To estimate the rate of admissions to NICUs, as well as infants’ morbidity and neonatal interventions, after exposure to antidepressant drugs in utero.
Data on pregnancies, deliveries, prescription drug use, and health status of the newborn infants were obtained from the Swedish Medical Birth Register, the Prescribed Drug Register, and the Swedish Neonatal Quality Register. We included 741 040 singletons, born between July 1, 2006, and December 31, 2012. Of the infants, 17 736 (2.4%) had mothers who used selective serotonin reuptake inhibitors (SSRIs) during pregnancy. Infants exposed to an SSRI were compared with nonexposed infants, and infants exposed during late pregnancy were compared with those exposed during early pregnancy only. The results were analyzed with logistic regression analysis.
After maternal use of an SSRI, 13.7% of the infants were admitted to the NICU compared with 8.2% in the population (adjusted odds ratio: 1.5 [95% confidence interval: 1.4–1.5]). The admission rate to the NICU after treatment during late pregnancy was 16.5% compared with 10.8% after treatment during early pregnancy only (adjusted odds ratio: 1.6 [95% confidence interval: 1.5–1.8]). Respiratory and central nervous system disorders and hypoglycemia were more common after maternal use of an SSRI. Infants exposed to SSRIs in late pregnancy compared with early pregnancy had a higher risk of persistent pulmonary hypertension (number needed to harm: 285).
Maternal use of antidepressants during pregnancy was associated with increased neonatal morbidity and a higher rate of admissions to the NICU. The absolute risk for severe disease was low, however.
Comments
RE: Treating depression in pregnant women: yes, but with psychotherapy first
Dear Dr Braillon,
Thank you for commenting on our publication concerning neonatal morbidity after in utero exposure to antidepressant drugs. We would like to clarify that our statement “The absolute risk for severe disease was low”, only referred to the neonatal conditions analyzed in our study. Every clinical situation is unique and a thorough risk assessment must be undertaken before any decisions regarding treatment are made. Untreated psychiatric conditions in the pregnant woman could have serious negative consequences for both the mother and her child.
1. Jarde A, Morais M, Kingston D, Giallo R, MacQueen GM, Giglia L, et al. Neonatal Outcomes in Women With Untreated Antenatal Depression Compared With Women Without Depression: A Systematic Review and Meta-analysis. JAMA psychiatry. 2016.
2. Davalos DB, Yadon CA, Tregellas HC. Untreated prenatal maternal depression and the potential risks to offspring: a review. Archives of women's mental health. 2012;15(1):1-14.
3. Cohen LS, Altshuler LL, Harlow BL, Nonacs R, Newport DJ, Viguera AC, et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA. 2006;295(5):499-507.
4. Sohr-Preston SL, Scaramella LV. Implications of timing of maternal depressive symptoms for early cognitive and language development. Clinical child and family psychology review. 2006;9(1):65-83.
5. Bonari L, Pinto N, Ahn E, Einarson A, Steiner M, Koren G. Perinatal risks of untreated depression during pregnancy. Canadian journal of psychiatry Revue canadienne de psychiatrie. 2004;49(11):726-35.
Treating depression in pregnant women: yes, but with psychotherapy first
Nörby et al must be commended but their brilliant study showing evidence that “maternal use of antidepressants during pregnancy was associated with increased neonatal morbidity and a higher rate of admissions to the NICU”. However their conclusion “The absolute risk for severe disease was low”(abstract)… it must be carefully weighed against the potentially negative consequences for both the woman and her child that untreated psychiatric conditions could entail.”(full paper) deserves strong comment.
First, there is a major overdiagnosis. In the US, as probably elsewhere, most adults who are treated for depression did not screen positive for depression.(2)
Second, the list of serious adverse effects of antidepressant during pregnancy is not limited to admissions to the NICU. It has begun long ago with congenital anomalies and is regularly updated as recently with the risk of postpartum haemorrhage with serotonin reuptake inhibitor and, concerns for child's development are increasing (eg. autism spectrum, and attention deficit disorders).(3,4)
Third, cognitive behavioural therapy is an effective treatment for depression, including for those who have not responded to antidepressants, and has no serious adverse effects.(5) Moreover, it is patient’s preference.
Antidepressant should not be the first option for any woman of childbearing age (teratogenicity can occur before women are aware they are pregnant) as cognitive behavioural therapy is similarly effective against major depression without adverse effects. If antidepressants are to be prescribed, written informed consent should be a pre-requisite. It is women who must concluded if “the risk of severe disease is low” or not!
1 Nörby U, Forsberg L, Wide K, et al. Neonatal morbidity after maternal use of antidepressant drugs during pregnancy. Pediatrics. 2016;138:e20160181.
2 Olfson M, Blanco C, Marcus SC. Treatment of adult depression in the United States. JAMA Intern Med 2016;176:1482-1491.
3 Hanley GE, Smolina K, Mintzes B, Oberlander TF, Morgan SG. Postpartum hemorrhage and use of serotonin reuptake inhibitor antidepressants in pregnancy. Obstet Gynecol 2016;127:553-61.
4 Hayes RM, Wu P, Shelton RC et al. Maternal antidepressant use and adverse outcomes: a cohort study of 228,876 pregnancies. Am J Obstet Gynecol 2012;207:49.e1-9.
5 Wiles NJ, Thomas L, Turner N et al. Long-term effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: follow-up of the CoBalT randomised controlled trial. Lancet Psychiatry 2016;3:137-44.