Use of Selective Serotonin Reuptake Inhibitors during Pregnancy and Risk of Autism

Autism and its causes have been a heavily discussed issue.  This study specifically concerns the issue of the use of antidepressants during pregnancy and increased risk of autism spectrum disorders.  The study was conducted in Denmark and looked at live births from 1996 to 2005.  It looked at the use of SSRIs by the mother before and during pregnancy, autism spectrum disorders that were diagnosed and any other potential confounders.

The results of the study showed that there was no increased risk of autism spectrum disorders associated with use of SSRIs during pregnancy when compared to no SSRI use both before and during pregnancy.  While no significant association could be found, based on the upper boundary of the confidence interval relative risk of up to 1.61 could exist.  Therefore, the study concluded that more research had to be conducted to determine a conclusive answer.

I found this article interesting because of how much attention is being paid to autism and its potential causes.  I think it is extremely important to always do your research before making a claim or even sharing an article on Facebook.  So many people are willing to accept inaccurate information, especially if its explains something in their life that was previously unexplainable.

Hviid A, Melbye M, and Pasternak B. Use of Selective Serotonin Reuptake Inhibitors during Pregnancy and Risk of Autism. N Engl J Med. 2013;369(25): 2406-415.

http://www.nejm.org/doi/full/10.1056/NEJMoa1301449

Comparative Benefits and Harms of Antidepressant, Psychological, Complementary, and Exercise Treatments for Major Depression

In a systematic review done by Gartlehner and colleagues, benefits and safety of second-generation antidepressants were compared with psychological, complementary and alternative medicine (CAM) and exercise treatments as first and second-step interventions in adults with acute major depressive disorder (MDD). They searched many data sources like MEDLINE and the Cochrane Library from 1990 to September 2015 for patients who were treated with second-generation antidepressants, psychological interventions, CAM interventions, exercise, or a combination of any of these treatments. Overall, they found that there was no significant differences in the efficacy of second-generation antidepressants and other types of treatments as first-step treatments. Also, second-generation antidepressants in general had higher risk of adverse events compared to the other interventions. The intervention with the strongest evidence was cognitive behavioral therapy (CBT).

I found the results of this systematic review to be very interesting because I would not have guessed that the effectiveness of CBT would be comparable to that of antidepressant medications. I feel that both interventions are very valid in treating acute MDD, and that choosing between the two will be choosing which risks are most manageable. Seeing how CBT can be effective, I wonder how other interventions, like exercise, will compare. These options may seem a lot more appealing to patients as they would not have to use a medication to treat their condition. I hope that in the future more studies will take a closer look at comparing the efficacy and safety of antidepressants and other non-medication based therapies.

Ann Intern Med. 2016;164:331-341.

Studying Antidepressant Nonadherence Using Discarded Blood Samples

Studies show that antidepressant nonadherence is very common. Published reports vary widely, placing the percentage of nonadherent antidepressant users somewhere between 25-50%. It is no secret that these medications work better when taken on a consistent basis. However, it is hard to measure actual adherence due to the fact that patients may become embarrassed or lie, appearing to be more adherent to their medications than they really are. Robertson and colleagues came up with a unique idea in order to measure adherence and bring light to the fact that more individuals may be nonadherent then we, as pharmacist, are led to believe. This team used discarded blood samples from routine clinical blood draws to measure antidepressant nonadherence. They surveyed the electronic health data and collected patients 14-90 days from treatment initiation who were prescribed sertraline, citalopram, bupropion, or venlafaxine. They examined the discarded blood samples from 109 such individuals with active and recently filled antidepressant prescriptions, and looked for detectable serum levels of that drug. Overall, 17% of the samples lacked a detectible level of antidepressants. I think this was a unique way to study nonadherence and although I do not think it could be used at the community level, I think there are areas of pharmacy in which this might one day play a role.

In what ways do you think this could work in our profession?

Link

Roberson AM, Castro VM, Cagan A, Perlis RH. Antidepressant nonadherence in routine clinical settings determined from discarded blood samples. J Clin Psychiatry. doi.org/10.4088/JCP.14m09612. (published 24 November 2015).

Use of Antidepressants During Pregnancy and Risk of Autism Spectrum Disorder

To determine the correlation between the use of antidepressants during pregnancy and the child being born with autism spectrum disorder, a group of researchers looked at infant and mother data in Quebec from 1998 to 2009. From looking at his data, they collected 145,546 infants born to mothers who were covered by Regie de l’assurance maladie du Quebec for at least a year prior to and throughout their entire pregnancy. They determined that use of an antidepressant was established by the filling of at least one prescription throughout their pregnancy. By the end of their study, with the children having a mean age of six, 1,054 children had been diagnosed with autism spectrum disorder. The women who had used antidepressants, specifically those using selective serotonin reuptake inhibitors in the second or third trimester, had a much higher frequency of giving birth to a child whom would be diagnosed with at least one diagnosis of autism spectrum disorder.

Identifying a potential cause or contributor to the autism spectrum disorder can create a great sense of caution among future mothers. When making people aware of the concern and issue of using antidepressants, it becomes a much stronger argument when you have data and research to back up the claim. Hopefully in the future, mothers will become more aware of their impact on children with the prescription medications they take and will be able to plan accordingly.

As medical professionals should we be able to restrict the access that pregnant women have to antidepressants as it poses a risk to their unborn child?

JAMA Pediatr. 2016;170(2):117-124.