Best Antidepressants in Pregnancy (esp Effexor)

[Adam21]

To All,

I have yet again to return to the bewildering question about which antidepressants are "safe" in pregnancy.

What are our general opinions about this?

I have a woman who I treated previously who had a great response to Effexor. Now she is relapsed and pregnant.

Reprotox and the literature seem to suggest Effexor is safe, but it is technically class C so I feel the safer route would be an SSRI.

I know about the neonatal withdrawal syndromes with SSRI's, but these cases seem to be mild.

Please share your knowledge.................................

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[Milo]

Bupropion is the only class B antidepressant in pregnancy.

 

[whopper]

As mentioned Wellbutrin is the only class B antidepressant.

However if Buspirone, while not an antidepressant is also class B and treats anxiety, which SSRIs also do.

And Buspirone if added to already exsiting antidpressant therapy boosts the efficacy of the treatment.

Another treatment to consider is molecularly distilled fish oil. It contains EPA which supposedly is the active component in fish oil's benefits to depression and anxiety. It also is beneficial to a developing fetal brain. The reason why I stress molecularly distilled fish oil is because that type has the heavy metals distilled out of them while regular fish oil can have some troublesome amounts of mercury or lead. That type should be taken with some caution in a pregnant woman or a woman who is breastfeeding.

Also, theres a theory that one of the causes of post partum depression or psychosis is lack of EPA. When a pregnant woman has a developing fetus in her, the theory is the developing brain needs a lot of EPA and sucks all available EPA that could've gone to the mother--exacerbating a psychiatric illness.

Unfortunately the only other thing I can tell you-and this is from Kaplan (not K&S, Kaplan the USMLE testing people) one of their questions dealt with SSRIs and breast feeding. The answer said that if a woman demands to stay on an SSRI and breast feeds, suggest to her to go onto an SSRI (or SNRI) with a short half life and breast feed before redosing to make sure the baby gets the least amount of medication in the milk. (I guess avoid paxil though because its class D, and it is the SSRI with the shortest half life.)

One thing I found odd is a number of ob-gyn doctors I've seen in my area give out SSRIs to their pregnant patients and tell them there's nothing to worry about it while being pregnant. Ouch. Yeah I'd bet good money that nothing bad would happen to them or their baby but its not accurate or honest to say there is nothing to fear. SSRIs (except Paxil which is class D) are class C--there's no good studies proving there'll be no ill effect on fetal development.

 

[Adam21]

Sorry to the two posters above, but Wellbutrin is Category C.

That still leaves me with my original problem.

Which antidepressant is the safest?

 

[whopper]

Actually you are right. I double checked on Epocrates/ I do remember it being Class B several months ago. Did something happen to change that classification?

 

[50960]

Just recently changed. The best info on risks in pregnancy is actually had from the pharma companies, as they have the most to lose if they are wrong. Call and ask them, you will get a very serious response...............

 

[Doc Samson]

http://www.womensmentalhealth.org/topics/pregnancy.html

Great website, I use it all the time.

 

[sdn1977]

Actually you are right. I double checked on Epocrates/ I do remember it being Class B several months ago. Did something happen to change that classification?

Yes...the FDA changed in in Nov 2006 to Category C - I think due to animal studies, post-marketing survelliance & to bring it in alignment with most of the others - which is category C.

 

[sdn1977]

http://www.womensmentalhealth.org/topics/pregnancy.html

Great website, I use it all the time.

Yes - good website - pretty up to date &, most importantly, gives you the reasons why not one or the other in a particular trimester.

 

[Milo]

Bupropion is the only class B antidepressant in pregnancy.

I should have rechecked that before posting, my bad.

 

[kugel]

Adam21,
Few issues here:
- "relapse?" relapse of depression or illicit substance use. If Substance use, this becomes the major safety issue.

- what is the "best" treatment? The one that works for THIS pt. In this case, that's Effexor. It is probably safer for Mom and baby for Mom to NOT be depressed than to quibble about the evidence and politics that go into Cat B vs Cat C. It's time to have a discussion with her about the difference between safety categories & efficacy.

- Review the pregnancy literature on Effexor, discuss the pros/cons with her, then call her OB to discuss it and make your case. If you don't discuss it with the OB, he/she may well discontinue it without talking to you - making all your efforts useless and maybe leaving pt w/o the best treatment option.

As always, document your discussions, listing highlights of the risks/benefits/side-effects you discuss with pt and noting the things the pt considers most important. Something like "disc'd R/B/SE of Effexor incl HTN and possibly less safety in preg than SSRI. Pt has no hx HTN. Also disc'd risk of no efficacy if switch to diff anti-depr med. Pt decided more important to use med she knows works than poss incr safety. She would like to restart Effexor. Awaiting return call from OB re: Effexor in this pt's pregnancy."