Cindy-Lee Dennis, PhD


An Evidence-Based Algorithm to Quantify Risk-Benefit Decision-Making for Use of Antidepressant Medication during Pregnancy and Lactation

Treatment of depression during the perinatal period is of paramount importance, given the potential risks associated with untreated depression for mother, infant, and family unit. Despite availability of treatment options and the benefits of treatment for mother and infant, depression is seriously under-treated during the perinatal period. Evidence about the safety of antidepressant use during pregnancy and lactation is accumulating; however, recent widely publicized studies have reported adverse sequelae associated with fetal/neonatal exposure to both antidepressant medication and untreated maternal depression. The low rates of antidepressant use by pregnant and breastfeeding women may be related to their concerns about safety of these therapies for the fetus/infant. Moreover, the recent reports have refuelled uncertainty among many prescribing physicians concerning the use of antidepressants in this population. As such, there is incredible potential for knowledge translation in this area to improve uptake of appropriate treatment.

Objectives: (1) to synthesize existing research evidence to identify the variables needing consideration in informed decision-making regarding use of antidepressant medication during the perinatal period; (2) to survey end-users and experts to identify gaps in the existing literature; and (3) to summarize the synthesized knowledge into a synopsis that will be accessible to consumers, mental health providers, researchers, funding agencies, and policy makers. This study will provide the basis for future development of quantitative treatment algorithms to assist in determining whether or not to use antidepressant medication in treating depression during pregnancy or lactation.

Methods: an Advisory Committee (AC) of diverse stakeholders has been convened to guide this knowledge translation project from the outset. To identify relevant evidence, systematic searches of MEDLINE, EMBASE, CINAHL, PsycInfo and the Cochrane Library from their start dates to the present will be conducted using keywords relevant to maternal depression.  Original data will be extracted relating to the relationship between maternal depression (during any week of pregnancy or lactation) and the following outcomes: (1) maternal outcomes associated with antidepressant treatment; (2) fetal/neonatal outcomes associated with antidepressant treatment; (3) maternal outcomes associated with untreated depression; (4) fetal/neonatal outcomes associated with untreated depression; (5) risk factors for perinatal depression; and (6) general and perinatal- specific medical contradictions for treatment with antidepressant medication. Where sufficient data exist, meta-analysis will be performed. AC members will provide feedback regarding potential gaps in the literature. The results of the research syntheses, together with a list of identified research gaps, will be presented to members of our three stakeholder groups (psychiatrists, family practitioners and obstetricians) and 15 experts in the field of perinatal psychiatry (5 from Canada, 5 from the U.S., 5 international) for feedback and to survey their clinical opinion regarding the relevant variables needing consideration when deciding whether or not to use antidepressant medication during pregnancy or postpartum.  The data obtained from the systematic review and survey will be summarized into a report and disseminated to mental health providers, researchers, funding agencies and policy makers. As a companion to this report, one-page summaries of the existing literature and research gaps will be developed for distribution to consumers. A modified version of the report, together with the companion summaries, will be submitted for publication in a scientific journal. This preliminary work will serve as the basis for the development of treatment algorithms, which will be further disseminated to family physicians, obstetricians, psychiatrists and other health care professionals working with perinatal women. This project will promote consistent and evidence-based treatment decision-making by Canadian physicians who work with depressed perinatal women.

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