Feasibility of a mindfulness-based cognitive therapy group intervention as an adjunctive treatment for postpartum depression and anxiety.

BACKGROUND: Many women experience moderate-to-severe depression and anxiety in the postpartum period for which pharmacotherapy is often the first-line treatment. Many breastfeeding mothers are reticent to increase their dose or consider additional medication, despite incomplete response, due to potential adverse effects on their newborn. These mothers are amenable to non-pharmacological intervention for complete symptom remission. The current study evaluated the feasibility of an eight-week mindfulness-based cognitive therapy (MBCT) intervention as an adjunctive treatment for postpartum depression and anxiety. METHODS: Women were recruited at an outpatient reproductive mental health clinic based at a maternity hospital. Participants had a diagnosis of postpartum depression/anxiety within the first year following childbirth. They were enrolled in either the MBCT intervention group (n = 14) or the treatment-as-usual control group (n = 16), and completed the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder-7 (GAD-7) questionnaire, and the Mindful Attention Awareness Scale (MAAS) at baseline and at 4 weeks, 8 weeks, and 3 months following baseline. RESULTS: Multivariate analyses demonstrated that depression and anxiety levels decreased, and mindfulness levels increased, in the MBCT group, but not in the control group. Many of the between-group and over time comparisons displayed trends towards significance, although these differences were not always statistically significant. Additionally, the effect sizes for anxiety, depression, and mindfulness were frequently large, indicating that the MBCT intervention may have had a clinically significant effect on participants. LIMITATIONS: Limitations include small sample size and the non-equivalent control group design. CONCLUSIONS: We demonstrated that MBCT has potential as an adjunctive, non-pharmacological treatment for postpartum depression/anxiety that does not wholly remit with pharmacotherapy. (249 words).

Predictors of Recovery from Depression and Anxiety in Women: A Longitudinal Study from Childbirth to 6 Years.

OBJECTIVE: This study prospectively examined maternal biopsychosocial predictors of recovery from comorbid depression and anxiety from 25 weeks' gestation to 6 years postbirth. Specifically, the study investigated the influence of 1) maternal factors and 2) the child's behaviours and physical health on the course of the mother's depressed mood and anxiety. METHODS: Eighty-six women diagnosed with antenatal depression/anxiety were recruited through the Reproductive Mental Health Program and family practices in Vancouver. Based on the trajectory and status of their symptom remission, participants were categorised into 3 groups: full recovery, partial recovery, and no recovery. The following measures were completed over 6 years: Hamilton Anxiety Rating Scale (HAM-A) and Hamilton Depression Rating Scale (HAM-D) at baseline; Parental Stress Index (PSI) added at 6 months postpartum; Beck Anxiety Inventory (BAI), Beck Depression Inventory II (BDI-II), and Child Behavior Checklist (CBCL) at 3 years postbirth; and HAM-A, HAM-D, MacArthur Health and Behavior Questionnaire (HBQ-P), and PSI at 6 years postbirth. RESULTS: Factors that predicted full recovery from depression included the absence of maternal health concerns, low total parental stress, and few child behavioural issues, whereas low levels of spousal stress were a significant factor in achieving full recovery from anxiety. CONCLUSION: A variety of maternal and child-related factors govern full recovery or sustained remission of depression/anxiety in the postpartum up to 6 years postbirth. Early awareness of these predictors could lead to timely interventions, ensuring long-term maternal-child well-being.

Overcoming functional impairment in postpartum depressed or anxious women: a pilot trial of desvenlafaxine with flexible dosing.

OBJECTIVES: Antidepressants are the first line treatment for moderate to severe major depressive disorder (MDD) in perinatal and general populations. However, there appears to be paucity of evidence around antidepressant use in women with postpartum depression or anxiety. Selection of an appropriate antidepressant is crucial in promoting efficacy, optimizing tolerability, and managing comorbid anxiety or depression. Our aim was to investigate the treatment effect and tolerability profile of desvenlafaxine, and to examine the functionality of women with postpartum depression or anxiety after desvenlafaxine treatment. METHODS: Fifteen postpartum women with depression or anxiety completed this 12-week prospective pilot study with a flexible dose of desvenlafaxine (50-100 mg). Participants were recruited at a tertiary care level program. Measures of depression (Montgomery-Åsberg Depression Rating Scale, MADRS), anxiety (Hamilton Anxiety Rating Scale, HAM-A), worry (Penn State Worry Questionnaire, PSWQ) and functional impairment (Sheehan Disability Scale, SDS) were completed at baseline, 8 weeks, and 12 weeks. RESULTS: In the intention-to-treat analysis (n = 17), the majority of women responded to medication (88.2%, n = 15), and reached remission of depressive (82.4%, n = 14) and anxiety symptoms (82.4%, n = 14). Remission of depression was achieved in a mean of 6.9 weeks [standard deviation (SD) = 3.01] at a mean dose of 71 mg/day (SD = 25.7). Significant decreases were observed on PSWQ worry scores (p < 0.0001) and SDS scores for social (p < 0.0001) and family life impairment (p < 0.0001). The medication was generally well tolerated. CONCLUSION: The results of our prospective pilot study suggest that treatment with desvenlafaxine of postpartum mothers with depression or anxiety can lead to symptom remission and restoration of functionality.

Generalized Anxiety Disorder and Major Depressive Disorder in Pregnant and Postpartum Women: Maternal Quality of Life and Treatment Outcomes.

OBJECTIVES: Comorbid generalized anxiety disorder (GAD) and major depressive disorder (MDD) in perinatal women is often under-diagnosed, resulting in suboptimal treatment and leading to significant maternal dysfunction. We describe a prospective, longitudinal study of the course, treatment outcomes, and quality of life (QoL) in pregnant and postpartum women with MDD and anxiety disorders. METHODS: Two separate cohorts of women were recruited through the Reproductive Mental Health Program, Women's and Children's Hospital, Vancouver, British Columbia, for pharmacotherapy of depressed mood. One cohort was recruited during pregnancy and followed to one month postpartum; the other cohort was recruited postpartum and followed for 12 weeks. All women met the DSM-5 criteria for MDD and anxiety disorders. This non-lactating perinatal population completed measures of depression, anxiety, worry symptoms, and QoL at multiple study visits. Depressed women with GAD or excessive worry were compared to those without GAD in each cohort. RESULTS: Analysis revealed that despite the majority of women with MDD having remission of symptoms with treatment, those with postpartum GAD displayed a poorer quality of life, with persistent worry symptoms, and their illness was slower to remit. Pregnant depressed women with uncontrollable worry (a GAD indicator) showed a lower probability of achieving remission of symptoms with treatment than those without uncontrollable worry. CONCLUSION: All pregnant and postpartum women with GAD and MDD responded to pharmacotherapy, and the majority attained complete remission of MDD. However, their GAD symptoms persisted, and their QoL was compromised. Given the chronic debilitating course of concomitant MDD and GAD in the perinatal population, it is essential to focus on adjunctive therapies to aim for full recovery.

Objectifs : La présence comorbide d'un trouble d'anxiété généralisée (TAG) et d'un trouble dépressif majeur (TDM) pendant la période périnatale est souvent sous-diagnostiquée, ce qui se traduit en un traitement sous-optimal et qui mène à un dysfonctionnement maternel important. Nous décrivons une étude longitudinale prospective de l'évolution, des résultats du traitement et de la qualité de vie (QdV) chez des femmes enceintes et en postpartum qui présentent un TDM et des troubles anxieux. Méthodes : Deux cohortes distinctes de femmes ont été recrutées par l'intermédiaire du Reproductive Mental Health Program du Women's and Children's Hospital de Vancouver, en Colombie-Britannique, aux fins de la mise en œuvre d'une pharmacothérapie visant l'humeur dépressive : une cohorte a été recrutée pendant la grossesse et a fait l'objet d'un suivi postpartum d'un mois, tandis que l'autre cohorte a été recrutée pendant la période postpartum et a fait l'objet d'un suivi de 12 semaines. Toutes les femmes répondaient aux critères du DSM-5 pour ce qui est du TDM et des troubles anxieux. Les femmes de cette population périnatale n'étant pas en lactation ont rempli des mesures de la dépression, de l'anxiété, des symptômes d'inquiétude et de la QdV dans le cadre de multiples consultations menées aux fins de l'étude. Les femmes déprimées qui connaissaient un TAG ou des inquiétudes excessives ont été comparées aux femmes ne connaissant pas un TAG au sein de chacune des cohortes. Résultats : L'analyse a révélé que malgré le fait que le traitement ait donné lieu à une rémission des symptômes chez la majorité des femmes connaissant un TDM, les femmes connaissant un TAG postpartum présentaient une qualité de vie moindre, s'accompagnant de symptômes d'inquiétude persistants, et la rémission de leur maladie était plus lente. Les femmes enceintes déprimées qui connaissaient des inquiétudes incontrôlables (un indicateur de TAG) ont présenté une probabilité moindre d'obtenir la rémission de leurs symptômes à la suite de la mise en œuvre d'un traitement, par comparaison avec les femmes qui ne connaissaient pas d'inquiétudes incontrôlables. Conclusion : Toutes les femmes enceintes et en postpartum qui présentaient un TAG et un TDM ont réagi à la pharmacothérapie, et la majorité d'entre elles ont obtenu la rémission complète du TDM. Toutefois, leurs symptômes TAG ont persisté et leur QdV a été compromise. Compte de l'évolution débilitante chronique de la présence concomitante d'un TDM et d'un TAG au sein de la population périnatale, il s'avère essentiel de centrer les traitements adjuvants sur l'obtention d'une récupération complète.

Perinatal Generalized Anxiety Disorder: Assessment and Treatment.

Perinatal generalized anxiety disorder (GAD) has a high prevalence of 8.5%-10.5% during pregnancy and 4.4%-10.8% postpartum. Despite its attendant dysfunction in the patient, this potentially debilitating mental health condition is often underdiagnosed. This overview will provide guidance for clinicians in making timely diagnosis and managing symptoms appropriately. A significant barrier to the diagnosis of GAD in the perinatal population is difficulty in distinguishing normal versus pathological worry. Because a perinatal-specific screening tool for GAD is nonexistent, early identification, diagnosis and treatment is often compromised. The resultant maternal dysfunction can potentially impact mother-infant bonding and influence neurodevelopmental outcomes in the children. Comorbid occurrence of GAD and major depressive disorder changes the illness course and its treatment outcome. Psychoeducation is a key component in overcoming denial/stigma and facilitating successful intervention. Treatment strategies are contingent upon illness severity. Cognitive behavior therapy (CBT), relaxation, and mindfulness therapy are indicated for mild GAD. Moderate/severe illness requires pharmacotherapy and CBT, individually or in combination. No psychotropic medications are approved by the FDA or Health Canada in pregnancy or the postpartum; off-label pharmacological treatment is instituted only if the benefit of therapy outweighs its risk. SSRIs/SNRIs are the first-line treatment for anxiety disorders due to data supporting their efficacy and overall favorable side effect profile. Benzodiazepines are an option for short-term treatment. While research on atypical antipsychotics is evolving, some can be considered for severe manifestations where the response to antidepressants or benzodiazepines has been insufficient. A case example will illustrate the onset, clinical course, and treatment strategies of GAD through pregnancy and the postpartum.

Factors impacting decisions to decline or adhere to antidepressant medication in perinatal women with mood and anxiety disorders.

PURPOSE: To identify specific quantitative and qualitative factors that govern the decision to adhere or decline antidepressant medication in antenatal women with moderate-to-severe mood and anxiety disorders. METHODS: Fifty women (30 adherers, 20 decliners) were recruited between 18 and 34 weeks gestation in a tertiary care clinic for perinatal mothers. They were prospectively monitored 4 weeks apart up to 1-month postpartum on the: Hamilton Anxiety Scale, Hamilton Depression Scale, Mood Disorders Insight Scale, Antidepressant Compliance Questionnaire, Penn State Worry Questionnaire, and NEO Personality Inventory. Qualitative interviews were conducted at baseline. Hierarchical linear modeling determined illness trajectories of the two groups. RESULTS: Significantly different course of illness was observed in adherers versus decliners. Adherers had healthier attitudes toward depression and compliance with medication (P < .005). Decliners had less illness insight (P < .001) and cited fear of fetal exposure, and thought medication was unwarranted. CONCLUSIONS: Pregnant women experienced significantly divergent illness trajectories depending on if they accepted antidepressant medication therapy for their illness. Risk perception, attitudes, and illness insight impacted decisions surrounding adherence and decline.

Biopsychosocial determinants of treatment outcome for mood and anxiety disorders up to 8 months postpartum.

Little is known about the biopsychosocial determinants that predict postpartum treatment outcome for mood and anxiety disorders. Postpartum mood and anxiety symptoms and psychosocial/biological variables were recorded for 8 months of 22 women treated with antidepressants during pregnancy. Depression scores decreased by 58%, whereas anxiety scores decreased by 35%. Family history of psychiatric illness and prior psychiatric illness unrelated to pregnancy predicted depressive treatment outcome, and sexual abuse history and prior psychiatric illness unrelated to pregnancy predicted anxiety outcome. Biological and psychosocial variables predicted pharmacological treatment outcome in postpartum-depressed and anxious women.

Affect Expression and Self-Regulation Capacities of Infants Exposed in utero to Psychotropics.

This study explored the affect expression and self-regulation capacities of 8-month-old infants exposed in utero to psychotropic medications. This was a continuation of our previous study conducted on the same cohort when the infants were 3 months old. Psychotropics implicated included selective serotonin reuptake inhibitors (SSRIs), and a benzodiazepine derivative anxiolytic (clonazepam). The three comparison groups were: control (n = 23; infants not exposed to psychotropics in utero), SSRI-alone (n = 22; infants exposed to SSRIs only and having mothers who had a primary diagnosis of depressive disorder without having comorbid anxiety disorder), and SSRI+ group (n = 15; infants gestationally exposed to SSRIs and clonazepam and having mothers that had both clinical depression and anxiety disorder). Using the Parent-Child Early Relational Assessment Scale, infants were assessed in a dyadic context during free play and a structured task. There were significant differences in psychotropic exposed and non-exposed dyads regarding infant negative affect management. There were significant associations between the SSRI+ group of mothers and infant negative affect. This group of mothers also showed significant associations with infants' averting and avoiding behaviors in both play situations. The SSRI-alone group was similar to the control group and showed variable associations with infant's positive, negative, and sober moods unlike the SSRI+ group. There were no differences in infants' capacity for self-regulation in psychotropic exposed and non-exposed groups. Increased awareness of these vulnerable subgroups (SSRI-alone and SSRI+) is needed, in order to safeguard these dyads through better support systems and improved management.

Prenatal effects of selective serotonin reuptake inhibitor antidepressants, serotonin transporter promoter genotype (SLC6A4), and maternal mood on child behavior at 3 years of age.

OBJECTIVES: To investigate whether prenatal selective serotonin reuptake inhibitor (SSRI) antidepressant exposure affects behavior in 3-year-olds of antenatally anxious or depressed mothers and whether risk was moderated by the serotonin transporter promoter (SLC6A4) genotype. DESIGN: Prospective longitudinal cohort design. SETTING: Vancouver. PARTICIPANTS: Mothers and their 3-year-old children (n = 33 SSRI exposed and n = 42 nonexposed). Main Exposures Prenatal exposure to SSRI antidepressants and prenatal and postnatal maternal mood disturbances. MAIN OUTCOME MEASURES: Parent report of child behavior (Child Behavior Checklist, ages 1.5-5 years) and the child SLC6A4 genotype. The covariates used were maternal mood during the third trimester, 3 months postpartum, and at the 3-year follow-up study and the child's 5-minute Apgar score. RESULTS: Prenatal exposure to both maternal depressed mood and SSRI antidepressants were associated with increased internalizing behaviors during early childhood, whereas current maternal mood increased risk for externalizing behaviors. Increased child anxiety and depression symptoms were predicted by higher third-trimester maternal anxiety only in children with 2 short S alleles. In contrast, increased aggression and externalizing behaviors were predicted by third-trimester maternal anxiety only in children with 2 copies of the L allele. CONCLUSIONS: Exposure to prenatal SSRIs and maternal mood had distinct effects on child behavior at 3 years of age, reflected in an increased level of internalizing behaviors. The impact of antenatal maternal anxiety on child mood was moderated by the child SLC6A4 genotype. Despite SSRI treatment for prenatal maternal mood disturbances, childhood behavior at 3 years of age remained at risk.

Antenatal depression and anxiety affect postpartum parenting stress: a longitudinal, prospective study.

OBJECTIVE: Postpartum depression has been associated with parenting stress, impacting attachment and child development. However, the relation between antenatal depression or anxiety and postpartum parenting stress has not been investigated. We studied the effect of antenatal depression and anxiety and treatment with selective serotonin reuptake inhibitors and selective norepinephrine reuptake inhibitors (antidepressants [ADs]) on postpartum parenting stress. METHOD: Ninety-four pregnant women (part of a larger study examining prenatal AD exposure on infants) were prospectively monitored for depression and anxiety during the third trimester and 3- and 6-months postpartum using the Hamilton Depression Rating Scale (HDRS) and Hamilton Anxiety Rating Scale. Parenting stress was assessed using the Parenting Stress Index-Short Form at 3- and 6-months postpartum. RESULTS: Both antenatal third trimester depression and anxiety were significant predictors of 3- and 6-month postpartum parenting stress, after controlling for maternal age, number of children, and exposure to prenatal ADs (all Ps < 0.001). Third trimester depression accounted for 13% to 22% of the variance in postpartum stress at 3 and 6 months. Prenatal AD use was not a significant predictor in any of the models (all Ps > 0.2). Twenty of 41 mothers on ADs achieved remission (HDRS = 7) in pregnancy and had average parenting stress scores of about 1 standard deviation lower than those who did not at 3- and 6-months postpartum (t = 3.32, df = 32, P = 0.002 and t = 2.52, df = 32, P = 0.02, respectively). CONCLUSIONS: Our findings indicate that antenatal depression and anxiety directly impact postpartum parenting stress, regardless of antenatal AD treatment. Ongoing maternal mental illness in pregnancy is an important predictor of postpartum parenting stress. Early recognition and treatment to remission is key.

Managing unipolar depression in pregnancy.

PURPOSE OF REVIEW: The management of depression in pregnancy is complex, as it is based on balancing the risks with the benefits of treatment versus no treatment for both the mother and the fetus. The current literature in the field of reproductive psychiatry is difficult to navigate and at times contradictory. This article aims to review both nonpharmacological and pharmacological modalities in the treatment of perinatal depression. A literature review using PubMed and MEDLINE databases was used to collect literature from the past 2 years; however, given the relatively small amount of research in reproductive psychiatry, several salient articles from the past 5 years have also been included in this review. RECENT FINDINGS: Recent US Food and Drug Administration and Health Canada warnings regarding poor neonatal adaptation and adverse perinatal outcomes associated with antidepressant use in pregnancy have changed patterns of practice for prescribing physicians. Many physicians are now left with a sense of indecisiveness regarding the safety of treating their depressed, pregnant patients. Similarly, these warnings have changed patients' attitudes and their willingness to consider pharmacological treatment for depression. Although these warnings demand attention and careful consideration, research has also shown that exposure to mental illness in pregnancy has deleterious short-term and long-term effects for the exposed mother and fetus. SUMMARY: The field of reproductive psychiatry is rapidly evolving. Clinicians need to keep abreast of changes in the management of depression during pregnancy. Ongoing research in this field is important so that the most up-to-date recommendations may be provided to pregnant women.

Caregiving behavior and interactions of prenatally depressed mothers (antidepressant-treated and non-antidepressant-treated) during newborn acute pain.

This exploratory study aimed to examine time-based measures of the behaviors and interactions of prenatally depressed serotonin reuptake inhibitors (SRI)-medicated mothers to their infant's pain (n = 10) by comparing them with similar measures obtained from prenatally depressed nonmedicated mothers and their infants (n = 10), and nondepressed mothers and their infants (n = 10). During the second trimester of their pregnancy, the 30 study mothers were assessed for depression and anxiety, with no further measures of maternal mood taken. Maternal and infant interactions were continuously videorecorded while the infant underwent a scheduled heel lance for routine blood screening that occurred when study infants were between the ages of 24 and 60 hr. Maternal behavior and infant cry, for all 30 cases, were coded second-by-second for the full duration of each infant's heel lance using a reliable coding system and analyzed using odds ratio and regression analyses. Infants exposed to prenatal SRIs and depressed maternal mood were more likely to have lower Apgar scores and to exhibit weak and absent cry. Even when duration of the heel lance was controlled for, women with depression during the second trimester were more likely to exhibit depressed behavior at 2 days' postpartum despite sustained SRI antidepressant treatment. Both groups of prenatally depressed mothers were more likely to exhibit diminished response to their infants' pain cue although nonmedicated mothers' expressions of depressed behavior were more similar to healthy controls. Comprehensive understanding is essential to optimize the clinical care of mothers and their infants in this complex setting. This study contributes preliminary new findings that warrant prospective and longitudinal studies to clarify further the impacts of prenatal SRI and maternal mental mood (e.g., chronic depression and anxiety) effects on the mother-infant interaction and infant pain and stress reactivity.

Hypothalamic-pituitary-adrenal (HPA) axis function in 3-month old infants with prenatal selective serotonin reuptake inhibitor (SSRI) antidepressant exposure.

BACKGROUND: Prenatal exposure to stress and selective serotonin reuptake inhibitors (SSRIs) alter hypothalamic-pituitary-adrenal (HPA) stress reactivity in offspring, however, the effects of combined exposure to HPA activity in human infants is unknown. OBJECTIVE: To examine HPA basal levels and stress responsiveness in 3-month olds with prenatal exposure to SSRIs. METHODS: Salivary cortisol levels in infants of SSRI treated mothers (n=31, mean exposure 230.2+/-72.2 days) were compared with non-SSRI exposed (n=45) infants in response to a challenge (infant-controlled habituation task) and under basal conditions in the late afternoon/early evening. Mode of feeding, to account for possible postnatal drug exposure via breast milk, as well as measures of pre and postnatal maternal mood, were included as covariates. RESULTS: Lower post-stress cortisol levels were observed in non-SSRI exposed/non-breastfed infants compared with non-SSRI exposed infants who were breastfed at 3 months of age. Stress reactivity patterns among SSRI exposed infants did not differ with mode of feeding. The cortisol reactivity slope (CRS) was significantly lower among non-SSRI exposed non-breastfed infants compared with non-SSRI exposed breastfed infants. Early evening basal cortisol levels were lower in SSRI exposed infants than in non-SSRI exposed infants, controlling for maternal mood and mode of feeding. Postnatal SSRI exposure (infant SSRI drug levels) via breast milk was not associated with stress or basal cortisol levels. Total cortisol, reflected by the AUC measure, did not differ significantly between exposure groups. CONCLUSIONS: Prenatal SSRI exposure altered HPA stress response patterns and reduced early evening basal cortisol levels. Stress challenge HPA response differences only became apparent when the moderating effect of method of feeding was accounted for. These findings suggest an early "programming" effect of antenatal maternal mood, prenatal SSRI exposure and postnatal maternal care giving on the HPA system.

Prenatal exposure to maternal depression, neonatal methylation of human glucocorticoid receptor gene (NR3C1) and infant cortisol stress responses.

BACKGROUND: In animal models, variations in early maternal care are associated with differences in hypothalamic-pituitary-adrenal(HPA) stress response in the offspring, mediated via changes in the epigenetic regulation of glucocorticoid receptor (GR) gene (Nr3c1) expression. OBJECTIVE: To study this in humans, relationships between prenatal exposure to maternal mood and the methylation status of a CpG-rich region in the promoter and exon 1F of the human GR gene (NR3C1) in newborns and HPA stress reactivity at age three months were examined. RESULTS: Prenatal exposure to increased third trimester maternal depressed/anxious mood was associated with increased methylation of NR3C1 at a predicted NGFI-A binding site. Increased NR3C1 methylation at this site was also associated with increased salivary cortisol stress responses at 3 months, controlling for prenatal SRI exposure, postnatal age and pre and postnatal maternal mood. METHODS: The methylation status of a CpG-rich region of the NR3C1 gene, including exon 1F, in genomic DNA from cord blood mononuclear cells was quantified by bisulfite pyrosequencing in infants of depressed mothers treated with a serotonin reuptake inhibitor antidepressant (SRI) (n = 33), infants of depressed nontreated mothers (n = 13) and infants of non depressed/non treated mothers (n = 36). To study the functional implications of the newborn methylation status of NR3C1 in newborns, HPA function was assessed at three months using salivary cortisol obtained before and following a non noxious stressor and at a late afternoon basal time. CONCLUSIONS: Methylation status of the human NR3C1 gene in newborns is sensitive to prenatal maternal mood and may offer a potential epigenetic process that links antenatal maternal mood and altered HPA stress reactivity during infancy.

Effects of timing and duration of gestational exposure to serotonin reuptake inhibitor antidepressants: population-based study.

BACKGROUND: Late-gestational serotonin reuptake inhibitor (SRI) exposure has been linked to adverse neonatal outcomes; however, the impact of timing and duration of exposure is unknown. AIMS: To determine whether late-gestational exposure to an SRI is associated with increased risk of adverse neonatal outcome relative to early exposure. METHOD: Population-based maternal and neonatal health records were linked to prenatal maternal prescription records for an SRI medication (n=3500). RESULTS: After controlling for maternal illness and duration of exposure, using propensity score matching, neonatal outcomes did not differ between late and early exposure (P>0.05). After controlling for maternal illness, longer prenatal exposure increased the risks of lower birth weight, respiratory distress and reduced gestational age (P<0.05). CONCLUSIONS: Using population health data, length of gestational SRI exposure, rather than timing, increased the risk for neonatal respiratory distress, lower birth weight and reduced gestational age, even when controlling for maternal illness and medication dose. These findings highlight the importance of distinguishing the specific impact of medication exposure from exposure to maternal illness itself.

Major congenital malformations following prenatal exposure to serotonin reuptake inhibitors and benzodiazepines using population-based health data.

BACKGROUND: To determine a population-based incidence of congenital anomalies following prenatal exposure to serotonin reuptake inhibitor (SRI) antidepressants used alone and in combination with a benzodiazepines (BZ). METHODS: Population health data, maternal health, and prenatal prescription records were linked to neonatal records, representing all live births (British Columbia, Canada, N=119,547) during a 39-month period (1998-2001). The incidence and risk differences (RD) for major congenital anomalies (CA) and congenital heart disease (CHD), including ventricular and atrial septal defects (VSD, ASD), from infants of mothers treated with an SRI alone, a benzodiazepine (BZ) alone, or SRI+BZ in combinationcompared to outcomesno exposure. RESULTS: Risk for a CA or CHD did increase following combined SRI+BZ exposure compared with no exposure. However, using a weighted regression model, controlling for maternal illness characteristics, combination therapy risk remained significantly associated only with CHD. The risk for an ASD was higher following SRI monotherapy compared with no exposure, after adjustment for maternal covariates. Dose/day was not associated with increased risk. CONCLUSIONS: Infants exposed to prenatal SRIs in combination with BZs had a higher a incidence of CHD compared to no exposure, even after controlling for maternal illness characteristics. SRI monotherapy was not associated with an increased risk for major CA, but was associated with an increased incidence of ASD. Risk was not associated with first trimester medication dose/day.

Treatment of perinatal mood and anxiety disorders: a review.

OBJECTIVES: To review the nonpharmacologic and pharmacologic treatment modalities for perinatal mood and anxiety disorders and to discuss the importance of weighing the risks and the benefits of exposing the fetus or baby to maternal mental illness as opposed to exposure to antidepressant medications. METHODS: We conducted a literature search of the PubMed and MEDLINE databases. Key words included the following: perinatal, pregnancy, postpartum, depression, anxiety, pharmacologic, nonpharmacologic, psychotherapy, and treatment. RESULTS: Recent literature reflects that both pharmacologic and nonpharmacologic treatments for perinatal women are associated with positive and negative outcomes. No treatment decision was found to be risk-free. The detrimental effects of untreated mental illness on the mother, as well as on the baby, highlight the need for treatment intervention. The long-term effects of exposure to either medications or maternal mental illness are unknown, as yet. CONCLUSION: Women with perinatal depression and anxiety disorders require timely and efficient management with a goal of providing symptom relief for the suffering mother while simultaneously ensuring the baby's safety. Although knowledge in the area of appropriate intervention is constantly evolving, rigorous and scientifically sound research in the future is critical.