Q. I have taken Paxil for about six years for depression and obsessive-compulsive disorder. I have tried several times to stop the medication but the symptoms come back within a few weeks of stopping the medication. My husband and I are now planning a pregnancy, and my obstetrician tells me that I cannot take Paxil during pregnancy. Are there any other options?
A recent report suggests that newborns exposed to selective serotonin reuptake inhibitors (SSRI) antidepressants such as Prozac, Zoloft, Celexa and Paxil may be at risk for developing withdrawal symptoms after delivery (Levinson-Castiel 2005). However, the investigators also noted that the symptoms usually disappeared within 48 hours and did not require medical intervention.
Literature accumulated over the last decade supports the use of certain selective serotonin reuptake inhibitors (SSRIs) and the older tricyclic antidepressants during pregnancy, indicating no increased risk of congenital malformation in children exposed to these medications during the first trimester of pregnancy. Still, questions remain regarding the purported risk for "toxicity" in newborns exposed to antidepressants around the time of labor and delivery (see Fall 2004 and Spring 2005 Newsletters). In addition, a recent study published in the New England Journal of Medicine has linked SSRI use during late pregnancy to an increased risk of persistent pulmonary hypertension in the newborn (Chambers 2006).
Over the last decade, the number of reproductive-age women treated for depression has increased significantly. Given the incomplete information available regarding the reproductive safety of many antidepressant medications, many women choose to discontinue pharmacologic treatment during pregnancy. However, several studies estimate that about 10 to 15% of women suffer from depression during pregnancy (O'Hara et al, 1990; Evans et al, 2001). A recent study from the Center for Women's Mental Health indicates that the risk for depression is particularly high among women with histories of major depression (Cohen et al, 2006).
Literature accumulated over the last decade supports the use of certain selective serotonin reuptake inhibitors (SSRIs) and the older tricyclic antidepressants during pregnancy, indicating no increased risk of congenital malformation in children exposed to these medications during the first trimester of pregnancy. Still, questions remain regarding the purported risk for "toxicity" in newborns exposed to antidepressants around the time of labor and delivery. Several recent studies have suggested that exposure to SSRIs at the time of delivery may be associated with poor perinatal outcomes (Casper 2003, Laine 2003, Simon 2002, Zeskind and Stephens 2004) and prompted the FDA to include warnings in the packaging inserts regarding the use of certain antidepressants, including the selective serotonin reuptake inhibitors (SSRIs) and venlafaxine (Effexor), during pregnancy. These studies have been reviewed previously on the CWMH website (Newsletters Fall 2004 and Spring 2005).
Over the past 15 years, multiple studies have addressed the reproductive safety of the selective serotonin reuptake inhibitors (SSRIs). Data on the overall teratogenicity of SSRIs come from relatively small cohort studies and larger international programs, and they have cumulatively supported the reproductive safety of fluoxetine (Prozac) and certain other SSRIs. However, several recent studies have raised concerns regarding the use of SSRIs during pregnancy.
Every year more than 1.7 million women in the United States enter into menopause. During this time of hormonal fluctuations it is typical for women to experience hot flashes, night sweats and sleep disturbance. More recently, studies have identified an association between menopausal transition and an increased risk for developing depressive symptoms (Harlow et al., 2003; Freeman et al., 2004). It is not clear how physicians and patients should deal with menopause-related physical and emotional symptoms. While hormone therapy effectively treats insomnia and hot flashes, the results have been mixed in treating mood and anxiety symptoms. Moreover, the safety of long-term use of hormone therapy is not known.
Although primarily used to treat schizophrenia and other psychotic disorders, the newer “atypical” antipsychotic agents are now used widely to treat a spectrum of psychiatric disorders, including major depression, bipolar disorder, PTSD and other anxiety disorders. While the reproductive safety of the older typical antipsychotic drugs, such as haloperidol (Haldol) and perphenazine (Trilafon), is supported by data accumulated over the past 40 years, we have far less data on the newer atypical agents: olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), and clozapine (Clozaril).
Because rates of postpartum illness are very high in women with bipolar disorder, it is generally recommended that mothers continue treatment with a mood stabilizer throughout the postpartum period to reduce their risk of relapse; however, the use of medications during the postpartum period is complicated by the issue of breastfeeding. All medications are secreted into the breast milk, although their concentrations appear to vary (Chaudron and Jefferson, 2000).
More than 50 percent of women experience some perimenopausal symptoms, including hot flushes, night sweats, and sleep disturbance, before reaching the menopause. A recent article from Aetna Intelihealth notes that many women may also experience depression. In a study form Dr. Claudio Soares, women with clinically confirmed perimenopause were interviewed:
