials. Methods This paper summarizes current state of knowledge on the safety of antidepressants during pregnancy by providing a summary of the literature published in the past 3 years (January 2013-October 2015). We identified 21 reviews and meta-analyses that were included in this summary report. This report is meant to provide a user-friendly, yet comprehensive guide summarizing the abundant, and in part contradicting, literature on risks and benefits of antidepressants during pregnancy, in order to assist busy primary care prescribers in educating their patients. Our goal is also to contrast the risks/benefits of untreated depression in pregnancy versus treatment with antidepressant medication in pregnancy, and in such support prescribers in their decision-making. Results The past 3 years have yielded an abundance of publications on the topic, in part, with conflicting findings adding to confusion and concern among providers, patients, and their families. Many reported studies have methodological problems limiting their impact. Data on adverse effects of medications on pregnancy and fetal outcomes have to be weighed against the impact of untreated illness and poor health habits associated with untreated illness on the same outcomes. Discussion Medical-decision making is often complex and seldom free of risks. Obviously, as providers we cannot guarantee that fetal exposure to antidepressants is totally free of risk, yet this is true for any medicine taken in pregnancy. However, to date, perinatal psychiatry has collected enough evidence to suggest that, if the clinical picture warrants it, the use of many antidepressants, especially the SSRIs, is favorable compared to exposing mother and child to untreated depressive illness.

Links between serotonin reuptake inhibition during pregnancy and neurodevelopmental delay/spectrum disorders: A systematic review of epidemiological and physiological evidence

OBJECTIVE

To investigate possible linkages between neurodevelopmental delay and neurodevelopmental spectrum disorders and exposure to medication with effects on serotonin reuptake inhibition during pregnancy.

METHODS

We systematically reviewed the epidemiological literature for studies bearing on this relationship in children born with neurodevelopmental spectrum disorder and related conditions, as well as animal studies giving serotonin reuptake inhibitors to pregnant animals and in addition reviewed the literature for proposals as to possible mechanisms that might link effects on serotonin reuptake with cognitive changes post-partum.The epidemiological studies were analysed to produce Forest plots to illustrate possible relations.

RESULTS

The odds ratio of Autistic Spectrum or related Disorders in children born to women taking serotonin reuptake inhibiting antidepressants during pregnancy in case control studies was 1.95 (95% C.I. 1.63, 2.34) and in prospective cohort studies was 1.96 (95% C.I. 1.33, 2.90).

CONCLUSIONS

There appears to be a link between serotonin reuptake inhibition in pregnancy and developmental delay and spectrum disorders in infancy leading to cognitive difficulties in childhood. More work needs to be done to establish more precisely the nature of the difficulties and possible mechanisms through which this link might be mediated.

Neonatal and childhood neurodevelopmental, health and educational outcomes of children exposed to antidepressants and maternal depression during pregnancy: protocol for a retrospective population-based cohort study using linked administrative data

INTRODUCTION

Antidepressants are commonly prescribed during pregnancy; however, there are inconsistent data on the safety of these medications during the prenatal period. To address this gap, this study will investigate short-term and long-term neurodevelopmental, physical and mental health, and educational outcomes of children who have been exposed to selective serotonin reuptake inhibitors (SSRIs) or selective serotonin norepinephrine reuptake inhibitors (SNRIs) and/or maternal depression during pregnancy.

METHODS AND ANALYSIS

Administrative data will be linked to generate 4 population-based exposed groups from all children born in Manitoba between 1996 and 2014 whose mother had at least 2 prescriptions for either an SSRI or SNRI: (1) throughout the prenatal period (beginning of pregnancy until birth); (2) in the first trimester (≤14 weeks gestation); (3) in the second trimester (15-26 weeks gestation); (4) in the third trimester (≥27 weeks gestation) and 1 population-based unexposed group consisting of children whose mothers had a diagnosis of mood or anxiety disorder during pregnancy but did not use antidepressants. Propensity scores and inverse probability treatment weights will be used to adjust for confounding. Multivariate regression modelling will determine whether, compared with untreated mood/anxiety disorder, prenatal exposure to antidepressant medications is associated with: (1) adverse birth and neonatal outcomes, including: preterm birth, low birth weight, low Apgar scores, respiratory distress, congenital malformations and persistent pulmonary hypertension; (2) adverse early childhood outcomes, including: early childhood education challenges, diagnosis of neurodevelopmental disorders and diagnosis of mental disorders. We will determine if exposure effects differ between SSRIs and SRNIs, and determine if exposure effects differ between gestation timing of exposure to antidepressants.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Manitoba Health Research Ethics Board. Dissemination of results will include engagement of stakeholders and patients, writing of reports for policymakers and patients, and publication of scientific papers.

Maternal postpartum depressive symptoms predict delay in non-verbal communication in 14-month-old infants

We investigated the potential relationship between maternal depressive symptoms during the postpartum period and non-verbal communication skills of infants at 14 months of age in a birth cohort study of 951 infants and assessed what factors may influence this association. Maternal depressive symptoms were measured using the Edinburgh Postnatal Depression Scale, and non-verbal communication skills were measured using the MacArthur-Bates Communicative Development Inventories, which include Early Gestures and Later Gestures domains. Infants whose mothers had a high level of depressive symptoms (13+ points) during both the first month postpartum and at 10 weeks were approximately 0.5 standard deviations below normal in Early Gestures scores and 0.5-0.7 standard deviations below normal in Later Gestures scores. These associations were independent of potential explanations, such as maternal depression/anxiety prior to birth, breastfeeding practices, and recent depressive symptoms among mothers. These findings indicate that infants whose mothers have postpartum depressive symptoms may be at increased risk of experiencing delay in non-verbal development.

Plasma adiponectin and depressive symptoms during pregnancy and the postpartum period: A prospective cohort study

BACKGROUND

Some authors have described an inverse association between adiponectin and depression, but this association has not yet been investigated during the perinatal period.

OBJECTIVE

To evaluate the association between the plasma adiponectin levels and symptoms of depression in women from early pregnancy to 30-45 days postpartum.

METHODS

A prospective cohort of 235 women was analyzed, with four waves of follow-up: 5-13th, 22-26th, and 30-36th gestational weeks and 30-45 days postpartum. Depressive symptoms were measured using the Edinburgh Postnatal Depression Scale (EPDS; cutoff ≥ 11). The plasma adiponectin concentrations were measured using an enzyme-linked immunosorbent assay. The statistical analyses included linear mixed effects regressions to model the association between these time-dependent variables.

RESULTS

The prevalence of depressive symptoms was 35.5%, 22.8%, 21.8%, and 16.9% and the median (µg/mL) adiponectin levels were 4.8, 4.7, 4.4, and 7.5 in the 1st, 2nd, and 3rd trimesters and the postpartum period, respectively. Women who remained non-depressed throughout the study tended to have higher values of adiponectin throughout pregnancy and the postpartum period compared to those who had depressive symptoms at least once, but this difference was not statistically significant (β=-0.14; p=0.071). There was no statistically significant association between the plasma adiponectin levels and the EPDS scores in the multiple model (β=-0.07; p=0.320).

LIMITATIONS

Losses to follow-up, different procedures for the blood draws at the prenatal and postpartum visits, and the presence of a nested clinical trial with omega-3 supplementation.

CONCLUSION

The plasma adiponectin levels were not associated with depressive symptoms during the perinatal period.

Managing Your Own Mood Lability: Use of Mood Stabilizers and Antipsychotics in Pregnancy

The management of psychiatric disorders during the perinatal period can be difficult; psychiatric decompensation during pregnancy can affect not only the mother but also the fetus and neonate. It is imperative that psychiatric providers proactively discuss pregnancy planning, and be able to thoughtfully weigh the risks of untreated psychiatric illness and psychotropic medications in pregnancy and breast-feeding. With the exception of valproate and carbamazepine, several mood stabilizers and antipsychotics can be utilized during pregnancy with minimal risk to the fetus and neonate in terms of major malformations; there is a growing body of evidence regarding the risk profile of use of these medications in pregnancy. Key Points Preconception planning is very helpful when it can be done; consider discussion and documentation of risks at time of administration of psychotropic medications for any reproductive-aged women, regardless of plans for conception. Continued psychiatric stability through the perinatal period is imperative; the risks of an untreated psychiatric disorder are just as important, if not more so important, than the risks of psychotropic medication exposure. Exposure to one psychotropic medication is safer than exposure to multiple medications. Utilize lowest effective dose of medication; most risks are not dose dependent, therefore would typically prefer higher dose of medication, rather than emergence of psychiatric symptoms, in order to avoid exposure of the fetus to both psychotropic medications and psychiatric symptoms. General recommendations are to avoid valproate and carbamazepine in reproductive-aged women. With close monitoring, lithium can be safely utilized in pregnancy. Preliminary data regarding use of atypical antipsychotics is reassuring in regards to major malformations; however, larger numbers of participants are needed to provide more complete reproductive safety data with this class. Clearly document risks of an untreated psychiatric illness as well as risks of psychotropic medication management to the mother and developing fetus/neonate.

Antidepressants, pregnancy, and stigma: how we are failing mothers and babies

There is considerable public debate over the use of antidepressants in pregnancy. In this article, we offer a commentary on Gail Robinson's important overview of the current controversies. Dr Ronbinson gives a thorough review of the literature, including the risks posed by both antidepressants and depression itself. We summarize her arguments and point out that, in the public conversation, the risks posed to a fetus from antidepressants are consistently overestimated while the risks of untreated depression are consistently underestimated because of the pervasive stigma against mental health. We review recent lay media analyses and urge our fellow physicians to make decisions about prescribing in pregnancy on the basis of evidence and individual patient needs rather than media and stigma.

Use of selective serotonin reuptake inhibitor antidepressants in pregnancy does carry risks, but the risks are small

The paper by Robinson posits that risks from prenatal exposure to selective serotonin reuptake inhibitor (SSRI) antidepressants are not different from the risks encountered in the general population and that untoward effects of SSRIs are difficult to distinguish from those of the mood disorder. Indeed, maternal depression and anxiety can have negative consequences for fetal and postnatal development. Fortunately, experimental evidence suggests that mood and anxiety disorder symptoms often respond to psychosocial interventions. If pharmacotherapy becomes necessary, it is, however, important to know that even if SSRI drugs have been shown to be safe overall, research has shown that fetal development can be adversely affected by in utero exposure to SSRIs in a subgroup of neonates. Examples would be the transient neonatal adaptation syndrome, an increased risk of persistent pulmonary hypertension of the newborn, and small, albeit measurable, changes in motor and social adaptability in infancy and childhood.