Hormones And Mood In PMDD And Pregnancy - Faina Novosolov, MD
Hormones And Mood In PMDD And Pregnancy - Faina Novosolov, MD
Hormones And Mood In PMDD And Pregnancy - Faina Novosolov, MD
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<strong>Hormones</strong> and <strong>Mood</strong><br />
in <strong>P<strong>MD</strong>D</strong> and<br />
<strong>Pregnancy</strong><br />
<strong>Faina</strong> <strong>Novosolov</strong>, M.D.<br />
Women’s <strong>Mood</strong> and Hormone Clinic<br />
UCSF/ LPPI<br />
415-771-7711 www.fainamd.com<br />
No other financial disclosures.
Educational Objectives<br />
• Diagnosis/treatment of <strong>P<strong>MD</strong>D</strong> vs PMS<br />
vs PME<br />
• Better understanding of the menstrual<br />
cycle in relation to mood symptoms<br />
• Understanding the second mechanism<br />
of SSRI’s<br />
• How to treat depression in pregnancy<br />
and risk factors to review with women<br />
during pregnancy/delivery
Menstrual Cycle<br />
Estrogen / E2 <br />
Testosterone <br />
Follicular <br />
Phase <br />
Luteal <br />
Phase
Brain Variability Controlled by<br />
Ovarian <strong>Hormones</strong><br />
Depending on where a woman is in her cycle,<br />
there is variability in the following:<br />
• <strong>Mood</strong><br />
• Verbal performance<br />
• Sexual interest<br />
• Visual-spatial performance<br />
-Sherwin, “Estrogenic effects on memory in women.” Ann N Y Acad Sci., Nov 1994 <br />
-Goldstein et al., “Sex Differences in Stress Response Circuitry Activation Dependent on Female Hormonal Cycle.” J<br />
Neurosci. 2010 January 13. <br />
-L. Brizendine, The Female Brain, 2006
Menstrual Cycle<br />
<strong>Mood</strong>/verbal <br />
Highest<br />
Sex Drive <br />
Visual-spatial
Best <br />
Worst <br />
week 1 2 3 4 <br />
-Stanicić A et al., “Psychophysical characteristics of the premenstrual period.” Coll Antropol. 2010 Dec;34(4):1421-5.
<strong>P<strong>MD</strong>D</strong> vs Normal PMS<br />
Normal PMS (Premenstrual Syndrome):<br />
• 80% of women<br />
• Mild to moderate emotional fluctuations<br />
<strong>P<strong>MD</strong>D</strong> (Premenstrual Dysphoric Disorder):<br />
• 8-10% of women<br />
• Severe moods swings, depressed mood,<br />
irritability, or anxiety and 4 other symptoms<br />
(occurring exclusively during the luteal phase<br />
(weeks 3-4) and remitting within a few days of the<br />
onset of menses
DSM-IV Research Criteria For <strong>P<strong>MD</strong>D</strong><br />
-It is considered “Depression NOS”<br />
A. <strong>In</strong> most menstrual cycles during the past year, five (or more) of the following symptoms<br />
were present for most of the time during the last week of the luteal phase, began to remit<br />
within a few days after the onset of the follicular phase, and were absent in the week<br />
postmenses, with at least one of the symptoms being either (1), (2), (3), or (4):<br />
1. Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts<br />
2. Marked anxiety, tension, feelings of being "keyed up" or "on edge"<br />
3. Marked affective lability (e.g., feeling suddenly sad or tearful )<br />
4. Persistent and marked anger or irritability or increased interpersonal conflicts<br />
5. Decreased interest in usual activities (e.g., work, school, friends, hobbies)<br />
6. Subjective sense of difficulty in concentrating<br />
7. Lethargy, easy fatigability, or marked lack of energy<br />
8. Marked change in appetite, overeating, or specific food cravings<br />
9. Hypersomnia or insomnia<br />
10. A subjective sense of being overwhelmed or out of control<br />
11. Other physical symptoms, such as breast tenderness or swelling, headaches, joint or<br />
muscle pain, a sensation of "bloating," or weight gain<br />
B. The disturbance markedly interferes with work or school or with usual social activities and<br />
relationships with others<br />
C. The disturbance is not merely an exacerbation of the symptoms of another disorder<br />
(although it may be superimposed on any of these disorders).<br />
D. Criteria A, B, and C must be confirmed by prospective daily ratings during at least two<br />
consecutive symptomatic cycles.
Daily Record of Symptoms
Menstrual Cycle Week and<br />
All Psychiatric Admissions<br />
• If random,<br />
admissions of<br />
women to<br />
psychiatric hospitals<br />
for all psychiatric<br />
diagnoses would be<br />
25% on each week<br />
of the menstrual<br />
cycle<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
1st 2nd 3rd 4th<br />
Week of Menstrual Cycle <br />
Hospital<br />
Admits<br />
-Luggin et al. “Acute psychiatric admission related to the menstrual cycle.” Acta Psychiatrica Scandinavica, Vol 69, Issue 6, pp 461–465,<br />
June 1984. <br />
-Targum et al. “Menstrual cycle phase and psychiatric admissions.” , J Affect Disord. 22(1-2):49-53, May-Jun 1991.
Menstrual Cycle<br />
Estrogen / E2 <br />
Progesterone <br />
Testosterone <br />
Follicular <br />
Phase <br />
Luteal <br />
Phase
<strong>P<strong>MD</strong>D</strong><br />
Progesterone → Allopregnanolone (ALLO)<br />
soothing, like Valium<br />
• ALLO= a neuroactive metabolite of progesterone<br />
and works on GABA (gamma-aminobutyric acid)<br />
receptors in the brain<br />
• Hence, ALLO is a powerful anxiolytic,<br />
anticonvulsant, and anesthetic agent which<br />
decreases anxiety and depression.<br />
• Barbituates, benzodiazepines and alcohol also<br />
work at this receptor<br />
-Lisa Griffin, 1999
<strong>P<strong>MD</strong>D</strong><br />
Progesterone → Allopregnanolone (ALLO)<br />
soothing, like Valium<br />
-Prozac, Paxil and Zoloft were found not only to increase<br />
Serotonin, but also to increase ALLO production by<br />
activating the enzyme that converts progesterone to ALLO<br />
(by decreasing the enzyme’s K m 10- to 30-fold)<br />
-Imipramine (Tofranil) had no effect on ALLO production<br />
-Works almost immediately<br />
Journal:<br />
-Lisa Griffin, <strong>MD</strong>, PhD and Synthia Mellon, PhD.<br />
Selective serotonin reuptake inhibitors directly alter activity of<br />
neurosteroidogenic enzymes.<br />
Proc Natl Acad Sci U S A. 1999 Nov 9;96(23):13512-7.
2 Main Treatments<br />
• SSRI’s:<br />
<strong>P<strong>MD</strong>D</strong><br />
– Either 7-10 days before menses to help boost ALLO, or<br />
daily if also depressed<br />
– Or, you can increase SSRI dose in luteal phase<br />
• <strong>Hormones</strong>:<br />
– Start an OCP, or change to one with a progesterone<br />
good for mood<br />
– Take OCP continuously<br />
• Women are sensitive to hormones in different ways – some to<br />
the hormone fluctuation, some to the amount, and some to the<br />
progestin type
All Possible <strong>P<strong>MD</strong>D</strong> Treatments<br />
Antidepressants<br />
-SSRI*<br />
-SNRI*<br />
-Clomipramine**<br />
Ovulation Suppression<br />
-OCP’s*<br />
-GnRH Agonists (Lupron)**<br />
-Danazol (inhibits LH/FSH)<br />
-Oophorectomy <br />
Anxiolytics<br />
-BZD**<br />
-Buspar**<br />
Other<br />
-Exercise<br />
-Calcium**<br />
-CBT*<br />
-Vit B6<br />
-NSAIDS<br />
-Diet<br />
-Chasteberry<br />
(may reduce FSH or Prolactin)<br />
*Efficacy in double-blind studies of <strong>P<strong>MD</strong>D</strong><br />
**Efficacy in double-blind studies of PMS<br />
-Teri Pearlstein, M.D. Warren Alpert Medical School of Brown University, APA Conference 2008
Advantages of SSRI’s<br />
• Fluoxetine, Sertraline and Paroxetine CR are FDA<br />
approved for <strong>P<strong>MD</strong>D</strong><br />
• Both continuous and intermittent dosing effective<br />
• <strong>In</strong>termittent Fluoxetine is effective for mood symptoms<br />
at both 10 and 20 mg. 20 mg is more effective for<br />
physical symptoms than 10 mg.*<br />
• No discontinuation symptoms with intermittent dosing<br />
• Dosing strategies can be tailored to a woman’s<br />
preferences<br />
*Cohen LS, et al. Obstet Gynecol. 2002; 100: 435-444.<br />
-Teri Pearlstein, M.D. Warren Alpert Medical School of Brown University, APA Conference 2008
<strong>In</strong>termittent Fluoxetine in <strong>P<strong>MD</strong>D</strong><br />
0<br />
-2<br />
DRSP <strong>Mood</strong><br />
Cluster<br />
DRSP Physical<br />
Cluster<br />
DRSP Social<br />
<strong>And</strong> Functional<br />
Impairment Cluster<br />
Mean change<br />
from<br />
baseline<br />
-4<br />
-6<br />
-8<br />
-10<br />
-12<br />
-14<br />
-16<br />
Placebo<br />
Fluoxetine 10 mg<br />
Fluoxetine 20 mg<br />
DRSP = Daily Record of Severity of Problems<br />
Cohen LS, et al. Obstet Gynecol. 2002; 100: 435-444.
Concerns With SSRI’s<br />
• Potential long-term effects: weight gain, sexual SEs<br />
• Lower doses are less effective for physical<br />
symptoms than for mood/ anxiety symptoms<br />
• Tolerance to dose over time<br />
• Symptom recurrence after dose discontinuation<br />
• <strong>Pregnancy</strong> during treatment (may not want to<br />
choose Paroxetine CR if pregnancy is a possibility)<br />
-Teri Pearlstein, M.D. Warren Alpert Medical School of Brown University, APA Conference 2008<br />
-Cohen LS, et al.” Obstet Gynecol. 2002; 100: 435-444.
Other Luteal Phase Treatments<br />
• Alprazolam up to 0.25 mg tid prn (taper at<br />
menses), or Ativan 0.5 mg prn<br />
• Spironolactone 50 mg bid for edema<br />
• Bromocriptine 2.5 mg for breast pain/<br />
tenderness (mastalgia)<br />
• NSAIDS for cramps/ leg pain<br />
-Teri Pearlstein, M.D. Warren Alpert Medical School of Brown University, APA<br />
Conference 2008
Which birth control pill is good for mood<br />
• Lower progestin potency:<br />
Ortho Evra patch <br />
Ovcon 35 <br />
Ortho-TriCyclen <br />
Othro-Cyclen <br />
Brevicon <br />
Modicon <br />
Necon 1/35 <br />
Alesse <br />
Levlite <br />
Tri-Levlen <br />
Triphasil <br />
Trivora <br />
-Rohr, UD. “The impact of testosterone imbalance on depression and women's health.” Maturitas. 2002 Apr 15;41<br />
Suppl 1:S25-46. <br />
-Jelovsek, FR. (2003). “Accurate Answers to Questions About Birth Control Pills. “ [e-book].
Which OCP is good for mood<br />
• Women are sensitive to hormones in different<br />
ways – some to the progestin, some to the<br />
amount and some to the hormonal fluctuation<br />
• Seasonale or any monophasic OCP taken<br />
continuously can stabilize mood<br />
• Women who are sensitive to hormonal<br />
fluctuation should avoid triphasic OCP’s<br />
• It takes about 2 cycles to see if a certain OCP<br />
will work
YAZ®<br />
• Contains:<br />
– Drospirenone 3 mg<br />
– Ethinyl estradiol 20 µg (Yasmine has 30 µg)<br />
• Shortened hormone-free interval:<br />
– 24 active pills, 4 inactive pills (Yasmine has 21<br />
active/ 7 inactive pills)<br />
• Efficacy was expected for physical symptoms.<br />
But, surprisingly, efficacy in mood and irritability<br />
was also seen with YAZ<br />
-Yonkers KA, Brown C, Pearlstein TB, et al. “Efficacy of a new low-dose oral contraceptive with<br />
drospirenone in premenstrual dysphoric disorder.” Obstet Gynecol. 2005;106:492-501.
Drospirenone<br />
• Derived from 17 alpha spirolactone<br />
• Analogue of spironolactone<br />
• Has antimineralocorticoid activity (leads<br />
to water diuresis)<br />
• <strong>In</strong>creases K+ retention, Na+ and water<br />
excretion<br />
• Has antiandrogenic activity
All OCPs (with estrogen)<br />
Can Lower Libido<br />
• The oral estrogen in OCPs increases SHBG (Sex<br />
Hormone Binding Globulin)<br />
• <strong>In</strong>creased SHBG → lower free testosterone<br />
• Oral estrogen and thyroid increase SHBG<br />
– Oral estrogen passes through the liver (vs<br />
some patches or endogenous estrogen) and<br />
binds up SHBG, increasing production of<br />
SHBG. Progesterone is bound by transcortin.<br />
-Rosner W. “Plasma steroid-binding proteins.” Endocrinology and Metabolism Clinics of North Am [1991, 20(4):697-720]. <br />
-Goodman MP. “Are all estrogens created equal A review of oral vs. transdermal therapy.” J Wom Health (Larchmt). 2012 Feb;21(2):161-9. Epub 2011 Oct 19. <br />
-Pakarinen P et al. “The effect of intrauterine and oral levonorgestrel administration on serum concentrations of SHBG, insulin and insulin-like growth factor<br />
binding protein-1.” Acta Obstet Gynecol Scand. 1999 May;78(5):423-8.
<strong>P<strong>MD</strong>D</strong> <strong>In</strong> Summary<br />
• <strong>P<strong>MD</strong>D</strong>: 8-10% of women<br />
• The current hypothesis: women who<br />
experience <strong>P<strong>MD</strong>D</strong> are sensitive to the change<br />
in estrogen and progesterone<br />
• SSRIs are effective treatments with daily or<br />
luteal phase dosing—higher doses are more<br />
effective for physical symptoms<br />
• YAZ® has similar efficacy to SSRI’s, both for<br />
physical and mood symptoms<br />
• The big question: should women with <strong>P<strong>MD</strong>D</strong><br />
be treated with OCP’s or SSRI’s first
Disorders with<br />
Premenstrual Exacerbation<br />
(PME)<br />
• Affective disorders<br />
• Anxiety disorders<br />
• Psychotic disorders<br />
• Eating disorders<br />
• Substance abuse<br />
• Migraine<br />
• Allergies<br />
• Asthma<br />
• Seizures<br />
• Personality<br />
disorders
Sample Question:<br />
Premenstrual dysphoric disorder (<strong>P<strong>MD</strong>D</strong>):<br />
A. is associated with hormonally abnormal<br />
menstrual cycles<br />
B. is associated with abnormal levels of hormones<br />
C. is associated with changing levels of sex steroids<br />
that accompany ovulatory menstrual cycles<br />
D. is seen in approximately 50% of women<br />
E. is not treated with SSRI’s<br />
F. all of the above
Sample Question:<br />
Premenstrual dysphoric disorder (<strong>P<strong>MD</strong>D</strong>):<br />
A. is associated with hormonally abnormal<br />
menstrual cycles<br />
B. is associated with abnormal levels of hormones<br />
C. is associated with changing levels of sex steroids<br />
that accompany ovulatory menstrual cycles<br />
D. is seen in approximately 50% of women<br />
E. is not treated with SSRI’s<br />
F. all of the above
Sample Case: “Help my <strong>P<strong>MD</strong>D</strong>”<br />
• 27 y/o married woman<br />
• “I have a serious case of<br />
<strong>P<strong>MD</strong>D</strong>. I get low energy,<br />
irritable and depressed. I start<br />
fights with my husband and<br />
often have to skip work. Then,<br />
when my period comes, I feel<br />
fine.”<br />
• “I have been using YAZ OCP<br />
and Effexor XR. It kinda helps,<br />
but not 100%.”
Things to Consider<br />
• PMS charting<br />
• Check labs: TSH, cbc to r/o anemia<br />
• Meds: educate about SSRIs being 1 st<br />
choice for <strong>P<strong>MD</strong>D</strong> (and safety in<br />
pregnancy since she’s a young, married<br />
woman)<br />
• Effexor not ideal: SSRIs are 1 st line<br />
(though some data that Effexor and<br />
Clomipramine also help with <strong>P<strong>MD</strong>D</strong>)<br />
• Since Effexor not working great<br />
anyway, consider Zoloft 25 mg or<br />
Prozac 10 mg<br />
• Discuss her future plans for pregnancy<br />
• Therapy
Things to Consider<br />
• Ask about libido: She’s on YAZ, which<br />
can lower her libido (via 2 mechanisms!!!)<br />
• If unsure, you can also check libido labs:<br />
– Free and total testosterone<br />
– SHBG<br />
– TSH<br />
– Prolactin<br />
– DHEA-S<br />
• May want to switch to another OCP or the<br />
Mirena or Copper IUD.
The Mommy Brain:<br />
<strong>Hormones</strong>, <strong>Pregnancy</strong> and <strong>Mood</strong><br />
• The smell of a newborn baby stimulates the<br />
woman to produce oxytocin – a love potion<br />
creating baby lust<br />
– Oxytocin is also released when talking to friends,<br />
or creating a connection<br />
– “A feel good” hormone – released in bonding and<br />
during orgasm<br />
• Throughout pregnancy, a woman is<br />
marinated in neurohormones manufactured<br />
by the fetus and placenta<br />
-L. Brizendine, The Female Brain, 2006
The Mommy Brain:<br />
<strong>Hormones</strong>, <strong>Pregnancy</strong> and <strong>Mood</strong><br />
• Progesterone: Spikes from 10-100x normal!<br />
• Thirst and hunger centers on full blast<br />
• Women become sensitive to smells,<br />
especially of foods—to avoid eating<br />
something that could harm the fragile fetus<br />
-L. Brizendine, The Female Brain, 2006
The Mommy Brain:<br />
<strong>Hormones</strong>, <strong>Pregnancy</strong> and <strong>Mood</strong><br />
• The size and structure of a woman’s brain change<br />
• Between 6 months to the end of pregnancy, fMRI<br />
scans show that her brain is shrinking!<br />
– Restructuring and building new maternal circuits<br />
• This state gradually returns to normal 6 months<br />
after giving birth<br />
-Oatridge et al. “Change in brain size during and after pregnancy: study in healthy women and women with<br />
preeclampsia.” AJNR Am J Neuroradiol. 2002 Jan;23(1):19-26.
Depression and <strong>Pregnancy</strong><br />
• 1-2 out of every every 10 pregnant women<br />
have symptoms of major depression<br />
• Women who have been depressed before are<br />
at higher risk<br />
• Range of treatments:<br />
– Support groups, light therapy, medications and ECT<br />
– <strong>In</strong>dividual therapy is highly recommended<br />
-Dobie SA, Walker EA. “Depression after childbirth.” J Am Board Fam Pract. 1992 May-Jun;5(3):<br />
303-11.
Depression and <strong>Pregnancy</strong><br />
• Depression carries serious risks:<br />
– poor nutrition<br />
– poor self-care<br />
– substance abuse<br />
– SI<br />
• Can lead to premature birth, low birth weight<br />
and developmental problems<br />
• Depressed mothers are often less able to care<br />
for themselves and/ or their children, or to bond<br />
with their children
What are the symptoms of PPD<br />
• <strong>MD</strong>E symptoms 1 month to 1 year<br />
postpartum<br />
• Things other than depression can<br />
cause some of these symptoms<br />
– Changes in appetite and trouble sleeping are<br />
common in pregnancy<br />
– Medical conditions, such as anemia and<br />
hypothyroidism, can cause low energy
Depression and <strong>Pregnancy</strong><br />
• What I tell women: the risks….<br />
– During pregnancy<br />
– During delivery<br />
– After delivery
During <strong>Pregnancy</strong><br />
• 2006 study—pregnant women with <strong>MD</strong>D are very<br />
likely to become ill again if they stop taking their<br />
medication<br />
• Many studies have found no link between<br />
antidepressants and serious malformations in<br />
newborns<br />
• 2005—FDA issued a warning about Paxil: taking<br />
the drug during the first three months of<br />
pregnancy may increase the risk of birth defects,<br />
particularly heart defects<br />
-Lee S. Cohen et al. “Relapse of Major Depression During <strong>Pregnancy</strong> in Women Who Maintain or Discontinue<br />
Antidepressant Treatment.” JAMA. 2006;295(5):499-507. <br />
-Levinson-Castiel R et al. “Neonatal abstinence syndrome after in utero exposure to SSRIs in term infants.”<br />
Arch Pediatr Adolesc Med. 2006 Feb;160(2):173-6.
During <strong>Pregnancy</strong><br />
• SSRI’s have been linked to small increased risks of:<br />
– heart defects (0.9% for 1 SSRI, 2.1% >1 SSRI, vs 0.5%)<br />
– hydronephronsis (kidney defects)<br />
– cleft palate (5% vs 2-4%)<br />
• 2012 study—found<br />
– Untreated maternal depression was associated with<br />
slower rates of fetal body and head growth<br />
– Fetuses from mothers treated with SSRIs had no delay<br />
in body growth but did have delayed head growth and<br />
were at increased risk for preterm birth<br />
-Pedersen LH et al. “SSRIs in pregnancy and congenital malformations: population based cohort study.” BMJ. 2009 Sep 23;339:b3569.<br />
doi: 10.1136/bmj.b3569. <br />
-El Marroun H et al. “Maternal Use of SSRIs, Fetal Growth, and Risk of Adverse Birth Outcomes.” Arch Gen Psychiatry. 2012 Mar 5.<br />
[Epub ahead of print]
During <strong>Pregnancy</strong>: Autism Risk<br />
• 2011 study—examined fetal SSRI exposure in 298<br />
children with autism spectrum disorders (ASDs) and<br />
1507 control children<br />
• Possible association between SSRI exposure and<br />
childhood ASD<br />
• Things to consider<br />
– Rx use not confirmed<br />
– dx from records not interview<br />
– factors not controlled for (tobacco, alcohol, drug use)<br />
– mothers of ASD kids were much older<br />
– need to distinguish role of meds vs underlying dz<br />
-Croen LA et al. “Antidepressant use during pregnancy and childhood autism spectrum disorders.” Arch Gen Psychiatry.<br />
2011 Nov;68(11):1104-12. doi: 10.1001/archgenpsychiatry.2011.73. Epub 2011 Jul 4.
During <strong>Pregnancy</strong> (cont)<br />
• "Clinicians and patients need to balance the small risks<br />
associated with SSRIs against those associated with<br />
undertreatment or no treatment.”<br />
-Sept 2009, Pederson et al., British Medical Journal (BMJ)<br />
• Although relative risks for certain anomalies are elevated<br />
with SSRI use, absolute risks are low. For example,<br />
excess risk for a major cardiovascular anomaly<br />
attributable to SSRI use is 37 additional cases per<br />
10,000 women.<br />
-July 2011, Malm et al., Obstetrics and Gynecology
During Delivery<br />
Neonatal Abstinence Syndrome (NAS):<br />
– Baby “withdrawal” from SSRIs<br />
• breathing or feeding problems, jerky movements, seizures,<br />
irritability, abnormal crying, tremor<br />
• Sx usually subside from 48 hours to a few days<br />
Persistent Pulmonary Hypertension of the Newborn (PPHN):<br />
– 2006 study—babies exposed to SSRIs in late pregnancy (after 20<br />
weeks) may be more likely to have PPHN<br />
– Since then, we have 7 studies total: 3 showed no link between PPHN<br />
and SSRI’s, the other 4 showed some increased risk<br />
– FDA will update their SSRI drug label to reflect the conflicting results<br />
– Key point: Factors associated with depression itself (vs. SSRI<br />
exposure) can increase PPHN risk (obesity, smoking, premature birth,<br />
cesarean section)<br />
-Chambers CD et al. “SSRIsand risk of persistent pulmonary hypertension of the newborn”. New Engl J Med 2006; 354(6):579-87. <br />
-Ruta Nonacs. “SSRI’s and PPHN: the FDA revises its warning.” MGH Center for Women’s Health website, Jan 17, 2012. <br />
-Jordan AE et al. “SSRI use in pregnancy and the neonatal behavioral syndrome..” J Matern Fetal Neonatal Med. 2008 Oct;21(10):745-51.
During Delivery (cont)<br />
• Both untreated depression/ anxiety and SSRI<br />
exposure have been correlated with early or<br />
preterm birth<br />
• 2009 study—SSRI use in late pregnancy<br />
correlated with an elevated risk of gestational<br />
hypertension and preeclampsia in the mother<br />
-Catov JM et al. “Anxiety and optimism associated with gestational age at birth and fetal growth.” Matern Child Health J.<br />
2010 Sep;14(5):758-64. <br />
-Rita Suri et al. “Effects of Antenatal Depression and Antidepressant Treatment on Gestational Age at Birth and Risk of<br />
Preterm Birth.” The American Journal of Psychiatry. 2007 August ; 8(164):1206-1213. <br />
-Li, D. Liu L., Odouli R. “Presence of depressive symptoms during early pregnancy and the risk of preterm delivery: a<br />
prospective cohort study.” Human Reproduction 2008 Oct 23 (E-published ahead of print). <br />
-Toh et al. “SSRI use and risk of gestational hypertension.” Am J Psychiatry. 2009 Mar;166(3):320-8. Epub 2009 Jan 2.
After Delivery<br />
• No link to serious problems with language,<br />
behavior or intelligence<br />
• There has been no data reported on long<br />
term effects of antidepressants on the baby’s<br />
well being<br />
-<br />
Nulman I, et al. “Child development following exposure to tricyclic antidepressants or fluoxetine throughout fetals<br />
life: a prospective, controlled study.” Am J Psychiatry 2002; 159: 1889-1895. <br />
-Nulman I, et al. “Neurodevelopment of children exposed to antidepressant and antipsychotic medications during<br />
pregnancy.” <strong>In</strong> Clinics in Developmental Med No. 188. London, Mac Kieth Press, 2011.
Choosing an Antidepressant<br />
• We don't know all the answers. No drug is entirely safe. A<br />
woman and her health care team must look at her case and<br />
carefully weigh risks/ benefits of:<br />
– The drug<br />
– Other treatments<br />
– The risk of untreated depression<br />
• If a woman has been or is currently stable on a certain<br />
SSRI, that medication is usually continued (unless it is<br />
Paxil, which is generally contraindicated)<br />
• Zoloft and Prozac are often chosen b/c Zoloft has the<br />
lowest levels in breast milk and Prozac’s long half-life
Important Points<br />
• Pt should be followed closely by psychiatrist and ob/gyn<br />
• Prenatal vitamins and folic acid<br />
• Check thyroid, CBC and other lab work<br />
• Deliver the baby in a hospital to adequately monitor and<br />
assess any possible delivery complications<br />
• Stress reduction techniques and individual therapy<br />
• Be on the lowest number of meds and the lowest dose<br />
necessary<br />
• Start low and go slow
Within the first month after giving<br />
birth: 10% of women will have had<br />
‘Postpartum Depression’<br />
• Huge ‘crash’ in hormones after<br />
pregnancy<br />
• Postpartum: the brain and ovaries<br />
experience the re-establishment of<br />
menstrual cycle hormone pulses just as<br />
during the onset of puberty
Psychiatric Admissions in 2 Years<br />
70<br />
Before and After Delivery<br />
Admissions/month*<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
<strong>Pregnancy</strong><br />
0<br />
–2 Years – 1 Year Childbirth +1 Year +2 Years<br />
*Rate of psychiatric admissions in the 2 years before and after delivery in a population of<br />
470,000 people with 54,087 births in a 12-year period<br />
Kendell RE, et al. Br J Psychiatry. 1987;150:662.
Postpartum Depression<br />
• Postpartum Depression:<br />
– Technically, onset is within 4 weeks after childbirth, but<br />
can be seen up to 1 yr later (in DSM, it’s a specifier:<br />
“With Postpartum Onset”)<br />
– 10-15% of women will experience postpartum depression<br />
within the 1 st month after giving birth<br />
• ‘Baby blues’:<br />
– Affect up to 80% of women during the 10 days<br />
postpartum (usually lasts 2 weeks)<br />
– These are transient, do not impair function, and don’t<br />
meet <strong>MD</strong>D criteria
Sample Question:<br />
Which antidepressant is found to be<br />
transmitted in the lowest amounts in breast<br />
milk<br />
A. Prozac<br />
B. Celexa<br />
C. Zoloft<br />
D. Lexapro<br />
E. Klonopin
Sample Question:<br />
Which antidepressant is found to be<br />
transmitted in the lowest amounts in breast<br />
milk<br />
A. Prozac<br />
B. Celexa<br />
C. Zoloft<br />
D. Lexapro<br />
E. Klonopin
Sample Case: “I want to stop my meds”<br />
• 33-year-old married<br />
woman<br />
• Had a <strong>MD</strong>E 1 yr ago<br />
• She responded well to<br />
Zoloft 100 mg and has<br />
been symptom free for<br />
9 months.<br />
• She wants to stop her<br />
Zoloft so she can get<br />
pregnant.<br />
• What do you do
Consider a Trial off Meds If:<br />
• There was only one previous <strong>MD</strong>E<br />
• It occurred more than 9 months ago<br />
• It resolved quickly with medication<br />
• She has been functioning well for<br />
more than 6 months<br />
• No family history<br />
• No current stressors<br />
• Good financial and emotional<br />
supports<br />
• Good insight into her illness so she<br />
can recognize early signs<br />
• She is cooperative with treatment<br />
and willing to restart meds if needed<br />
• At it’s worst, there was no significant<br />
decompensation or SI
Educational Objectives<br />
• Diagnosis/treatment of <strong>P<strong>MD</strong>D</strong> vs PMS<br />
vs PME.<br />
• Better understanding of the menstrual<br />
cycle in relation to mood symptoms.<br />
• Understanding the second mechanism<br />
of SSRI’s.<br />
• How to treat depression in pregnancy<br />
and risk factors to review with women<br />
during pregnancy/delivery.
The End<br />
Thank You!<br />
A special thank you to Dr. Louann Brizendine