Common Mental Disorders Depression - New Zealand Doctor

Chapter 7 Special issues: women with mental disorders in the antenatal and postnatal period
Pharmacological therapies
A search was conducted for RCTs of antidepressant use in women with depression in
the antenatal or postnatal period. The evidence comprised one guideline 101 with three
relevant studies conducted in mixed primary and secondary care populations. 479,486,490
Given the dearth of evidence from controlled studies on the safety of antidepressants
in this population, recent reviews of relevant observational evidence were also
retrieved. Three narrative reviews 453,456,470 were identified and studies from their lists of
references were accessed. Advice on relevant studies was also sought from a maternal
mental health specialist.
Efficacy
There was some evidence (from a single RCT) 486 of the efficacy of the SSRI fluoxetine
with a single session of CBT in the postnatal period. However, fluoxetine with six
sessions of CBT was only as effective as 6 sessions of CBT alone. This finding was
supported by low-quality evidence from uncontrolled trials. 65
Safety and adverse effects on the infant/foetus
Selective serotonin reuptake inhibitors in pregnancy
Small prospective cohort studies in the 1990s found no association between maternal
SSRI use and birth defects. 453 However, more recently large case-control studies 464,491
and a population-based cohort study 492 found a significant association between
maternal SSRI use in early pregnancy and major birth defects. In two studies, 464,491 the
increase associated with SSRIs applied only to specific rare defects (eg, omphalocele),
with no increase in the overall rate, but in the third 492 there was a moderate increase
in overall risk of birth defects (RR 1.34, 95% CI 1.00 – 1.79). There has been concern
about a possible increase in the risk of cardiovascular malformations associated
with the use of paroxetine during the first trimester. 465,493 A Canadian study linking
databases of medications and hospital discharges involving International Classification
of Diseases, Ninth Revision (ICD9) codes for malformations, also showed an
association between major cardiac malformations and exposure to paroxetine, though
only at daily doses of greater than 25 mg (adjusted odds ratio 3.07; 95% CI 1.00 –
9.42). 494 However, a recent study identified outcomes in over 3000 infants exposed to
paroxetine during the first trimester and found that the rate of malformations was well
within incidence in the general population, at around 1%. 495 Current Medsafe advice
recommends avoiding the use of paroxetine in pregnancy. 462
A systematic review of more than 20 small observational studies reported a neonatal
syndrome with symptoms of increased muscle tone, tremulousness, and difficulty
with respiration, feeding, and sleep in infants who had third-trimester exposure to
SSRIs. 496 A large study using British Columbian population health data over a 3-year
period found that prenatal exposure to SSRIs was associated with an increased risk of
neonatal respiratory distress, even after accounting for maternal illness severity. 496,497
Identification of Common Mental Disorders and Management of Depression in Primary Care 105