Skip to main content

Main menu

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums

User menu

  • My alerts

Search

  • Advanced search
The College of Family Physicians of Canada
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums
  • My alerts
The College of Family Physicians of Canada

Advanced Search

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • RSS feeds
  • Follow cfp Template on Twitter
Research ArticlePractice

Selective serotonin reuptake inhibitor discontinuation during pregnancy

At what risk?

Resham Ejaz, Tom Leibson and Gideon Koren
Canadian Family Physician December 2014, 60 (12) 1105-1106;
Resham Ejaz
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Tom Leibson
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Gideon Koren
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • eLetters
  • Info & Metrics
  • PDF
Loading

Abstract

Question I have a patient who discontinued her selective serotonin reuptake inhibitor in pregnancy against my advice owing to fears it might affect the baby. She eventually attempted suicide. How can we deal effectively with this situation?

Answer The “cold turkey” discontinuation of needed antidepressants is a serious public health issue strengthened by fears and misinformation. It is very important for physicians to ensure that evidence-based information is given to women in a way that is easy to understand. The risks of untreated moderate to severe depression far outweigh the theoretical risks of taking selective serotonin reuptake inhibitors.

Depression is a common medical condition that can be exacerbated during periods of stress and that can result in devastating consequences if left untreated. Up to 1 in 5 pregnant women experience depression. Treatment in this subpopulation is particularly challenging, partially secondary to discomfort with medication use during pregnancy.1 While there have been conflicting reports regarding the safety of antidepressant use during pregnancy, current data do not show any substantial clinical adverse outcomes caused by their use.2 Pregnant women and health care professionals continue to debate the use of antidepressants, such as selective serotonin reuptake inhibitors, often at medical risk to the women.3

We report the experience of a pregnant woman with a history of depression who abruptly stopped taking her selective serotonin reuptake inhibitor medication, sertraline. Her presentation underscored the importance of appropriately treating depression to minimize adverse effects to the mother and, consequently, the fetus.

Case

A 30-year-old woman who was pregnant for the second time after a previous termination of pregnancy presented to the Motherisk clinic at the Hospital for Sick Children in Toronto, Ont, to discuss the safety of sertraline use during pregnancy. She was at 6 to 7 weeks’ gestation and had stopped taking her sertraline 1 week previously, following confirmation of her planned pregnancy. She also used alprazolam occasionally for anxiety or difficulty sleeping, and had alcohol once per month. She was not exposed to any other chemicals, herbal medicines, infections, or recreational drugs. She had been diagnosed with depression at age 23 outside of Canada and, since then, she reported intermittent use of sertraline based on personal recognition of symptoms, typically during periods of stress or change. She had no psychiatrist in Canada.

Since discontinuation of her sertraline, which she had been taking for the past 6 months, she reported a substantial increase in her depressive symptoms. She developed ambivalent feelings about her pregnancy, difficulty sleeping, anhedonia, and episodes of uncontrollable crying. Her Edinburgh Postnatal Depression Scale score was 25; scores greater than 14 necessitate comprehensive psychosocial assessment for depression.4 She reported thoughts of harming herself via attempts to terminate her pregnancy.

Counseling was provided regarding the safety of sertraline and antidepressants during pregnancy. It was emphasized that there was no strong evidence for clinically meaningful risk of fetal malformation.5 It has been noted that there is a statistically significant risk of spontaneous abortion, preterm birth, or low birth weight (P < .05), but it is uncertain whether this risk is related to medication use or to depression itself.6–8 The rare possibility of poor neonatal adaptation syndrome, a period of self-limiting signs requiring monitoring of respiratory rate, feeding, and irritability, was also discussed.9 Before the counseling, the woman reported a 75% tendency toward pregnancy termination using the Motherisk visual analogue scale. After counseling, the tendency decreased to 60%.

Discussion

A healthy pregnancy requires an emotionally and medically healthy mother. The resurgence of severe depressive symptoms places women at risk of developing suicidal thoughts and poor health outcomes.10,11 Our team has encountered a number of cases in which pregnant women died by suicide following abrupt discontinuation of their antidepressants.12 Moreover, a large study found that women who discontinued antidepressants during pregnancy were nearly 3 times more likely to have a major depressive relapse or to be hospitalized than their counterparts who continued treatment were.13 Worsening or re-emergence of depression can also affect a woman’s attitude toward her pregnancy, as observed in this case.

Conclusion

This case highlights the need for ongoing education in the public and medical spheres regarding continuing antidepressant use during pregnancy, where the benefits of continuing use usually outweigh the risks. This is especially true in cases of severe depression. Pregnant women receive conflicting information from the Internet, media, and medical clinics, making it challenging for them to make a well-informed decision on controlling their symptoms. By equipping patients who have depression with evidence-based knowledge on antidepressant safety, health care professionals can ensure that the personal decisions the women subsequently make are grounded in science and support, as opposed to uncertainty and fear.

Notes

MOTHERISK

Motherisk questions are prepared by the Motherisk Team at the Hospital for Sick Children in Toronto, Ont. Ms Ejaz is a visiting trainee with, Dr Leibson is a clinical fellow with, and Dr Koren is Director of the Motherisk Program. Dr Koren is supported by the Research Leadership for Better Pharmacotherapy during Pregnancy and Lactation.

Do you have questions about the effects of drugs, chemicals, radiation, or infections in women who are pregnant or breastfeeding? We invite you to submit them to the Motherisk Program by fax at 416 813–7562; they will be addressed in future Motherisk Updates. Published Motherisk Updates are available on the Canadian Family Physician website (www.cfp.ca) and also on the Motherisk website (www.motherisk.org).

Footnotes

  • Competing interests

    None declared

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.↵
    1. Yonkers KA,
    2. Wisner KL,
    3. Stewart DE,
    4. Oberlander TF,
    5. Dell DL,
    6. Stotland N,
    7. et al
    . The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114(3):703-13.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Koren G,
    2. Nordeng H
    . Antidepressant use during pregnancy: the benefit-risk ratio. Am J Obstet Gynecol 2012;207(3):157-63. Epub 2012 Feb 21.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Mulder E,
    2. Davis A,
    3. Gawley L,
    4. Bowen A,
    5. Einarson A
    . Negative impact of non-evidence-based information received by women taking antidepressants during pregnancy from health care providers and others. J Obstet Gynaecol Can 2012;34(1):66-71.
    OpenUrlPubMed
  4. 4.↵
    1. Cox JL,
    2. Holden JM,
    3. Sagovsky R
    . Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782-6.
    OpenUrlAbstract/FREE Full Text
  5. 5.↵
    1. McDonagh MS,
    2. Matthews A,
    3. Phillipi C,
    4. Romm J,
    5. Peterson K,
    6. Thakurta S,
    7. et al
    . Depression drug treatment outcomes in pregnancy and the postpartum period: a systematic review and meta-analysis. Obstet Gynecol 2014;124(3):526-34.
    OpenUrlPubMed
  6. 6.↵
    1. Andersson L,
    2. Sundström-Poromaa I,
    3. Wulff M,
    4. Aström M,
    5. Bixo M
    . Neonatal outcome following maternal antenatal depression and anxiety: a population-based study. Am J Epidemiol 2004;159(9):872-81.
    OpenUrlAbstract/FREE Full Text
  7. 7.
    1. Rahimi R,
    2. Nikfar S,
    3. Abdollahi M
    . Pregnancy outcomes following exposure to serotonin reuptake inhibitors: a meta-analysis of clinical trials. Reprod Toxicol 2006;22(4):571-5. Epub 2006 May 23.
    OpenUrlCrossRefPubMed
  8. 8.↵
    1. Källén B
    . Neonate characteristics after maternal use of antidepressants in late pregnancy. Arch Pediatr Adolesc Med 2004;158(4):312-6.
    OpenUrlCrossRefPubMed
  9. 9.↵
    1. Byatt N,
    2. Deligiannidis KM,
    3. Freeman MP
    . Antidepressant use in pregnancy: a critical review focused on risks and controversies. Acta Psychiatr Scand 2013;127(2):94-114. Epub 2012 Dec 14.
    OpenUrlPubMed
  10. 10.↵
    1. Andersson L,
    2. Sundström-Poromaa I,
    3. Wulff M,
    4. Aström M,
    5. Bixo M
    . Implications of antenatal depression and anxiety for obstetric outcome. Obstet Gynecol 2004;104(3):467-76.
    OpenUrlPubMed
  11. 11.↵
    1. Christian LM
    . Effects of stress and depression on inflammatory immune parameters in pregnancy. Am J Obstet Gynecol 2014;211(3):275-7. Epub 2014 Jun 20.
    OpenUrlPubMed
  12. 12.↵
    1. Chan J,
    2. Natekar A,
    3. Einarson A,
    4. Koren G
    . Risks of untreated depression in pregnancy. Can Fam Physician 2014;60:242-3.
    OpenUrlAbstract/FREE Full Text
  13. 13.↵
    1. Cohen LS,
    2. Altshuler LL,
    3. Harlow BL,
    4. Nonacs R,
    5. Newport DJ,
    6. Viguera AC,
    7. et al
    . Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA 2006;295(5):499-507.
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

Canadian Family Physician: 60 (12)
Canadian Family Physician
Vol. 60, Issue 12
1 Dec 2014
  • Table of Contents
  • About the Cover
  • Index by author
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on The College of Family Physicians of Canada.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Selective serotonin reuptake inhibitor discontinuation during pregnancy
(Your Name) has sent you a message from The College of Family Physicians of Canada
(Your Name) thought you would like to see the The College of Family Physicians of Canada web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Selective serotonin reuptake inhibitor discontinuation during pregnancy
Resham Ejaz, Tom Leibson, Gideon Koren
Canadian Family Physician Dec 2014, 60 (12) 1105-1106;

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Respond to this article
Share
Selective serotonin reuptake inhibitor discontinuation during pregnancy
Resham Ejaz, Tom Leibson, Gideon Koren
Canadian Family Physician Dec 2014, 60 (12) 1105-1106;
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Abstract
    • Case
    • Discussion
    • Conclusion
    • Notes
    • Footnotes
    • References
  • Info & Metrics
  • eLetters
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

Practice

  • Managing type 2 diabetes in primary care during COVID-19
  • Effectiveness of dermoscopy in skin cancer diagnosis
  • Spontaneous pneumothorax in children
Show more Practice

Motherisk Update

  • Hepatitis A infection during pregnancy
  • Fluconazole use during breastfeeding
  • Is it safe to breastfeed while taking methylphenidate?
Show more Motherisk Update

Similar Articles

Navigate

  • Home
  • Current Issue
  • Archive
  • Collections - English
  • Collections - Française

For Authors

  • Authors and Reviewers
  • Submit a Manuscript
  • Permissions
  • Terms of Use

General Information

  • About CFP
  • About the CFPC
  • Advertisers
  • Careers & Locums
  • Editorial Advisory Board
  • Subscribers

Journal Services

  • Email Alerts
  • Twitter
  • RSS Feeds

Copyright © 2022 by The College of Family Physicians of Canada

Powered by HighWire