A 28-year-old white female sees you for preconception counseling. For the past 3 years she has been successfully treated with fluoxetine (Prozac) for depression, and she asks if she can continue taking it when she becomes pregnant. It is labeled by the FDA as category C for use in pregnancy.
Which one of the following would you advise?
Correct Answer D:
Physicians are often asked to advise women on the use of medicines during pregnancy, even if they are not providing the primary obstetrical care. FDA category C means that animal studies demonstrated teratogenic or embryocidal effects, but there are not controlled studies in women. Fluoxetine caused a higher incidence of stillbirths in rat reproductive studies, but the surviving litter mates showed no evidence of neurotoxicity. There are no controlled studies in humans, although there are no reports of major malformations in babies born to mothers who took fluoxetine in the first trimester.
Category A medications are those for which controlled studies in women show no risk to the fetus. Category B indicates that animal studies have shown no risk but there are no controlled human studies. Category D agents have “positive evidence” of human fetal risk but their use is allowed in situations where the benefit outweighs that risk. Category X medicines are those which have evidence of harm to human fetuses and should not be used at all during pregnancy.
Which one of the following antidepressants is least likely to cause sexual dysfunction?
Correct Answer A:
Sexual dysfunction, including decreased libido, ejaculatory disturbance, and anorgasmia, is common with the SSRIs (e.g. sertraline and fluoxetine). Tricyclic antidepressants such as imipramine also cause sexual dysfunction. Trazodone can cause priapism. Only bupropion is relatively free of sexual side effects.
A 23-year-old black female visits your office because a home pregnancy test was positive. You confirm that she is pregnant, at 6 weeks gestation.
She has a several-year history of moderate to severe depression which is well controlled with fluoxetine (Prozac), and is concerned about the drug’s effect on her pregnancy.
You advise her that she should:
Fluoxetine has been shown to be safe and effective throughout pregnancy. Tricyclic antidepressants are not safer. Valproic acid and lithium can cause significant teratogenic effects in the first trimester. There is limited data on bupropion, and its use is therefore not recommended during pregnancy.
A 36-year-old female with moderate depression desires treatment, but prefers a plan that does not include pharmacologic therapy. She asks about cognitive therapy.
Which one of the following statements is true about cognitive treatment for depression?
Correct Answer B:
Numerous studies and meta-analyses convincingly demonstrate that cognitive therapy effectively treats patients with unipolar major depression. The evidence suggests that it is a valid alternative to antidepressants for patients with mild to moderate depression and in combination with antidepressants for patients with more severe depression. Cognitive therapy is recommended for patients who do not respond appropriately to medication, and should be considered for adolescents with mild to moderate depression. Cognitive therapy can decrease the risk of relapse.
The only antidepressant with demonstrated efficacy in childhood and adolescent depression is:
Fluoxetine is the only antidepressant with demonstrated efficacy in childhood and adolescent depression. Other SSRIs, tricyclic agents, and newer antidepressants have not been shown to be effective for treating depression in this age group. Fluoxetine is the only SSRI currently approved for pediatric use.
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