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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 14 of 14. This is the beginning of the thread.
Posted by ed_uk on February 11, 2006, at 12:01:43
From the Pharmaceutical Journal......
'Women who discontinue antidepressants during pregnancy are more likely to have a relapse of their illness than those who do not, a study has found (JAMA 2006;295:499). In contrast, two recent studies have examined the association between various neonatal conditions and antenatal use of selective serotonin reuptake inhibitors.
In the JAMA study, investigators enrolled 201 pregnant women with major depression and found that 68 per cent of those who stopped taking their antidepressant medicines experienced a major depressive relapse during pregnancy, compared with 26 per cent of those who continued their treatment (hazard ratio 5, 95 per cent confidence interval 2.8–9.1; P<0.001). This, the authors state, refutes the “common belief that characteristic hormonal changes associated with pregnancy are inherently ‘protective’ with respect to … risk of depressive relapse and that discontinuation of psychiatric medications should be almost uniformly pursued given concerns regarding prenatal exposure”. However, the authors admit that risk of relapse could indeed be lower for pregnant women with less severe depression who discontinue treatment.
The first of the other two studies (Archives of Pediatrics and Adolescent Medicine 2006;160:173) found that neonatal abstinence syndrome — in which withdrawal from substances present in maternal blood results in neuro-behavioural changes in a neonate — occurs in 30 per cent of babies exposed to SSRIs during pregnancy, compared with none of the babies unexposed to SSRIs (P<0.001). The second study found an association between the development of persistent pulmonary hypertension of the newborn (PPHN) and SSRI use in late pregnancy (New England Journal of Medicine 2006;354:579). The case-control study looked at 377 cases of PPHN and 836 matched controls and found that, after week 20 of gestation, 14 infants exposed to an SSRI had PPHN, compared with six of those who had not been exposed to an SSRI (adjusted odds ratio 6.1, 95 per cent confidence interval 2.2–16.8).
Neither antenatal exposure to non-SSRI antidepressants nor exposure to SSRIs during the first half of pregnancy was associated with PPHN. This suggests, say the authors, that maternal depression itself is unlikely to be independently associated with PPHN.'
Posted by SLS on February 11, 2006, at 19:53:51
In reply to Depression and use of antidepressants in pregnancy, posted by ed_uk on February 11, 2006, at 12:01:43
This is a complex issue with no easy answers.
First of all, it has been my observation that pregnancy can produce a true antidepressant effect in unremitted individuals. However, this is not the same thing as subjecting the system to an abrupt discontinuation of a medication. Pregnancy might not be protective against a depressive rebound when drugs are discontinued too quickly.
There is little doubt that infants who are born to mothers taking SRIs suffer an intense withdrawal syndrome that can result in critical complications. Symptoms include irritability, constant crying, shivering, increased tonus, eating and sleeping difficulties and convulsions. I would be inclined to gradually taper and discontinue a SRI in the third trimester, particularly paroxetine and venlafaxine.
There is also the issue of birth defects occurring when SSRIs are taken during the first trimester. The US FDA recently asked that the manufacturer of Paxil (paroxetine) add warnings to their package labelling.
http://www.fda.gov/cder/drug/advisory/paroxetine200512.htm
SSRIs are not guaranteed to be safe to continue during pregnancy. However, neither is a relapse into depression. Most investigations into this issue conclude that the risks of relapse outweigh the risks of gestational complications. Perhaps it would be worth attempting a switch to a non-SRI drug like Wellbutrin, Remeron, or nortriptyline when beginning a pregnancy.
- Scott
Posted by Racer on February 11, 2006, at 20:34:39
In reply to Re: Depression and use of antidepressants in pregnancy, posted by SLS on February 11, 2006, at 19:53:51
> >Perhaps it would be worth attempting a switch to a non-SRI drug like Wellbutrin, Remeron, or nortriptyline when beginning a pregnancy.
>
>
> - ScottGood idea, but Remeron is teratogenic, although for some reason they're still calling it Category C? {shrug} Whatever. Nortriptyline is described as "not established," even after all this time, and the animal studies are inconclusive. It didn't have a category listed, though.
Wellbutrin, though, is Category B. The animal studies didn't show any problems. That's not true of most of the other antidepressants.
Not, you understand, that I've looked any of this up lately...
Posted by Phillipa on February 11, 2006, at 22:35:03
In reply to Re: Depression and use of antidepressants in pregn » SLS, posted by Racer on February 11, 2006, at 20:34:39
I'm going to E-mail this thread to my friend who is preganant. Thaks guys Fondly, Phillipa
Posted by SLS on February 12, 2006, at 6:08:51
In reply to Re: Depression and use of antidepressants in pregn » SLS, posted by Racer on February 11, 2006, at 20:34:39
> but Remeron is teratogenic, although for some reason they're still calling it Category C? {shrug}
I didn't know that. Where did you find this information. Is it recent?
I'm sure you are aware that the TCAs as a group are considered safe. My *guess* is that nortriptyline would not pose a threat. However, it would be interesting to thoroughly evaluate clomipramine to see if it doesn't produce complications similar to the SSRIs.
- Scott
Posted by Racer on February 12, 2006, at 12:06:08
In reply to Re: Depression and use of antidepressants in pregn » Racer, posted by SLS on February 12, 2006, at 6:08:51
> > but Remeron is teratogenic, although for some reason they're still calling it Category C? {shrug}
>
> I didn't know that. Where did you find this information. Is it recent?
>Dunno how recent, but I looked it up on Rxlist.com. They have the pregnancy and fertility information on most drugs, which is timely for me, as well as generally having useful information about all the drugs I've looked up there. I like that they have matrices of side effects, so that you can draw your own conclusions about how much risk there actually is. (Like, if 15% of the people who take Drug A get headaches, that might be significant -- unless 20% of those on the placebo do, too...)
For myself, I'm sticking with Wellbutrin, although I've lately been thinking that, since I have surgery scheduled, and won't be able to try again until after that, it might be worth adding something in to try to get stabilized, but realistically, I doubt anything could really happen in that time, so I'm gonna stick with what I got, even though it ain't working so good. (Although I may try Buspar again. May not, but may, if my anxiety gets any worse than it is now.)
How are you doing, Scott?
Posted by joslynn on February 12, 2006, at 20:58:55
In reply to Depression and use of antidepressants in pregnancy, posted by ed_uk on February 11, 2006, at 12:01:43
Thanks for the info. I didn't understand the last few sentences though. Can someone explain? That last short paragraph went over my head. I think maybe what they were saying was that the depression itself in the moms does not cause the withdrawal-like symptoms in the baby, but it is the drugs? or something else?
This is a tough question. I have wondered about it, for my future. I am moving towards a higher risk age group anyway, with or without SSRIs during pregnancy.
If my significant other and I got married and if I decided to have a baby, I still think I would stop the antideps. If I got depressed, that would still be less depressing than if I saw my baby suffer in some way because of meds I took. I would go back on the meds right away after the birth though, if I suffered a relapse, and not nurse. (I know nursing is best, but not if the mom is depressed because she is not on her meds because of it, IMO.)
I would want to protect the health of my baby at all costs. Even if, God forbid, I got so depressed I couldn't take care of the baby in the beginning, I would have to make sure my husband, grandparents etc could step in. I guess the difference, for me, is than I am an adult, and can put into place some sort of strategy to deal with a temporary relapse, but a baby is a baby and I wouldn't want the baby to go through any discomfort or pain. I would rather go through it myself.
I think it would be best, for me, to try going off meds before trying to get pregnant, and see how it goes.
Just thinking about it makes me head spin.
With my age, I may be better of not having kids or adopting anyway. I am getting close to 40.
But then, would I have trouble adopting because I have episodes of severe depression in my records?
Well, one thing at a time, I am not even married yet.
Posted by linkadge on February 14, 2006, at 14:46:38
In reply to Re: Depression and use of antidepressants in pregn » SLS, posted by Racer on February 12, 2006, at 12:06:08
I would assume that all drug which produce withdrawl to patient would produce withdrawl to child.
I would expect that a withdrawl might be felt more significantly by child and may have lasting impact on emotional developement. Thats just my oppinion, I have no data to back it up.
Linkadge
Posted by tizza on February 14, 2006, at 17:44:19
In reply to Re: Depression and use of antidepressants in pregn, posted by linkadge on February 14, 2006, at 14:46:38
my sister was taking 60mg of citalopram during her 2nd pregnancy. Her pdoc was concerned about this but she was in such a bad state they strongly advised her not to stop or lower her dose. So she and her hubby decided that she should stay on her medication but she did taper back to 30mg of citalopram and went the hard yards. She has a beautiful, healthy 2 year old girl. The poor thing developed terrible post natal depression after her first child and fell pregnant again during this episode. It nearly pushed her over the edge. Now she is doing better than ever and she is on 225mg of effexor xr. It works really well for her and I haven't seen her this happy for 5 years.
Posted by Racer on February 14, 2006, at 21:04:40
In reply to Re: Depression and use of antidepressants in pregn, posted by linkadge on February 14, 2006, at 14:46:38
> I would assume that all drug which produce withdrawl to patient would produce withdrawl to child.
>
> I would expect that a withdrawl might be felt more significantly by child and may have lasting impact on emotional developement. Thats just my oppinion, I have no data to back it up.
>
> Linkadge
>
>I'd agree that if a drug causes withdrawal for adults, it's likely to cause problems for neonates. And I would not be surprised to find that it had lasting effects -- we already know that not being held enough as an infant, and not having certain needs met during that time, can lead to adjustment problems, etc. I'd assume that the withdrawal would create some needs that couldn't be met, therefore creating those same problems, or similar.
What worries me more, though, and the reason I will probably stop even the Wellbutrin if we succeed in getting pregnant, is what the drugs are doing to the development of the nervous system and brain in the first place. Are they causing changes to the receptor density? Sensitivity? Will this cause changes that will hold on? Plasticity or not, I would expect some sort of changes to occur in that development.
Then again, I think I can struggle through with the thought of a healthy baby at the end, and I'm hardly in remission now, so maybe it's not so vital for me to stay medicated?
Posted by wildcard11 on February 15, 2006, at 14:30:17
In reply to Interesting thought » linkadge, posted by Racer on February 14, 2006, at 21:04:40
I have two beautiful healthy boys, ages 10 and 1 and am expecting my 3rd and took A/D's w/ all. I did try the stop effect for my baby's health but when i fell apart i was doing my unborn child no good. There are always risks, it's just weighing the benefits against them. I not only talked openly to my doc. but i did my own research.
Posted by linkadge on February 15, 2006, at 17:00:57
In reply to Re: Depression and use of antidepressants in pregn, posted by tizza on February 14, 2006, at 17:44:19
The baby is a living organism too. We know that babies withdrawl from crack, caffiene, nicotine, and all the rest. We know they withdrawl from SSRI's too, and 60mg of celexa to zero within the of a snip of the embilical cord is not the way I want to enter the world.
We also know that mice exposed to SSRI's during certain timeframes of developement show significant depressive symtpoms later on.
Linkadge
Posted by linkadge on February 15, 2006, at 17:05:48
In reply to Interesting thought » linkadge, posted by Racer on February 14, 2006, at 21:04:40
How is the delicate sertonergic system supposed to develop properly when it is exposed to super high levels of serotonin and the **whammo** almost nill. I don't even want to begin to imagine the hell it would put a baby through.
And you are right, traumatic early life events can have BIG effects on later development, this could easily be categorizes as a traumatic early life event, my god, comming of 100mg Zoloft was one of the most traumatic events of my whole life.
I say, as long as you are not going to kill yourself, then drop the AD. Its only 9 months for you, its a lifetime for the child. Don't meant to sound harsh.
Linkadge
Posted by Laurie Beth on February 15, 2006, at 19:51:21
In reply to Re: Depression and use of antidepressants in pregn, posted by joslynn on February 12, 2006, at 20:58:55
"I would want to protect the health of my baby at all costs."
I think most moms feel this way. However, it's far from clear that going off antidepressants and becoming very depressed or very anxious does protect the child. There is a fair amount of evidence that depression or anxiety during pregnancy or during infancy may cause short- and long-term cognitive and emotional problems in the exposed child.
Which of course, isn't to say that no one should discontinue an antidepressant in anticipation of pregnancy or after getting pregnant. The long-term, more subtle effects of prenatal SSRI-exposure are not known, so if the med may not be necessary (or may not even be helping), a trial off the medicine prior to pregnancy or once a pregnancy is established may make sense for some moms.
But this isn't a simple issue of mom's welfare versus baby's welfare.
This is the end of the thread.
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