2.  Depression is an illness that
involves the body, mood and
thoughts
 It impacts the way a person
functions socially, at work,
and in relationships.
 It is a medical condition that
requires diagnosis and
treatment

3.  Depression can be caused by one or more
 Imbalance of certain chemicals in the brain.
 Triggered by
stress, medication ,other medical problems.
 Certain personality factors or genetic traits.

5.  Over the last 2 weeks, most of the day nearly every day, five of
the following (one symptom must be mood or interest), which
must cause marked distress or impairment in important areas of
functioning
① Depressed mood
② Markedly diminished interest or pleasure
③ Significant weight loss or gain unrelated to dieting
④ Insomnia or hypersomnia
⑤ Psychomotor agitation/retardation
⑥ Fatigue or loss of energy
⑦ Feelings of worthlessness/guilt
⑧ Diminished ability to concentrate
⑨ Recurrent thoughts of death

6.  6 to 12% - Gavin and co-workers (2005)
 10.7% - Dennis and associates (2007)
 13% of pregnant women -Cooper and associates (2007)
 Incidence to be as high as 30%
(Lee and colleagues, Westdahl and associates, 2007)
 3.2 % of more than 25,000 prenatal patients at the Mayo
Clinic took SSRIs during pregnancy Conversely(Wichman
and colleagues (2009))

7.  Postpartum depression—major or minor—develops in
10 to 20 % of parturients
 Associated with
 Young maternal age
 Unmarried status
 Smoking or drinking
 Substance abuse
 Hyperemesis gravidarum
 Preterm birth
 High utilization of sick leave during pregnancy

8.  Approximately 80% of people who receive
treatment for Depression improve.
 Three types of treatment:
 Psychotherapy
 Medication
 Electroconvulsive Therapy (ECT)

9. 1. Selective Serotonin Reuptake Inhibitor (SSRI)
 Sertraline (Zoloft)
 Fluoxetine (Prozac)
 Paroxetine (Paxil)
 Citalopram (Celexa)
 Escitalopram (Lexapro)
2. Tricyclic Antidepressant (TCA)
 Amitriptyline (Elavil)
 Nortriptyline (Pamelor)
 Imipramine (Tofranil)
 Desipramine (Norpramin)
 Doxepine (Sinequan)
 Trimipramine (Surmontil)

10. 3. Serotonin-Norepinephrine Reuptake Inhibitors (SNRI)
• Venlafexine (Effexor)
• Desvenlafaxin (Pristiq)
• Duloxetine (Cymbalta)
4. MAO Inhibitors
• Phenelzine (Nardil)
• Tranylcypromine (Parnate)
5. Atypical Antidepressants
• Bupropion (Wellbutrin)
• Trazodone (Desyrel)
• Mirtazepine (Remeron)

11. 1. Risk of pregnancy loss or miscarriage.
2. Risk of organ malformation or teratogenesis.
3. Risk of neonatal toxicity or withdrawal syndromes during the acute
neonatal period.
4. Risk of long-term neurobehavioral sequelae.
 FDA classification (A, B, C, D, X)
 this system of classification is often ambiguous and may lead
some to make conclusions that are not warranted.
 TCAs have been labeled as category D agents :available data
do not support this assertion, suggest that these drugs are
safe for use during pregnancy.

13.  TCAs
 The lowest known risk in pregnancy and breast feeding
 Dangerous if overdosed
 SSRIs
 Paroxetine (Paxil)
: 1st trimester : ASD, VSD, Right ventricular outflow
defects
 Sertraline (Zoloft)
: ASD, VSD,omphalocele
 Citalopram (Celexa) + Esitalopram (Lexapro)
: anencephaly, omphalocele, craniosynostosis

14.  SSRIs and TCAs
Late pregnancy  persistent pulmonary hypertension
 Miscarriage/stillbirth/low birth weight
Data is conflicting and inconclusive

15.  SSRI –m/c used antidepressants in pregnancy
 citalopram, escitalopram, fluoxetine, fluvoxamine,
paroxetine, sertraline
 Congenital cardiac malformations was increased 1.5
to 2 fold following 1st trimester paroxetine exposure.

16.  The overall rate of infants with cardiovascular malformations
among women who took paroxetine was increased
approximately 0.5 to 1.0 percentage points above the rate for
infants with other antidepressant exposure in utero.
 Most of these defects were atrial and ventricular septal
defects
• Recommended that paroxetine use be avoided in women
who are either pregnant or planning pregnancy and that fetal
echocardiography should be considered for women with
early pregnancy paroxetine exposure.
• the American College of Obstetricians and Gynecologists (2007)

17.  There are two types of neonatal effects that have been
described following maternal SSRI use in pregnancy.
1. Neonatal behavioral syndrome
 Up to a fourth of fetuses exposed in the last
trimester
 Most SSRI-related neonatal case reports
specifically involved paroxetine and fluoxetine
exposures

18.  Symptoms include:
 Jitteriness
 Tachypnea
 Tremulousness
 Hypertonia
 Restlessness
 Signs include CNS, motor, respiratory, and GI signs
 Usually mild, transient with resolution by 2 weeks
 Severe syndrome
 Seizures, dehydration, excessive weight loss,
hyperpyrexia, intubation
 Rare in full-term infants

19.  Tapering and discontinuation of the antidepressant
over 10 to 14 days before the EDC
 Reintroduction of the drug immediately after birth.
 However, if a woman has a history of rapid
decompensation during antidepressant taper or
discontinuation, this strategy is likely to carry more risk
than continued treatment.

20. 2. The second neonatal syndrome
 Rare
 Persistent pulmonary hypertension in the newborn
(PPHN).
 High pulmonary vascular resistance, right-to-left
shunting, and profound hypoxemia
 Mortality rates are as high as 20 percent, and many
survivors have long-term morbidity
Treatment with these medications during pregnancy
should be individualized

21.  In patients with less severe depression, it may be
appropriate to consider discontinuation of
pharmacological therapy during pregnancy
 Women with recurrent or refractory depressive illness
may decide in collaboration with their clinician that the
safest option is to continue pharmacological trea
tment during pregnancy
 Paroxetine -> fluoxetine or citalopram.

22.  Fluoxetine and citalopram - first-line choices
 The TCAs and bupropion have also been relatively well
characterized and can be considered reasonable
treatment options during pregnancy.
 Several investigators have described a reduction in
serum levels of TCAs during pregnancy.
 Increase in daily TCA or SSRI dosage may be required
to obtain remission.

23.  The American College of Obstetricians and
Gynecologists (2007) concluded that the absolute risk of
any birth defect is very small and that SSRIs are not
major teratogens.
 May be enough data to not pick as first line drug in
pregnancy (or planning pregnancy):
 Fluoxetine (Prozac) – if will be breastfeeding
 Larger prospective studies with better controls for
confounding variables are required