TO THE EDITOR: Risk-benefit analysis is central when forming a treatment plan for pregnant women with mental illness. This task is further complicated by limited data pertaining to the effects of antidepressants on the fetus, neonate, and child. To our knowledge, this is the first case report of in utero exposure to duloxetine. "Ms. A" was a 36-year-old Caucasian female with a history of recurrent major depression, anorexia, and chronic neck pain. When she sought psychiatric consultation at 34 weeks' gestation, she was 1) in complete remission, 2) being treated by an anesthesiologist, 3) and receiving monotherapy duloxetine (90 mg/day). She was educated about neonatal behavioral syndrome, and duloxetine was subsequently decreased to 60 mg/day.The child was delivered without complication at 38 weeks. Upon delivery, she was blue, with minimal respiratory effort and oxygen saturations in the 80s. Her Apgar scores were 7 and 9. After birth, she was transferred to the neonatal intensive care unit because she continued to require oxygen. The child was started on antibiotics while possible causes of transient tachypnea were assessed. Basic laboratory examination, blood gas, echocardiogram, and chest and abdominal x-rays were all normal on day 1. Breast feeding was discouraged because of concerns of exposure to duloxetine, and the mother was advised to switch to sertraline. Antibiotic treatment was discontinued after blood cultures remained negative.On day 3, the child was weaned to room air but developed "jerky rhythmic movements," or "twitchiness." An electroencephalogram (EEG) showed nonspecific encephalopathic findings. The child did have episodes of shaking, and the EEG revealed no correlated changes. Phenobarbital was started, and despite a high blood level the following day, the child continued to experience occasional twitching. Head computed tomography, magnetic resonance imaging, and lumbar puncture were all normal. A repeat EEG conducted at 7 days was suggestive of subclinical seizures. A follow-up EEG at 7 weeks was normal. Phenobarbital was discontinued, and the child was diagnosed with tremors and neonatal seizures associated with neonatal behavior syndrome. At age 2, the child is healthy with consistently normal neurobehavioral development.

results reveal that training on FASDs is inadequate. Psychiatry trainees poorly understand the importance of abstinence throughout pregnancy. Trainees who report receiving supervision specifically addressing FASDs also report making the diagnosis much more frequently, suggesting that supervision in clinical settings is effective teaching. Results reveal that FASDs are underrecognized, resulting in missed opportunities for prevention and intervention.