A Tale of 2s: Optimizing Maternal—Child Health in the Context of Antenatal Maternal Depression and Antidepressant Use

Abstract

Abbreviations 5-HT serotonin AD antidepressant LBW low birth weight MDD major depressive disorder PTB preterm birth SSRI selective serotonin reuptake inhibitor Not a week goes by without new studies reporting on depression during and outcomes following exposure to prenatal SSRIs. Recent public and scientific attention has focused on interpreting contrasting reports of increased risk for congenital anomalies - particularly vascular and cardiac defects' and the apparent lack of risks related to SSRI exposure.21 Reports of neurobehavioural disturbances associated with prenatal SSRI exposure5·6 contrast with other studies that find no increased developmental vulnerability.1·7 This constantly evolving literature raises scientific8 and public9·10 concern about managing mood disorders during pregnancy and conceptualizing the responsible inclusion of pregnant women in medical research.12·13 In this issue of The Canadian Journal of Psychiatry, 2 key papers address this pressing question.14·15 The paper by Dr Dan Rurak and colleagues (see Shea et al14) highlights key factors that influence fetal drug exposure, and presumably influence the long-term developmental consequences of prenatal drug exposure. Given the variable outcomes associated with pharmacotherapy, the paper by Dr Sherryl H Goodman and Dr Sona Dimidjian15 offers a developmental psychopathology perspective and promising evidence for psychosocial interventions to treat depression during pregnancy. These 2 perspectives offer ways to optimize antenatal mental health treatment and pharmacotherapy to minimize fetal drug exposure. As clinicians, we are frequently faced with questions about how best to promote optimal care for mothers and support development and behaviour in the children of mothers who were depressed during pregnancy. As antenatal maternal mood disorders themselves influence infant and child behaviour,16·17 we are challenged to provide appropriate and timely care when both antenatal SSRI and maternal mood effects are often indistinguishable. To appreciate the impact of these prenatal exposures, we recognize the interplay of 3 key features influencing child development in this setting. This is a story of interplay between the 2s: 2 environmental pathogens - exposure to depressed-anxious maternal mood and SSRI ADs; 2 time periods - spanning pre- and postnatal periods; and 2 highly interrelated individuals, spanning 2 generations - the mother and her infant. Accounting for the ongoing interplay between these factors is essential, but our current understanding of the impact, both of SSRI medications and of psychiatric disorders, on early human development limit our ability to distinguish between the impact of disease and treatment. The incidence and period prevalence of MDDs during are 7.5% and 12.7%, respectively.'8 Although MDD is common, only 1 in 5 Americans receive any guideline-concordant intervention, and most are inadequately treated.6 Treatment rates for mood disorders are even lower for pregnant women (14%) than in the general population of women (26%).7 Pregnancy frequently results in discontinuation of both psychotherapy and pharmacotherapy, and women do not resume care in the postpartum period.8 Most women do not receive prescriptions for ADs beyond 6 weeks of gestation. Pregnant women who discontinue ADs proximate to conception have a higher risk for relapse (68%), compared with those who maintain treatment (26%). Although psychotherapy is the preferred treatment of most women,6 it is neither available in all practice settings nor accessible for some mothers. Low treatment rates are juxtaposed against mounting evidence that MDD increases multiple risks for the pregnant woman and fetus. Gestational MDD is associated with risk directly related to the physiological sequelae of psychiatric illness as well as secondary to associated maternal behaviours, such as smoking, poor nutrition, substance abuse, inadequate obstetrical care, and interpersonal isolation and suicide. …