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Important Points to Consider Before Prescribing

Weighing up whether or not to prescribe psychotropic medication for your pregnant or breastfeeding patient is not a straightforward decision.  It can be fraught with concern and uncertainty around potential harmful medication effects on the pregnancy, fetus and infant; yet this must be balanced against the increasingly convincing evidence for the deleterious consequences of untreated maternal mental illness.  Each decision must be tailored to the individual patient and, where possible, include the father of the pregnancy in the decision-making.

Historically, many doctors have avoided prescribing psychotropic medications in pregnancy or breastfeeding due to concerns about their safety, particularly for the unborn baby. Although psychotropic medication can pose potential risks in pregnancy and/or breastfeeding, it should always be noted that there is a baseline risk in the general population for giving birth to a child with any defect of 3-5%.

 

In addition, there is a growing body of literature to suggest that untreated maternal mental illness can have serious adverse outcomes on fetal well-being that may be equal to, or even surpass, any potential and largely unknown adverse effects of psychotropic medications.  For example, untreated ante-natal depression and/or anxiety is associated with poor maternal nutrition, poor antenatal attendance, increased smoking and alcohol use (as well as increased illicit substance use), and obstetric complications (eg spontaneous abortion, pre-eclampsia, increased uterine artery resistance, intra-uterine growth retardation, pre-term delivery, and low birth-weight babies).  Also, neonates born to depressed and/or anxious mothers tend to have smaller head circumferences, lower Apgar scores, higher cortisol levels at birth (which could lead to psychopathology later in life), and an increased need for special care nursery due to some medical complication (1,5-7,8-10)

 

There is also a greater likelihood that a woman with untreated antenatal depression and anxiety will go on to develop post-natal depression (PND).  In Australia, PND affects almost 16% of women giving birth every year (11), making it one of the most common complications of pregnancy (12).  It can have a devastating effect on the woman, including a reduced ability to care for and interact with her infant leading to a sense of inadequacy and failure as a mother.  At its worst, PND can lead to maternal suicide and/or infanticide, and can impact negatively on the mother-infant relationship as well as on the mother’s other familial relationships.  Increasingly, research suggests that women with PND are less attuned, less responsive, less focussed, and less able to provide stimulation to their infants.  These early mother-infant interactional problems can have longer-term detrimental impacts on the infant’s cognitive, emotional, behavioural and social development.  (13)

 

Therefore, the risks and benefits of prescribing psychotropic medications during pregnancy and/or lactation must always be weighed up against the risks and benefits of not prescribing.

 

The psychotropic medication of choice in pregnancy &/or breastfeeding will depend upon:

  • The safety profile of the medication/s
  • The woman’s symptoms and their severity
  • Her history of mental illness (eg duration, hospitalizations)
  • Past treatments and responses to these
  • Therapeutic preferences, and
  • Her medical health during pregnancy

Discontinuing psychotropic medication prior to conceiving

Where circumstances might allow a woman to discontinue psychotropic medication prior to conceiving, (eg where her mental illness has been of ‘mild’ severity and where she has been symptom-free for more than one year), she should be informed about the possible risks and benefits of her treatment options.  Switching or changing a medication that has been effective always carries the risk of relapse. Importantly, women with major depression who discontinue their antidepressants in pregnancy have a 50-75% risk of relapse (4).  Ongoing consultation between the woman’s General Practitioner and/or a Psychiatrist is recommended, with close monitoring of her mental state.

 

When to treat antenatal depression and/or anxiety with antidepressants

The decision in cases of mild depression is straightforward, as evidence is available in these cases for the efficacy of non-pharmacological treatmentsegpsychotherapy.  Similarly in women with severe depression, the risk of not treating far outweighs the risk of treating, for both mother and infant.

 

It would be prudent to prescribe under the following circumstances:

●Where there are moderate to severe depressive symptoms, including vegetative symptoms, psychomotor agitation/retardation, and suicidal ideation and/or actual attempts

●Where there is co morbid panic/anxiety disorder or co morbid psychotic symptoms

●Where there is significant impairment in functioning eg inability to work, relationship breakdown

●A history of recurrent depression with hospitalizations

 

What other treatments are available

Remember that antidepressant medication is only part of the treatment for antenatal depression and anxiety. Also consider:

●Psychological therapies – such as Cognitive Behaviour Therapy, Interpersonal Therapy, Couples and Family Therapy.

●Exclude organic illness as a cause of mental health symptomseganaemia, hypothyroidism)

●Address any alcohol and/or illicit substance abuse

●Assess the social situation and increasing social supports where appropriate (eg linking in with community groups; reviewing housing situation; enquiring about domestic violence)

●General lifestyle measures: adequate rest/sleep, balanced diet, exercise.

References

  • Evans J, Heron J, Francombe H, Oke S, Golding J.  Cohort Study (ALSPAC) of Depressed Mood During Pregnancy and after Childbirth.  British Medical Journal 2001; 323; 257-260
  • Gotlib IH, Whiffen VE, Wallace PM, Mount JH.  Prospective Investigation of Postpartum Depression: Factors Involved in Onset and Recovery.  Journal of Abnormal Psychology 1991; 100; 122-132
  • Green J & Murray D.  The Use of the Edinburgh Postnatal Depression Scale in Research to Explore the Relationship Between Antenatal and Postnatal Dysphoria.  Perinatal Psychiatry (ed J. Cox & J. Holden).  Gaskell: London In: Austin MP.  To treat or Not to Treat: Maternal Depression, SSRI Use in Pregnancy and Adverse Neonatal Effects.  Psychological Medicine 2006; 36; 1663 – 1670
  • Cohen et al. Relapse of Major Depression During Pregnancy in Women who Maintain or Discontinue Antidepressant Treatment.  JAMA 2006 February 1; 295; 499-507
  • Wisner KL, Zarin DA, Holmboe ES, Appelbaum PS, Gelenberg AJ, Leonard HL.  Risk-benefit decision making for the Treatment of Depression During Pregnancy.  American Journal of Psychiatry 2000; 157; 1933-1940
  • Nonacs R, Cohen LS.  Depression During Pregnancy: Diagnosis and Treatment Options.  Journal of Clinical Psychiatry 2002; 63 Suppl 7; 24-30
  • Kurki T, Hiilesmaa V, Raitasalo R, Mattila H, Ylikorkala O.  Depression and Anxiety in Early Pregnancy and Risk of Pre-eclampsia.  Obstet Gynaecol 2000; 95; 4; 487-90
  • Chung TK, Lau TK, Yip AS, Chiu HF, Lee DT.  Antepartum depressive symptomatology is Associated with Adverse Obstetric and Neonatal Outcomes.  Psychosomatic Medicine 2001; 63; 5; 830-4
  • Ashman SB, Dawson G, Panagiotides H, Yamada E, Wilkins CW.  Stress Hormone Levels of Children of Depressed Mothers.  Dev Psychopathol 2002; 14;2; 333-49
  • Orr ST, Miller CA.  Maternal Depressive Symptoms and the Risk of Poor Pregnancy Outcome.  Review of the Literature and Preliminary Findings.  Epidemiol Rev 1995; 17; 1; 165-71
  • Beyond Blue website: http://www.beyondblue.org.au/index.aspx?link_id=94
  • Lattimore KA, Donn SM, Kaciroti N, Kemper AR, Neal CR, Vazquez DM.  Selective Serotonin Reuptake Inhibitor (SSRI) Use During Pregnancy and Effects on the Fetus and Newborn: A Meta-analysis.  Journal of Perinatology 2005 July; 25; 595-604
  • Murray L, Fiori-Cowley A, Hooper R, Cooper PJ. The impact of postnatal depression and associated adversity on early mother-infant interactions and later infant outcome. Child Development 1996; 67: 2512-252

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