Q. I am currently talking Remeron for depression. I am about 16 weeks pregnant and doing well. I recently started working with a new psychiatrist, and my new doctor suggested that I switch to Prozac because he thought it would be safer for the baby. I am a little worried about making a change; I have never tried Prozac before and had a bad reaction (horrible anxiety and insomnia) when I tried Lexapro.
Over the past few years, multiple reports have raised questions regarding the safety of selective serotonin reuptake inhibitor (SSRI) antidepressants during pregnancy. Chambers and colleagues reported that exposure to SSRIs late in pregnancy may be associated with an increased risk of persistent pulmonary hypertension of the newborn (PPHN). In the general population, PPHN affects about 1 to 2 per 1000 live births. Infants with PPHN are typically full-term or near-term and present shortly after delivery with severe respiratory distress. In the worst cases, PPHN requires intubation and mechanical ventilation and may result in long-term morbidity. In 2006, Chambers and colleagues published an article linking SSRI use during late pregnancy to an increased risk of persistent pulmonary hypertension in the newborn. Based on the results of this analysis, the authors estimated the risk of PPHN to be about 1% in infants exposed to SSRIs late in pregnancy (after 20 weeks).
Over the past 15 years, multiple studies have addressed the reproductive safety of various antidepressants. Data on the overall teratogenicity of SSRIs has come from relatively small prospective observational studies, larger international birth registries, managed health care databases, and case series; these data have cumulatively supported the reproductive safety of fluoxetine and certain other SSRIs. In a recent meta-analysis including 1774 antidepressant-exposed infants, first trimester exposure to SSRIs was not associated with an increased risk of major malformations above the baseline of 2%-3% seen in the general population (Einarson & Einarson, 2005). The bulk of the data thus far has suggested that SSRIs are not major teratogens; however, concerns about the potential teratogenicity of SSRIs were first raised in 2005 when several preliminary studies suggested that paroxetine may be associated with a small increase in risk of congenital abnormalities.
Depression during pregnancy is common. While concerns have been raised regarding the potential teratogenic and long-term neurobehavioral effects of psychotropic drug use during pregnancy, what is often overlooked is the fact that untreated maternal depression may also put the unborn baby at risk.
As many of the traditional mood stabilizers used to treat bipolar disorder, including lithium and valproic acid, carry some teratogenic risk and the reproductive safety of other medications, including the atypical antipsychotic agents, has not been well-characterized, many women with bipolar disorder decide to discontinue their treatment during pregnancy. A new study from Dr. Adele Viguera and her colleagues at the Massachusetts General Hospital and the Emory University School of Medicine helps to better define the risks associated with discontinuing treatment during pregnancy.
Epidemiologic studies suggest that about 10% to 15% of women suffer from clinically significant depressive symptoms during pregnancy. Little is known, however, about the prevalence of depression among women with high risk pregnancies. A recent study published online in the Journal of Clinical Psychiatry suggests that this population may be at significant risk for antenatal depression.
At our clinic we have the opportunity to see patients at various stages of pregnancy. When we evaluate a patient while she is still in the planning stages, we may recommend changing medications to those that have a better studied safety profile during pregnancy and see how she does on those medications prior to conception. If that same patient came into our clinic for an evaluation, but was already pregnant, we may make different recommendations than if she was in the planning stages.
A few weeks ago, January 7-13, 2008, was National Folic Acid Awareness Week at the Centers for Disease Control (CDC), therefore we wanted to take the opportunity to remind women of the importance of folic acid in the prevention of birth defects. Folic acid can prevent from 50-70% of neural tube defects, which are defects of the spine (spina bifida) or the skull (anencephaly). Spina bifida is the leading cause of childhood paralysis and anencephaly is nearly always fatal.
Electroconvulsive therapy (ECT) is one of the most effective treatments for depression, with response rates that are consistently higher than those observed in clinical trials of antidepressants. Furthermore, ECT may be more effective than medications for treatment-refractory depression. The American Psychiatric Association (APA) recommends ECT for patients who have had previous positive response to ECT or who are non-responsive to pharmacological treatments, as well as for those patients who experience severe psychiatric symptoms, including depression with psychosis. suicidal ideation, and mania.
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