Sunday, November 15, 2009

Prenatal SSRI usage

I was over at Mitchsmom's blog checking out her latest posts. She had posted a link to a Medscape article entitled Prenatal SSRIs Linked to Problems in Newborns. I find mental health interesting and as a midwife I am in the position of dealing with these issues at times. We have patients suffering from depression, PTSD, bipolar, etc. I feel comfortable enough prescribing antidepressants/antianxiety meds, although not all of the midwives I work with do. But I feel even more comfortable if I have somewhere to refer these patients, and therein lies a huge issue.

My counseling of women with depression typically involves a discussion of SSRIs and third trimester use. Prior to reading this article, my discussion focused on neonatal risks. I was not aware of the possibility of preterm birth, lower 5 minute apgars, or increased risk for NICU admission.

The problem of access to mental health services is a huge one in this country and where I live. Patients without private insurance must call Magellan themselves (which is an issue sometimes - when your depressed, who wants to pick up the phone when all seems hopeless?), then they often get to wait up to 2 months for services! Once they have their initial appointment, they often are put into group therapy while being on a waitlist for one-on-one therapy. But they also get their meds managed. My personal preference is to start someone ona SSRI and then have mental health take over management of that.

We do need to carefully weigh the benefit to the mother against the risk to the fetus/neonate. This article seems to imply that as well as being in favor of the well-being of the baby as a priority. This is a slippery slope - and a source of much controversy in general - to consider that the well-being of the baby may be more important than the well-being of the mother. In a perfect world, where patients could easily get access to counseling and other forms of therapy, it would be easier to say "ok, let's not use SSRIs until baby comes". Research shows that patients will benefit from both counseling and med therapy. But the reality is that with resources severely limited, sometimes SSRIs are the only tool we have.


Anonymous said...

I am really hating that study. ORs should have been calculated for the no-SSRI group, not the no illness group. I want statistical significances included, dammit! Please continue to take this with a grain of salt...
- Reader, CNM

Ciarin said...

I take anything medscape says with a grain of salt...they certainly haven't always been the most unbiased or scientific!

mitchsmom said...

It's a difficult situation, yes? (This situation in particular, and mental health in general... very fascinating but frustrating field to me... we've come a long way but not nearly far enough for me to be comfortable...I can never be satisfied because we so often can't do enough...)

I had a patient and personal acquaintance recently who ended up trying to halve her SSRI dose for the third trimester... well that didn't work for her. She ended up taking a regular dose every two days and that did the trick. Baby and mom are doing well here about 2 weeks postpartum.

The next question was whether her practitioner would prescribe SSRI's during breastfeeding. In the lactational pharmacology/IBCLC (lactation consultant) world, it's generally accepted to use them if needed, but I don't think all of our practitioners will do it.

pinky said...

The complete lack of services for mental health is really appalling. I am working in a psych hospital and I am amazed how poorly we treat mentally ill folks. No wonder nobody wants to stand up and say, "oh yes I have postpartum depression!"