More on SSRIs and Pregnancy

With recent FDA warnings regarding potential risks associated with both continuation and discontinuation of antidepressants during and after pregnancy, the impact on both the clinician and patient is striking. In the hopes of highlighting some of the most relevant implications, I wanted to review some of this information.

Here are some highlights of the findings:

–The use of an SSRI antidepressant beyond the 20th week of pregnancy was linked to a 6-fold increase in the risk for persistent pulmonary hypertension (PPHN) in newborns. (New England Journal of Medicine, Christina D. Chambers, Ph.D., M.P.H.) PPHN, which typically occurs in 1 or 2 per 1000 births, often involves severe respiratory failure that requires immediate treatment. The higher risk also was not seen in women who stopped taking SSRIs by the 20th week of pregnancy

–68 percent of women who stopped taking their antidepressant after getting pregnant had a significant relapse into depression. (Lee S. Cohen, MD, Perinatal and Reproductive Psychiatry Clinical Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Mass )

–The FDA advises that women taking antidepressants during their pregnancy (or if they are thinking about becoming pregnant) consult with their healthcare professional prior to discontinuing or continuing their antidepressant. Patients who decide to discontinue these medications should always be closely monitored for discontinuation symptoms as well as for depression relapse.

–Use of paroxetine (Paxil) during the first trimester has been linked to an increased risk for cardiac birth defects.(Birth Defects Research Part B: Developmental and Reproductive Toxicology, December 2006)

–Since we know that approximately 10% to 15% of women in the general population suffer from depression during pregnancy, this information is important (not to mention anxiety producing) for a large number of women. This information is particularly pertinent to women with histories of depression who are thinking of discontinuing their antidepressants during pregnancy.

Because of these recent findings, the SSRIs have been under some scrutiny, which can be a good thing. The decision to take antidepressant medication, especially during pregnancy, is complicated and should be carefully considered. As we know, this decision should ALWAYS include a risk-benefit analysis. Women need to be made aware of both sides: the risks of taking the meds as well as the risk of not taking them. The last thing we want is women on medication if they don’t need it, OR women who do need it, to be afraid to take it.

Therefore, we all must be vigilant about understanding this information and making certain our clients have all the information so we can help them make informed decisions. Women with severe or recurrent illnesses may determine that the risks associated untreated symptoms is greater than the risk of SSRI exposure.

Clinicians should keep the following in mind:

1) Make certain you stay in touch with your client’s prescribing physician so you are all on the same page.
2) A client should NEVER discontinue her meds abruptly and should always contact her physician, even if she unexpectedly finds herself pregnant and feels it is best to be off her meds. Abrupt discontinuation can be associated with withdrawal symptoms in some women.
3) Make certain your client is aware of all risks, the risk of taking meds as well as the risk of not taking meds. This should include comprehensive dialogues with healthcare providers, therapy sessions with with or without partner, literature review of pertinent studies and a careful examination of her history on or off meds.

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