Identifying the Benefits and Risks of Antidepressant Use During Pregnancy

Treating maternal psychiatric disorder with commonly used antidepressants is associated with a lower risk of certain pregnancy complications including preterm birth and delivery by Caesarean section, according to researchers at Columbia University’s Mailman School of Public Health, Columbia University Medical Center, and the New York State Psychiatric Institute. However, the medications — selective serotonin reuptake inhibitors, or SSRIs — resulted in an increased risk of neonatal problems. Findings are published online in the American Journal of Psychiatry.

“To our knowledge, the association between taking antidepressants in pregnancy and a lower risk of preterm birth is a novel finding,” said Alan Brown, MD, MPH, professor of Psychiatry and Epidemiology and senior author. “Up to now, studies which were based on maternal underlying psychiatric illness had small sample sizes and reported inconsistent results.”

The Columbia researchers with colleagues in Finland studied 845,345 single births in 1996 through 2010 from the Finnish Medical Birth Register. They also analyzed data from national registers on prescription drug purchases, mothers’ psychiatric history, maternal medical history, hospital sources, and healthcare professionals. The women were categorized into mutually exclusive groups: SSRI users, those with a psychiatric diagnosis related to SSRI use but no antidepressant purchases, and those without a diagnosis or antidepressant purchases, to determine if outcomes were a result of maternal underlying psychiatric illness or due to use of the drugs.

This class of antidepressants is the most commonly used for treating depression and anxiety during pregnancy, with 4-10% of pregnant women prescribed them in Finland and in the U.S. A total of 12,817 women in the study had purchased the antidepressants during the first trimester or 30 days before the beginning of gestation, and 9,322 (59%) made two or more purchases.

The risk of preterm birth was 16% lower, and the risk of very preterm birth nearly 50% lower in women using the antidepressants during pregnancy compared to mothers with a psychiatric diagnosis but no medication use. Preterm birth is the most important single cause of neonatal and infant death and is associated with long-term neurological disabilities in the surviving infants.

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This shows a pregnant woman.
The risk of preterm birth was 16% lower, and the risk of very preterm birth nearly 50% lower in women using the antidepressants during pregnancy compared to mothers with a psychiatric diagnosis but no medication use. Image is for illustrative purposes only.

Maternal psychiatric disorder without medication use was associated with an increased risk of Caesarean section (26.5 percent) compared to those without a diagnosis or antidepressant purchases (17 percent). There was a slightly greater risk of bleeding during or after delivery (3.5 percent) for women with a diagnosis but in the no-medication group as compared to those without a diagnosis or anti-depressant purchases (3 percent).

While the risk of being born small for gestational age did not differ for the babies of mothers with or without antidepressant drug treatment, SSRI use was associated with an increased risk of all neonatal problems, including breathing issues, that led to longer hospital stays and neonatal care.

“Our findings provide evidence that taking these antidepressants is associated with a lower risk of preterm birth and Caesarean section and further confirm the results from previous research of a higher risk for several neonatal problems,” noted Dr. Brown. “Given these divergent findings, the decision whether to prescribe these medications during pregnancy should be individualized to the mother’s medical and psychiatric history.”

About this neuropsychopharmacology research

Funding: The study was funded by NIH Grant P50MH090966 and the Sigrid Juselius Foundation, the Foundation for Pediatric Research in Finland and the Finnish Medical Foundation. The authors report no competing interests.

Source: Stephanie Berger – Columbia University’s Mailman School of Public Health
Image Credit: The image is in the public domain
Original Research: Abstract for “Pregnancy Complications Following Prenatal Exposure to SSRIs or Maternal Psychiatric Disorders: Results From Population-Based National Register Data” by Heli Malm, Andre Sourander, Mika Gissler, David Gyllenberg, Susanna Hinkka-Yli-Salomäki, Ian W. McKeague, Miia Artama, and Alan S. Brown in American Journal of Psychiatry. Published online August 4 2015 doi:10.1176/appi.ajp.2015.14121575


Abstract

Pregnancy Complications Following Prenatal Exposure to SSRIs or Maternal Psychiatric Disorders: Results From Population-Based National Register Data

Objective:
Using national register data, the authors examined the relationship between prenatal selective serotonin reuptake inhibitor (SSRI) treatment and pregnancy complications, accounting for psychiatric diagnoses related to SSRI use.

Method:
This was a population-based prospective birth cohort study using national register data. The sampling frame included 845,345 offspring, representing all singleton live births in Finland between 1996 and 2010. Pregnancies were classified as exposed to SSRIs (N=15,729), unexposed to SSRIs but with psychiatric diagnoses (N=9,652), and unexposed to medications and psychiatric diagnoses (N=31,394). Pregnancy outcomes in SSRI users were compared with those in the unexposed groups.

Results:
Offspring of mothers who received SSRI prescriptions during pregnancy had a lower risk for late preterm birth (odds ratio=0.84, 95% CI=0.74–0.96), for very preterm birth (odds ratio=0.52, 95% CI=0.37–0.74), and for cesarean section (odds ratio=0.70, 95% CI=0.66−0.75) compared with offspring of mothers unexposed to medications but with psychiatric disorders. In contrast, in SSRI-treated mothers, the risk was higher for offspring neonatal complications, including low Apgar score (odds ratio=1.68, 95% CI=1.34–2.12) and monitoring in a neonatal care unit (odds ratio=1.24, 95% CI=1.14–1.35). Compared with offspring of unexposed mothers, offspring of SSRI-treated mothers and mothers unexposed to medications but with psychiatric disorders were both at increased risk of many adverse pregnancy outcomes, including cesarean section and need for monitoring in a neonatal care unit.

Conclusions:
In a large national birth cohort, treatment of maternal psychiatric disorders with SSRIs during pregnancy was related to a lower risk of preterm birth and cesarean section but a higher risk of neonatal maladaptation. The findings provide novel evidence for a protective role of SSRIs on some deleterious reproductive outcomes, possibly by reducing maternal depressive symptoms. The divergent findings suggest that clinical decisions on SSRI use during pregnancy should be individualized, taking into account the mother’s psychiatric and reproductive history.

“Pregnancy Complications Following Prenatal Exposure to SSRIs or Maternal Psychiatric Disorders: Results From Population-Based National Register Data” by Heli Malm, Andre Sourander, Mika Gissler, David Gyllenberg, Susanna Hinkka-Yli-Salomäki, Ian W. McKeague, Miia Artama, and Alan S. Brown in American Journal of Psychiatry. Published online August 4 2015 doi:10.1176/appi.ajp.2015.14121575

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