Psychopharmacology in Pregnancy and Postpartum

Abstract

Psychiatric illness can occur during pregnancy and the postpartum period. Not only will the mother feel dis- tressed but also these illnesses can cause direct and indirect harm to the baby as well as create long-term negative conse- quences for the mother and the couple. Although using medication during pregnancy or breastfeeding may worry some patients and physicians, untreated depression, anxiety, or psychoses may cause even more harm. Research on the effects of psychotropic drugs on the fetus and on breastfeeding is limited by the inability to establish gold standard trials. Re- search that is published must also be viewed critically because poor methodologies can lead to unwarranted and alarm- ing conclusions. To date, available information suggests that most antidepressants do not cause major clinical malfor- mations but do cause a slightly elevated risk of miscarriage and preterm delivery. Typical antipsychotics also appear to be relatively safe to use during pregnancy. Less information is available about atypical antipsychotics, but no specific patterns of harm have been detected. Valproic acid has a high risk of causing malformations. Most psychotropic medi- cations are compatible with breastfeeding. The clinician must use the evidence available to make risk/benefit analyses about the best course of action. Educating the mother about what information is available assists her in making deci- sions that will be of most benefit to her and her baby. In the best of all worlds, pregnancy and the post- partum period would be times of joy, contentment, and peace of mind. In the real world, pregnancy is not a protected state. Mild to moderate symptoms of depression are common. At any one time, 7.4%– 11% of women are depressed in the first trimester, 8.9%–12.8% in the second trimester, and 8.5%– 12% in the third (1, 2). The prevalence of depres- sion over the 40-week course of a pregnancy is 18.4% (12.7% for major depressive episodes) as opposed to 7%–9% in the general population (2). In the postpartum period 10%–15% (3) of women become depressed. One to 2 women per 1,000 de- velop a psychotic disorder. Indeed, the postpartum period is the time during which women are most likely be admitted for mental health problems. Given these facts, most physicians will have to help a woman or couple decide how to manage a psychiatric disorder during pregnancy or the post- partum. The initial reaction will be to avoid any medication during these periods. If the depression is mild to moderate, it might be managed by psy- chotherapy (psychodynamic, interpersonal, or cog- nitive behavior therapy). In the case of more severe disorders, it is necessary to balance the risks of using medication with the risks of not treating the disor- der. Depression, anxiety, or psychosis during preg- nancy may result in failure to obtain prenatal care, focus.psychiatryonline.org p