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Which SSRIs Are Safest in Pregnancy?

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Argirios Argiriou:
July 9, 2015

Which SSRIs Are Safest in Pregnancy? New Findings May Help Guide Treatment Decisions

By Amy Orciari Herman Edited by Susan Sadoughi, MD, and Richard Saitz, MD, MPH, FACP, FASAM

A new study in the BMJ may help guide clinicians' and patients' choice of antidepressant in pregnancy.Using data from a large U.S. study, researchers identified nearly 18,000 birth defect cases and 10,000 controls. The mothers of 660 cases and 300 controls had used selective serotonin reuptake inhibitors (SSRIs) in the month before or first 3 months of pregnancy.

Among the findings:

Sertraline (Zoloft) wasn't associated with any of five defects to which it had previously been linked (e.g., septal defects).

Neither citalopram (Celexa) nor escitalopram (Lexapro) was associated with defects, except for a "marginal" link between citalopram and neural tube defects.

Fluoxetine (Prozac) was associated with ventricular septal defects, right ventricular outflow tract obstruction cardiac defects, and craniosynostosis.

Paroxetine (Paxil) was associated with anencephaly, atrial septal defects, right ventricular outflow tract obstruction cardiac defects, gastroschisis, and omphalocele.

The authors note that if the associations observed are causal, the absolute risks are small. For example, for babies exposed to paroxetine, the absolute risk for anencephaly would increase from 2 to 7 per 10,000.

Allison Bryant, associate editor with NEJM Journal Watch Women's Health, said: "Any risk ... cannot yet be entirely separated from risks attributed to the underlying condition. Women and their providers should keep this in mind when considering the risk-benefit balance for treating maternal depression."

Link(s):BMJ article (Free)Background: Recent NEJM Journal Watch General Medicine coverage of antidepressants and birth defects (Your NEJM Journal Watch subscription required)

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Argirios Argiriou:
And an interesting comment by John Gray MD Physician 11 Jul 2015 2:18 PM

1. Most physicians want to do "something" to help the patient but we should not prescribe unless the likely benefit is much greater than the possible harm.

2. If a class of similar drugs can cause major measured defects, then there is a good possibility that it can cause other defects that are less obvious and difficult to measure.

3. Long term studies show that antidepressants have significant benefit over placebo mostly in major depression and then only in a minority ( 10%-20% ) of patients.

4. The above would suggest great caution in using any antidepressant, and indeed any medication, during pregnancy. -

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