Depression in Pregnancy and Post-Partum

7/31/2019 Depression in Pregnancy and Post-Partum

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Depression in PregnancyDepression in Pregnancyand the Post-Partumand the Post-Partum

Ali Al-IbrahimAli Al-Ibrahim

MFM FellowMFM Fellow


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Myth BustersMyth Busters

Pregnancy is a time ofPregnancy is a time ofemotional well-beingemotional well-being

Category B is a safe category in pregnancyCategory B is a safe category in pregnancy

There is a specific algorithm for the treatmentThere is a specific algorithm for the treatmentof pregnant patientsof pregnant patients

It is best to stop psychotropic medicationsIt is best to stop psychotropic medications

priorpriorto conceptionto conception It is best to taper psychotropic medicationsIt is best to taper psychotropic medications

prior to deliveryprior to delivery


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MDD in pregnancyMDD in pregnancy

10-16% of women have major depression during10-16% of women have major depression during

pregnancypregnancy

Associated with problems for both mother and fetusAssociated with problems for both mother and fetus

When emerges in pregnancy, is frequently overlookedWhen emerges in pregnancy, is frequently overlooked

Pregnancy is neither protective, nor exacerbating forPregnancy is neither protective, nor exacerbating for

depressive disordersdepressive disorders

Under-recognized and under-treated in primary careUnder-recognized and under-treated in primary caresettingssettings

Cohen L, Nonacs R (editors):Mood and Anxiety Disorders During Pregnancy and Postpartum (Review of Psychiatry Series, Vol 24,

umber 4 . ashin ton DC APPI 005


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PERCENTAGE OF MOTHERSPERCENTAGE OF MOTHERS

WITH SEVERE DEPRESSIONWITH SEVERE DEPRESSION

WHO DID NOT TALK TO DOCTOR OR COUNSELORWHO DID NOT TALK TO DOCTOR OR COUNSELOR

57.5

72.2

79.9 78.3

100

73.1

0

10

2030

40

50

60

70

80

90

100

White African

American

Hispanics Asian Pacific

Islander

Native

American


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Antidepressant Use inAntidepressant Use inPregnancyPregnancy

Recent studies estimate up to 9% ofRecent studies estimate up to 9% of

pregnant women may take an SSRIpregnant women may take an SSRI

during pregnancyduring pregnancy

Several studies have also shown anSeveral studies have also shown an

increaseincrease in antidepressant usein antidepressant use

SSRIs accounted for the largestSSRIs accounted for the largest

increaseincrease


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A Multisite Retrospective Study

118,935 deliveries2001-2005, 6.6% women

took antidepressants

Antidepressant useincreased from 2%

deliveries in 1996 to 7.6%

deliveries in 2005

SSRI use increased

from 1.5% in 1996 to

6.4% in 2004

Andrade S et al. Use of antidepressant medications during pregnancy: a multisite study. American Journal of Obstetrics and Gynecology.

Feb. 2008


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Why is this important?Why is this important?

All women of childbearing years areAll women of childbearing years are

potentiallypotentiallypregnant until provenpregnant until proven

otherwiseotherwise

Approximately 50% pregnancies areApproximately 50% pregnancies are

unplannedunplanned

10-16% women have major depression during10-16% women have major depression during

pregnancypregnancy

Risk benefit analysis ideally prior toRisk benefit analysis ideally prior to

conception, every medication change!conception, every medication change!


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Weighing the Risks and BenefitsWeighing the Risks and Benefits

Risk of untreated mental illnessRisk of untreated mental illness Risk of relapse of psychiatric illnessRisk of relapse of psychiatric illness

Effects of psychiatric illness on the fetusEffects of psychiatric illness on the fetus

Teratogenicity of psychotropic medicationsTeratogenicity of psychotropic medications

Long term behavioral effectsLong term behavioral effects

Incomplete reproductive safety data forIncomplete reproductive safety data for

medicationsmedications


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Risk of Untreated PsychiatricRisk of Untreated PsychiatricIllness in PregnancyIllness in Pregnancy

Maternal Depression may cause:Maternal Depression may cause: Preterm birth, low birth-weight, smaller headPreterm birth, low birth-weight, smaller head

circumference, and lower Apgar scorescircumference, and lower Apgar scores Contribute to poor self-care, inattention toContribute to poor self-care, inattention to

prenatal careprenatal care Women are more likely to smoke, useWomen are more likely to smoke, use

alcohol or illicit drugsalcohol or illicit drugs Children of depressed mothers are moreChildren of depressed mothers are more

likely to have behavioral problems, delayslikely to have behavioral problems, delaysin cognitive, motor and emotionalin cognitive, motor and emotionaldevelopmentdevelopment

Risk for suicideRisk for suicide

Nonacs R, Viguera A, Cohen L.Psychiatric Aspects of Pregnancy. Womens Mental Health, a Comprehensive Textbook. Ed. SusanKornstein and Anita Clayton. New York, NY, 2002.


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Anxiety and Stress in PregnancyAnxiety and Stress in Pregnancy

Lead to poor outcomesLead to poor outcomes

Increase cortisol and adrenocorticotropicIncrease cortisol and adrenocorticotropic

hormone levelshormone levels

May be associated with preeclampsiaMay be associated with preeclampsia

May reduce uteroplacental blood-flowMay reduce uteroplacental blood-flow

Antenatal anxiety predicts postpartum anxietyAntenatal anxiety predicts postpartum anxietyand depressionand depression

Cohen L, Nonacs R (editors):Mood and Anxiety Disorders During Pregnancy and Postpartum (Review of Psychiatry Series, Vol. 24,

Number 4). Washington, DC, APPI, 2005

Heron J, O;Connor T et al. The course of anxiety and depression through pregnancy and the postpartum in a community sample. J. Affect.

Disord 80:65-73,2004.


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Depression Relapse in Pregnancy:Depression Relapse in Pregnancy:Cohen et al. 2006:Cohen et al. 2006:

43% of the women

experienced relapse

during pregnancy

26% who maintained

medication relapsed

68% who discontinued

medication relapsed

Cohen L, Altshuler L, Harlow B et al.Relapse of Major Depression During Pregnancy in Women Who Maintain or Discontinue

Antidepressant Treatment. JAMA Vol 295 (5),: 499-507, 2006.


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Risks Associated withRisks Associated withMedications in PregnancyMedications in Pregnancy

Pregnancy loss or miscarriagePregnancy loss or miscarriage

Organ malformation or teratogenesisOrgan malformation or teratogenesis

Neonatal toxicity or withdrawal syndromesNeonatal toxicity or withdrawal syndromes Long-term neurobehavioral sequelaeLong-term neurobehavioral sequelae


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OrganogenesisOrganogenesis


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SSRIs in PregnancySSRIs in Pregnancy

No major teratogenic risk associated withNo major teratogenic risk associated with

SSRI useSSRI use

Possible increase in cardiac defects with firstPossible increase in cardiac defects with first

trimester exposure totrimester exposure toparoxetineparoxetine

Adverse perinatal outcomes: conflicting dataAdverse perinatal outcomes: conflicting data

Persistent pulmonary hypertensionPersistent pulmonary hypertension Possible increase in spontaneous abortionPossible increase in spontaneous abortion

No significant developmental delay in childrenNo significant developmental delay in children

Cohen L. Treatment of Bipolar Disorder During Pregnancy.J. Clinical Psychiatry 68 (9), 2007: 4-9.


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Late 3Late 3rdrd trimester exposuretrimester exposure

Neonatal Behavioral SyndromeNeonatal Behavioral Syndrome Symptoms include:Symptoms include:

JitterinessJitteriness

TachypneaTachypnea TremulousnessTremulousness HypertoniaHypertonia RestlessnessRestlessness

Difficult to differentiate reported adverseDifficult to differentiate reported adverseoutcomes related to:outcomes related to: Antidepressant exposureAntidepressant exposure

Antidepressant withdrawalAntidepressant withdrawal

Maternal depression and anxietyMaternal depression and anxiety

R d P


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SSRIs and PersistentSSRIs and PersistentPulmonary HypertensionPulmonary Hypertension

Cohort Study: SSRIs in late pregnancy may beCohort Study: SSRIs in late pregnancy may bea risk factor for PPHNa risk factor for PPHN (Chambers et al 1996)(Chambers et al 1996)

Case-Control Study:Case-Control Study: (Chambers et al 2006)(Chambers et al 2006)

14 infants were exposed to an SSRI after the 2014 infants were exposed to an SSRI after the 20ththweek of gestationweek of gestation

Retrospective designRetrospective design

Absolute risk: 7/1000 womenAbsolute risk: 7/1000 women

Based on this study, in April 2006 the FDABased on this study, in April 2006 the FDArequired a label change to include SSRIsrequired a label change to include SSRIsincreasing the risk for PPHNincreasing the risk for PPHN

Chambers C, Hernandez-Diaz S, Van-Marter L et al. Selective Serotonin-Reuptake Inhibitors and Risk of Persistent Pulmonary Hypertension

of the Newborn. N Engl J Med. Vol 354:6 579-587, February 9, 2006.


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Paxil and Cardiac DefectsPaxil and Cardiac Defects

Multiple studies show no increased risk ofMultiple studies show no increased risk ofcardiac defects with Paxil or othercardiac defects with Paxil or otherantidepressantsantidepressants

Meta-analysis (Koren et al. 2007)Meta-analysis (Koren et al. 2007) Increased risk for cardiac malformationIncreased risk for cardiac malformation Women using antidepressants had higherWomen using antidepressants had higher

numbers of echocardiograms, amniocentesisnumbers of echocardiograms, amniocentesisand ultrasoundsand ultrasounds

Women on paroxetine used the drug for anxietyWomen on paroxetine used the drug for anxietyand panicand panic

Epidemiologic Study (Koren et al. 2008)Epidemiologic Study (Koren et al. 2008) 1,174 unpublished cases and 2,061 cases from1,174 unpublished cases and 2,061 cases from

published database studiespublished database studies

The rate of cardiovascular defect falls within theThe rate of cardiovascular defect falls within thenormal rate in the general populationnormal rate in the general populationBar-Oz, Einarson T, Koren G et al. Clinical Therapeutics. 2007: 29: 918-926.

Einarson A, Pistelli A, Koren G.AJP. 1008: 1-4. April, 2008

FDA C iFDA C t i


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FDA CategoriesFDA CategoriesCATEGORY INTERPRETATION

A Adequate, well-controlled studies in pregnant women have not shown an increased risk offetal abnormalities to the fetus in any trimester of pregnancy.

B Animal studies have revealed no evidence of harm to the fetus, however, there are noadequate and well-controlled studies in pregnant women.OR

Animal studies have shown an adverse effect, but adequate and well-controlled studies inpregnant women have failed to demonstrate a risk to the fetus in any trimester.

CAnimal studies have shown an adverse effect and there are no adequate and well-controlled studies in pregnant women.OR

No animal studies have been conducted and there are no adequate and well-controlledstudies in pregnant women.

D Adequate well-controlled or observational studies in pregnant women have demonstrateda risk to the fetus.However, the benefits of therapy may outweigh the potential risk. For example, the drug

may be acceptable if needed in a life-threatening situation or serious disease for whichsafer drugs cannot be used or are ineffective.

X Adequate well-controlled or observational studies in animals or pregnant women havedemonstrated positive evidence of fetal abnormalities or risks.

The use of the product is contraindicated in women who are or may become pregnant.


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Other AntidepressantsOther Antidepressants

VenlafaxineVenlafaxine

TrazodoneTrazodone

MirtazapineMirtazapine DuloxetineDuloxetine

BupropionBupropion

MAOI inhibitors are avoided inMAOI inhibitors are avoided inpregnancypregnancy


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Tricyclic AntidepressantsTricyclic Antidepressants

No major risk for malformationsNo major risk for malformations

Desipramine and nortriptylineDesipramine and nortriptyline

preferred - less anticholinergicpreferred - less anticholinergic

activityactivity

Perinatal syndromes described inPerinatal syndromes described in

infantsinfants Anticholinergic effects are transientAnticholinergic effects are transient

(bowel obstruction, urinary retention)(bowel obstruction, urinary retention)

Withdrawal SyndromeWithdrawal Syndrome

No lon -term neurobehavioral effectsNo lon -term neurobehavioral effects


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Medication Reduction orMedication Reduction orDiscontinuation Prior To DeliveryDiscontinuation Prior To Delivery

Adverse effects on the fetus:Adverse effects on the fetus: HypotoniaHypotonia

Neonatal withdrawal syndromesNeonatal withdrawal syndromes

Neonatal apneaNeonatal apnea

Temperature dysregulationTemperature dysregulation

But rare, temporary, treatable, andBut rare, temporary, treatable, and

reversiblereversible

Higher risk of relapse in pregnancyHigher risk of relapse in pregnancy

and post-partumand post-partum


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Other Treatment OptionsOther Treatment Options

Cognitive Behavioral TherapyCognitive Behavioral Therapy

Interpersonal TherapyInterpersonal Therapy

Group TherapyGroup Therapy Light TherapyLight Therapy


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Electroconvulsive TherapyElectroconvulsive Therapy

Safety well documented over 50years

Organ Dysgenesis

Occasional reports of malformations but noOccasional reports of malformations but nodirect causal link to ECTdirect causal link to ECT

Intrauterine Growth Defects/NeonatalToxicity NoneNone

Neurobehavioral Teratogenicity Few case reports - developmental delays or MRFew case reports - developmental delays or MR

No direct causal link to ECTNo direct causal link to ECT


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Recommendations continuedRecommendations continued

ECT for psychotic depressionECT for psychotic depression

Review all risks and benefits ofReview all risks and benefits of

treatmenttreatment

Moms should be monitored carefullyMoms should be monitored carefully

for increased depression, mania orfor increased depression, mania or

psychosispsychosis

Dosages may need to be adjustedDosages may need to be adjusted

GoalGoal is monotherapy and minimalis monotherapy and minimal

effective dosageeffective dosageAltshuler L, Cohen, L, Moline M et al. Treatment of Depression in Women: A Summary of the ExpertConsensus Guidelines.Journal of Psychiatric Press: 185-208, May, 2001


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Postpartum Depression versusPostpartum Depression versusPostpartum BluesPostpartum Blues

DisorderDisorder IncidencIncidencee

(%)(%)

TimeTimeCourseCourse

ClinicalClinicalFeaturesFeatures

PostpartumPostpartum

BluesBlues

75-8575-85 11stst PPPPweek- 2week- 2

weeksweeks

Mood instability,Mood instability,

tearfulness,tearfulness,

anxiety, insomniaanxiety, insomnia

PostpartumPostpartumDepressionDepression

1010 11stst

ppppmonthmonth

Depressed mood, guilt,Depressed mood, guilt,

fear of harm coming tofear of harm coming to

baby, obsessionalbaby, obsessional

featuresfeatures

PostpartumPostpartum

Ps chosisPs chosis

0.1-0.20.1-0.2 11stst pppp

monthmonth

Disorientation,Disorientation,

confusion, delusions,confusion, delusions,hallucinations, ra idhallucinations, rapid


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Risk Factors for PostpartumRisk Factors for PostpartumDepressionDepression

Previous history of MDD- 24% riskPrevious history of MDD- 24% risk Depression during pregnancy- 35%Depression during pregnancy- 35% Previous postpartum depression-50%Previous postpartum depression-50% Stressful life eventsStressful life events Marital dissatisfactionMarital dissatisfaction Demographic variables may be weakDemographic variables may be weak

contributorscontributors Hormonal fluctuationsHormonal fluctuations

Burt, V. Hendrick, V. Clinical manual of Womens Mental Health. Arlington, VA 2005.


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Recommendations for ScreeningRecommendations for Screening

Edinburgh Postnatal DepressionEdinburgh Postnatal Depression

ScaleScale

PP Depression ScalePP Depression Scale

Responsiveness of mom and babyResponsiveness of mom and baby

Sleep patternsSleep patterns

Weight loss or gainWeight loss or gain Assess for fears of infant harmAssess for fears of infant harm


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Individualized Risk BenefitIndividualized Risk BenefitAnalysis PlanAnalysis Plan

Risk ofUntreated

PPD

Benefits ofTreatment

Previous TxOf Depression

Risk ofAntidepressant

Treatment

Risk ofBreastfeeding

Infant SerumLevels

TargetSymptoms

Maternal

Wishes


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SSRIs and LactationSSRIs and Lactation

ParoxetineParoxetine andand Sertraline-Sertraline- 11stst lineline Less than 10% maternal levelLess than 10% maternal level

FluoxetineFluoxetine Exceeded 10% maternal level (22%Exceeded 10% maternal level (22%

cases)cases)

CitalopramCitalopram Exceeded 10% maternal level (17%Exceeded 10% maternal level (17%

cases)cases)

EscitalopramEscitalopram andand FluvoxamineFluvoxamine Few case reportsFew case reportsAcademy of Breastfeeding Medicine Protocol Committee Clinical Protocol #18: Use of Antidepressants in NursingMothers.Breast eedin Medicine. VOl 3. 1 2008.


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Tricyclics, Heterocyclics, andTricyclics, Heterocyclics, andLactationLactation

NortriptylineNortriptyline- undetectable in infant serum- undetectable in infant serum Growing evidence that other tricyclics appear to be safeGrowing evidence that other tricyclics appear to be safe

DoxepinDoxepin-- cautionedcautioneddue to hypotonia, poor feedingdue to hypotonia, poor feeding

MirtazapineMirtazapine- no adverse effects reported- no adverse effects reported BupropionBupropion

SNRIsSNRIs

Trazodone-Trazodone- infant levels less than 10%infant levels less than 10% MAOI inhibitors-MAOI inhibitors- discontinuediscontinue

Menon, S. Psychotropic Medication during Pregnancy and Lactation. Arch. Gynecol. Obstet. 277: 1-13, 2008.

Complementary and AlternativeComplementary and Alternative


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Complementary and AlternativeComplementary and AlternativeMedications for PerinatalMedications for Perinatal

DepressionDepression

Omega-3-fatty acidsOmega-3-fatty acids:: general datageneral data

support use in pregnancy andsupport use in pregnancy and

postpartumpostpartum

S-adenosyl-methionine:S-adenosyl-methionine: SomeSome

efficacy in reducing depressionefficacy in reducing depression

Folate:Folate: some evidence to supportsome evidence to support

augmentation for depressionaugmentation for depression

St. Johns Wort-St. Johns Wort- some evidence ofsome evidence of

efficacy- possible drug interactionsefficacy- possible drug interactionsFreeman, M. Complementary and Alternative Medicine for Perinatal Depression. Journal of Affective Disorders, 2008.


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CAM continuedCAM continued

Bright light therapy:Bright light therapy: evidenceevidence

supports potential use in perinatalsupports potential use in perinatal

and postpartumand postpartum

Acupuncture:Acupuncture: caution advised incaution advised in

pregnant womenpregnant women

Massage:Massage: some efficacy insome efficacy in

pregnancypregnancy

Exercise:Exercise: appears to haveappears to have

antidepressant effectsantidepressant effects

Recommendations forRecommendations for


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Recommendations forRecommendations forAntidepressant Treatment inAntidepressant Treatment in

Lactating WomenLactating Women Individualized risk-benefit analysisIndividualized risk-benefit analysis PsychotherapyPsychotherapy

Mild to moderate depressionMild to moderate depression

PsychotherapyPsychotherapy ++ antidepressantantidepressant Moderate to severe depressionModerate to severe depression

NoNo prior antidepressant:prior antidepressant: ParoxetineParoxetine oror SertralineSertraline

Prior successfulsuccessfulantidepressantantidepressanttreatmenttreatment

Discuss data with mom; consider as firstDiscuss data with mom; consider as firstAcademy of Breastfeeding Medicine Protocol Committee Clinical Protocol #18: Use of Antidepressants in Nursing Mothers. BreastfeedingMedicine. VOl 3. (1), 2008.


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ConclusionsConclusions

Every female patient ofEvery female patient ofchildbearing years ischildbearing years ispotentially pregnant!potentially pregnant!

Ideally, decisions aboutIdeally, decisions aboutpsychotropic medications shouldpsychotropic medications should

be made prior to conceptionbe made prior to conception

Consider non-pharmacologicConsider non-pharmacologic

lC l i


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ConclusionsConclusions

Risk-benefit analysisRisk-benefit analysis Minimize medication number andMinimize medication number and

dosedose

Document, document, document!Document, document, document!

In all cases, optimizing theIn all cases, optimizing themothers health and ability tomothers health and ability toparent should be consideredparent should be considered

crucial for the developing childcrucial for the developing child


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Thanks for coming!!Thanks for coming!!

Questions?Questions?

R fReferences


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ReferencesReferences

Bupropion Pregnancy Registry Interim Report September 1997 through 31 August 2007 Issued: December 2007 Glaxo Smith Kline

CDC: Births: Preliminary Data 2006; National Vital Statistics Report. Volume 57, Number 7, December 2007.

Cohen L, Nonacs R (editors):Mood and Anxiety Disorders During Pregnancy and Postpartum (Review of Psychiatry Series, Vol 24, Number 4).

Washington, DC, APPI, 2005

Cohen L. Treatment of Bipolar Disorder During Pregnancy.J. Clinical Psychiatry 68 (9), 2007: 4-9.

Altshuler et al. Pharmacological Management of psychiatric illness in pregnancy: dilemmas and guidelines. Am J. Psychiatry 1996;

153: 592-606.

Chambers C, Hernandez-Diaz S, Van-Marter L et al. Selective Serotonin-Reuptake Inhibitors and Risk of Persistent Pulmonary Hypertension of

the Newborn. N Engl J Med. Vol 354:6 579-587, February 9, 2006.

Finer, L and Henshaw K. Disparities in Rates of Unintended Pregnancy in the United States, 1994 and 2001.Perspectives on Sexual andReproductive Health. Vol 38 (2), 90-96, 2006.

Cohen L, Altshuler L, Harlow B et al.Relapse of Major Depression During Pregnancy in Women Who Maintain or Discontinue

Antidepressant Treatment. JAMA Vol 295 (5),: 499-507, 2006.

Chambers C, Johnson K, Dick, L et al.Birth Outcomes in Pregnant Women Taking Fluoxetine.N Engl J Med 335:1010-1015, 1996.

Bar-Oz B. Einarson T, Einarson A. et al.Paroxetine and Congenital Malformations: Meta-Analysis and Considerations of

Potential Confounding Factors. Clinical Therapeutics, Vol 29(5)918-926, 2007.

Einarson A, Pistelli A, DeSantis M. et al.Evaluation of the Risk of Congenital cardiovascular Defects Associated with Use of Paroxetine

During Pregnancy. Am J Psychiatry in advance- April 1, 2008.

ABM Clinical Protocol #18: Use of Antidepressants in Nursing Mothers. Breastfeeding Medicine.VOl 3. (1), 2008.

Burt, V. Hendrick, V. Clinical manual of Womens Mental Health. Arlington, VA 2005.

Andrade S et al. Use of antidepressant medications during pregnancy: a multisite study. American Journal of Obstetrics and Gynecology.

Feb. 2008

F M A t t l D i N i ti th T t t Dil A J P hi t V l 164(8)1162 1165 2007


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U.S. Food and Drug Administration. FDA Public Health Advisory,Paroxetine. Available at:

http://www.fda.gov/cer/drug/advisory/paroxetine200512.htm. Accessed April 7, 2008

Newport D, Viguera A, Nemeroff C et al.Atypical Antipsychotic Administration During Late Pregnancy: Placental Passage and

Obstetrical Outcome. Am J Psychiatry, 164:8, 1214-1220 August 2007.

Yaeger D., Smith H., Altshuler L.Atypical Antipsychotics in the Treatment of Schizophrenia During Pregnancy and the Postpartum. Am J

Psychiatry 163:12, 2064-2070, 2006.

Nonacs R, Viguera A, Cohen L.Psychiatric Aspects of Pregnancy. Womens Mental Health, a Comprehensive Textbook. Ed. Susan Kornstein

and Anita Clayton. New York, NY, 2002.

Koren, G.Medication Safety in Pregnancy and Breastfeeding. 2007

Heron J, O;Connor T et al. The course of anxiety and depression through pregnancy and the postpartum in a community sample. J.

Affect. Disord 80:65-73,2004.

Gentile S.Prophylactic Treatment of Bipolar Disorder in Pregnancy and Breastfeeding: Focus on Emerging Mood

Stabilizers. Bipolar Disorders. 8:207-220, 2006.

Newport D, Stowe Z et al.Psychiatric Disorders in Pregnancy.Neurologic Clinics Vol 22: 863-893, 2004.

Viguera A, Stowe Z, Cohen C et al. Risk of Recurrence in Women with Bipolar Disorder During Pregnancy: Prospective Study of Mood

Stabilizer Discontinuation. Am J Psychiatry. 164:12 December 2007, 1817-1824.

Freeman M.Antenatal Depression: Navigating the Treatment Dilemmas. Am J Psychiatry Vol 164(8)1162-1165, 2007.

Menon, S. Psychotropic Medication during Pregnancy and Lactation. Arch. Gynecol. Obstet. 277: 1-13, 2008.
http://www.fda.gov/cer/drug/advisory/paroxetine200512.htm.%20Accessed%20April%207http://www.fda.gov/cer/drug/advisory/paroxetine200512.htm.%20Accessed%20April%207

Depression in Pregnancy and Post-Partum

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