A Case Report of the Use of Vilazodone in Pregnancy

A Case Report of the Use of Vilazodone in Pregnancy

To the Editor: The appropriate management of mood disorders in pregnant patients is a challenging issue for psychiatrists, particularly when our patients are taking newer medications with few, if any, available data concerning their use in pregnancy. Both untreated depression and antidepressant exposure in pregnancy are associated with similar rates of obstetrical risk, including miscarriage, babies who are small for gestational age, and premature labor.1,2 Transitory neonatal symptoms, including irritability and respiratory difficulties, have been reported with antidepressant exposure, but research has not controlled for the impact of depression itself or other obstetric issues.2 We must also consider the risk of relapse of depression during pregnancy when antidepressants are discontinued.3 Vilazodone is a selective serotonin reuptake inhibitor and 5-HT1A receptor partial agonist and is designated by the US Food and Drug Administration as Pregnancy Category C.4

Case report. Ms A became pregnant unexpectedly at the age of 32 years, in the midst of a regimen of vilazodone 40 mg/d. She had a long history of DSM-IV major depressive disorder. Ms A had previously had adequate trials of sertraline, escitalopram, bupropion, duloxetine, desvenlafaxine, and lamotrigine, which were terminated due to inadequate response or loss of response. She had achieved the best control of her depressive symptoms with vilazodone over the past 6 months. Ms A was very fearful of relapse if she discontinued her antidepressant. She was advised of the absence of information concerning the use of vilazodone in human pregnancies.

After careful consideration of the risks and benefits, she elected to continue vilazodone 40 mg daily throughout her pregnancy. She had an episode of preterm labor at 35 weeks’ gestation, which her obstetrician attributed to dehydration. She delivered her male infant at 39 weeks, 3 days. The baby was 20 inches (50.8 cm) in length and weighed 7 lb 1 oz (3,205 g) with a head circumference of 33 cm. Apgar score was 9 at 1 minute and 5 minutes. The baby had neonatal jaundice, which did not require treatment and resolved within the first 2 weeks of birth. He was discharged to home the day after his birth. His neonatal course was otherwise uneventful. He did not experience irritability or respiratory or feeding difficulties, which have been associated with exposure to antidepressants during pregnancy. Ms A has been nursing her baby, who is meeting his developmental milestones. Ms A herself has continued to do well, exhibiting no evidence of postpartum depression at 6 months.

Although there has been considerable information in the medical literature to support the use of selective serotonin reuptake inhibitors (SSRIs) in pregnant women whose depression warrants pharmacologic treatment, vilazodone has a unique mechanism of action. A literature search revealed no other cases of vilazodone exposure during pregnancy. Its package insert carries the same warning regarding potential neonatal toxicity as is found with the SSRIs.4 Similar antidepressants, including trazodone and nefazodone, have been less studied, but do not appear to increase the risk of major malformations above the baseline rate of 1%-3%.5 However, until more clinical experience has been gained with vilazodone in pregnancy, one cannot extrapolate the more reassuring aspects of the SSRI literature to vilazodone.6,7

References

1. Chaudron LH. Complex challenges in treating depression during pregnancy. Am J Psychiatry. 2013;170(1):12-20. PubMed doi:10.1176/appi.ajp.2012.12040440

2. Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol. 2009;114(3):703-713. PubMed doi:10.1097/AOG.0b013e3181ba0632

3. Cohen LS, Nonacs RM, Bailey JW, et al. Relapse of depression during pregnancy following antidepressant discontinuation: a preliminary prospective study. Arch Women Ment Health. 2004;7(4):217-221. PubMed doi:10.1007/s00737-004-0059-3

4. Viibryd (vilazodone HCl) [package insert]. St. Louis, MO: Forest Pharmaceuticals, Inc; 2012.

5. Einarson A, Bonari L, Voyer-Lavigne S, et al. A multicentre prospective controlled study to determine the safety of trazodone and nefazodone use during pregnancy. Can J Psychiatry. 2003;48(2):106-110. PubMed

6. Stephansson O, Kieler H, Haglund B, et al. Selective serotonin reuptake inhibitors during pregnancy and risk of stillbirth and infant mortality. JAMA. 2013;309(1):48-54. PubMed doi:10.1001/jama.2012.153812

7. Wisner KL, Bogen DL, Sit D, et al. Does fetal exposure to SSRIs or maternal depression impact infant growth? Am J Psychiatry. 2013;170(5):485-493. PubMed doi:10.1176/appi.ajp.2012.11121873

Caroline M. Morrison, MD

napervillepsych@aol.com

Author affiliation: Naperville Clinical Associates, Naperville, Illinois.

Potential conflicts of interest: Dr Morrison has served on the speakers/advisory board for Forest.

Funding/support: None reported.

Published online: March 27, 2014.

Prim Care Companion CNS Disord 2014;16(2):doi:10.4088/PCC.13l01612

© Copyright 2014 Physicians Postgraduate Press, Inc.