_______________________________________________________________________ Depression and Suicide
mg/70 kg) psilocybin [326; 327]. Patients in all sessions were accompanied by trained therapy support. Both studies reported significant improvements in depression and anxiety scores, measures of spiritual well-being, emotional distress related to the cancer, and quality of life. Immediate post-treatment gains were sustained for six-month study durations by 60% to 80% of subjects. These studies confirmed psilocybin could be given safely without significant adverse effects in a controlled environment with trained therapists [326; 327]. PERINATAL DEPRESSION Approximately 5% to 14% of women experience significant mood or anxiety symptoms during pregnancy, and the goal of perinatal treatment is to minimize the risks of both depres- sion and its treatment to the mother and child [328; 329]. Misperception about treatment risk can result in the termina- tion of otherwise wanted pregnancies or avoidance of needed pharmacotherapy. By informing patients of both the nature of medication risks and the risks of untreated illness, providers can help patients reach their own educated decisions. For depressed pregnant women, both continuous SSRI expo- sure and continuous untreated depression are associated with preterm birth rates in excess of 20% [330]. The potential impact of untreated maternal depression on pregnancy outcome and infant health include preterm birth and low birth weight, birth defects, developmental delay and cognitive impairment, behavioral and emotional maladjustment, and poor maternal health behaviors such as smoking and alcohol and substance use, which secondarily affect birth outcome [331]. MILD-TO-MODERATE DEPRESSION Several non-drug therapies effective in mild-to-moderate depres- sion are available for pregnant and breastfeeding women, including interpersonal psychotherapy, bright-light therapy, and CBT [332; 333; 334]. Interpersonal therapy is efficacious in postpartum depression and can improve functioning for
six months postpartum [334]. While these interventions are more efficacious than routine care for postpartum depression, there is little indication of superiority for any one interven- tion [334]. Other nonpharmacologic treatments that may be effective include acupuncture, progressive relaxation, music therapy, sleep deprivation, and exercise [331]. Empirical sup- port for nutritional or supplemental omega-3 fatty acids is lacking, although they pose little to no risk of adverse effects [335]. Progesterone is ineffective in postpartum depression and may intensify depressive symptoms in some patients [331]. SEVERE DEPRESSION In many circumstances, the risks of untreated illness may outweigh the potential negative effects of certain antidepres- sant medications. Partial SSRI treatment during pregnancy to reduce the risk of preterm birth is not recommended, as inadequate dosing does not successfully treat the depression. When possible, medication choice should be based on what has worked previously and the risk/benefit of continuing the current medication during pregnancy and/or postpartum. Optimal dosing and safety is best ensured by consultation with a health professional with perinatal expertise. PHARMACOLOGY AND PERINATAL DEPRESSION The largest amount of reproductive safety information is available for TCAs and SSRIs ( Table 5 ). Available pregnancy data have found no evidence that fluoxetine, sertraline, flu- voxamine, venlafaxine, or bupropion are associated with an increased risk of major congenital malformations. In 2006, the FDA warned that paroxetine was associated with increased risk for cardiovascular malformations compared to other antidepressants. Therefore, women of childbearing age taking paroxetine should be advised of the potential risk, and other treatment options should be considered [175; 336]. The use of SSRIs before the 20th week of gestation has not been associated with persistent pulmonary hypertension, but use of SSRIs in late pregnancy has shown a small but sig- nificantly increased risk of persistent pulmonary hypertension
FDA RATINGS OF ANTIDEPRESSANT PREGNANCY RISK
Rating
Definition and Examples
A
No currently available antidepressant medications are rated A, which would indicate a failure to demonstrate risk to the fetus in well-controlled studies of pregnant women. Maprotiline—no evidence of risk in humans, and either animal findings show risk but human findings do not, or animal findings are negative if no adequate human studies have been performed. Amitriptyline, amoxapine, bupropion, protriptyline, sertraline, trazodone, trimipramine, and venlafaxine—risk cannot be ruled out, and although human studies are lacking and animal studies are either positive for fetal risk or are lacking, potential benefits may justify the potential risks. Imipramine, nortriptyline, and paroxetine—positive evidence of risk. Investigational or postmarketing data show risk to the fetus. The potential benefits may outweigh the potential risks, and if needed in a life-threatening situation or a serious disease, the drug may be acceptable if safer drugs cannot be used or are ineffective. No currently used antidepressant medications are rated X, which would indicate that use is contraindicated in pregnancy due to animal or human studies that conclude that fetal risk clearly outweighs potential benefits.
B
C
D
X
Source: [21]
Table 5
201
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