I have several concerns with the recent editorial by Dr. Blier regarding antidepressant drugs and pregnancy.1 In his editorial, Dr. Blier failed to adequately discuss the association of the selective serotonin reuptake inhibitors (SSRIs) with congenital anomalies; he failed to discuss the neonatal syndrome associated with maternal SSRI use; and he failed to comment on the association of SSRIs with numerous pregnancy complications. A review of the studies he referenced reveals the absence of vital studies on this issue from some of the world’s most respected journals.2–4
The SSRIs may be associated with congenital malformations. Paxil, for example, has been associated with cardiac defects. On September 29, 2005, GlaxoSmithKline, in discussions with Health Canada, warned health professionals about this association.5 In December 2005, at the Food and Drug Administration’s (FDA) request, GlaxoSmithKline changed paroxetine’s pregnancy category from C to D.6 Why didn’t Dr. Blier mention this major issue in his editorial, and how does he justify his statement: “SSRIs do not increase the risk of major and minor malformations?” He also failed to reference a study published in the New England Journal of Medicine (N Engl J Med) showing that fluoxetine exposure was associated with increased rates of 3 or more minor malformations.2
SSRI use in pregnancy has been associated with low birth weight,2,7 preterm birth2,7 and neonatal neurobehavioural problems.2–4 Additionally, fetal death and seizures have been shown to be increased.7 Surely, these complications merited some mention in a discussion on antidepressant use in pregnancy. Although some people have argued that depression itself accounts for the above-mentioned associations, recent work by Oberlander and others8 suggests that SSRI use may account for such pregnancy complications.
I found Dr. Blier’s discussion of Dr. Chambers’ study on the association between maternal SSRI use and persistent pulmonary hypertension of the newborn (PPHN)9 inadequate. He spent approximately one-third of his editorial criticizing her study and concluded: “The purported role of SSRI exposure in PPHN after the first 20 weeks of pregnancy appears doubtful.” The association may appear doubtful to Dr. Blier. However, the editors and reviewers at the N Engl J Med did not doubt the association nor did their editorialist, Dr. Mills.10 Health Canada and the FDA have issued advisories concerning PPHN based on Chambers’ study.11,12
In sum, in various studies, SSRI use during pregnancy has been associated with increased rates of spontaneous abortion,13 congenital malformations,2,5,6 preterm birth,2,7 low birth weight,2,7 fetal death,7 seizures,7 neonatal withdrawal syndrome,2–4 PPHN9 and a possible predisposition to psychopathology.14 Dr. Blier inadequately covered these complications. An editorial, such as his, on antidepressant drug use and pregnancy that fails to discuss major Health Canada and FDA public health advisories and several important pregnancy complications is potentially misleading for readers, as well as for pregnant women with depression, their obstetrical providers and the public.
Footnotes
Competing interests: None declared.