Authors’ reply to Braillon and BewleyBMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2583 (Published 11 May 2016) Cite this as: BMJ 2016;353:i2583
- Simone N Vigod, assistant professor, psychiatrist, Shirley Brown clinician scientist1,
- Claire A Wilson, academic clinical fellow2,
- Louise M Howard, NIHR research professor, professor in women’s mental health, and consultant perinatal psychiatrist2
- 1Department of Psychiatry, Faculty of Medicine, University of Toronto; Women’s College Hospital and Women’s College Research Institute, ON, Canada M5S 2B1
- 2Section of Women’s Mental Health, King’s College London, London, UK
Firstly, we agree with Braillon and Bewley that more is needed to support education in this area at the point of care,1 2 and our teams have been working on developing an online patient decision aid that aims to help women make decisions about drugs during pregnancy in collaboration with their providers.3 This tool is currently being evaluated, and one main advantage is that its electronic nature will enable timely updating when new evidence emerges and broad access. Because of the rapidly changing literature, with the harms and benefits of antidepressant use in pregnancy being inconsistently reported, we would also argue that printed leaflets may not be sufficient for patient information. We would instead direct patients and providers to national guidelines and websites maintained by professional organisations (see additional education resources at the end of our article).
Secondly, we fully agree that psychological treatments should be offered for depression of all severity. Unfortunately, psychological interventions are not universally accessible, so for women who have moderate or severe depression, we believe antidepressants are an acceptable alternative, as recommended by National Institute for Health and Care Excellence and other clinical guidelines.4 However, as we state in our article: “Owing to concerns about fetal safety, the threshold for drug interventions is higher during pregnancy.”2 We agree that the “Need to know” box does not do full justice to the subtleties of decision making around antidepressant use in pregnancy, so we direct the reader to the full article.
Thirdly, Braillon and Bewley’s comment on the safety of selective serotonin reuptake inhibitors (SSRIs) in pregnancy raises an important problem. Virtually all SSRIs and serotonin noradrenaline reuptake inhibitors (not just paroxetine and fluoxetine) have been found to be associated with small increased risks of various child outcomes in one study or another.5 6 7 We therefore believe that the most cautious position to take is that no SSRI is more acceptable during pregnancy than another. The exception of paroxetine is related more to its short half life and more severe withdrawal effects on discontinuation than to the risk of cardiac anomalies being greater than for other SSRIs. As our review indicated, we agree that more research is needed to disentangle the effects of in utero SSRI exposure on long term child outcomes from those of antenatal and postnatal confounders.
Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following: SNV holds funding from the Canadian Institutes of Health Research and the Hospital for Sick Children Foundation to conduct two of the randomised controlled trials mentioned in this manuscript (NCT02308592; NCT02116127). LMH receives funding from the National Institute for Health Research (NIHR), including for two randomised controlled trials mentioned herein (NCT02308592; http://public.ukcrn.org.uk/search/StudyDetail.aspx?StudyID=17048) (NIHR research professorship in maternal mental health (NIHR-RP-R3-12-011) and NIHR programme grant for applied research (RP-PG-1210-12002) on the effectiveness of perinatal mental health services). She chaired the NICE update on Antenatal and Postnatal Mental Health Guidance (CG192) and she is also the national clinical adviser on the NICE/NCCMH technical advisory group for the NHS England access and waiting time perinatal mental health programme.