What are the risks associated with different Selective Serotonin Re-uptake Inhibitors (SSRIs) to treat depression and anxiety in pregnancy? An evaluation of current evidence.

A literature review was conducted to elucidate the respective reproductive safety profiles of different SSRIs to inform the prescribing practices of doctors treating pregnant women with anxiety and depression.
BACKGROUND: Women are most likely to be diagnosed with depression or anxiety between the ages of 25 and 44 years, which are also the years of childbearing potential (Burke et al., 1991). Therefore a substantial number of women face a decision about whether or not to take an antidepressant or anxiolytic during pregnancy. There are no psychotropic medications that have UK marketing authorisation (NICE, 2014), no clear clinical consensus has been reached regarding the use of SSRIs in pregnancy, and clinicians lack a resource which discusses the reproductive safety profiles of different SSRIs rather than the class of drugs as a whole. SUBJECTS AND METHODS: We performed a search for the English language literature indexed on MEDLINE/PubMed for the period 2012 to 2017, using the following key terms: fluoxetine, prozac, paxil, oxactin, paroxetine, seroxat, sertraline, lustral, citalopram, cipramil, escitalopram, cipralex, fluvoxamine, faverin, with 'pregnant woman', 'pregnant women', pregnancy. We excluded general SSRI and pregnancy articles (although we did read these papers for valuable background information) because we are interested in elucidating the differences between the drugs in this class, rather than the general effects of the SRRI class as a whole.
RESULTS: The literature shows that paroxetine and fluoxetine have the strongest association with negative outcomes (significant malformations, PPHN and PNAS) whilst the associations between sertraline and citalopram with negative outcomes remains mixed and generally unsubstantiated when studies that show an association are controlled for the effects of maternal depression and associated factors. There are too few studies to draw definite conclusions regarding the safety of escitalopram and fluvoxamine.
CONCLUSIONS: Sertraline and citalopram should be first-line drug treatments for anxiety and depression in pregnant women in the SSRI class. Sertraline can be continued in breast-feeding as the concentration found in breast milk is very low and has not been linked to infant complications. Furthermore, it would be useful to assess GPs current knowledge and confidence levels about prescribing, to see whether further education is needed in this area to encourage an open discussion of the risks and benefits of medication or no medication. It would also be useful to conduct further research on escitalopram which is likely to grow in popularity in the coming years as it came off patent in 2012. When these holes are filled, a clinical protocol for treating anxiety and depression in pregnant women should be created and implemented for the UK population.