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Esen BÖ, Ehrenstein V, Petersen I, Sørensen HT, Pedersen L. Understanding the impact of non-shared unmeasured confounding on the sibling comparison analysis. Int J Epidemiol 2024; 53:dyad179. [PMID: 38110565 DOI: 10.1093/ije/dyad179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 12/06/2023] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND The sibling comparison analysis is used to deal with unmeasured confounding. It has previously been shown that in the presence of non-shared unmeasured confounding, the sibling comparison analysis may introduce substantial bias depending on the sharedness of the unmeasured confounder and the sharedness of the exposure. We aimed to improve the awareness of this challenge of the sibling comparison analysis. METHODS First, we simulated sibling pairs with an exposure, a confounder and an outcome. We simulated sibling pairs with no effect of the exposure on the outcome and with positive confounding. For varying degrees of sharedness of the confounder and the exposure and for varying prevalence of the exposure, we calculated the sibling comparison odds ratio (OR). Second, we provided measures for sharedness of selected treatments based on Danish health data. RESULTS The confounded sibling comparison OR was visualized for varying degrees of sharedness of the confounder and the exposure and for varying prevalence of the exposure. The confounded sibling comparison OR was seen to increase with increasing sharedness of the exposure and the confounded sibling comparison OR decreased with an increasing prevalence of exposure. Measures for sharedness of treatments based on Danish health data showed that treatments of chronic diseases have the highest sharedness and treatments of non-chronic diseases have the lowest sharedness. CONCLUSIONS Researchers should be aware of the challenge regarding non-shared unmeasured confounding in the sibling comparison analysis, before applying the analysis in non-randomized studies. Otherwise, the sibling comparison analysis may lead to substantial bias.
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Affiliation(s)
- Buket Öztürk Esen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Vera Ehrenstein
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Irene Petersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Lars Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Heuvelman H, Davies NM, Ben-Shlomo Y, Emond A, Evans J, Gunnell D, Liebling R, Morris R, Payne R, Storey C, Viner M, Rai D. Antidepressants in pregnancy: applying causal epidemiological methods to understand service-use outcomes in women and long-term neurodevelopmental outcomes in exposed children. Health Technol Assess 2023; 27:1-83. [PMID: 37842916 DOI: 10.3310/aqtf4490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
Background Antidepressants are commonly prescribed during pregnancy, despite a lack of evidence from randomised trials on the benefits or risks. Some studies have reported associations of antidepressants during pregnancy with adverse offspring neurodevelopment, but whether or not such associations are causal is unclear. Objectives To study the associations of antidepressants for depression in pregnancy with outcomes using multiple methods to strengthen causal inference. Design This was an observational cohort design using multiple methods to strengthen causal inference, including multivariable regression, propensity score matching, instrumental variable analysis, negative control exposures, comparison across indications and exposure discordant pregnancies analysis. Setting This took place in UK general practice. Participants Participants were pregnant women with depression. Interventions The interventions were initiation of antidepressants in pregnancy compared with no initiation, and continuation of antidepressants in pregnancy compared with discontinuation. Main outcome measures The maternal outcome measures were the use of primary care and secondary mental health services during pregnancy, and during four 6-month follow-up periods up to 24 months after pregnancy, and antidepressant prescription status 24 months following pregnancy. The child outcome measures were diagnosis of autism, diagnosis of attention deficit hyperactivity disorder and intellectual disability. Data sources UK Clinical Practice Research Datalink. Results Data on 80,103 pregnancies were used to study maternal primary care outcomes and were linked to 34,274 children with at least 4-year follow-up for neurodevelopmental outcomes. Women who initiated or continued antidepressants during pregnancy were more likely to have contact with primary and secondary health-care services during and after pregnancy and more likely to be prescribed an antidepressant 2 years following the end of pregnancy than women who did not initiate or continue antidepressants during pregnancy (odds ratioinitiation 2.16, 95% confidence interval 1.95 to 2.39; odds ratiocontinuation 2.40, 95% confidence interval 2.27 to 2.53). There was little evidence for any substantial association with autism (odds ratiomultivariableregression 1.10, 95% confidence interval 0.90 to 1.35; odds ratiopropensityscore 1.06, 95% confidence interval 0.84 to 1.32), attention deficit hyperactivity disorder (odds ratiomultivariableregression 1.02, 95% confidence interval 0.80 to 1.29; odds ratiopropensityscore 0.97, 95% confidence interval 0.75 to 1.25) or intellectual disability (odds ratiomultivariableregression 0.81, 95% confidence interval 0.55 to 1.19; odds ratiopropensityscore 0.89, 95% confidence interval 0.61 to 1.31) in children of women who continued antidepressants compared with those who discontinued antidepressants. There was inconsistent evidence of an association between initiation of antidepressants in pregnancy and diagnosis of autism in offspring (odds ratiomultivariableregression 1.23, 95% confidence interval 0.85 to 1.78; odds ratiopropensityscore 1.64, 95% confidence interval 1.01 to 2.66) but not attention deficit hyperactivity disorder or intellectual disability; however, but results were imprecise owing to smaller numbers. Limitations Several causal-inference analyses lacked precision owing to limited numbers. In addition, adherence to the prescribed treatment was not measured. Conclusions Women prescribed antidepressants during pregnancy had greater service use during and after pregnancy than those not prescribed antidepressants. The evidence against any substantial association with autism, attention deficit hyperactivity disorder or intellectual disability in the children of women who continued compared with those who discontinued antidepressants in pregnancy is reassuring. Potential association of initiation of antidepressants during pregnancy with offspring autism needs further investigation. Future work Further research on larger samples could increase the robustness and precision of these findings. These methods applied could be a template for future pharmaco-epidemiological investigation of other pregnancy-related prescribing safety concerns. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (15/80/19) and will be published in full in Health Technology Assessment; Vol. 27, No. 15. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Hein Heuvelman
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Neil M Davies
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Yoav Ben-Shlomo
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Alan Emond
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Jonathan Evans
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - David Gunnell
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Rachel Liebling
- Fetal Medicine Unit, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Richard Morris
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Rupert Payne
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | | | | | - Dheeraj Rai
- Department of Population Health Sciences, University of Bristol, Bristol, UK
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Arzuaga AL, Edmison DD, Mroczek J, Larson J, Ragozzino ME. Prenatal stress and fluoxetine exposure in mice differentially affect repetitive behaviors and synaptic plasticity in adult male and female offspring. Behav Brain Res 2023; 436:114114. [DOI: 10.1016/j.bbr.2022.114114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/17/2022] [Accepted: 09/11/2022] [Indexed: 10/14/2022]
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Besag FMC, Vasey MJ. Should Antidepressants be Avoided in Pregnancy? Drug Saf 2023; 46:1-17. [PMID: 36538238 DOI: 10.1007/s40264-022-01257-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 12/24/2022]
Abstract
Many (> 40%) women discontinue antidepressants during pregnancy because of concerns about effects on the foetus, based on information from inadequately-controlled studies. The sibling-control study design provides the best control for confounding factors, notably maternal depression. The purpose of this review was to investigate the evidence from sibling-control analyses for adverse outcomes in offspring associated with antidepressant exposure during pregnancy. Fourteen sibling-control studies were identified through searches of PubMed and Embase. Outcomes included preterm birth, small for gestational age, neonatal size, birth defects, autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), behavioural problems, neurodevelopmental deficits, and scholastic attainment. For the majority of these outcomes, no statistically significant associations were found when comparing exposed and unexposed siblings. Single studies reported associations with preterm birth, reduced gestational age, ADHD, anxiety at 36 months, and lower mathematics test scores, which persisted in the sibling-control analyses. However, differences were small and possibly not clinically significant. Moreover, effects of residual confounding could not be excluded. These findings provide evidence that many of the previously reported associations between prenatal antidepressant exposure and adverse outcomes in offspring are no longer statistically significant when exposed offspring are compared with unexposed siblings. The few statistically significant differences in sibling-control analyses were generally small with doubtful clinical significance. Decisions on antidepressant treatment during pregnancy should be made individually, based on evidence from properly controlled studies, not on misleading information based on studies that have not controlled adequately for confounding factors.
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Lee J, Chang SM. Confounding by Indication in Studies of Selective Serotonin Reuptake Inhibitors. Psychiatry Investig 2022; 19:873-883. [PMID: 36444151 PMCID: PMC9708863 DOI: 10.30773/pi.2022.0209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/01/2022] [Indexed: 11/25/2022] Open
Abstract
Selective serotonin reuptake inhibitors (SSRIs) are used worldwide as the first-line pharmacological treatment for depression. Although SSRI use can increase the risk of suicide, fractures, and infertility, the nature of these relationships is controversial. This review reports confounding by indication and confounding by severity for SSRI side effects in previously published observational studies. The PubMed and Google Scholar databases were searched for English-language articles published from 2005 to 2022. SSRIs are often prescribed for depressive symptoms, and depression is associated with an increased risk of side effects. Therefore, confounding by indication, whereby patients are selected for a particular treatment depending on their diagnosis or severity of illness, may lead to erroneous treatment conclusions, resulting in an adverse outcome. The side effects of SSRIs that can be considered due to confounding by indication or severity include suicide, fractures, infertility, atrial fibrillation, stroke, autism spectrum disorder, and congenital malformation. When prescribing SSRIs for depression, physicians must consider confounding by indication and severity in the management of side effects. In addition, medication discontinuation should be carefully considered when side effects occur during the treatment.
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Affiliation(s)
- Jimin Lee
- Department of Psychiatry, Kyungpook National University Hospital, Daegu, Republic of Korea.,Department of Psychiatry, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Sung Man Chang
- Department of Psychiatry, Kyungpook National University Hospital, Daegu, Republic of Korea.,Department of Psychiatry, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
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Ramsteijn AS, Verkaik-Schakel RN, Houwing DJ, Plösch T, Olivier JDA. Perinatal exposure to fluoxetine and maternal adversity affect myelin-related gene expression and epigenetic regulation in the corticolimbic circuit of juvenile rats. Neuropsychopharmacology 2022; 47:1620-1632. [PMID: 35102259 PMCID: PMC9283398 DOI: 10.1038/s41386-022-01270-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 12/11/2021] [Accepted: 01/04/2022] [Indexed: 12/30/2022]
Abstract
Many pregnant women experience symptoms of depression, and are often treated with selective serotonin reuptake inhibitor (SSRI) antidepressants, such as fluoxetine. In utero exposure to SSRIs and maternal depressive symptoms is associated with sex-specific effects on the brain and behavior. However, knowledge about the neurobiological mechanisms underlying these sex differences is limited. In addition, most animal research into developmental SSRI exposure neglects the influence of maternal adversity. Therefore, we used a rat model relevant to depression to investigate the molecular effects of perinatal fluoxetine exposure in male and female juvenile offspring. We performed RNA sequencing and targeted DNA methylation analyses on the prefrontal cortex and basolateral amygdala; key regions of the corticolimbic circuit. Perinatal fluoxetine enhanced myelin-related gene expression in the prefrontal cortex, while inhibiting it in the basolateral amygdala. SSRI exposure and maternal adversity interacted to affect expression of genes such as myelin-associated glycoprotein (Mag) and myelin basic protein (Mbp). We speculate that altered myelination reflects altered brain maturation. In addition, these effects are stronger in males than in females, resembling known behavioral outcomes. Finally, Mag and Mbp expression correlated with DNA methylation, highlighting epigenetic regulation as a potential mechanism for developmental fluoxetine-induced changes in myelination.
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Affiliation(s)
- Anouschka S. Ramsteijn
- grid.4830.f0000 0004 0407 1981Department of Neurobiology, Groningen Institute for Evolutionary Life Sciences, University of Groningen, Groningen, The Netherlands ,grid.7107.10000 0004 1936 7291Present Address: Rowett Institute of Nutrition and Health, University of Aberdeen, Aberdeen, UK
| | - Rikst Nynke Verkaik-Schakel
- grid.4830.f0000 0004 0407 1981Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Danielle J. Houwing
- grid.4830.f0000 0004 0407 1981Department of Neurobiology, Groningen Institute for Evolutionary Life Sciences, University of Groningen, Groningen, The Netherlands ,grid.10417.330000 0004 0444 9382Present Address: Department of Cognitive Neuroscience, Center for Medical Neuroscience, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Torsten Plösch
- grid.4830.f0000 0004 0407 1981Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jocelien D. A. Olivier
- grid.4830.f0000 0004 0407 1981Department of Neurobiology, Groningen Institute for Evolutionary Life Sciences, University of Groningen, Groningen, The Netherlands
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Leussis MP, Thanos JM, Powers A, Peterson E, Head JP, McGovern NJ, Malarkey FJ, Drake A. Sex differences in long-term behavioral alterations, especially anxiety, following prenatal fluoxetine exposure in C57BL/6 mice. Pharmacol Biochem Behav 2021; 211:173293. [PMID: 34744001 DOI: 10.1016/j.pbb.2021.173293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 10/20/2022]
Abstract
Evidence demonstrates that psychiatric disorders during pregnancy are detrimental to the offspring. Many disorders are treated with SSRIs and increasing numbers of pregnant women now receive these drugs during gestation. The long-term neurobehavioral consequences of prenatal SSRI exposure require further evaluation. This study examined the effects of prenatal fluoxetine exposure in mice in an extensive battery of behaviors related to neurodevelopment, mood, social, and repetitive behaviors. C57BL/6J dams were administered fluoxetine at a low (0.6 mg/kg/day) or high (6 mg/kg/day) dose or saline from embryonic days 8 to 18. Juvenile mice were tested for changes in ultrasonic vocalizations and neuromotor development. In adulthood, offspring were tested for changes in behaviors related to anxiety, depression, social, and repetitive behaviors. Prenatal exposure to fluoxetine impaired surface righting reflex at P5, and sex-dependently reduced the frequency of ultrasonic vocalizations in juvenile males but not females. In adulthood, both males and females prenatally exposed to high, but not low, doses of fluoxetine exhibited an increase in repetitive behaviors in the marble burying task and a decrease in sucrose preference. Males, but not females, exposed to fluoxetine exhibited increased anxiety-related behaviors in the elevated plus maze. Prenatal fluoxetine exposure did not affect other adult behaviors including social preference, self-grooming, passive avoidance and open field activity. These findings suggest males are more sensitive than females to disruptions in serotonin balance during prenatal development and highlight the need for additional systematic and mechanistic studies to evaluate the impact of fluoxetine exposure during other periods of gestation.
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Affiliation(s)
- Melanie P Leussis
- Department of Psychology & Neuroscience, Emmanuel College, Boston, MA 02115, United States of America.
| | - Jessica M Thanos
- Department of Biology, Emmanuel College, Boston, MA 02115, United States of America
| | - Alex Powers
- Department of Biology, Emmanuel College, Boston, MA 02115, United States of America
| | - Emalee Peterson
- Department of Biology, Emmanuel College, Boston, MA 02115, United States of America
| | - Joshua P Head
- Department of Psychology & Neuroscience, Emmanuel College, Boston, MA 02115, United States of America
| | - Nathan J McGovern
- Department of Psychology & Neuroscience, Emmanuel College, Boston, MA 02115, United States of America
| | - Francis J Malarkey
- Department of Psychology & Neuroscience, Emmanuel College, Boston, MA 02115, United States of America
| | - Anna Drake
- Department of Biology, Emmanuel College, Boston, MA 02115, United States of America
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Christensen J, Trabjerg BB, Sun Y, Dreier JW. Association of Maternal Antidepressant Prescription During Pregnancy With Standardized Test Scores of Danish School-aged Children. JAMA 2021; 326:1725-1735. [PMID: 34726709 PMCID: PMC8564575 DOI: 10.1001/jama.2021.17380] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Concerns exist about long-term neurodevelopmental consequences of prenatal exposure to antidepressants. OBJECTIVE To evaluate whether maternal prescription fill for antidepressants in pregnancy was associated with performance in standardized tests among Danish schoolchildren. DESIGN, SETTING, AND PARTICIPANTS Population-based retrospective cohort study of children born in Denmark between January 1, 1997, and December 31, 2009, attending public primary and lower secondary school. The children included had completed a language or mathematics test as part of the Danish National Test Program between January 1, 2010, and December 31, 2018. The age range of the eligible schoolchildren was 7 to 17 years. EXPOSURES Maternal prescription fill for antidepressants during pregnancy, obtained from the Danish Prescription Register. MAIN OUTCOMES AND MEASURES The difference in standardized scores between children with and without maternal prescription fill for antidepressants in mathematics and language tests (scale, 1-100; higher scores indicate better test results) was estimated using linear regression models, adjusted for relevant confounders. Ten sensitivity analyses were performed, including a sibling-controlled analysis. RESULTS Among the 575 369 children included (51.1% males), 10 198 (1.8%) were born to mothers filling an antidepressant prescription during pregnancy. The mean (SD) age of children at the time of testing spanned from 8.9 (0.4) years in grade 2 to 14.9 (0.4) years in grade 8. Maternal prescription fill for antidepressants was significantly associated with a poorer performance in mathematics (mean test scores for the group exposed to maternal antidepressant fill: 52.1 [95% CI, 51.7-52.6] and for the group not exposed to maternal antidepressant fill: 57.4 [95% CI, 57.3-57.4]; adjusted difference, -2.2 [95% CI, -2.7 to -1.6]), but not in language (mean test scores for the exposed group: 53.4 [95% CI, 53.1-53.7] and for the not exposed group: 56.6 [95% CI, 56.5-56.6]; adjusted difference, -0.1 [95% CI, -0.6 to 0.3]). In the sibling-controlled analysis, the adjusted difference in mathematics (mean scores for the exposed group: 53.5 [95% CI, 52.7-54.3] and for the not exposed group: 59.0 [95% CI, 58.9-59.1]) was -2.8 (95% CI, -4.5 to -1.2) and in language (mean test scores for the exposed group: 53.9 [95% CI, 53.2-54.6] and for the not exposed group: 56.6 [95% CI, 56.5-56.7]) was -0.3 (95% CI, -1.9 to 1.2). CONCLUSIONS AND RELEVANCE In this study of public schoolchildren in Denmark, children whose mothers had filled prescriptions for antidepressants during pregnancy, compared with children whose mothers did not fill prescriptions for antidepressants during pregnancy, had a 2-point lower standardized test score in mathematics, a difference that was statistically significant, but had no significant difference in language test scores. The magnitude of the difference in the mathematics test score was small and of uncertain clinical importance, and the findings must be weighed against the benefits of treating maternal depression during pregnancy.
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Affiliation(s)
- Jakob Christensen
- National Centre for Register-Based Research, Department of Economics and Business Economics, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Betina B. Trabjerg
- National Centre for Register-Based Research, Department of Economics and Business Economics, Aarhus University, Aarhus, Denmark
- Centre for Integrated Register-based Research (CIRRAU), Aarhus University, Aarhus, Denmark
| | - Yuelian Sun
- National Centre for Register-Based Research, Department of Economics and Business Economics, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Julie Werenberg Dreier
- National Centre for Register-Based Research, Department of Economics and Business Economics, Aarhus University, Aarhus, Denmark
- Centre for Integrated Register-based Research (CIRRAU), Aarhus University, Aarhus, Denmark
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Grivas G, Frye R, Hahn J. Pregnant Mothers' Medical Claims and Associated Risk of Their Children being Diagnosed with Autism Spectrum Disorder. J Pers Med 2021; 11:950. [PMID: 34683092 PMCID: PMC8537202 DOI: 10.3390/jpm11100950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/13/2021] [Accepted: 09/21/2021] [Indexed: 12/11/2022] Open
Abstract
A retrospective analysis of administrative claims containing a diverse mixture of ages, ethnicities, and geographical regions across the United States was conducted in order to identify medical events that occur during pregnancy and are associated with autism spectrum disorder (ASD). The dataset used in this study is comprised of 123,824 pregnancies of which 1265 resulted in the child being diagnosed with ASD during the first five years of life. Logistic regression analysis revealed significant relationships between several maternal medical claims, made during her pregnancy and segmented by trimester, and the child's diagnosis of ASD. Having a biological sibling with ASD, maternal use of antidepressant medication and psychiatry services as well as non-pregnancy related claims such hospital visits, surgical procedures, and radiology exposure were related to an increased risk of ASD regardless of trimester. Urinary tract infections during the first trimester and preterm delivery during the second trimester were also related to an increased risk of ASD. Preventative and obstetrical care were associated with a decreased risk for ASD. A better understanding of the medical factors that increase the risk of having a child with ASD can lead to strategies to decrease risk or identify those children who require increased surveillance for the development of ASD to promote early diagnosis and intervention.
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Affiliation(s)
- Genevieve Grivas
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, New York, NY 12180, USA;
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York, NY 12180, USA
- OptumLabs Visiting Fellow, OptumLabs, Eden Prairie, MN 55344, USA
| | - Richard Frye
- Department of Child Health, University of Arizona College of Medicine, Phoenix, AZ 85004, USA;
- Phoenix Children’s Hospital, Phoenix, AZ 85016, USA
| | - Juergen Hahn
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, New York, NY 12180, USA;
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York, NY 12180, USA
- Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, New York, NY 12180, USA
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Ames JL, Ladd-Acosta C, Fallin MD, Qian Y, Schieve LA, DiGuiseppi C, Lee LC, Kasten EP, Zhou G, Pinto-Martin J, Howerton E, Eaton CL, Croen LA. Maternal Psychiatric Conditions, Treatment With Selective Serotonin Reuptake Inhibitors, and Neurodevelopmental Disorders. Biol Psychiatry 2021; 90:253-262. [PMID: 34116791 PMCID: PMC8504533 DOI: 10.1016/j.biopsych.2021.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND This study aims to clarify relationships of maternal psychiatric conditions and selective serotonin reuptake inhibitor (SSRI) use during preconception and pregnancy with risk of neurodevelopmental disorders in offspring. METHODS We used data from the Study to Explore Early Development, a multisite case-control study conducted in the United States among children born between 2003 and 2011. Final study group classifications of autism spectrum disorder (ASD) (n = 1367), developmental delays or disorders (DDs) (n = 1750), and general population controls (n = 1671) were determined by an in-person standardized developmental assessment. Maternal psychiatric conditions and SSRI use during pregnancy were ascertained from both self-report and medical records. We used logistic regression to evaluate associations of ASD and DDs (vs. population controls) with maternal psychiatric conditions and SSRI treatment in pregnancy. To reduce confounding by indication, we also examined SSRI associations in analyses restricted to mothers with psychiatric conditions during pregnancy. RESULTS Psychiatric conditions and SSRI use during pregnancy were significantly more common among mothers of children with either ASD or DDs than among population controls. Odds of ASD were similarly elevated among mothers with psychiatric conditions who did not use SSRIs during pregnancy (adjusted odds ratio 1.81, 95% confidence interval 1.44-2.27) as in mothers who did use SSRIs (adjusted odds ratio 2.05, 95% confidence interval 1.50-2.80). Among mothers with psychiatric conditions, SSRI use was not significantly associated with ASD in offspring (adjusted odds ratio 1.14, 95% confidence interval 0.80-1.62). Primary findings for DDs exhibited similar relationships to those observed with ASD. CONCLUSIONS Maternal psychiatric conditions but not use of SSRIs during pregnancy were associated with increased risk of neurodevelopmental disorders in offspring.
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Affiliation(s)
| | - Christine Ladd-Acosta
- Wendy Klag Center for Autism and Developmental Disabilities, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - M. Daniele Fallin
- Wendy Klag Center for Autism and Developmental Disabilities, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Yinge Qian
- Division of Research, Kaiser Permanente, Oakland, CA
| | | | - Carolyn DiGuiseppi
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Li-Ching Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Eric P. Kasten
- Clinical and Translational Sciences Institute, Michigan State University, East Lansing, MI
| | - Guoli Zhou
- Clinical and Translational Sciences Institute, Michigan State University, East Lansing, MI
| | - Jennifer Pinto-Martin
- School of Nursing and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ellen Howerton
- Wendy Klag Center for Autism and Developmental Disabilities, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Christopher L. Eaton
- The Permanente Medical Group, Kaiser Permanente Medical Center, San Francisco, CA
| | - Lisa A. Croen
- Division of Research, Kaiser Permanente, Oakland, CA
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Liu K, Garcia A, Park JJ, Toliver AA, Ramos L, Aizenman CD. Early Developmental Exposure to Fluoxetine and Citalopram Results in Different Neurodevelopmental Outcomes. Neuroscience 2021; 467:110-121. [PMID: 34048796 DOI: 10.1016/j.neuroscience.2021.05.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/25/2022]
Abstract
Although selective serotonin reuptake inhibitors are commonly prescribed for prenatal depression, there exists controversy over adverse effects of SSRI use on fetal development. Few studies have adequately isolated outcomes due to SSRI exposure and those due to maternal psychiatric conditions. Here, we directly investigated outcomes of exposure to widely-used SSRIs Fluoxetine and Citalopram on the developing nervous system of Xenopus laevis tadpoles, using an integrative experimental approach. We exposed tadpoles to low doses of Citalopram and Fluoxetine during a critical developmental period and found that different experimental groups displayed opposing behavioral effects. While both groups showed reduced schooling behavior, the Fluoxetine group showed increased seizure susceptibility and reduced startle habituation. In contrast, Citalopram treated tadpoles had decreased seizure susceptibility and increased habituation. Both groups had abnormal dendritic morphology in the optic tectum, a brain area important for behaviors tested. Whole-cell electrophysiological recordings of tectal neurons showed no differences in synaptic function; however, tectal cells from Fluoxetine-treated tadpoles had decreased voltage gated K+ currents while cells in the Citalopram group had increased K+ currents. Both behavioral and electrophysiological findings indicate that cells and circuits in the Fluoxetine treated optic tecta are hyperexcitable, while the Citalopram group exhibits decreased excitability. Taken together, these results show that early developmental exposure to SSRIs is sufficient to induce neurodevelopmental effects, however these effects can be complex and vary depending on the SSRI. This may explain some discrepancies across human studies, and further underscores the importance of serotonergic signaling for the developing nervous system.
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Affiliation(s)
- Karine Liu
- Department of Neuroscience, Brown University, United States
| | - Alfonso Garcia
- Department of Neuroscience, Brown University, United States
| | - Jenn J Park
- Department of Neuroscience, Brown University, United States
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Van der Knaap N, Wiedermann D, Schubert D, Hoehn M, Homberg JR. Perinatal SSRI exposure affects brain functional activity associated with whisker stimulation in adolescent and adult rats. Sci Rep 2021; 11:1680. [PMID: 33462357 DOI: 10.1038/s41598-021-81327-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 01/05/2021] [Indexed: 01/29/2023] Open
Abstract
Selective serotonin reuptake inhibitors (SSRI), such as fluoxetine, are used as first-line antidepressant medication during pregnancy. Since SSRIs cross the placenta the unborn child is exposed to the maternal SSRI medication, resulting in, amongst others, increased risk for autism in offspring. This likely results from developmental changes in brain function. Studies employing rats lacking the serotonin transporter have shown that elevations in serotonin levels particularly affect the development of the whisker related part of the primary somatosensory (barrel) cortex. Therefore, we hypothesized that serotonin level disturbances during development alter brain activity related to whisker stimulation. We treated female dams with fluoxetine or vehicle from gestational day 11 onwards for 21 days. We investigated offspring's brain activity during whisker stimulation using functional magnetic resonance imaging (fMRI) at adolescence and adulthood. Our results indicate that adolescent offspring displayed increased activity in hippocampal subareas and the mammillary body in the thalamus. Adult offspring exhibited increased functional activation of areas associated with (higher) sensory processing and memory such as the hippocampus, perirhinal and entorhinal cortex, retrospinal granular cortex, piriform cortex and secondary visual cortex. Our data imply that perinatal SSRI exposure leads to complex alterations in brain networks involved in sensory perception and processing.
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Leshem R, Bar-Oz B, Diav-Citrin O, Gbaly S, Soliman J, Renoux C, Matok I. Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) During Pregnancy and the Risk for Autism spectrum disorder (ASD) and Attention deficit hyperactivity disorder (ADHD) in the Offspring: A True Effect or a Bias? A Systematic Review & Meta-Analysis. Curr Neuropharmacol 2021; 19:896-906. [PMID: 33655866 PMCID: PMC8686301 DOI: 10.2174/1570159x19666210303121059] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/03/2020] [Accepted: 01/23/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVE An inconsistent association between exposure to SSRIs and SNRIs and the risk for ASD and ADHD in the Offspring was observed in observational studies. Some suggest that the reported association might be due to unmeasured confounding. We aimed to study this association and to look for sources of bias by performing a systematic review and meta-analysis. METHODS Medline, Embase, and the Cochrane Library were searched up to June 2019 for studies reporting on ASD and ADHD in the Offspring following exposure during pregnancy. We followed the PRISMA 2009 guidelines for data selection and extraction. Outcomes were pooled using random- effects models and odds ratios (OR), and 95% confidence intervals (CI) were calculated for each outcome using the adjusted point estimate of each study. RESULTS Eighteen studies were included in the meta-analysis. We found an association between SSRIs/ SNRIs prenatal use and the risk for ASD and ADHD (OR=1.42, 95% CI: 1.23-1.65, I2=58%; OR=1.26, 95% CI: 1.07-1.49, I2=48%, respectively). Similar findings were obtained in women who were exposed to SSRIs/SNRIs before pregnancy, representing statistically significant association with ASD (OR=1.39, 95% CI: 1.24-1.56, I2=33%) and ADHD (OR=1.63, 95% CI: 1.50-1.78, I2=0%) in the Offspring, although they were not exposed to those medications in utero. CONCLUSIONS Although we found an association between exposure to SSRIs/SNRIs during pregnancy and the risk for ASD and ADHD, an association with those disorders was also present for exposure pre-pregnancy, suggesting that the association might be due to unmeasured confounding. We are aiming to further assess the role of potential unmeasured confounding in the estimation of the association and perform a network meta-analysis.
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Affiliation(s)
- Regina Leshem
- School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Benjamin Bar-Oz
- Hadassah-Hebrew University Medical Centers, Jerusalem, Israel
| | - Orna Diav-Citrin
- School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- The Israeli Teratology Information Service, Ministry of Health, Jerusalem, Israel
| | - Siham Gbaly
- School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Jessica Soliman
- School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Ilan Matok
- School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
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Smearman EL, Hendrix CL, Winiarski DA, Johnson KC, Smith AK, Ousley OY, Stowe ZN, Newport DJ, Brennan PA. School-age social behavior and pragmatic language ability in children with prenatal serotonin reuptake inhibitor exposure. Dev Psychopathol 2020; 32:21-30. [PMID: 30728091 DOI: 10.1017/S0954579418001372] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Studies examining associations between fetal serotonin reuptake inhibitor (SRI) exposure and child autism spectrum disorder (ASD) diagnoses or delayed language remain mixed and rarely prospectively follow children or employ gold-standard assessments. We prospectively followed a cohort of mother-child dyads from pregnancy through early elementary school (N = 178), and obtained maternal and alternate-caregiver ratings of behaviors related to ASD (N = 137), as well as direct, gold-standard assessments of child ASD symptoms and pragmatic language among dyads who experienced prenatal depression and either took SRIs or were medication free during pregnancy (N = 44). Prenatal SRI exposure was related to maternal ratings of ASD-related behaviors (β = 0.24 95% confidence interval; CI [0.07, 0.48]), and, among boys, alternative caregiver ratings (males-only β = 0.28 95% CI [0.02, 0.55], females-only β = -0.21 95% CI [-0.63, 0.08]). However, results of our direct assessments suggest an association between SRI exposure and reduced pragmatic language scores (β = -0.27, 95% CI [-0.53, -0.01], but not ASD (Autism Diagnostic Observation Schedule β = 0.14 95% CI [-0.15, 0.41]; Social Responsiveness Scale β = 0.08 95% CI [-0.25, 0.40]). These discrepancies point to issues regarding how ASD is assessed, and the possibility that SRIs may be more strongly associated with language or other broader behaviors that coincide with ASD. Larger prospective studies that incorporate thorough, gold-standard assessments of ASD, language, and other ASD-related behaviors are needed.
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Carlsson T, Molander F, Taylor MJ, Jonsson U, Bölte S. Early environmental risk factors for neurodevelopmental disorders - a systematic review of twin and sibling studies. Dev Psychopathol 2020;:1-48. [PMID: 32703331 DOI: 10.1017/S0954579420000620] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
While neurodevelopmental disorders (NDDs) are highly heritable, several environmental risk factors have also been suggested. However, the role of familial confounding is unclear. To shed more light on this, we reviewed the evidence from twin and sibling studies. A systematic review was performed on case control and cohort studies including a twin or sibling within-pair comparison of neurodevelopmental outcomes, with environmental exposures until the sixth birthday. From 7,315 screened abstracts, 140 eligible articles were identified. After adjustment for familial confounding advanced paternal age, low birth weight, birth defects, and perinatal hypoxia and respiratory stress were associated with autism spectrum disorder (ASD), and low birth weight, gestational age and family income were associated with attention-deficit/hyperactivity disorder (ADHD), categorically and dimensionally. Several previously suspected factors, including pregnancy-related factors, were deemed due to familial confounding. Most studies were conducted in North America and Scandinavia, pointing to a global research bias. Moreover, most studies focused on ASD and ADHD. This genetically informed review showed evidence for a range of environmental factors of potential casual significance in NDDs, but also points to a critical need of more genetically informed studies of good quality in the quest of the environmental causes of NDDs.
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Li L, Sujan AC, Butwicka A, Chang Z, Cortese S, Quinn P, Viktorin A, Öberg AS, D'Onofrio BM, Larsson H. Associations of Prescribed ADHD Medication in Pregnancy with Pregnancy-Related and Offspring Outcomes: A Systematic Review. CNS Drugs 2020; 34:731-747. [PMID: 32333292 PMCID: PMC7338246 DOI: 10.1007/s40263-020-00728-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Increasing numbers of reproductive-aged women are using attention-deficit/hyperactivity disorder (ADHD) medications. Findings from studies exploring the safety of these medications during pregnancy are mixed, and it is unclear whether associations reflect causal effects or could be partially or fully explained by other factors that differ between exposed and unexposed offspring. OBJECTIVES The aim of this systematic review was to evaluate the adverse pregnancy-related and offspring outcomes associated with exposure to prescribed ADHD medication during pregnancy with a focus on how studies to date have handled the influence of confounding. METHODS We searched PubMed, Embase, PsycINFO, and Web of Science up to 1 July 2019 without any restrictions on language or date of publication. We included all observational studies (e.g., cohort studies, case-control studies, case-crossover studies, cross-sectional studies, and registry-based studies) with pregnant women of any age or from any setting who were prescribed ADHD medications and evaluated any outcome, including both short- and long-term maternal and offspring outcomes. Two independent authors then used the Newcastle-Ottawa Scale to rate the quality of the included studies. RESULTS Eight cohort studies that estimated adverse pregnancy-related and offspring outcomes associated with exposure to ADHD medication during pregnancy were included in the qualitative review. The included studies had substantial methodological differences in data sources, type of medications examined, definitions of studied pregnancy-related and offspring outcomes, types of control groups, and confounding adjustment. There was no convincing evidence for teratogenic effects according to the relative risk of pregnancy-related and offspring outcomes, and the observed differences in absolute risks were overall small in magnitude. Adjustment for confounding was inadequate in most studies, and none of the included studies adjusted for ADHD severity in the mothers. CONCLUSION The current evidence does not suggest that the use of ADHD medication during pregnancy results in significant adverse consequences for mother or offspring. However, the data are too limited to make an unequivocal recommendation. Therefore, physicians should consider whether the advantages of using ADHD medication outweigh the potential risks for the developing fetus according to each woman's specific circumstances. Future research should attempt to triangulate research findings based on a combination of different designs that differ in their underlying strengths and limitations and should investigate specific confounding factors, the potential impact of timing of exposure, and potential long-term outcomes in the offspring.
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Affiliation(s)
- Lin Li
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Ayesha C Sujan
- Department of Psychological and Brain Sciences, Indiana University, 1101 E. 10th St., Bloomington, IN, 47405, USA
| | - Agnieszka Butwicka
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Child and Adolescent Psychiatry Stockholm, Stockholm Health Care Services, Stockholm, Region Stockholm, Sweden
- Department of Child Psychiatry, Medical University of Warsaw, Warsaw, Poland
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Samuele Cortese
- Centre for Innovation in Mental Health, School of Psychology, Life and Environmental Sciences, University of Southampton, Southampton, UK
- Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, UK
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham, UK
- New York University Child Study Center, New York, NY, USA
| | - Patrick Quinn
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, IN, USA
| | - Alexander Viktorin
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - A Sara Öberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Epidemiology, T.H. Chan School of Public Health, Harvard, Boston, MA, USA
| | - Brian M D'Onofrio
- Department of Psychological and Brain Sciences, Indiana University, 1101 E. 10th St., Bloomington, IN, 47405, USA.
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
| | - Henrik Larsson
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Ramsteijn A, Van de Wijer L, Rando J, van Luijk J, Homberg J, Olivier J. Perinatal selective serotonin reuptake inhibitor exposure and behavioral outcomes: A systematic review and meta-analyses of animal studies. Neurosci Biobehav Rev 2020; 114:53-69. [DOI: 10.1016/j.neubiorev.2020.04.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 03/29/2020] [Accepted: 04/09/2020] [Indexed: 12/15/2022]
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Levy M, Kovo M, Miremberg H, Anchel N, Herman HG, Bar J, Schreiber L, Weiner E. Maternal use of selective serotonin reuptake inhibitors (SSRI) during pregnancy-neonatal outcomes in correlation with placental histopathology. J Perinatol 2020; 40:1017-24. [PMID: 31988450 DOI: 10.1038/s41372-020-0598-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 01/08/2020] [Accepted: 01/16/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVE We investigated the association between prenatal selective serotonin reuptake inhibitors (SSRI) exposure and pregnancy-outcomes with correlation to placental-histopathology. STUDY DESIGN Included were pregnancies with maternal SSRI use throughout pregnancy (SSRI-group) and the control group was matched with pregnancies unexposed to SSRI. Placental lesions were classified according to the "Amsterdam" criteria. Adverse neonatal outcome was defined as ≥1 early neonatal-complications. RESULTS SSRI group had lower birthweights (p < 0.001), higher rates of meconium (p = 0.009), NICU admissions (p < 0.001), and adverse neonatal-outcome (p < 0.001). SSRI placentas had lower birthweight-to-placental-weight ratio (p = 0.02) and higher rates of fetal vascular malperfusion (FVM) lesions (p = 0.03). Using multivariable analyses: GA < 37 weeks (aOR = 2.1, 95%CI 1.7-4.6) and SSRI (aOR = 1.7, 95%CI 1.3-3.9) were independently associated with adverse neonatal outcome while GA < 37 weeks (aOR = 1.6, 95%CI 1.2-3.4), SSRI (aOR = 1.3, 95%CI 1.1-2.6), and smoking (aOR = 1.2, 95%CI 1.1-4.0) were independently associated with FVM lesions. CONCLUSION SSRI use during pregnancy was independently associated with adverse neonatal outcome and placental FVM.
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Vega ML, Newport GC, Bozhdaraj D, Saltz SB, Nemeroff CB, Newport DJ. Implementation of Advanced Methods for Reproductive Pharmacovigilance in Autism: A Meta-Analysis of the Effects of Prenatal Antidepressant Exposure. Am J Psychiatry 2020; 177:506-517. [PMID: 32375539 DOI: 10.1176/appi.ajp.2020.18070766] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Observational studies of prenatal antidepressant safety are hindered by methodological concerns, including susceptibility to surveillance bias. Some studies address potential bias by using alternative strategies to operationalize study comparison groups. In a meta-analysis of the association between prenatal antidepressant exposure and autism risk, the authors examined the utility of comparison group operationalization in reducing surveillance bias. METHODS A systematic search of multiple databases through August 2017 was conducted, selecting controlled observational studies of the association of prenatal antidepressant exposure with autism. Study quality was assessed using the Newcastle-Ottawa Scale. Random-effects meta-analysis produced summary effect measures with 95% confidence intervals stratified by comparator group composition, antidepressant class, and trimester of exposure. RESULTS Fourteen studies were included, with 13 reporting results using a population-based comparison group, five using a psychiatric control group, and four using a discordant-sibling control group. Eight of the 14 studies were rated poor because of inadequate control for prenatal depression and maternal ethnicity. Autism risk estimates after prenatal exposure to any antidepressant were decidedly different for population-based designs (hazard ratio=1.42, 95% CI=1.18, 1.70; odds ratio=1.58, 95% CI=1.25, 1.99) compared with psychiatric control (hazard ratio=1.14, 95% CI=0.84, 1.53; odds ratio=1.24, 95% CI=0.93, 1.66) and discordant-sibling (hazard ratio=0.97, 95% CI=0.68, 1.37; odds ratio=0.85, 95% CI=0.54, 1.35) designs. Findings for prenatal exposure to selective serotonin reuptake inhibitors were similar. Meta-regression of population-based studies demonstrated that despite statistical adjustment, ethnicity differences remained a significant source of study heterogeneity. CONCLUSIONS In this meta-analysis, neither psychiatric control nor discordant-sibling designs supported an association between prenatal antidepressant exposure and autism. Discordant-sibling designs effectively addressed surveillance bias in pharmacovigilance reports derived from national registries and other large databases.
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Affiliation(s)
- Monica L Vega
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami (Vega, Bozhdaraj, Saltz); Department of Psychology, University of South Florida St. Petersburg (G.C. Newport); Department of Psychiatry (Nemeroff, D.J. Newport), University of Texas at Austin Dell Medical School, Austin
| | - Graham C Newport
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami (Vega, Bozhdaraj, Saltz); Department of Psychology, University of South Florida St. Petersburg (G.C. Newport); Department of Psychiatry (Nemeroff, D.J. Newport), University of Texas at Austin Dell Medical School, Austin
| | - Durim Bozhdaraj
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami (Vega, Bozhdaraj, Saltz); Department of Psychology, University of South Florida St. Petersburg (G.C. Newport); Department of Psychiatry (Nemeroff, D.J. Newport), University of Texas at Austin Dell Medical School, Austin
| | - Samantha B Saltz
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami (Vega, Bozhdaraj, Saltz); Department of Psychology, University of South Florida St. Petersburg (G.C. Newport); Department of Psychiatry (Nemeroff, D.J. Newport), University of Texas at Austin Dell Medical School, Austin
| | - Charles B Nemeroff
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami (Vega, Bozhdaraj, Saltz); Department of Psychology, University of South Florida St. Petersburg (G.C. Newport); Department of Psychiatry (Nemeroff, D.J. Newport), University of Texas at Austin Dell Medical School, Austin
| | - D Jeffrey Newport
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami (Vega, Bozhdaraj, Saltz); Department of Psychology, University of South Florida St. Petersburg (G.C. Newport); Department of Psychiatry (Nemeroff, D.J. Newport), University of Texas at Austin Dell Medical School, Austin
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Abstract
Depression during pregnancy is associated with adverse maternal, pregnancy, and infant outcomes. Treatment during pregnancy requires a balanced discussion of the risks of both drug exposure and untreated depression. An updated review of the epidemiology, outcomes, and management of maternal depression is presented. Adverse outcomes are associated with both maternal depression and antidepressants. Research gaps include data on the longitudinal developmental trajectory of offspring exposed to antidepressants compared to depression, with assessment of in utero symptom exposure and environmental exposures. Additionally, neonatal syndrome associated with antidepressant use during pregnancy has no consensus definition or mechanistic explanation. With sophisticated large-scale epidemiologic studies, there has been progress in distinguishing the impact of depression processes from medication used for treatment. Optimal treatment of perinatal depression includes close symptom monitoring and medication adjustments to maintain symptom remission. This evolving field requires frequent consultation with reproductive data sources included in this article.
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Affiliation(s)
- Gabrielle A. Mesches
- Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Katherine L. Wisner
- Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, IL, USA,Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hannah K. Betcher
- Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, IL, USA,Mayo Clinic, Rochester, MN, USA
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Bastaki KN, Alwan S, Zahir FR. Maternal Prenatal Exposures in Pregnancy and Autism Spectrum Disorder: An Insight into the Epigenetics of Drugs and Diet as Key Environmental Influences. Adv Neurobiol 2020; 24:143-62. [PMID: 32006359 DOI: 10.1007/978-3-030-30402-7_5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Autism spectrum disorder (ASD) is a rapidly growing global pandemic that affects an estimated 1 in 59-68 children. It is a complex disease with both genetic and environmental etiologies. Due to the rapid increase in the incidence of ASD, environmental causes for ASD are gaining attention. Efforts to probe several environmental exposures that could contribute to causing ASD are underway. In this regard, this chapter is directed towards understanding prenatal exposure to key environmental factors i.e., drugs and dietary nutrients that may act via the same molecular pathway - epigenetics as a potential etiological factor for ASD. Epigenetic regulation is a molecular mechanism known to be a significant contributor to neurodevelopmental disorders. It also offers a means to explain how environmental exposures can impact genetics. We discuss the impact of maternal exposures to certain drugs, and dietary intake, on the developing fetus during pregnancy. Maternal Exposure to some drugs during gestation are associated with a higher risk of ASD, while exposure to other dietary compounds may offer promise to rescue epigenetic regulatory insults related to ASD. However, more work in this important area is still required, nevertheless preliminary research already has important implications in the understanding, prevention and treatment of ASD.
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Wang Z, Ho PWH, Choy MTH, Wong ICK, Brauer R, Man KKC. Advances in Epidemiological Methods and Utilisation of Large Databases: A Methodological Review of Observational Studies on Central Nervous System Drug Use in Pregnancy and Central Nervous System Outcomes in Children. Drug Saf 2020; 42:499-513. [PMID: 30421346 DOI: 10.1007/s40264-018-0755-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Studies have used various epidemiological approaches to study associations between central nervous system (CNS) drug use in pregnancy and CNS outcomes in children. Studies have generally focused on clinical adverse effects, whereas variations in methodologies have not received sufficient attention. OBJECTIVE Our objective was to review the methodological characteristics of existing studies to identify any limitations and recommend further research. METHODS A systematic literature search was conducted on observational studies listed in PubMed from 1 January 1946 to 21 September 2017. Following independent screening and data extraction, we conducted a review addressing the trends of relevant studies, differences between various data sources, and methods used to address bias and confounders; we also conducted statistical analyses. RESULTS In total, 111 observational studies, 25 case-control studies, and 86 cohort studies were included in the review. Publications dating from 1978 to 2006 mainly focused on antiepileptic drugs, but research on antidepressants increased from 2007 onwards. Only one study focused on antipsychotic use during pregnancy. A total of 46 studies obtained data from an administrative database/registry, 20 from ad hoc disease registries, and 41 from ad hoc clinical samples. Most studies (58%) adjusted the confounding factors using general adjustment, whereas only a few studies used advanced methods such as sibling-matched models and propensity score methods; 42 articles used univariate analyses and 69 conducted multivariable regression analyses. CONCLUSION Multiple factors, including different study designs and data sources, have led to inconsistent findings in associations between CNS drug use in pregnancy and CNS outcomes in children. Researchers should allow for study designs with clearly defined exposure periods, at the very least in trimesters, and use advanced confounding adjustment methodology to increase the accuracy of the findings.
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Affiliation(s)
- Zixuan Wang
- Research Department of Practice and Policy, UCL School of Pharmacy, Mezzanine Floor, BMA House, Entrance A, Tavistock Square, London, WC1H 9JP, UK
| | - Phoebe W H Ho
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Michael T H Choy
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Ian C K Wong
- Research Department of Practice and Policy, UCL School of Pharmacy, Mezzanine Floor, BMA House, Entrance A, Tavistock Square, London, WC1H 9JP, UK.,Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Ruth Brauer
- Research Department of Practice and Policy, UCL School of Pharmacy, Mezzanine Floor, BMA House, Entrance A, Tavistock Square, London, WC1H 9JP, UK
| | - Kenneth K C Man
- Research Department of Practice and Policy, UCL School of Pharmacy, Mezzanine Floor, BMA House, Entrance A, Tavistock Square, London, WC1H 9JP, UK. .,Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong. .,Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands.
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Bond C, Johnson J, Chaudhary V, McCarthy E, McWhorter M, Woehrle N. Perinatal fluoxetine exposure results in social deficits and reduced monoamine oxidase gene expression in mice. Brain Res 2020; 1727:146282. [DOI: 10.1016/j.brainres.2019.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 05/28/2019] [Accepted: 06/01/2019] [Indexed: 12/27/2022]
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Kapra O, Rotem R, Gross R. The Association Between Prenatal Exposure to Antidepressants and Autism: Some Research and Public Health Aspects. Front Psychiatry 2020; 11:555740. [PMID: 33329095 PMCID: PMC7719777 DOI: 10.3389/fpsyt.2020.555740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 10/08/2020] [Indexed: 01/22/2023] Open
Abstract
Use of antidepressants (ADs) in general, and in pregnant notwithstanding, has been increasing globally in recent decades. Associations with a wide range of adverse perinatal and childhood outcomes following prenatal ADs exposure have been observed in registry-based studies, with Autism Spectrum Disorders (ASD) frequently reported. Studies using animal models, sibling analyses, and negative control approaches, have linked dysfunctional serotonin metabolism with ASD, but did not convincingly tease apart the role of maternal mental health from that of ADs. As work to decipher the nature of the AD-ASD association continues, this review raises some public health concerns pertinent to a hypothetical conclusion that this association is causal, including the need to identify specific gestation periods with higher risk, the importance of precise assessment of the ASD potential prevention that might be attributed to AD discontinuation, and the estimation of risks associated with prenatal exposure to untreated depression.
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Affiliation(s)
- Ori Kapra
- Department of Epidemiology and Preventive Medicine, Sackler Faculty of Medicine, School of Public Health, Tel Aviv University, Tel-Aviv, Israel
| | - Ran Rotem
- School of Public Health, Harvard University, Boston, MA, United States.,Morris Kahn Maccabi Health Data Science Institute, Tel-Aviv, Israel
| | - Raz Gross
- Department of Epidemiology and Preventive Medicine, Sackler Faculty of Medicine, School of Public Health, Tel Aviv University, Tel-Aviv, Israel.,Sheba Medical Center, Ramat Gan, Israel.,Department of Psychiatry, Sackler Faculty of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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25
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Araujo JSAD, Delgado IF, Paumgartten FJR. Antenatal exposure to antidepressant drugs and the risk of neurodevelopmental and psychiatric disorders: a systematic review. CAD SAUDE PUBLICA 2020; 36:e00026619. [DOI: 10.1590/0102-311x00026619] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 12/02/2019] [Indexed: 12/17/2022] Open
Abstract
Abstract: This study investigated whether antenatal exposure to antidepressants (ADs) increases the risks of autism spectrum disorders (ASD), attention deficit/hyperactivity disorders (ADHD), schizophrenia and other mental illnesses, and cognitive and developmental deficits in infants or preschool children. PubMed, EMBASE, BIREME/BVS databases were searched to identify studies examining associations of ADs in pregnancy with neurodevelopmental and psychiatric disorders. Twenty studies addressed ASD and/or ADHD risks while 30 focused on developmental and cognitive deficits in infants or preschool children. Most studies detected no association of antenatal AD with ASD after adjustment of risk ratios for maternal depression or psychiatric disorders. Some studies showed that maternal depression, regardless of whether it is treated or untreated, increased ASD risks. Seven out of 8 studies found no increase in ADHD risk associated with antenatal exposure to selective serotonin reuptake inhibitors, the most commonly used AD. No consistent evidence was found linking AD in pregnancy to neurocognitive developmental deficits in infants or preschool children. A residual confounding by indication (depression severity) remained in almost all studies. This systematic review found no consistent evidence suggesting that ADs in pregnancy increase risks of ASD, ADHD, and neurocognitive development deficits. Some studies, however, found evidence that maternal depression increases ASD risks.
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26
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Bracken MB. SSRIs and autism: interpreting an umbrella review. Lancet Psychiatry 2019; 6:893. [PMID: 31631870 DOI: 10.1016/S2215-0366(19)30392-X] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 08/07/2019] [Indexed: 10/25/2022]
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Sun Y, Pedersen LH, Wu CS, Petersen I, Sørensen HT, Olsen J. Antidepressant use during pregnancy and risk of congenital heart defects: A case-time-control study. Pharmacoepidemiol Drug Saf 2019; 28:1180-1193. [PMID: 31359557 DOI: 10.1002/pds.4844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 05/09/2019] [Accepted: 05/31/2019] [Indexed: 11/10/2022]
Abstract
PURPOSE We estimated the association between maternal antidepressant (AD) use in early pregnancy and risk of congenital heart defects. METHODS We applied a case-time-control design with the aim of controlling for confounding from time-invariant factors and compared the results of the design to results from a cohort design in a population of 792 685 singletons born alive in Denmark during 1995-2008. In the case-time-control design, we identified children diagnosed with a congenital heart defect in the first 5 years of life (cases) and compared maternal AD use in the risk period (the first 3 months of pregnancy) and the reference period (gestational months 5-7). A nondiseased control group was included to adjust for time trends of exposure. In the cohort design, we identified children whose mothers redeemed at least one AD prescription in the first 3 months of pregnancy (the exposed) and two other groups including the unexposed children with maternal AD prescriptions in the 12 months before pregnancy. We applied conditional logistic regression and logistic regression to compute odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS The case-time-control OR for any congenital heart defect was 1.03 (95% CI, 0.61-1.73), which was similar to the OR (1.09, 95% CI, 0.88-1.35) from the cohort design when we compared the exposed children with the unexposed children with maternal AD use before pregnancy. CONCLUSIONS The case-time-control design provided results similar to the cohort design when the cohort design had a better confounder control strategy. We discussed the strengths and drawbacks of case-time-control design.
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Affiliation(s)
- Yuelian Sun
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Neurology, Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.,National Center of Register-based Research, Department of Economics and Business Economics, Business and Social Science, Aarhus University, Aarhus, Denmark
| | - Lars Henning Pedersen
- Department of Obstetrics and Gynecology, Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Chun Sen Wu
- Research Unit of Gynecology and Obstetrics, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
| | - Irene Petersen
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Primary Care and Population Health, University College London, London, UK
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Jørn Olsen
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, California, USA
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28
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Velasquez JC, Zhao Q, Chan Y, Galindo LC, Simasotchi C, Wu D, Hou Z, Herod SM, Oberlander TF, Gil S, Fournier T, Burd I, Andrews AM, Bonnin A. In Utero Exposure to Citalopram Mitigates Maternal Stress Effects on Fetal Brain Development. ACS Chem Neurosci 2019; 10:3307-3317. [PMID: 31184110 DOI: 10.1021/acschemneuro.9b00180] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Human epidemiological and animal-model studies suggest that separate exposure to stress or serotonin-selective reuptake inhibitor (SSRI) antidepressants during pregnancy increases risks for neurodevelopmental disorders in offspring. Yet, little is known about the combined effects of maternal stress and SSRIs with regard to brain development in utero. We found that the placenta is highly permeable to the commonly prescribed SSRI (±)-citalopram (CIT) in humans and mice, allowing rapid exposure of the fetal brain to this drug. We investigated the effects of maternal chronic unpredictable stress in mice with or without maternal oral administration of CIT from embryonic day (E)8 to E17. We assessed fetal brain development using magnetic resonance imaging and quantified changes in serotonergic, thalamocortical, and cortical development. In utero exposure to maternal stress did not affect overall fetal brain growth. However, serotonin tissue content in the fetal forebrain was increased in association with maternal stress; this increase was reversed by maternal CIT. In utero exposure to stress increased the numbers of deep-layer neurons in specific cortical regions, whereas CIT increased overall cell numbers without changing the proportions of layer-specific neurons to offset the effects of stress on deep-layer cortical development. These findings suggest that stress and SSRI exposure in utero differentially impact serotonin-dependent fetal neurodevelopment such that CIT reverses key effects of maternal gestational stress on offspring brain development.
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Affiliation(s)
- Juan C. Velasquez
- Department of Physiology and Neuroscience, Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, California 90089, United States
| | - Qiuying Zhao
- Department of Physiology and Neuroscience, Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, California 90089, United States
| | - Yen Chan
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California 90089, United States
| | - Ligia C.M. Galindo
- Department of Anatomy, Federal University of Pernambuco, Recife 50670, Brazil
| | | | - Dan Wu
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland 21287, United States
| | - Zhipeng Hou
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland 21287, United States
| | - Skyla M. Herod
- Department of Biology and Chemistry, Azusa Pacific University, Azusa, California 91702, United States
| | - Tim F. Oberlander
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 3 V4, Canada
| | - Sophie Gil
- UMR-S 1139 INSERM/University of Paris Descartes, 75006 Paris, France
- PremUp Foundation, 75014 Paris, France
| | - Thierry Fournier
- UMR-S 1139 INSERM/University of Paris Descartes, 75006 Paris, France
- PremUp Foundation, 75014 Paris, France
| | - Irina Burd
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland 21287, United States
| | - Anne M. Andrews
- Terry and Jane Semel Institute for Neuroscience & Human Behavior, Shirley and Stefan Hatos Center for Neuropharmacology, and Departments of Psychiatry and Biobehavioral Sciences and Chemistry and Biochemistry, University of California, Los Angeles, Los Angeles, California 90095, United States
| | - Alexandre Bonnin
- Department of Physiology and Neuroscience, Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, California 90089, United States
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Hjorth S, Bromley R, Ystrom E, Lupattelli A, Spigset O, Nordeng H. Use and validity of child neurodevelopment outcome measures in studies on prenatal exposure to psychotropic and analgesic medications - A systematic review. PLoS One 2019; 14:e0219778. [PMID: 31295318 PMCID: PMC6622545 DOI: 10.1371/journal.pone.0219778] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 07/01/2019] [Indexed: 02/07/2023] Open
Abstract
In recent years there has been increased attention to child neurodevelopment in studies on medication safety in pregnancy. Neurodevelopment is a multifactorial outcome that can be assessed by various assessors, using different measures. This has given rise to a debate on the validity of various measures of neurodevelopment. The aim of this review was twofold. Firstly we aimed to give an overview of studies on child neurodevelopment after prenatal exposure to central nervous system acting medications using psychotropics and analgesics as examples, giving special focus on the use and validity of outcome measures. Secondly, we aimed to give guidance on how to conduct and interpret medication safety studies with neurodevelopment outcomes. We conducted a systematic review in the MEDLINE, Embase, PsycINFO, Web of Science, Scopus, and Cochrane databases from inception to April 2019, including controlled studies on prenatal exposure to psychotropics or analgesics and child neurodevelopment, measured with standardised psychometric instruments or by diagnosis of neurodevelopmental disorder. The review management tool Covidence was used for data-extraction. Outcomes were grouped as motor skills, cognition, behaviour, emotionality, or "other". We identified 110 eligible papers (psychotropics, 82 papers, analgesics, 29 papers). A variety of neurodevelopmental outcome measures were used, including 27 different psychometric instruments administered by health care professionals, 15 different instruments completed by parents, and 13 different diagnostic categories. In 23 papers, no comments were made on the validity of the outcome measure. In conclusion, establishing neurodevelopmental safety includes assessing a wide variety of outcomes important for the child's daily functioning including motor skills, cognition, behaviour, and emotionality, with valid and reliable measures from infancy through to adolescence. Consensus is needed in the scientific community on how neurodevelopment should be assessed in medication safety in pregnancy studies. Review registration number: CRD42018086101 in the PROSPERO database.
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Affiliation(s)
- Sarah Hjorth
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Rebecca Bromley
- Division of Evolution and Genomic Science, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, England
- Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, England
| | - Eivind Ystrom
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Mental Disorders, Norwegian Institute of Public Health, Oslo, Norway
- PROMENTA Research Center, Department of Psychology, University of Oslo, Oslo, Norway
| | - Angela Lupattelli
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Olav Spigset
- Department of Clinical Pharmacology, St. Olav's University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hedvig Nordeng
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
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30
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Halvorsen A, Hesel B, Østergaard SD, Danielsen AA. In utero exposure to selective serotonin reuptake inhibitors and development of mental disorders: a systematic review and meta-analysis. Acta Psychiatr Scand 2019; 139:493-507. [PMID: 30937904 DOI: 10.1111/acps.13030] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Several studies have investigated whether in utero exposure to selective serotonin reuptake inhibitors (SSRIs) is associated with increased risk of developing mental or behavioural disorders. The aim of this study was to perform a systematic review and meta-analysis based on this literature. METHODS A systematic search of eligible literature in PubMed, EMBASE, and PsycINFO and subsequent meta-analysis was conducted in adherence with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guideline. RESULTS A total of 20 studies were included in the review, and results from 18 of these were meta-analyzed. We found a statistically significant positive association between in utero exposure to SSRIs and mental or behavioural disorders such as autism spectrum disorder (hazard ratio (HR) = 1.27; 95% confidence interval (CI) = 1.10-1.47), attention-deficit/hyperactivity disorder (HR = 1.33; 95% CI = 1.06-1.66) and mental retardation (HR = 1.41; 95% CI = 1.03-1.91). Confounding by indication was identified in five of seven studies investigating this aspect. CONCLUSION Exposure to SSRIs in utero is associated with increased risk of developing mental or behavioural disorders. However, these associations do not necessarily reflect a causal relationship since the results included in this meta-analysis are likely affected by residual confounding by indication, which is likely to account for some (or all) of the positive association.
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Affiliation(s)
- A Halvorsen
- Psychosis Research Unit, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - B Hesel
- Psychosis Research Unit, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - S D Østergaard
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Affective Disorders, Aarhus University Hospital, Aarhus, Denmark
| | - A A Danielsen
- Psychosis Research Unit, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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31
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Abstract
Risks, benefits, alternatives, and appropriateness of psychotropic medications, including risks of no treatment, are discussed for antidepressants, mood-stabilizing medications, anxiolytic/sedative hypnotic medications, stimulants, and medication-assisted treatment of substance use disorders. Early screening, diagnosis, and intervention prior to and/or during pregnancy often reduce morbidity and mortality of mental health disorders for mothers and infants.
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Affiliation(s)
- Edwin R Raffi
- Perinatal and Reproductive Psychiatry Program, Massachusetts General Hospital Center for Women's Mental Health, Harvard Medical School, Simches Research Building, 185 Cambridge Street, Suite 2200, Boston, MA 02114, USA.
| | - Ruta Nonacs
- Perinatal and Reproductive Psychiatry Program, Massachusetts General Hospital Center for Women's Mental Health, Harvard Medical School, Simches Research Building, 185 Cambridge Street, Suite 2200, Boston, MA 02114, USA
| | - Lee S Cohen
- Perinatal and Reproductive Psychiatry Program, Massachusetts General Hospital Center for Women's Mental Health, Harvard Medical School, Simches Research Building, 185 Cambridge Street, Suite 2200, Boston, MA 02114, USA
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32
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Ornoy A, Koren G. SSRIs and SNRIs (SRI) in Pregnancy: Effects on the Course of Pregnancy and the Offspring: How Far Are We from Having All the Answers? Int J Mol Sci 2019; 20:E2370. [PMID: 31091646 DOI: 10.3390/ijms20102370] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/08/2019] [Accepted: 05/09/2019] [Indexed: 12/31/2022] Open
Abstract
Serotonin has important roles in the development of the brain and other organs. Manipulations of synaptic serotonin by drugs such as serotonin reuptake inhibitors (SRI) or serotonin norepinephrine reuptake inhibitors (SNRI) might alter their development and function. Of interest, most studies on the outcome of prenatal exposure to SRI in human have not found significant embryonic or fetal damage, except for a possible, slight increase in cardiac malformations. In up to a third of newborns exposed to SRI, exposure may induce transient neonatal behavioral changes (poor neonatal adaptation) and increased rate of persistent pulmonary hypertension. Prenatal SRI may also cause slight motor delay and language impairment but these are transient. The data on the possible association of prenatal SRIs with autism spectrum disorder (ASD) are inconsistent, and seem to be related to pre-pregnancy treatment or to maternal depression. Prenatal SRIs also appear to affect the hypothalamic hypophyseal adrenal (HPA) axis inducing epigenetic changes, but the long-term consequences of these effects on humans are as yet unknown. SRIs are metabolized in the liver by several cytochrome P450 (CYP) enzymes. Faster metabolism of most SRIs in late pregnancy leads to lower maternal concentrations, and thus potentially to decreased efficacy which is more prominent in women that are rapid metabolizers. Studies suggest that the serotonin transporter SLC6A4 promoter is associated with adverse neonatal outcomes after SRI exposure. Since maternal depression may adversely affect the child's development, one has to consider the risk of SRI discontinuation on the fetus and the child. As with any drug treatment in pregnancy, the benefits to the mother should be considered versus the possible hazards to the developing embryo/fetus.
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33
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Ayano G, Maravilla JC, Alati R. Risk of autistic spectrum disorder in offspring with parental mood disorders: A systematic review and meta-analysis. J Affect Disord 2019; 248:185-197. [PMID: 30739049 DOI: 10.1016/j.jad.2019.01.038] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 01/18/2019] [Accepted: 01/22/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND The association between mood disorders in parents and autism spectrum disorder (ASD) risk in offspring has been investigated in several studies, but the evidence is inconclusive. This systematic review and meta-analysis will explore whether an association exists between parental mood disorders and ASD risk in offspring. METHODS A literature search was performed using the electronic databases PubMed, EMBASE, PsycINFO, and Scopus. We also reviewed reference lists from retrieved articles. Meta-analysis was conducted, and combined effect values and their 95% confidence intervals were calculated. Study-specific risk ratios (RRs) were pooled using a random effect model. The risk of publication bias was assessed by funnel plot and Egger's regression asymmetry test. RESULTS Nine observational studies (two cohort and seven case-control studies) were included for analysis. Our meta-analysis found a greater risk of ASD in children exposed to parental affective, depressive, and bipolar disorders [(RRs 1.65 (95%CI 1.45-1.88); 1.37 (95%CI 1.04-1.81) and 1.87; 95%CI 1.69-2.07) respectively]. We also found increased ASD risk in children of mothers who experienced affective and depressive disorders [(RRs 1.67 (95%CI 1.34-2.09) and 1.62 (95%CI 1.32-1.99) respectively]. We found no increased risk of ASD in children exposed to paternal affective and depressive disorders. Subgroup and sensitivity analysis confirmed the robustness of our main analysis. CONCLUSION The evidence from the present study suggests parental affective, depressive and bipolar, as well as maternal affective and depressive disorders increased the risk of ASD in offspring. Exposure to affective and depressive disorders in fathers only was not linked with ASD risk in children.
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Affiliation(s)
- Getinet Ayano
- School of Social Sciences, The University of Queensland, 80 Meiers Rd, Indooroopilly, Queensland 4068Australia.
| | - Joemer Calderon Maravilla
- School of Social Sciences, The University of Queensland, 80 Meiers Rd, Indooroopilly, Queensland 4068Australia.
| | - Rosa Alati
- School of Social Sciences, The University of Queensland, 80 Meiers Rd, Indooroopilly, Queensland 4068Australia; School of public Heath, Curtin University, Western Australia, Australia.
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35
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Emberti Gialloreti L, Mazzone L, Benvenuto A, Fasano A, Alcon AG, Kraneveld A, Moavero R, Raz R, Riccio MP, Siracusano M, Zachor DA, Marini M, Curatolo P. Risk and Protective Environmental Factors Associated with Autism Spectrum Disorder: Evidence-Based Principles and Recommendations. J Clin Med 2019; 8:E217. [PMID: 30744008 DOI: 10.3390/jcm8020217] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/03/2019] [Accepted: 02/05/2019] [Indexed: 02/06/2023] Open
Abstract
Autism Spectrum Disorder (ASD) is a complex condition with early childhood onset, characterized by a set of common behavioral features. The etiology of ASD is not yet fully understood; however, it reflects the interaction between genetics and environment. While genetics is now a well-established risk factor, several data support a contribution of the environment as well. This paper summarizes the conclusions of a consensus conference focused on the potential pathogenetic role of environmental factors and on their interactions with genetics. Several environmental factors have been discussed in terms of ASD risk, namely advanced parental age, assisted reproductive technologies, nutritional factors, maternal infections and diseases, environmental chemicals and toxicants, and medications, as well as some other conditions. The analysis focused on their specific impact on three biologically relevant time windows for brain development: the periconception, prenatal, and early postnatal periods. Possible protective factors that might prevent or modify an ASD trajectory have been explored as well. Recommendations for clinicians to reduce ASD risk or its severity have been proposed. Developments in molecular biology and big data approaches, which are able to assess a large number of coexisting factors, are offering new opportunities to disentangle the gene⁻environment interplay that can lead to the development of ASD.
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36
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Garbarino VR, Gilman TL, Daws LC, Gould GG. Extreme enhancement or depletion of serotonin transporter function and serotonin availability in autism spectrum disorder. Pharmacol Res 2019; 140:85-99. [PMID: 30009933 PMCID: PMC6345621 DOI: 10.1016/j.phrs.2018.07.010] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 06/22/2018] [Accepted: 07/12/2018] [Indexed: 12/15/2022]
Abstract
A variety of human and animal studies support the hypothesis that serotonin (5-hydroxytryptamine or 5-HT) system dysfunction is a contributing factor to the development of autism in some patients. However, many questions remain about how developmental manipulation of various components that influence 5-HT signaling (5-HT synthesis, transport, metabolism) persistently impair social behaviors. This review will summarize key aspects of central 5-HT function important for normal brain development, and review evidence implicating perinatal disruptions in 5-HT signaling in the pathophysiology of autism spectrum disorder. We discuss the importance, and relative dearth, of studies that explore the possible correlation to autism in the interactions between important intrinsic and extrinsic factors that may disrupt 5-HT homeostasis during development. In particular, we focus on exposure to 5-HT transport altering mechanisms such as selective serotonin-reuptake inhibitors or genetic polymorphisms in primary or auxiliary transporters of 5-HT, and how they relate to neurological stores of serotonin and its precursors. A deeper understanding of the many mechanisms by which 5-HT signaling can be disrupted, alone and in concert, may contribute to an improved understanding of the etiologies and heterogeneous nature of this disorder. We postulate that extreme bidirectional perturbations of these factors during development likely compound or synergize to facilitate enduring neurochemical changes resulting in insufficient or excessive 5-HT signaling, that could underlie the persistent behavioral characteristics of autism spectrum disorder.
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Affiliation(s)
- Valentina R Garbarino
- Department of Cellular and Integrative Physiology, United States; The Sam and Ann Barshop Institute for Longevity and Aging Studies, United States.
| | - T Lee Gilman
- Department of Cellular and Integrative Physiology, United States; Addiction Research, Treatment & Training Center of Excellence, United States.
| | - Lynette C Daws
- Department of Cellular and Integrative Physiology, United States; Addiction Research, Treatment & Training Center of Excellence, United States; Department of Pharmacology, United States.
| | - Georgianna G Gould
- Department of Cellular and Integrative Physiology, United States; Center for Biomedical Neuroscience, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.
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Yamamoto-Sasaki M, Yoshida S, Takeuchi M, Tanaka-Mizuno S, Ogawa Y, Furukawa TA, Kawakami K. Association between antidepressant use during pregnancy and autism spectrum disorder in children: a retrospective cohort study based on Japanese claims data. Matern Health Neonatol Perinatol 2019; 5:1. [PMID: 30652008 PMCID: PMC6327597 DOI: 10.1186/s40748-018-0096-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 12/17/2018] [Indexed: 12/17/2022] Open
Abstract
Background Studies using data from Western countries have raised concerns that treating pregnant women with antidepressants may increase the risk of autism spectrum disorders (ASDs) in their offspring. However, to date, the studies are inconclusive. We therefore examined the association between antidepressant use and ASD using claims data collected in Japan. Methods This retrospective cohort study was based on claims data from mothers and their children from January 2005 to July 2014, obtained from the Japan Medical Data Center. The information from mothers and children was linked using the family identification code. Information on antidepressant prescriptions during pregnancy was extracted from the database. To collect information on ASD, children for whom data were available 24 months or more after birth were followed up from birth through July 2014 or up until their withdrawal from the database. To ensure appropriate diagnosis of ASD, mother-child pairs where the children's data did not cover the 24 months after birth or pairs where children had a diagnosis of ASD within only 23 months after birth were excluded from the study cohort. We used logistic regression analyses to evaluate the association between antidepressant use during pregnancy and the children's ASD diagnosis. All statistical analyses were performed using IBM SPSS (Statistical Package for the Social Sciences) Statistics ver. 21.0. Results Of the 53,864 eligible mother-child pairs, 26,925 met the study criteria. Crude analysis showed that the ASD prevalence in children was significantly higher with any antidepressant use than with non-use (odds ratio [OR], 2.32; 95% confidence interval [CI], 1.08, 4.95). However, when the analysis was adjusted for the confounding effect of maternal depression during pregnancy, statistical significance was lost (OR, 0.76; CI, 0.27, 2.18). Conclusions After adjustment for confounders, we found no significant association between antidepressant use during pregnancy and ASD in children in Japan. This result provides additional evidence to support the idea that antidepressant use during pregnancy itself is not associated with an increase in ASD in children. In addition, this represents the first evidence based on Asian data.
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Affiliation(s)
- Madoka Yamamoto-Sasaki
- 1Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoe-cho Sakyo-ku, Kyoto, 606-8501 Japan
| | - Satomi Yoshida
- 1Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoe-cho Sakyo-ku, Kyoto, 606-8501 Japan
| | - Masato Takeuchi
- 1Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoe-cho Sakyo-ku, Kyoto, 606-8501 Japan
| | - Sachiko Tanaka-Mizuno
- 2Department of Medical Statistics, Shiga University of Medical Science, Setatsukinowacho Otsu, Shiga, 520-2121 Japan
| | - Yusuke Ogawa
- 3Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoe-cho Sakyo-ku, Kyoto, 606-8501 Japan
| | - Toshiaki A Furukawa
- 4Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoe-cho Sakyo-ku, Kyoto, 606-8501 Japan
| | - Koji Kawakami
- 1Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoe-cho Sakyo-ku, Kyoto, 606-8501 Japan
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Hagberg KW, Robijn AL, Jick S. Maternal depression and antidepressant use during pregnancy and the risk of autism spectrum disorder in offspring. Clin Epidemiol 2018; 10:1599-1612. [PMID: 30464639 PMCID: PMC6219268 DOI: 10.2147/clep.s180618] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background Results of some studies suggest that prenatal antidepressant exposure increases the risk of autism spectrum disorder (ASD) in offspring, while other studies suggest that depression independently increases the risk of having a child with ASD. Thus, confounding by indication is a concern. Objective The aim of this study was to estimate the risk of ASD in offspring of women who were exposed to antidepressants and/or had depression during pregnancy compared to unexposed women. Materials and methods We conducted a cohort study with nested sibling case–control analysis. Using the UK Clinical Practice Research Datalink (CPRD), we identified mother– baby pairs where the mother had ≥12 months of history before the delivery date and the child had ≥3 years of follow-up. Exposures during pregnancy were classified as 1) depression treated with antidepressants, 2) untreated depression, 3) other indications for antidepressant use, and 4) 4:1 match of unexposed women with no history of depression or antidepressant use. We calculated the prevalence of ASD and relative risk (RR) with 95% CI. In the sibling analysis, we compared exposure among ASD cases to that of non-ASD siblings born to the same mother. We calculated ORs and 95% CIs for women with treated and untreated depression, compared to unexposed. Results We identified 2,154 offspring with ASD among 194,494 mother–baby pairs. Compared to unexposed, the RR of ASD was 1.72 (95% CI 1.54–1.93) for treated depression and 1.50 (95% CI 1.28–1.75) for untreated depression, while the RR was not elevated in women who received antidepressants for other indications (RR =0.73, 95% CI 0.41–1.29). Additional analyses to assess the effects of severity of depression suggest that the risk of ASD in offspring increases with increasing severity, not with the antidepressant treatment. The results of the sibling analysis were similar to the main analysis. Conclusion Women with depression during pregnancy have an increased risk of having a child with ASD, regardless of antidepressant use.
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Affiliation(s)
- Katrina Wilcox Hagberg
- Boston Collaborative Drug Surveillance Program, Boston University School of Public Health, Lexington, MA 02421, USA,
| | - Annelies L Robijn
- Boston Collaborative Drug Surveillance Program, Boston University School of Public Health, Lexington, MA 02421, USA,
| | - Susan Jick
- Boston Collaborative Drug Surveillance Program, Boston University School of Public Health, Lexington, MA 02421, USA,
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Thorsness KR, Watson C, LaRusso EM. Perinatal anxiety: approach to diagnosis and management in the obstetric setting. Am J Obstet Gynecol 2018; 219:326-345. [PMID: 29803818 DOI: 10.1016/j.ajog.2018.05.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/09/2018] [Accepted: 05/16/2018] [Indexed: 11/16/2022]
Abstract
Anxiety is common in women during the perinatal period, manifests with various symptoms and severity, and is associated with significant maternal morbidity and adverse obstetric and neonatal outcomes. Given the intimate relationship and frequency of contact, the obstetric provider is positioned optimally to create a therapeutic alliance and to treat perinatal anxiety. Time constraints, absence of randomized controlled trials, mixed quality of data, and concern for potential adverse reproductive outcomes all limit the clinician's ability to initiate informed risk-benefit discussions. Clear understanding of the role of the obstetric provider in the identification, stabilization, and initiation of medication and/or referral to psychotherapy for women with perinatal anxiety disorders is critical to maternal and neonatal wellbeing. Informed by our clinical practice as perinatal psychiatric providers, we have provided a concise summary of current research on the approach to the treatment of perinatal anxiety disorders in the obstetric setting that includes psychotherapy and supportive interventions, primary and adjuvant psychiatric medication, and general prescribing pearls. Medications that we examined include antidepressants, benzodiazepines, sedative-hypnotics, antihistamines, quetiapine, buspirone, propranolol, and melatonin. Further research into management of perinatal anxiety, particularly psychopharmacologic management, is warranted.
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Abstract
BACKGROUND We explored the association of 29 previously reported neonatal, perinatal, and prenatal conditions, and exposures with later diagnosis of autism spectrum disorder (ASD) in a large sample of children followed over multiple years. METHODS A retrospective case-cohort study was formed using the Military Health System database. Cases were identified by International Classification of Diseases, Ninth Revision codes for ASD between 2000 and 2013, and were matched 3:1 with controls on sex, date of birth, and enrollment time frame. Exposures included 29 conditions previously associated with ASD; 17 prenatal conditions and their pharmaceutical treatment, 5 perinatal conditions, and 6 neonatal conditions. RESULTS A total of 8,760 children diagnosed with ASD between the ages of 2 and 18 years were matched with 26,280 controls. ASD is associated with maternal mental illness, epilepsy, obesity, hypertension, diabetes, polycystic ovary syndrome, infection, asthma, assisted fertility, hyperemesis, younger maternal age, labor complications, low birth weight, infant infection, epilepsy, birth asphyxia, and newborn complications. The greatest increased risk was associated with infant epilepsy (odds ratio (OR) 7.57 (5.68-10.07)), maternal mental health (OR 1.80 (1.65-1.96)), and epilepsy (OR 1.60 (1.02-2.50)) medications. CONCLUSION ASD is associated with a range of prenatal, perinatal, and neonatal factors, with the highest magnitude associations with maternal medication use and neonatal seizure.
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Affiliation(s)
| | - Apryl Susi
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Theophil Stokes
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Gregory Gorman
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | | | - Cade M Nylund
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Abstract
OBJECTIVE To examine the association between paternal antidepressant use at conception and offspring preterm birth, malformations, autism spectrum disorder, and intellectual disability. DESIGN Observational prospective cohort study with regression methods, and negative control comparison. SETTING Sweden nationwide. PARTICIPANTS 170 508 children conceived from 29 July 2005 and born in 2006-07, followed up to 2014 at age 8-9 years. This cohort included 3983 children born to fathers receiving antidepressant treatment during the conception period (that is, from four weeks before conception to four weeks after), a control group of 164 492 children not exposed to paternal antidepressant use, and a negative control comparison group of 2033 children born to fathers who did not use antidepressants during the conception period but began antidepressant treatment later during the pregnancy period (that is, from four weeks after conception to childbirth). MAIN OUTCOME MEASURE Offspring preterm birth, malformation diagnosed at birth, diagnosis of autism spectrum disorder, and diagnosis of intellectual disability. RESULTS Paternal antidepressant use during conception was not associated with preterm birth (adjusted odds ratio 0.91 (95% confidence interval 0.79 to 1.04)) or malformations (1.06 (0.90 to 1.26)) using logistic regression, compared with offspring born to unexposed fathers. No association was seen between antidepressant use during conception and autism (adjusted hazard ratio 1.13 (0.84 to 1.53)) or intellectual disability (0.82 (0.51 to 1.31)) using Cox regression. In children whose fathers initiated antidepressant treatment during pregnancy, results were similar for all outcomes apart from intellectual disability, which had an increased adjusted hazard ratio (1.66 (1.06 to 2.59)). Compared with the 2033 children whose fathers initiated antidepressant treatment during pregnancy, the 3983 children exposed to paternal use of antidepressants at conception had no differences in preterm birth, malformation, and autism, but a reduced risk of intellectual disability (adjusted hazard ratio 0.49 (0.26 to 0.93)). CONCLUSION Paternal intake of antidepressants during the period around conception is safe with respect to the risk of the four major adverse outcomes in offspring-preterm birth, malformation, autism, or intellectual disability.
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Affiliation(s)
- Alexander Viktorin
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Stephen Z Levine
- Department of Community Mental Health, University of Haifa, Haifa, Israel
| | - Margret Altemus
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Abraham Reichenberg
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Seaver Autism Center for Research and Treatment at Mount Sinai, New York, NY, USA
| | - Sven Sandin
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Seaver Autism Center for Research and Treatment at Mount Sinai, New York, NY, USA
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Ackerman S, Schoenbrun S, Hudac C, Bernier R. Interactive Effects of Prenatal Antidepressant Exposure and Likely Gene Disrupting Mutations on the Severity of Autism Spectrum Disorder. J Autism Dev Disord 2018; 47:3489-3496. [PMID: 28770524 DOI: 10.1007/s10803-017-3246-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
To examine the interactive effects of two proposed risk factors which may contribute to symptom severity of Autism Spectrum Disorder (ASD): prenatal antidepressant exposure and likely gene-disrupting (LGD) mutations. Participants included 2748 individuals with ASD from the Simons Simplex Collection. We examined the effects of prenatal antidepressant exposure, maternal depression, presence of an LGD mutation and their interaction on ASD severity. We found a significant interactive effect between antidepressant exposure and the presence of an LGD mutation on ASD severity in the ADOS and ADI-R verbal communication domains. We consider a "two-hit" model in which one variable lays the foundation for an initial risk which is compounded by a second variable.
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Affiliation(s)
- Sean Ackerman
- Department of Psychiatry, Child & Adolescent Psychiatry, SSM Dean Medical Group, 1313 Fish Hatchery Rd, Madison, WI, 53715, USA.
| | | | - Caitlin Hudac
- Department of Psychiatry, University of Washington, Seattle, WA, USA
| | - Raphael Bernier
- Department of Psychiatry and Center on Human Development and Disability, University of Washington, Seattle, WA, USA
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Abstract
Autism Spectrum Disorder (ASD) refers to a group of neurodevelopmental disorders including autism, Asperger's syndrome (AS) and pervasive developmental disorder-not otherwise specified (PDD-NOS). The new diagnostic criteria of ASD focuses on two core domains: social communication impairment and restricted interests/repetitive behaviors. The prevalence of ASD has been steadily increasing over the past two decades, with current estimates reaching up to 1 in 36 children. Hereditary factors, parental history of psychiatric disorders, pre-term births, and fetal exposure to psychotropic drugs or insecticides have all been linked to higher risk of ASD. Several scales such as the Childhood Autism Rating Scale (CARS), The Autism Spectrum Disorder-Observation for Children (ASD-OC), The Developmental, Dimensional, and Diagnostic Interview (3di), are available to aid in better assessing the behaviors and symptoms associated with ASD. Nearly 75% of ASD patients suffer from comorbid psychiatric illnesses or conditions, which may include attention-deficit hyperactivity disorder (ADHD), anxiety, bipolar disorder, depression, Tourette syndrome, and others. Both pharmacological and non-pharmacological interventions are available for ASD. Pharmacological treatments include psychostimulants, atypical antipsychotics, antidepressants, and alpha-2 adrenergic receptor agonists. These medications provide partial symptomatic relief of core symptoms of ASD or manage the symptoms of comorbid conditions. Non-pharmacological interventions, which show promising evidence in improving social interaction and verbal communication of ASD patients, include music therapy, cognitive behavioral therapy and social behavioral therapy. Hormonal therapies with oxytocyin or vasopressin receptor antagonists have also shown some promise in improving core ASD symptoms. The use of vitamins, herbal remedies and nutritional supplements in conjunction with pharmacological and behavioral treatment appear to have some effect in symptomatic improvement in ASD, though additional studies are needed to confirm these benefits. Developing novel disease-modifying therapies may prove to be the ultimate intervention for sustained improvement of symptoms in ASD.
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Affiliation(s)
- Samata R Sharma
- Department of Psychiatry, Harvard Medical School, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Xenia Gonda
- Department of Psychiatry and Psychotherapy, Kutvolgyi Clinical Centre, Semmelweis University, Kutvolgyi ut 4, 1125 Budapest, Hungary
| | - Frank I Tarazi
- Department of Psychiatry and Neuroscience Program, , Harvard Medical School, McLean Hospital, Belmont, MA 02478, USA.
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Gingrich JA, Malm H, Ansorge MS, Brown A, Sourander A, Suri D, Teixeira CM, Caffrey Cagliostro MK, Mahadevia D, Weissman MM. New Insights into How Serotonin Selective Reuptake Inhibitors Shape the Developing Brain. Birth Defects Res 2018; 109:924-932. [PMID: 28714607 DOI: 10.1002/bdr2.1085] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 06/08/2017] [Accepted: 06/13/2017] [Indexed: 12/28/2022]
Abstract
Development passes through sensitive periods, during which plasticity allows for genetic and environmental factors to exert indelible influence on the maturation of the organism. In the context of central nervous system (CNS) development, such sensitive periods shape the formation of neuro-circuits that mediate, regulate, and control behavior. This general mechanism allows for development to be guided by both the genetic blueprint, as well as the environmental context. While allowing for adaptation, such sensitive periods are also windows of vulnerability during which external and internal factors can confer risk to brain disorders by derailing adaptive developmental programs. Our group has been particularly interested in developmental periods that are sensitive to serotonin (5-HT) signaling, and impact behavior and cognition relevant to psychiatry. Specifically, we review a 5-HT-sensitive period that impacts fronto-limbic system development, resulting in cognitive, anxiety, and depression-related behaviors. We discuss preclinical data to establish biological plausibility and mechanistic insights. We also summarize epidemiological findings that underscore the potential public health implications resulting from the current practice of prescribing 5-HT reuptake inhibiting antidepressants during pregnancy. These medications enter the fetal circulation, likely perturb 5-HT signaling in the brain, and may be affecting circuit maturation in ways that parallel our findings in the developing rodent brain. More research is needed to better disambiguate the dual effects of maternal symptoms on fetal and child development from the effects of 5-HT reuptake inhibitors on clinical outcomes in the offspring. Birth Defects Research 109:924-932, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Jay A Gingrich
- Columbia University Medical Center, Psychiatry, New York, New York
| | - Heli Malm
- Columbia University Medical Center, Psychiatry, New York, New York
| | - Mark S Ansorge
- Columbia University Medical Center, Psychiatry, New York, New York
| | - Alan Brown
- Columbia University Medical Center, Psychiatry, New York, New York
| | - Andre Sourander
- Columbia University Medical Center, Psychiatry, New York, New York
| | - Deepika Suri
- Columbia University Medical Center, Psychiatry, New York, New York
| | - Cátia M Teixeira
- Columbia University Medical Center, Psychiatry, New York, New York
| | | | | | - Myrna M Weissman
- Columbia University Medical Center, Psychiatry, New York, New York
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Zhou XH, Li YJ, Ou JJ, Li YM. Association between maternal antidepressant use during pregnancy and autism spectrum disorder: an updated meta-analysis. Mol Autism 2018; 9:21. [PMID: 29599960 PMCID: PMC5870683 DOI: 10.1186/s13229-018-0207-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 03/19/2018] [Indexed: 11/11/2022] Open
Abstract
Studies have investigated the risk of autism spectrum disorder (ASD) in children exposed in utero to antidepressant, with inconsistent results. Given the substantial public health implications on this topic, here, we presented an updated meta-analysis of the association between maternal antidepressant use during pregnancy and ASD. Cochrane Library, EMBASE, PsycINFO, and PubMed databases were systematically searched. A random effects model was used to pool the adjusted relative risk (RR) for cohort studies and the adjusted odds ratio (OR) for case-control studies as well as their corresponding 95% confidence intervals (CIs). Meta-analysis restricted to sibling studies was also conducted. Publication bias was systematically assessed. Fourteen studies were identified (eight cohort studies and six case-control studies). Pooled adjusted RR for cohort studies (n = 2,839,980) was 1.13 (0.93–1.39) showed a non-significant association; while two studies were potentially missing from the test of publication bias, filled estimates also showed a non-significant association (filled RR 0.97, 95% CI 0.79–1.19). Pooled OR was 1.51 (1.15–1.99) for case-control studies (n = 117,737) showed a significant association; two studies were potentially missing; however, the filled estimates suggested a non-significant association (filled OR 1.26, 95% CI 0.98–1.62). Analyses restricted to sibling studies also showed a non-significant association (RR 0.99, 95% CI 0.81–1.22). In summary, we did not evidence a significant association between maternal antidepressant use during pregnancy and ASD.
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Affiliation(s)
- Xi-Hong Zhou
- 1Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, 410011 Hunan China
| | - Yong-Jiang Li
- 2Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011 Hunan China.,3Institute of Clinical Pharmacy, Central South University, Changsha, 410011 Hunan China
| | - Jian-Jun Ou
- 4Mental Health Institute, The Second Xiangya Hospital, Central South University, Changsha, 410011 Hunan China
| | - Ya-Min Li
- 1Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, 410011 Hunan China
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Morales DR, Slattery J, Evans S, Kurz X. Antidepressant use during pregnancy and risk of autism spectrum disorder and attention deficit hyperactivity disorder: systematic review of observational studies and methodological considerations. BMC Med 2018; 16:6. [PMID: 29332605 PMCID: PMC5767968 DOI: 10.1186/s12916-017-0993-3] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 12/12/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Antidepressant exposure during pregnancy has been associated with an increased risk of autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) in several observational studies. We performed a systematic review of these studies to highlight the effect that important methodological limitations have on such analyses and to consider approaches to the conduct, reporting and interpretation of future studies. METHODS A review of MEDLINE and EMBASE identified case-control, cohort and sibling studies assessing the risk of ASD and ADHD with antidepressant use during pregnancy. Approaches to confounding adjustment were described. Crude and adjusted effect estimates for comparisons between antidepressant exposure during pregnancy vs. all unexposed women were first meta-analysed using a generic inverse variance method of analysis, followed by effect estimates for alternative pre-selected comparison groups. RESULTS A total of 15 studies measuring ASD as an outcome (involving 3,585,686 children and 40,585 cases) and seven studies measuring ADHD as an outcome (involving 2,765,723 patients and 52,313 cases) were identified. Variation in confounding adjustment existed between studies. Updated effect estimates for the association between maternal antidepressant exposure during pregnancy vs. all unexposed women remained statistically significant for ASD (adjusted random-effects risk ratio [RaRR] 1.53, 95% confidence interval [CI] 1.31-1.78). Similar significant associations were observed using pre-pregnancy maternal antidepressant exposure (RaRR 1.48, 95% CI 1.29-1.71) and paternal antidepressant exposure during pregnancy (1.29, 95% CI 1.08-1.53), but analyses restricted to using women with a history of affective disorder (1.18, 95% CI 0.91-1.52) and sibling studies (0.96, 95% CI 0.65-1.42) were not statistically significant. Corresponding associations for risk of ADHD with exposure were: RaRR 1.38, 95% CI 1.13-1.69 (during pregnancy), RaRR 1.38, 95% CI 1.14-1.69 (during pre-pregnancy), RaRR 1.71, 95% CI 1.31-2.23 (paternal exposure), RaRR 0.98, 95% CI 0.77-1.24 (women with a history of affective disorder) and RaRR 0.88, 95% CI 0.70-1.11 (sibling studies). CONCLUSIONS Existing observational studies measuring the risk of ASD and ADHD with antidepressant exposure are heterogeneous in their design. Classical comparisons between exposed and unexposed women during pregnancy are at high risk of residual confounding. Alternative comparisons and sibling designs may aid the interpretation of causality and their utility requires further evaluation, including understanding potential limitations of undertaking meta-analyses with such data.
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Affiliation(s)
- Daniel R Morales
- Pharmacovigilance and Epidemiology Department, European Medicines Agency, 30 Churchill Place, Canary Wharf, London, E14 5EU, UK. .,Division of Population Health Sciences, University of Dundee, Dundee, UK.
| | - Jim Slattery
- Pharmacovigilance and Epidemiology Department, European Medicines Agency, 30 Churchill Place, Canary Wharf, London, E14 5EU, UK
| | - Stephen Evans
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, University of London, London, UK
| | - Xavier Kurz
- Pharmacovigilance and Epidemiology Department, European Medicines Agency, 30 Churchill Place, Canary Wharf, London, E14 5EU, UK
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Muzik M, Hamilton SE. Use of Antidepressants During Pregnancy?: What to Consider when Weighing Treatment with Antidepressants Against Untreated Depression. Matern Child Health J 2017; 20:2268-2279. [PMID: 27461022 DOI: 10.1007/s10995-016-2038-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Maria Muzik
- Department of Psychiatry University of Michigan Rachel Upjohn Building, Women and Infants Mental Health Clinic, 4250 Plymouth Road, Ann Arbor, MI, 48109, USA. .,Department of Psychiatry, University of Michigan, Rachel Upjohn Building, 4250 Plymouth Road, Ann Arbor, MI, 48109, USA. .,Center for Human Growth and Development, University of Michigan, Ann Arbor, MI, USA.
| | - Susan E Hamilton
- Department of Psychiatry, University of Michigan, Rachel Upjohn Building, 4250 Plymouth Road, Ann Arbor, MI, 48109, USA
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Yang F, Chen J, Miao MH, Yuan W, Li L, Liang H, Ehrenstein V, Li J. Risk of autism spectrum disorder in offspring following paternal use of selective serotonin reuptake inhibitors before conception: a population-based cohort study. BMJ Open 2017; 7:e016368. [PMID: 29275337 PMCID: PMC5770959 DOI: 10.1136/bmjopen-2017-016368] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE The present study aimed to examine the association between paternal selective serotonin reuptake inhibitor (SSRI) use before conception and the risk of autism spectrum disorder (ASD) in offspring. DESIGN A population-based cohort study. METHODS We conducted a cohort study of 669 922 children born from 1998 to 2008, with follow-up throughout 2013. Based on Danish national registers, we linked information on paternal use of SSRIs, ASD diagnosed in children and a range of potential confounders. The children whose fathers used SSRIs during the last 3 months prior to conception were identified as the exposed. Cox regression model was used to estimate the HR for ASD in children. RESULTS Compared with unexposed children, the exposed had a 1.62-fold higher risk of ASD (95% CI 1.33 to 1.96) and the risk attenuated after adjusting for potential confounders, especially fathers' psychiatric conditions (HR=1.43, 95% CI 1.18 to 1.74). When extending the exposure window to 1 year before conception, the increased risk persisted in children of fathers using SSRIs only from the last year until the last 3 months prior to conception (HR=1.54, 95% CI 1.21 to 1.94) but not in children of fathers using SSRIs only during the last 3 months prior to conception (HR=1.17, 95% CI 0.75 to 1.82). We also performed stratified analyses according to paternal history of affective disorders and observed no increased ASD risk among children whose father had affective disorders. Besides, the sibling analysis showed that the ASD risk did not increase among exposed children compared with their unexposed siblings. CONCLUSIONS The mildly increased risk of ASD in the offspring associated with paternal SSRI use before conception may be attributable to paternal underlying psychiatric indications related to SSRI use or other unmeasured confounding factors.
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Affiliation(s)
- Fen Yang
- Key Laboratory of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan University, Shanghai, China
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jianping Chen
- Key Laboratory of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan University, Shanghai, China
| | - Mao-Hua Miao
- Key Laboratory of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan University, Shanghai, China
| | - Wei Yuan
- Key Laboratory of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan University, Shanghai, China
| | - Lin Li
- Key Laboratory of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan University, Shanghai, China
| | - Hong Liang
- Key Laboratory of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan University, Shanghai, China
| | - Vera Ehrenstein
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jiong Li
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Abstract
BACKGROUND Previous studies have examined if maternal antidepressant medication during pregnancy increase the risk of autism spectrum disorder (ASD) in the offspring, but the results have been conflicting. METHODS In a population-based cohort of 179 007 children born in 2006 and 2007 and followed through 2014 when aged 7 and 8, we estimated relative risks (RRs) of ASD and 95% confidence intervals (CIs) from Cox regression in children exposed to any antidepressant medication during pregnancy, and nine specific antidepressant drugs. Analyses were adjusted for potential confounders and were conducted in the full population sample, and in a clinically relevant sub-sample of mothers with at least one diagnosis of depression or anxiety during life. RESULTS The adjusted RR of ASD in children of mothers who used antidepressant medication during pregnancy was estimated at 1.23 (95% CI 0.96-1.57), and at 1.07 (95% CI 0.80-1.43) in women with a history of depression or anxiety. Analyses of specific antidepressants initially revealed increased RRs of offspring ASD confined to citalopram and escitalopram (RR: 1.47; 95% CI 0.92-2.35) and clomipramine (RR: 2.86; 95% CI 1.04-7.82). CONCLUSION Medication with antidepressants during pregnancy does not appear to be causally associated with an increased risk of ASD in the offspring. Instead, the results suggest that the association is explained by factors related to the underlying susceptibility to psychiatric disorders. Based on these findings, the risk of ASD in the offspring should not be a consideration to withhold treatment with commonly used antidepressant drugs from pregnant women.
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Affiliation(s)
- A. Viktorin
- Department of Psychiatry, Icahn School of Medicine, Mount Sinai, New York, NY, USA
- The Seaver Autism Center, Research and Treatment at Mount Sinai, New York, NY, USA
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - R. Uher
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - A. Reichenberg
- Department of Psychiatry, Icahn School of Medicine, Mount Sinai, New York, NY, USA
- The Seaver Autism Center, Research and Treatment at Mount Sinai, New York, NY, USA
| | - S. Z. Levine
- Department of Community Mental Health, University of Haifa, Haifa, Israel
| | - S. Sandin
- Department of Psychiatry, Icahn School of Medicine, Mount Sinai, New York, NY, USA
- The Seaver Autism Center, Research and Treatment at Mount Sinai, New York, NY, USA
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Affiliation(s)
- Beth Smith
- Department of Psychiatry, State University of New York at Buffalo, Buffalo, NY, USA
| | - Steven L. Dubovsky
- Department of Psychiatry, State University of New York at Buffalo, Buffalo, NY, USA
- Departments of Psychiatry and Medicine, University of Colorado, Denver, CO, USA
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