Antidepressant Medication in Pregnancy and Breastfeeding Dr Jeffrey Cubis Senior Lecturer Academic Unit of Psychiatry and Addiction Medicine Australian National University Medical School Senior Staff Specialist Child and Adolescent Mental Health Service, MHJHADS ACT 1
Topics for Discussion Current trends in antidepressant use in Australia in women childbearing Rationale for their use General principles and specific issues with antidepressants. Breastfeeding implications 2
Trends in Perinatal Mental Health Increased identification and referral of women with mental health problems associated with childbearing. Steady increase in interest and services. A move away from purely a postnatal depression focus to include anxiety disorders. Early presentations both antenatal and for preconception planning. Increased use of ADs in pregnancy and the general population. Rate in US in pregnancy has more than doubled over ten years. 2-3% exposed to SSRIs in Australia. 3
New Information: Better large studies of SSRI use in pregnancy but limits without RCT Still difficulties understanding risk in utero exposure; eg consequence of severity of depression, time and length of exposure, genetic factors, other important confounding variable data not obtained. More information on neurodevelopmental outcome but still limited. Less perceived risk when breastfeeding with newer medication. 4
Rationale for Use of ADs Current Depressive and Anxiety Disorders: Major Depression (7% during course of pregnant women),anxiety Disorders, OCD, Social Phobia, Eating Disorders, PTSD Maintenance Medication: relapse, inability to withdraw and fear of withdrawal Adjunctive to non medical therapies Effective in the past Risk of Relapse 5
Benefits Untreated Major Mental Illness: Associated with increased risk of pregnancy related complications Prematurity, gestational diabetes, low birth weight Major indirect cause of maternal mortality Smoking, alcohol use, poor care and compliance More negative offspring outcomes Poorer child development, childhood behavioural problems, and HPA stress abnormalities Still limited data compared to treatment 6
General Risk of Use in Pregnancy Teratogenic Increased risk of miscarriage or infant mortality Prematurity, birth and neonatal complications Neurodevelopmental long term consequences 7
Impressions in Canberra More interest in this population Antenatal referral exceed postnatal referral Many more on medication More comorbidity, particularly personality disorders, substance abuse and difficult social circumstances (homelessness) 8
SSRI and Antidepressants in Pregnancy Generally better clearer information but some continued controversies. Miscarriage risk similar to other psychoactive drugs Women who cease SSRI before pregnancy have same risk of miscarriage as those that continue. No evidence of increased stillborn. 9
SSRI and Antidepressants and Teratogenicity Teratogenic effects considered low < 3%. Mentally ill women have increased risks usually less than population rate < 3% but above 1.8% in well women. Issues mainly about cardiac septal defects. Paroxetine most highlighted, but all likely involved. TC do not known to produce any. 10
SSRI and Antidepressants at Birth and Neonatal Prematurity with risk from SSRI similar to depression and anxiety. Lower birth weight. Greater with exposure and more than 1 SSRI. Neonatal Adjustment Syndrome. 10-15% in exposed infants at birth. Common but no deaths and clinically insignificant. Neonatal Pulmonary Hypertension Syndrome reported as over-represented. Currently less concern, temporary and serotonergic withdrawal syndrome. Only 33 babies identified as exposed to SSRI 11
SSRI and Antidepressants and Neurodevelopment Concerns about neurodevelopmental but subtle Reports of ADHD, behavioural issues and cognitive differences in exposure to SSRi in pregnancy.not consistent findings and generally don t control severity of depression or other illness factors. Some evidence for better cognitive effects as well, but untreated definitely worse but no RCTs Some studies report increase in Autism rates from exposure. Unclear 12
SSRI Principle of Use Plan preferably before pregnancy and preferably withdrawal if indicated. Don t stop because of a pregnancy with out proper consideration. Consider non- medical interventions Inform of risk and uncertainties Some patience to allow adequate consent and discussion with others Often doesn t happen and difficult to withdraw 13
SSRI Principle use (cont.) Avoid first trimester use if possible but often present pregnant and then often need it again. Use drug at lower doses, preferable established AD as more data available. Avoid changing and polypharmacy as this associated with increased teratogenic risk Don t need to discontinue before birth 14
Breastfeeding Much less concerns than in the past because of studies showing the specific levels baby exposed to. This only applies to well normal babies. Very little literature otherwise May be not able to continue across delivery with the same medication Don t recommend withholding mane 15
Breastfeeding SSRI Can use modern ADs particularly as Maternal Weight adjusted dose less than 10 % and most less than 5% Sertraline 2%. Fluoxetine has a long half life in first 10 days Monitor the baby recommended still. 16
Conclusions: Clearer benefit, but some way to go Consider risk and uncertainty of risks Informed consent and support Plan well ahead and don t stop impulsively and only taper. Simple, proven effective, lower doses Consider non medical intervention; eg multidiscipline,psychotherapies,support, PANSI etc 17
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