Monday, October 5, 2009

BMJ 2009: heart septum defects twice as likely with SSRI in pregnancy: from half percent to one percent.

This issue is getting a lot of press: a pregnant woman taking antidepressants is doubling the risk of a heart septum defect in her baby.

Here is the actual article, including a snippet of the heart of the conclusion from the abstract:

Pedersen LH, Henriksen TB, Vestergaard M, Olsen J, Bech BH.Selective serotonin reuptake inhibitors in pregnancy and congenitalmalformations: population based cohort study.BMJ. 2009 Sep 23;339:b3569. doi: 10.1136/bmj.b3569.PMID: 19776103

"Redemptions for SSRIs were not associated with major malformationsoverall but were associated with septal heart defects (odds ratio 1.99, 95%confidence interval 1.13 to 3.53)."

"The absolute increase in the prevalence of malformations was low-for example, theprevalence of septal heart defects was 0.5% (2315/493 113) among unexposedchildren, 0.9% (12/1370) among children whose mothers were prescribed any SSRI,and 2.1% (4/193) among children whose mothers were prescribed more than one type of SSRI."

Is one in a hundred a lot? Or a little?
If the doctor told you, as you planned for pregnancy, that the likelihood of a heart defect was one-half percent, but would double to one percent if you were taking an antidepressant, would you opt for the antidepressant?

This study probably UNDERestimates the relation: the study is based on prescriptins that are turned in to the pharmacy, NOT on women who took the pills. For many who submit prescriptions for psych meds, many either NEVER take them, or take them very little, giving up. Thus, the "antidepressant" group includes a lot of women - who knows how many, but in all likelihood between 15 and 50% - who did not take the suspected danger-pills. That means the bad news emerged from an even smaller set of women - those actually taking the psych meds - and this effect shines through despite all of the woman who turned in prescriptions but either NEVER took the meds, or took VERY FEW.

Reasonably, the true effect should be suspected to be more profound.

So: Would you like your doctor to inform you of alternatives?

What if your doctor told you that there was a standardized, empirically valid intervention for depression that had only good side effects? Would your ears prick up?

Because there is: talk therapy.

Chances are, though, neither your obstetrician nor your psychiatrist will lead you in theis direction.

Why not?

1. Nearly all of professional medical practice has bouhgt into the idea that depression is a biologically based brain disorder, having nothing to do with life events, thinking patterns, or social circumstances.

2. The majority of "continuing medical education" for docs is developed and paid for by pharmaceutical companies.

3. The leading professional group for obstetricians joined up with the leading professional group for psychiatrists to push this pill-view, with a condescending nod to talk therapy added on to "treatment" if a mom insists, or for "minor" depression.

Press Release Aug 21, 2009:
"Depression During Pregnancy: Treatment RecommendationsA Joint Report from APA and ACOG"

"Psychotherapy may be beneficial in women who prefer to avoid antidepressant medication."

"There, there, little lady. If you would like to talk with someone about your biological brain disorder, sure, we will indulge you. If you prefer."

So, what would I suggest instead?

Educate the mom, and others involved.
Talk therapy.
Build social support.
Monitor the woman - if you have decent insurance, the obsetrician is peppering your calendar with visits, anyway.
Educate everyone around the woman regarding surveillance for behavioral problems: suicidality, poor self-care (mainly diet insufficient for a pregnant woman), and dangerous substance use (alcohol, illicit drugs, SSRIs, and smoking).

Develop a plan for self-neglect or suicidality: hospitalization, without meds, on a day-to-day basis until the crisis resolves.

This happens routinely for some with severe mental illness. And we lose very few people with serious mental illness (including, sadly, people who go through life regularly hearing voices urging the person to kill himself ro herself) who are well-monitored.

This proposed type of care would be expensive. But if it is appropriate, let's do it.

Consider the alternative: a newborn with a heart defect will eventually generate a great health care cost, and be very disruptive to the parents' life. In a pregnancy, their life will be disrupted anyway. Every pregnant woman's life is disrupted. So, put the hospitalization effort here, not later.

A child born with a congenital heart defect will have a pre-existing medical condition. So, at status quo (we are on the even of health care for all, or status quo), it will be difficult to insure the child.

It is also very challenging to get life insurance as a person with a heart defect. I have looked into this myself, and discovered that life insurnace companies have no good answer. American Heart Assocaition has no good answer. The Adult Congential Heart Association has no good answer.

Best to throw the effort at prevention, prenatally, and avoid all of this.

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