II. Epidemiology

  1. Pregnancy is not protective against Major Depression

III. Adverse Effects: Untreated Depression

  1. Untreated Depression risks
    1. Suicide
    2. Adverse effects on family functioning
    3. Increased risk of Intrauterine Growth Retardation and low birth weight
    4. Increased risk of preterm birth
  2. Concurrent adverse habit risks
    1. Tobacco abuse
    2. Alcohol Abuse
    3. Illicit Drug abuse

IV. Adverse Effects

  1. SSRIs appear to be safe as a class in pregnancy
  2. Persistent Pulmonary Hypertension
    1. Increased risk by 6 fold if SSRIs used after 20 weeks
    2. Number needed to harm: 286-351
    3. Grigoriadis (2014) BMJ 348:f6932 [PubMed]
  3. Paroxetine (Paxil)
    1. Made Category D in 2005
    2. See Paxil for details
    3. Associated with cardiac defects with first trimester exposure
  4. Fluoxetine
    1. Well studied in pregnancy, but data in 2015 showed association with cardiac defects
    2. Association with VSD, right ventricular outflow tract obstruction cardiac defects, and Craniosynostosis
    3. Avoid in Lactation due to increased Fluoxetine levels in Breast Milk
    4. Berard (2015) Br J Clin Pharmacol +PMID:26613360 [PubMed]
  5. Studies that show no longterm newborn effects
    1. Addis (2000) Psychol Med 30:89-94 [PubMed]
    2. Hendrick (2003) Am J Obstet Gynecol 188:812-5 [PubMed]
  6. Some reports of short-term neonatal withdrawal
    1. Weak cry, mild Tachypnea, jitteriness
    2. Wisner (1999) JAMA 282:1264-9 [PubMed]
  7. SSRIs that have shown mixed or weak associations with Autism (as one of many contributing factors)
    1. Boukhris (2016) JAMA Pediatr 170(2):117-2 +PMID:26660917 [PubMed]
    2. Harrington (2014) Pediatrics 133:e1241-8 +PMID:24733881 [PubMed]
    3. Hviid A (2013) N Engl J Med 369:2406-15 [PubMed]
    4. Rai (2013) BMJ 346:f2059 [PubMed]

V. Management

  1. Treat Major Depression in Pregnancy
  2. Consult mental health counseling
    1. Psychotherapy (esp. CBT) is preferred first-line therapy over medication
    2. However, untreated depression is associated with low birth weight, preterm-birth, C-Section
  3. Select SSRI Antidepressants with most safety data
    1. Sertraline (Zoloft)
      1. Most commonly used SSRI in pregnancy, and preferred agent
      2. May be continued into Lactation (poorly secreted into Breast Milk)
    2. Citalopram (Celexa)
    3. Escitalopram (Lexapro)
  4. Avoid agents associated with adverse effects
    1. Avoid Fluoxetine (Prozac)
      1. Best studied in pregnancy, but see adverse effects above
    2. Avoid Paroxetine (Paxil) due to higher fetal risk
  5. Avoid agents with insufficient efficacy and safety data in pregnancy
    1. Avoid Docosahexaenoic Acid
    2. Avoid St. John's Wort

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