TCPR: Dr. Becker, from a practical point of view, when a woman of childbearing age is on psychiatric medications and either is trying to get pregnant or is pregnant, what is your general approach to treatment?
Dr. Becker: The general approach starts with a good history. Ultimately, the decision as to whether or not this patient needs to be on a psychiatric medication depends on her risk for psychiatric events during the perinatal period. When treating a pregnant patient, I weigh the risks of exposure of the fetus to medication, versus the risk of relapse of depression. If risk of relapse is high, and there is a need for medication, I involve the patient in the decision making process, discussing risks as well as benefits of treatment. The goal of treatment should be to maintain euthymic mood throughout the pregnancy, using the lowest effective dose of medication necessary to do so.
TCPR: So what kinds of questions would you ask to determine risk?
Dr. Becker: Important questions include: how serious has depression been in the past? Did she need to be treated with medications, and which ones? Was she ever suicidal? Is there a history of postpartum depression or postpartum psychosis? Is the patient on medications now? How long has she been on the current medications? What happened when she stopped medications in the past? If the patient is on medications, is her mood stable?
TCPR: So really we shouldn’t assume that every woman that is on psychiatric medication needs to take medication throughout the pregnancy?
Dr. Becker: Not necessarily. Some patients have been on medications for a mild to moderate depression in the past, but have been stable in mood for years. In some cases, if depression was not severe, it may be worth a trial of psychotherapy, and discontinuing medication during the pregnancy with close monitoring of mood. I also try to avoid polypharmacy during pregnancy, because there’s some evidence to show that being on more than one medication during pregnancy is associated with more adverse outcomes (Byatt N et al, Acta Psychiatr Scand 2012;1–21). Optimizing one medication rather than using multiple medications is preferable. However, if it is determined by history that a patient needs to stay on a psychiatric medication while pregnant, and she is stable on her current medication, it is best to continue her current medication. Pregnancy is not the time to experiment with different medications.
TCPR: For a first pregnancy, are there any features of past episodes of psychiatric illness that might indicate a worse course during pregnancy?
Dr. Becker: Patients with a history of severe depression or bipolar disorder are at high risk for relapse when medications are stopped during pregnancy (Cohen LS, J Clin Psychiatry 2007;68). There is also a high risk of postpartum psychosis in patients with bipolar disorder, occurring in up to 40% of women with bipolar disorder (Chaudron LH and Pies RW, J Clin Psychiatry 2003;64(11):1284–1292). For a patient with a history of severe depression who is stable on medication, I usually recommend that they remain on their current medication during the pregnancy.
TCPR: How prevalent is psychiatric illness during pregnancy?
Dr. Becker: Depression is common during pregnancy. About 10% to 15% of pregnant women fulfill criteria for major depressive disorder, and up to 70% of pregnant women report depressive symptoms (Gottlib IH et al, J Consult Clin Psychol 1989;57:269–274). Postpartum depression, a major depressive episode that occurs within the postpartum period, is the most common complication of childbirth, occurring in about 10% to 20% of women (O’Hara MW & Swain AM, Int Rev Psychiatry 1996;8:37–54) and suicide accounts for about 20% of postpartum deaths (Lindahl V et al, Arch Wom Ment Health 2005;8(2):77–87). As I mentioned earlier, there is a high risk of relapse of bipolar disorder during pregnancy, and this risk is doubled when mood stabilizers are discontinued (Viguera AC et al, Am J Psychiatry 2007;164(12):1817–1824).
TCPR: When it comes to substance abuse or dependence, are there any general strategies you would recommend for a woman who abuses opioids or benzodiazepines?
Dr. Becker: Getting them into treatment is probably the most important thing to do. Opioid-dependent women can be entered into a methadone maintenance program or treated with buprenorphine, both of which provide better neonatal outcomes (Jones HE et al, NEJM 2010;363(24):2320–2331). Hospitalization can also offer a place to safely taper women who are dependent on benzodiazepines.
TCPR: Let’s switch gears for a moment and talk breastfeeding. What are some of the known benefits of breastfeeding itself for both the mother and for the infant, and when is it not recommended?
Dr. Becker: There are many reported benefits of breastfeeding for babies, including lower infection rates, lower rates of SIDS, and lower infant mortality rates. Additionally, breastfeeding promotes attachment and is more economical than formula, just to name a few benefits (Gartner LM et al, Pediatrics 2005;115(2):496). I encourage women to breastfeed if this is their preference. There are a few medications that are best avoided in nursing mothers. Preferred medications are those that are known to be secreted in very low concentrations into breast milk. These include SSRIs, benzodiazepines, and other medications with shorter half-lives. It is best to avoid medications like lithium in nursing moms because they are metabolized through the kidneys and they can easily accumulate in babies. Neonates can easily become dehydrated and suffer from lithium toxicity.
TCPR: Please tell us about psychotherapy in pregnancy and postpartum.
Dr. Becker: Psychotherapy should be the initial treatment for mild to moderate depression. Both cognitive behavioral therapy and interpersonal therapy can be effective for depression in women in the perinatal period. Therapy can be especially useful for women with mild depression, or women who are reluctant to use psychotropic medication. Therapy is also a helpful adjunct to medication treatment (Zlotnick C et al, Am J Psychiatry 2001;158(4):638–640).
TCPR: How do you approach herbal and natural treatments in pregnancy?
Dr. Becker: Because there are few data to show their safety or efficacy during pregnancy, I do not prescribe herbal remedies during pregnancy.
TCPR: Please tell us a little bit about the FDA’s pregnancy risk categories.
Dr. Becker: FDA pregnancy risk categories (A, B, C, D, and X) are based on published evidence and expert opinion. This system doesn’t consider the potential benefits of treatment of mental illness, which we do consider when we treat pregnant patients. Combining the published data with a specific risk/benefit assessment for each individual patient is a good way to approach a case.
TCPR: So, for instance, with atypical antipsychotics, the majority of them are Class C, but clozapine (Clozaril) and lurasidone (Latuda) are Class B. Does that make them more attractive drugs for a pregnant patient?
Dr. Becker: Not necessarily. In the case of lurasidone, it’s a newer medication and there much less information on its safety and use during pregnancy. Good data on medications in pregnancy are hard to come by, as there are few case-controlled studies done with pregnant women. Most data consist of case reports. Thus, the safety data on atypicals during pregnancy are limited, but those which have been around for a while are generally considered to have few adverse effects. Again, the use of medications during pregnancy should always be considered on an individual basis and a risk benefit assessment (ACOG Committee, Obstet Gynecol 2008;111(4):1001–1020, also reprinted on the APA site at http://bit.ly/1dAXDqC).
TCPR: Since they are the most widely studied and prescribed drugs in pregnancy, can you tell us about the use of SSRIs?
Dr. Becker: Most SSRIs are Category C. As a class, the SSRIs are not considered to be major teratogens—that is, they have no specific, consistent pattern of congenital malformations (Byatt N et al, op.cit). Paroxetine (Paxil) is category D, and has been inconsistently associated with an increase in cardiac malformations (Einarson et al, Am J Psychiatry 2008;165:749–752). The SSRIs have been associated with persistent pulmonary hypertension in the newborn (PPHN) (Kieler H et al, BMJ 2012;344:d8012). There is also evidence that other factors associated with maternal depression can contribute to the risk of PPHN, such as preterm birth and smoking (Wichman KL et al, Am J Perinatal 2010;28:19–24). SSRIs have also been associated with preterm delivery, lower birth weight, and slightly lower Apgar scores (Ross LE et al, JAMA Psychiatry 2013;70(4):436–443). Neonatal behavioral syndrome is a spectrum of symptoms including irritability, respiratory distress, tachypnea, decreased feeding, and lethargy. This cluster of symptoms are seen in 10% to 30% of babies exposed to SSRIs late in pregnancy (Chambers CD et al, NEJM 1996;335:1010–1015). The mechanism may either be one of drug toxicity or a withdrawal syndrome associated with the SSRIs. Symptoms generally occur after birth to days after delivery and tend to resolve in days to weeks (Moses-Kolko EL et al, JAMA 2005;293:2372–2383).
TCPR: When the fetus is exposed to medications in the mother, are there any long term behavioral or psychiatric consequences?
Dr. Becker: A few recent studies have associated the SSRIs with autism spectrum disorders (Croen LA et al, Arch Gen Psychiatry 2011;68:1104–1112), but this has recently been challenged (Hviid A et al, NEJM 2013;369(25):2406–2415). Few studies have looked at the long term effects on children exposed to SSRIs during pregnancy. One recent study that looked at IQ and behavioral measurements of kids who have been exposed to SSRIs and depression found that kids who were exposed either to untreated maternal depression or to psychiatric medications had similar IQs, which were lower than children of healthy mothers who were not depressed, and similar behavioral measures (Nulman I et al, Am J Psychiatry 2012;169:1165–1174). More studies need to be done on this topic.
TCPR: This brings up the important point that untreated mental illness is clearly associated with adverse pregnancy outcomes, right?
Dr. Becker: Yes. Untreated depression, has been associated with premature births, low birth weight, and postnatal complications in babies. It is also associated with poor prenatal care and increased use of drugs and tobacco (Wisner KL et al, Am J Psychiatry 2000;165(5):557–566), as well as increasing risk for postpartum depression. So, it is important that women receive treatment for depression throughout the perinatal period.
TCPR: Thank you, Dr. Becker.