DAILY / MAY 22, 2019  
Psychiatric News Update

Nine Tips for Managing Psychiatric Conditions Before, During, and After Pregnancy

Mom and baby
For psychiatrists looking to learn more about maternal mental health, this year’s Annual Meeting provided an excellent primer on psychiatric medications and pregnancy. The Tuesday session was hosted by four powerhouses in the field: Jennifer Payne, M.D., the director, and Lauren Osborne, M.D., the assistant director of the Johns Hopkins Women’s Mood Disorders Center; Samantha Meltzer-Brody, M.D., M.P.H., the director of the University of North Carolina Center for Women’s Mood Disorders; and Veerle Bergink, M.D., Ph.D., who has just launched and will direct a new Women’s Mental Health Research Program at the Icahn School of Medicine at Mount Sinai.

The quartet provided some practical tips and guidance for managing psychiatric conditions—particularly depression—in female patients throughout the pregnancy and the postpartum period. An important caveat they emphasized, however, is that every individual patient’s case is different, so the recommendations have room for adjustment.

The recommendations include the following:

  • Assume all women of reproductive age will get pregnant at some point, so make sure to discuss birth control and emphasize the need for a planned pregnancy. This will make medication planning easier.
  • To optimize the baby’s wellness, discontinue as many medications as possible in the mother and make any necessary medication switches and discontinuations before pregnancy begins. Make changes during pregnancy only when absolutely necessary.
  • To optimize the mother’s wellness, do not undertreat. Use the recommended therapeutic dose for all medications that are continued through pregnancy and monitor regularly.
  • Second-generation antidepressants like selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors are preferred to first-generation medications like tricyclic antidepressants. However, among the second-generation antidepressants, opt for more established medications like fluoxetine as they have more robust safety data than the more recently approved options.
  • Do not rely on the Food and Drug Administration's safety categories for pregnancy, since this classification is being phased out.
  • If a pregnancy is unplanned, do not panic. Taper medications you want to discontinue. Medication switches are not necessary since the baby has already been exposed.
  • Do not switch medications after birth because of concerns over drug concentrations in breast milk. Breast milk exposure is less than pregnancy exposure, regardless of the drug.
  • Sleep therapy is important for postpartum depression, so for late-night feedings, encourage bottle feeding over breastfeeding to ensure the mother gets four to five hours of interrupted sleep.
  • An important role of the psychiatrist is to be the “communicator,” so regularly update the mother's other doctors such as the pediatrician or OB/GYN to ensure there are no mixed messages.
In terms of specific antidepressants to use during pregnancy, they noted that most are generally safe, though not risk-free. One to avoid would be paroxetine since it is associated with very minor risks of birth defects.

Medications for bipolar disorder require more considerations, noted Bergink. Bergink advised stopping valproate and carbamazepine before pregnancy, or as soon as possible during, since these medications increase the risk of neural tube defects. Lithium is better, but blood levels during the first trimester should be kept low to reduce birth defect risk. Lithium is also risky during breastfeeding since toxicity may occur in the baby if he/she becomes dehydrated. Lamotrigine may be the best option. However, prophylactic treatment is important for pregnant women with bipolar disorder since studies have found a significantly elevated risk of bipolar relapse or onset of postpartum psychosis following birth.

Almost all medications that are considered safe during pregnancy are also safe during breastfeeding, with the exceptions of lithium (as noted above) and clozapine, since it may induce agranulocytosis in babies.

“What might be most important to remember is that the treatment plan during pregnancy is not your typical risk-benefit discussion,” Payne said. “This is a risk-risk discussion. Are there some risks with taking psychiatric drugs? Yes. But there are also significant risks of having maternal depression go untreated.”

(Image: iStock/FatCamera)


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