Updates on Antidepressant Use
TREATING PRECONCEPTION DEPRESSION: TO STOP SSRIs OR NOT
Andersen JT, Andersen NL, Horwitz H, et al. Exposure to selective serotonin reuptake inhibitors in early pregnancy and the risk of miscarriage. Obstet Gynecol. 2014;124(4):655-661. doi: 10.1097/AOG.0000000000000447.
Miscarriage rates in women taking selective serotonin reuptake inhibitors (SSRIs) in early pregnancy were higher than in those not taking SSRIs but similar to those who discontinued SSRI treatment prior to pregnancy, a Danish cohort study revealed.
Out of 1.3 million pregnancies between 1997 and 2010, researchers identified 22,884 women who were exposed to an SSRI during the first 35 days of pregnancy and found miscarriage rates of 13% in those exposed to the antidepressants, compared to 11% for those not exposed. Investigators also identified 14,016 women who discontinued SSRI treatment three to 12 months prior to conception and found a miscarriage rate of 14%.
The adjusted hazard ratio for miscarriage while taking SSRIs in early pregnancy was 1.27, and for miscarriage after discontinuing SSRIs prior to pregnancy, 1.24. When the data were stratified according to specific SSRIs, rates were lowest among those taking fluoxetine during pregnancy (1.10) and highest among those taking sertraline (1.45). Miscarriage rates among women who stopped SSRIs prior to pregnancy were lowest for fluoxetine (1.2) and highest for escitalopram (1.33).
“Because the risk for miscarriage is elevated in both groups compared with an unexposed population, there is likely no benefit in discontinuing SSRI use before pregnancy to decrease one’s chances of miscarriage,” the study authors conclude.
COMMENTARY
The effects of depression on a woman’s experience during pregnancy are large, as are the effects of depression on pregnancy outcomes. Depression during pregnancy is associated with increased rates of prematurity, low birth weight, and preeclampsia.1 Depression during pregnancy is also an important risk factor for postpartum depression, which affects babies as well as mothers and is associated with maternal suicide.
At the same time, use of SSRIs in pregnancy has been inconsistently associated with miscarriage, cardiac defects, premature birth, and primary pulmonary hypertension in the newborn.2 This study is reassuring in that SSRIs are unlikely to be a significant contributor to miscarriage. But it is important to realize that this article only addresses miscarriage rates, not other potential effects of SSRIs on the fetus. The decision about the use of SSRIs in pregnancy remains a difficult one, balancing risk and benefit. When determining that balance, bear in mind that cognitive behavioral therapy (CBT) has been shown in other studies to be equally effective to medication in treating depression and may also be considered in our range of options for treatment of depression in pregnancy.3,4
The decision about whether to use or continue an SSRI and whether to use or supplement with CBT instead is an important one and always requires detailed discussion with the mother-to-be.
1. Grigoriadis S, VonderPorten EH, Mamisashvili L, et al. The impact of maternal depression during pregnancy on perinatal outcomes: a systematic review and meta-analysis. J Clin Psych. 2013;74:e321-341.
2. Meltzer-Brody S. Treating perinatal depression: risks and stigma. Obstet Gynecol. 2014;124(4):653-654. doi: 10.1097/AOG.0000000000000498.
3. Keller MB, McCullough JP, Klein DN, et al. A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression [published correction appears in N Engl J Med. 2001;345(3):232]. N Engl J Med. 2000;342(20): 1462-1470.
4. Cuijpers P, Hollon SD, van Straten A, et al. Does cognitive behaviour therapy have an enduring effect that is superior to keeping patients on continuation pharmacotherapy? A meta-analysis. BMJ Open. 2013;3(4). pii: e002542. doi: 10.1136/bmjopen-2012-002542.
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