Journals club - Antidepressant use in pregnancy

Curriculum statements 10.1 Women's Health & 13 Care of people with Mental Health problems.

Photograph: JH Lancy
Photograph: JH Lancy

Key trials

  • In a study of pregnant women with major depression, 26 per cent of women who continued their antidepressant medication throughout their pregnancy experienced a relapse compared with 68 per cent of those who discontinued their medication (JAMA 2006; 295: 499-507).
  • Recent research showed that specific defects were associated with specific SSRIs, rather than a general association. Even in the worst case, only 5.5 cases will occur out of 10,000 live births (N Engl J Med 2007; 356: 2,675-83).
  • Fluoxetine appears to be the SSRI with the lowest known risk during pregnancy. However, a recent study has suggested a possible link between cardiovascular anomalies and first-trimester exposure to fluoxetine (Br J Clin Pharmacol 2008; 66: 695-705).

Evidence base

  • Clinical Knowledge Summaries state that information regarding the safety of anti-depressant drugs during pregnancy is limited and inconsistent.

Guidelines

  • NICE guidance on antenatal and postnatal mental health was produced in February 2007.

It covers the care of women with anxiety disorders and depression both during pregnancy and after birth.

  • NICE recommends that health professionals should acknowledge the uncertainty surrounding the risks regarding treatment.
  • The Royal College of Obstetricians and Gynaecologists has stated that the low risk associated with SSRIs during pregnancy should be reassuring to those women who find it difficult to stop taking them because of the severity of their depression.

Useful websites

Key points

  • Depression in pregnancy is often underdiagnosed.
  • Many women try to avoid antidepressants during their pregnancy.
  • Tricyclic antidepressants are usually used first line.
  • The risks with SSRIs in pregnancy is still unclear.
  • There is still limited evidence regarding the efficacy of alternative treatments.

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