Risk-benefit balance assessment of SSRI antidepressant use during pregnancy and lactation based on best available evidence – an update

ABSTRACT

Introduction: Depression affects 300 million individuals worldwide. While selective serotonin reuptake inhibitors (SSRI) are one of the first-line pharmacological treatments of major depression in the general population, there is still uncertainty regarding their potential benefits and risks during pregnancy.

Areas covered: Outcomes requisite for a proper risk/benefit assessment of SSRI in pregnancy and lactation were considered: (a) potential risks associated with untreated depression, (b) effectiveness of different treatment options of depression, (c) potential risks associated with SSRI.

Expert opinion: Despite the growing amount of literature on SSRI use during pregnancy, no new trials assessing the benefits of SSRIs on maternal depression were found. In the light of new data regarding the potential risks, depressed SSRI-treated pregnant women and their children seem at increased risk for several complications (mostly of small absolute risk). The interpretation of these findings remains quite similar to our previous review as the available methodology does not allow to disentangle the potential effect of SSRIs from those of the disease itself or/and of its unmeasured associated risk factors. Thus, in pregnant or lactating women who require a pharmacological treatment, SSRIs can still be considered as appropriate when effective as the abundant data support their relative safety.

KEYWORDS:

• Lactation
• pregnancy
• Selective Serotonin Reuptake Inhibitor
• risks
• benefit

Article highlights

• Untreated depression during pregnancy may have multiple adverse consequences for the mother and the child.

• In the absence of randomized trials to evaluate the effectiveness of antidepressant use in pregnancy, guidelines rely on observational studies and risk-benefit assessments.

• While depressed SSRI-treated pregnant women and their children seem to be at slightly greater risk for several complications (mostly of small absolute risk), it is still difficult to disentangle the potential effect of SSRIs from the potential effect of the disease itself or/and its unmeasured associated risk factors.

• Whenever effective, non-pharmacological treatments such as cognitive-behavioral or interpersonal therapy should be preferred, while SSRIs may be considered in pregnant women requiring a pharmacological treatment including adequate monitoring.

• The newborn should be monitored after delivery due to the risk of transitory poor neonatal adaptation or persistent pulmonary hypertension in the neonate. Breastfeeding should be encouraged whenever desired to strengthen the mother-child relationship.

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was funded by the University Hospital of Lausanne and the University of Geneva.