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April 2010

Depression during Pregnancy
New guidelines aid clinicians in treating pregnant women with depression.

SSRIs versus an SNRI
A new study failed to find enhanced benefit from duloxetine (Cymbalta) compared with generic selective serotonin reuptake inhibitors in patients with depression.

Zopiclone and Morning-After Impairment
In a small trial of older adults, driving ability and cognitive performance were impaired the morning after subjects took a dose of zopiclone at bedtime.

In Brief
Antipsychotic Polypharmacy Does Not Increase Mortality Risk in Schizophrenia; Tarenflurbil Fails to Slow Cognitive Decline in Alzheimer’s Disease

Second-Generation Antipsychotics Cause Weight Gain and Adverse Metabolic Effects in Young Patients
Second-generation antipsychotics can be life-saving for youth with serious psychiatric illnesses, but they carry the risk for weight gain and possible long-term cardiovascular and metabolic problems.

Depression during Pregnancy

April 2010

Approximately 10% to 20% of pregnant women suffer from depression. Between 1993 and 2003, the percentage of women treated with antidepressants during pregnancy increased from 5.7% to 13.4%.1 Use of selective serotonin reuptake inhibitors (SSRIs) during pregnancy increases the risks of septal heart defect, preterm delivery, low 5-minute Apgar score, and admission to a neonatal intensive care unit. Both antidepressant use and gestational depression have been associated with poor fetal growth, premature delivery, and short-term behavioral changes in neonates. SSRIs might cause a slightly increased risk of fetal malformations when taken early in pregnancy and may increase the risk of persistent pulmonary hypertension when used later (BTP 2006;29:25-26). However, depression itself may confound these associations.

A recent population-based study of almost 500,000 children born in Denmark between 1996 and 2003 found an association between maternal use of SSRIs during pregnancy and septal heart defects in the babies.2 Taking one SSRI during pregnancy doubled the risk of a septal heart defect, and if more than one type of SSRI was taken, the rate increased about fourfold. The lead author of this study, however, notes that the absolute risk of a septal heart defect when a pregnant woman is treated with an SSRI is relatively small: an increase of one infant having the cardiac anomaly per 240 treated mothers.

Interviewed for an article in JAMA,1 Dr Nada Stotland observed that a woman who finds out she's pregnant while taking an antidepressant may choose to switch to another antidepressant she believes to be safer. But such a switch can produce risks for both mother and fetus, as the new agent may not be as effective, and the embryo will be exposed to two different drugs.

A study of 57,000 Danish women treated with sertraline (Zoloft and others), citalopram (Celexa), fluoxetine (Prozac and others), paroxetine (Paxil and others), or escitalopram (Lexapro) found that SSRI treatment during pregnancy approximately doubled the chance of a premature delivery and increased the risk of the newborn having a 5-minute Apgar score of 7 or 3 Infants of mothers who used SSRIs were more likely to be admitted to neonatal intensive care units. The authors of this study suggest that women taking antidepressants during pregnancy should be followed closely and their babies monitored carefully.

The American College of Obstetricians and Gynecologists (ACOG) and the American Psychiatric Association (APA) have jointly developed new guidelines for the treatment of women who experience depression during pregnancy.1 These guidelines call for cognitive behavioral therapy (CBT) or interpersonal psychotherapy (IPT) as first-line treatment for women with mild to moderate depression who are pregnant or plan to become pregnant but are not yet taking antidepressants. If a woman is depressed and taking a medication but has not yet conceived, the guidelines call for careful assessment of the patient, continuation of the antidepressant if symptoms are moderate to severe, and possibly counseling the patient to delay conception until her condition improves. If symptoms are mild or absent, the guidelines suggest tapering the medication. If a pregnant woman has severe or recurring depression, continuation or initiation of an antidepressant may be appropriate, and clinicians are encouraged to add CBT or IPT. The guidelines acknowledge that it is often difficult to find therapists trained in CBT or IPT and suggest the alternative of web-based therapy.

Finally, the guidelines recommend asking a woman who wishes to take an antidepressant during pregnancy whether her family is supportive. If family members are skeptical, the woman should be encouraged to bring them to appointments and to share information with them.

It remains a truism that depression in a woman who is or could become pregnant creates a serious dilemma. The issues are best dealt with knowledgeably and openly among all clinicians involved, the patient, and concerned family members.

1Kuehn BM: No easy answers for physicians caring for pregnant women with depression. JAMA 2009;302:2413-2414,2420.

2Pedersen LH, Henriksen TB, Vestergaard M, Olsen J, Bech BH: Selective serotonin reuptake inhibitors in pregnancy and congenital malformations: Population based cohort study. BMJ 2009;339:b3569.

3Lund N, Pedersen LH, Henriksen TB: Selective serotonin reuptake inhibitor exposure in utero and pregnancy outcomes. Arch Pediatr Adolesc Med 2009;163:949-954.