Page last updated at 23:04 GMT, Thursday, 24 September 2009 00:04 UK
Anti-depressants pregnancy 'risk'
Woman about to take a pill
Medical treatment must balance the health of the mother with potential adverse effects to the developing baby
Children born to women taking anti-depressants in early pregnancy have a small but important increased risk of heart defects, researchers say.
The study published in the British Medical Journal says depression affects up to 20% of pregnant women.
Exposure to anti-depressants in the womb caused problems in less than 1% of children.
The authors say the overall risk is very low and women should speak to doctors before stopping their drugs.
Selective serotonin re-uptake inhibitors (SSRIs) are medicines commonly used for the treatment of depression .
In 2005, the US Food and Drug Administration issued a warning about the SSRI paroxetine because of an increase in birth defects if it was taken during pregnancy.
Septal heart defects
This study looked at whether there was an association between SSRIs taken in the first trimester of pregnancy and malformations in over 400,000 children born in Denmark between 1996 and 2003.
Maternal age and smoking were taken into account.
The defects found are known as septal heart defects where there is a problem with the wall that divides the left side of the heart from the right side.
The researchers from Aarhus University in Denmark said these defects were 0.4% more prevalent in children of women who redeemed a prescription for an SSRI in the first trimester of pregnancy.
Two SSRIs, sertraline and citalopram, were associated with the problem.
Two others, paroxetine and fluoxetine, were not.
A four-fold increase in septal heart defects was found if women were taking more than one SSRI.
There were no other malformations associated with taking SSRIs.
The benefits to the mother of taking SSRIs during pregnancy needs to be weighed up against the small increase in risk to the foetus
Cathy Ross, of the British Heart Foundation
The researchers say the absolute differences in heart defects were low.
Septal heart defects occurred in 2,315 (0.5%) of unexposed children, 12 (0.9%) of SSRI exposed children and 4 (2.1%) of children exposed to more than one type of SSRI.
They estimate that one child for every 246 children exposed was likely to suffer a heart defect.
Lars Henning Pedersen, who led the research, said: "Treatment of depression during pregnancy balances the risk of the medicine with that of the depression, and we investigated only a part of the information needed to make evidence based decisions.
"Even if SSRI use is causally related to septal heart defects, these heart defects might not necessarily require treatment and some might resolve spontaneously."
Professor Basky Thilaganathan, of the Royal College of Obstetrics and Gynaecology, said it was important to remember that many women who suffered depression could be treated without resorting to drugs.
He said: "All hospitals now have a dedicated doctor or liaison officer for women suffering psychiatric symptoms in pregnancy.
"This study shows a less than one in a 100 chance of getting a baby with a defect in the heart."
Cathy Ross, cardiac nurse at the British Heart Foundation (BHF), said: "Depression can be a debilitating condition.
"The benefits to the mother of taking SSRIs during pregnancy needs to be weighed up against the small increase in risk to the foetus."
Published 23 September 2009, doi:10.1136/bmj.b3569
Cite this as: BMJ 2009;339:b3569
Selective serotonin reuptake inhibitors in pregnancy and congenital malformations: population based cohort study
Lars Henning Pedersen, research assistant, visiting scholar 1,2, Tine Brink Henriksen, consultant3, Mogens Vestergaard, general practitioner and associate professor4, J?rn Olsen, professor and chair2, Bodil Hammer Bech, associate professor1
1 Department of Epidemiology, Institute of Public Health, Aarhus University, Bartolin Alle' 2, DK-8000 Aarhus, Denmark, 2 UCLA School of Public Health, Department of Epidemiology, 650 Charles E Young Drive South, Los Angeles, CA 90095-1772, USA, 3 Department of Paediatrics, Aarhus University Hospital, DK-8200 Aarhus, Denmark, 4 Department of General Practice, Institute of Public Health, Aarhus University, Bartolin Alle' 2, DK-8000 Aarhus, Denmark
Correspondence to: Lars Henning Pedersen, Department of Epidemiology, Institute of Public Health, Aarhus University, Bartolins Alle' 2, 8000 Aarhus C, Denmark LHP@dadlnet.dk
Objective To investigate any association between selective serotonin reuptake inhibitors (SSRIs) taken during pregnancy and congenital major malformations.
Design Population based cohort study.
Participants 493 113 children born in Denmark, 1996-2003.
Main outcome measure Major malformations categorised according to Eurocat (European Surveillance of Congenital Anomalies) with additional diagnostic grouping of heart defects. Nationwide registers on medical redemptions (filled prescriptions), delivery, and hospital diagnosis provided information on mothers and newborns. Follow-up data available to December 2005.
Results Redemptions for SSRIs were not associated with major malformations overall but were associated with septal heart defects (odds ratio 1.99, 95% confidence interval 1.13 to 3.53). For individual SSRIs, the odds ratio for septal heart defects was 3.25 (1.21 to 8.75) for sertraline, 2.52 (1.04 to 6.10) for citalopram, and 1.34 (0.33 to 5.41) for fluoxetine. Redemptions for more than one type of SSRI were associated with septal heart defects (4.70, 1.74 to 12.7)). The absolute increase in the prevalence of malformations was low―for example, the prevalence of septal heart defects was 0.5% (2315/493 113) among unexposed children, 0.9% (12/1370) among children whose mothers were prescribed any SSRI, and 2.1% (4/193) among children whose mothers were prescribed more than one type of SSRI.
Conclusion There is an increased prevalence of septal heart defects among children whose mothers were prescribed an SSRI in early pregnancy, particularly sertraline and citalopram. The largest association was found for children of women who redeemed prescriptions for more than one type of SSRI.
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Treatment guidelines issued on depression during pregnancy
For women with serious conditions, medication may be the best route, but 'talk therapy' may alleviate suffering for others, according to a document prepared by two national physicians groups.
By Melissa Healy
September 17, 2009 | 6:15 p.m
For the nearly one in four women who experience symptoms of depression during pregnancy, physicians on the front lines have long had little more than a prescription for antidepressants and a massive dose of uncertainty to offer.
The result: At last count, roughly 13% of pregnant women in the United States took antidepressant medications at some point in their pregnancy -- often with little to guide them in weighing the risks the drugs may pose to their fetus against the misery and dangers of untreated depression.
In a bid to resolve that conundrum, two of the nation's leading physicians groups have issued the first guidelines for the treatment of depression during pregnancy.
The document, hammered out by the American Psychiatric Assn. and the American College of Obstetricians and Gynecologists, asserts that for women with serious, recurring depression or suicidal inclinations, the dangers of under-treatment may well outweigh the risks that antidepressants may pose to a developing fetus. At the same time, the guidelines stress that for many pregnant women suffering from depression, "talk therapy" alone may be the best option, and should be routinely offered.
The guidelines were hailed as a clarion call to obstetricians to look for signs of depression in the population most at risk for it -- women of childbearing age -- as a matter of course, and to treat the common affliction with a range of options that goes beyond the prescription pad. At the same time, the document leaves psychiatrists, who are often reluctant to assume the care of a pregnant woman, with little doubt of their key role in guiding the treatment of mothers-to-be.
"This is a very exciting time in obstetrics and psychiatry, a golden opportunity for us to really make a difference in the lives of women and their children," said UCLA psychiatrist Vivien Burt, a leading researcher in mood disorders in women. "The professional organization of ob-gyns has now clearly stated depression is a problem, and that as the medical gateway for many women, it is incumbent on them to be aware of it and screen women of childbearing age."
The guidelines summarize a growing body of evidence suggesting that antidepressant use during pregnancy, while often necessary to protect the well-being of the mother-to-be, poses some risk to her fetus.
Babies who were exposed to antidepressants while in the womb are slightly more likely to be underweight at birth and, although the data are inconsistent, to be born earlier than those not exposed to such drugs. And those whose mothers took the newest generation of antidepressants in late pregnancy are far more likely to suffer a cluster of problems in their first two weeks of life, including irregular heartbeat, temperature and blood sugar instability, irritability and sometimes seizures.
But the guidelines are also notable for their focus on a danger to babies and children long ignored: that of having a mother with severe, untreated depression. Many studies suggest that the depression of a pregnant woman can result in poorer nutrition and prenatal care, earlier birth and a heightened risk that her child will also develop depression.
For women with a personal or family history of disabling depression, or with more serious mental illness such as bipolar disorder or psychosis, such considerations make the risks of taking medication worthwhile, the drafters of the guidelines concluded.
For the bulk of pregnant women with depression symptoms, the guidelines appear to tack toward the treatment considered widely effective and least risky: psychotherapy.
"Many people -- physicians and women alike -- will be glad to know that their choices go beyond 'medication or nothing,' " said Dr. Gerald Joseph Jr., president of the American College of Obstetricians and Gynecologists.
The guidelines come after years of escalating use of antidepressant medications in pregnant women. Between 1999 and 2003, the rate of antidepressant use by women at some point during pregnancy doubled.
The new recommendations may temper that growth -- or at least shift the drugs' use to the most severely depressed patients.
Copyright © 2009, The Los Angeles Times
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