Margaret A.WinkerMD, Senior EditorIndividualAuthorPhil B.FontanarosaMD, Senior EditorIndividualAuthor
To the Editor.— I congratulate Dr Kulin
and colleagues1 for undertaking the daunting
task of data collection from 9 teratology information centers. This is important
information for practitioners who care for pregnant women with major depression.
However, I have some concerns regarding the study design and conclusions.
Ascertainment of SSRI exposure comes from self-reporting by women to
teratology centers. Although this seems to be a reasonable approach, this
may represent a skewed population with a lesser degree of depression (and
potentially decreased drug exposure). Severely depressed, hospitalized patients
may lack either the energy or the degree of cognitive functioning needed to
voluntarily call a teratology hotline. However, I have greater concern with
the choice of the control group. Pregnant women with concerns of teratogen
exposure (even if deemed nonsignificant at a later date) do not represent
a "low-risk" control population. Indeed, the high risk of "major" anomalies
(3.8%) in this control group confirms that conclusion. A more appropriate
control group would be random selection of women from a low-risk or routine
prenatal clinic. Another interesting control group would be women with major
depression who are treated with tricyclic antidepressants since the choice
for women with major depression for the study groups should be those taking
an SSRI or a tricyclic, not an SSRI or no medication.
Witlin AG. Risk of Fetal Anomalies With Exposure to Selective Serotonin Reuptake Inhibitors. JAMA. 1998;279(23):1873. doi:10-1001/pubs.JAMA-ISSN-0098-7484-279-23-jbk0617