Prescribing selective serotonin reuptake inhibitors (SSRIs) for women of reproductive age, during pregnancy or breastfeeding: a systematic review of local formulary guidance in England and Wales.

Problem

Depression is the second most common chronic condition affecting women of reproductive age and this population are frequently prescribed selective serotonin reuptake inhibitors (SSRIs). When SSRIs are used during pregnancy, they can potentially cause congenital malformations, post-partum haemorrhage (PPH) and persistent pulmonary hypertension in the newborn (PPHN). Local guidance for prescribers should reflect these risks so that they can be conveyed to women of reproductive age if they are prescribed SSRIs. In UK primary care, prescribing formularies are the main mechanism by which prescribers are provided with local medicines advice. We sought to explore whether guidance within local prescribing formularies refers to the potentially teratogenic effects of SSRIs and/or advises what counselling should be provided to women of reproductive age when they are prescribed these medications.

Approach

Aim: To identify and compare all prescribing formularies in England and Wales, with respect to prescribing SSRIs in women of reproductive age and/or during pregnancy and breastfeeding. Method: A systematic keyword search of all Clinical Commissioning Group (CCG) websites in England (later termed Integrated Care Boards (ICBs)) and Local Health Board (LHB) websites in Wales was undertaken over one year from December 2021 to identify local prescribing formularies. Data was extracted on formulary structure, content and source of prescribing guidance for SSRIs in women of reproductive age, during pregnancy and breastfeeding. All formularies were extracted and reviewed by the lead reviewer and a 20% random sample by a second reviewer. Results were compared and discrepancies resolved by discussion and/or involvement of a third reviewer if required. The protocol was registered with the Research Registry, reference 1279.

Findings

74 individual prescribing formularies were reviewed. 14.9% (11/74) provided links to the Medicines and Healthcare Regulatory products Agency (MHRA) guidance on congenital abnormalities associated with the SSRIs fluoxetine or paroxetine, 28.4% (21/74) to guidance on PPH risk and 1.4% (1/74) to guidance on PPHN. 12.2% (9/74), 23% (17/74) and 21.6% (16/74) of formularies provided their own local guidance for women of reproductive age, during pregnancy and breastfeeding, respectively. This local guidance was often outdated and frequently included recommendations that conflicted those provided nationally. 21.9% (16/73), 13.7% (10/73) and 17.8% (13/73) of formularies did not provide any guidance, in the form of linked external guidance (e.g. National Institute for Health and care Excellence guidance) or internal local guidance, regarding SSRI use in women of reproductive age, during pregnancy and breastfeeding, respectively.

Consequences

Our results suggest that prescribers, and therefore women, may be poorly informed about the risks of SSRI use in women of reproductive age, during pregnancy and breastfeeding. This may place women and their babies at increased risk of unintentional SSRI exposure during pregnancy and the adverse effects associated with this.