What about a special case?
Antidepressants in pregnancy.
And so, if you're wondering because I didn't understand
what that picture was for a
minute when I first looked at it.
It is a baby in a blanket.
I thought it was a cabbage or a chili pepper for a minute.
No, it's actually a baby.
And I'm a dad.
So, I should know these things.
So, we know that depression in
and of itself is a risk factor in pregnancy.
So, it particularly increases the risk of pre-term birth.
Now, antidepressant therapy is not
necessarily proven to ameliorate that risk.
So, just giving a patient an
antidepressant doesn't mean that they
have a lower likelihood of giving a –
of having preterm birth.
do understand that antidepressants are associated
with multiple concerns during pregnancy.
A lot of these are controversial and
haven't been completely established,
but it seems that paroxetine
does have a positive association with
promoting congenital heart abnormalities
and generally should be avoided during pregnancy.
That agent in particular.
All SSRIs taken during the second half
of pregnancy have been associated with
persistent pulmonary hypertension in the newborn.
That's a pretty firmly established
link at this point as well.
But there are other questions as to
whether SSRI used during pregnancy
may be associated with a higher
risk of autism later in childhood,
whether it’s associated with other congenital defects.
These are more controversial
and continue to be studied,
but should be part of the
balance in making a decision,
a real patient-centered
decision involving the patient
as to whether to either continue or initiate
antidepressant treatment during pregnancy.
So, the preferred agents during
pregnancy might include drugs
like citalopram, fluoxetine has
been the most widely studied,
and sertraline, but not
preferred would be paroxetine.
And the bottom line is that
for most patients with mild or moderate depression,
I would recommend avoiding all the controversy,
discontinuing antidepressants during pregnancy
and you can always rely
on something like talk therapy,
which is not going to produce
any side effects on the fetus.
That's for sure.
For patients with more severe depression,
again, shared decision-making,
practicing with the patient to talk
about the potential risks and benefits,
and I would usually recommend
involving an OB/GYN specialist
as well as a mental health care
specialist in those cases as well.
A few more notes on antidepressants, odds and ends,
but that may come up on your exam.
Remember that the serotonin
norepinephrine reuptake inhibitors
have an added benefit beyond depression,
in that they can help with chronic pain.
Pain and depression,
commonly comorbid conditions.
If a patient is really feeling tired,
has difficulty initiating activity,
think about a serotonin
norepinephrine reuptake inhibitor (SNRI)
or think about fluoxetine.
Those drugs are good.
How about a patient who can’t sleep at night,
has a poor appetite?
Mirtazapine can be a good option for those patients.
That one works well, particularly it
seems like for older patients
who commonly have those
symptoms with their depression,
mirtazapine can be a good option.
And because SSRIs, SNRIs
both promote sexual side
effects, sexual dysfunction,
for patients who suffer with that condition,
also more common in
depression on its own right,
those patients are more
likely to have sexual dysfunction.
Bupropion doesn't add
to those side effects.
So, what we talked about today was define depression,
just in a little bit how – of how common it is
and a lot about treatment.
So, don't forget the basics of exercise
and don't forget that talk
therapy can be highly effective
because we know that
a third of patients who take
pharmacologic treatment for depression
aren’t going to even respond.
And so, therefore, it might take some trial and
error of trying out a couple of different drugs.
Usually, you can find something that works between
those different modalities of treatment
and make your patient feel better.