Clinical management of perinatal depression: focus on paroxetine

The literature on antidepressant use during pregnancy and lactation is replete with review articles and clinical decision algorithms. Remarkably, a limited number of such articles include the methodological advances that have served to define the extent of fetal and neonatal exposure to antidepressants. For this review, MEDLINE search for original research articles focusing on obstetrical, neonatal, and infant outcomes associated with antidepressant use was conducted. These articles were scrutinized to include those with data on the selective serotonin reuptake inhibitors (SSRIs) and limited to breast-feeding studies that included infant serum concentrations.Sixty-seven articles were identified that included a total of 3050 cases of SSRI use during pregnancy and 240 cases of use during lactation. The amount of obstetrical outcome data available for each SSRI was proportional to the duration of time each medication has been available. In contrast, the lactation data were heavily weighted toward sertraline and paroxetine relative to other antidepressants. The myriad of confounds, failure to control for maternal depression, lack of prospective documentation of other medications, and environmental exposures preclude any definitive conclusions. There was no clear association between SSRI exposure and obstetrical complications or poor outcome. In contrast, the amniotic fluid, umbilical cord, and nursing infant sera literature demonstrated significantly different exposures to individual medications.