What Is Evidence Base for Using SSRIs During Pregnancy?

That question prompted the following winning response from University of Michigan psychiatry resident Dharmesh Sheth, M.D., in an interactive contest about evidence-based medicine designed by residents and faculty:

“Depression is common among women of childbearing age, and affected women are frequently prescribed SSRIs. To date, none of the SSRIs studied in pregnancy has been found to increase the baseline rate of 1 percent to 3 percent for major malformations. A meta-analysis examined almost 1,800 women who used the newer antidepressants, including SSRIs, during pregnancy in seven prospective, comparative studies and found no increased risk for major malformations. Maternal exposure to antidepressants may be associated with increased risk for spontaneous abortion; however, depression itself cannot be ruled out. In two studies by the same group, no association between gestational use of TCAs or fluoxetine and language development, global IQ, or temperament was observed. A literature review by Moses-Kolko El et al., suggests that in utero exposure to SSRIs during the last trimester through delivery may result in a self-limited neonatal behavioral syndrome that can be managed with supportive care. The risks and benefits of discontinuing an SSRI during pregnancy need to be carefully weighed for each individual patient.

“APA's Committee on Research on Psychiatric Treatments identified treatment of major depression during pregnancy as a priority area in clinical management. On the basis of this recommendation, a position paper was published on the risk-benefit decision making for treatment of depression during pregnancy. The authors concluded that there was no evidence to implicate antidepressants as causing harm to an unborn baby and that a pregnant woman should be treated so long as the benefits and possible risks are well explained to her.

“Recent concerns have been for the increased risk of congenital malformations by paroxetine. As reported on the FDA Web site, `Preliminary results of two recent studies indicate that paroxetine increases the risk of congenital malformations, particularly cardiovascular malformations. Based on the new data, paroxetine's pregnancy category is being changed from C to D....' This FDA alert has been based on preliminary results of unpublished studies by GSK.”

Sheth's literature references as well as other winning responses are posted at<www.med.umich.edu/psych/education/evidence.htm>.