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Prescribing Psychotropic Medications for Pregnant and Lactating Women: Presented at APA

By Kristina R. Anderson

SAN DIEGO, CA -- May 21, 2007 -- Perinatal depression is common, and when it comes to prescribing psychotropic medications to pregnant and/or lactating women, no decision is going to be risk free, Shaila Kulkarni Misri, MD, explained here at the American Psychiatric Association 2007 Annual Meeting (APA).

"If a woman is depressed and anxious -- and up to 70% of pregnant women experience some degree of depressive symptoms with about 12% meeting the diagnostic criteria for major depressive disorder (MDD) -- we must keep our personal biases aside and make sure women get the treatment they need," said Dr. Misri, medical director, Reproductive Mental Health, BC Women's, Children's & Women's Health Centre, Vancouver, British Columbia, Canada. "When the patient is pregnant, you're always forever thinking about the fetus she's carrying and what are the effects on the growing fetus and eventually the child?"

Some of the consequences of nontreatment of the pregnant woman, Dr. Misri said, include poor prenatal care, risk of medical and obstetrical complications, exacerbation of psychiatric illness through the postpartum period, self-medication/substance abuse, impaired bonding, and suicide, "1 of the 3 leading causes of maternal death."

There are also long-term consequences when the mother suffers from anxiety and depression that show up in her baby. These include: neonatal complications, lower dopamine and serotonin levels, increased uterine artery resistance, greater right frontal EEG activation, lower scores on the Brazelton Neonatal Behavior Assessment Scale, and increased cortisol levels related to lower birth weight (anxiety is related to a poor oxygen supply in the developing fetus).

Down the road, there are antenatal anxiety problems in the child along with adolescent consequences. Behavioural and emotional problems have been identified in girls and ADHD symptoms in boys. "You can almost guarantee that this untreated mother will have a baby with symptoms of ADHD or increased hyperactivity," said Dr. Misri, who said that sons are being found to be symptomatic as late as of 14 or 15 years of age.

She attributes this phenomenon to the possibility that antenatal stress interferes with development of the HPA axis, the limbic system, and the prefrontal cortex. "Cortisol, placental corticotrophin-releasing hormone, and genetic predisposition are all possible mediators," said Dr. Misri, who also wrote Pregnancy Blues: What Every Woman Needs to Know about Depression During Pregnancy.

Dr. Misri stressed that all antidepressant medications will cross the placental barrier and will show up in the amniotic fluid. Zoloft crosses more slowly than some others, similarly to Paxil, although data is very sparse. Dr. Misri strongly recommended that if one chemical formula works for the patient, "don't for God's sake change that medication."

"Often when a new compound comes up, there is talk of switching the medication, but do not swap out a drug that has worked in the past in midpregnancy or the woman could relapse because, basically, all the medications act in the same way," Dr. Misri said. She emphasised that the dosages will have to be increased in the subsequent trimesters of pregnancy. Zoloft and Paxil are generally a good choice, too, for nursing mothers on antidepressants, she said.

Dr. Misri said that treating physicians should probably never use benzodiazepines for longer than 2 weeks "if possible" in the pregnant or lactating mother. "Use cautiously and monitor the baby; at the end of the day, what you want is a safe pregnancy and safety for the baby."

[Presentation title: Management of Psychiatric Disorders in Pregnant and Postpartum Women. Abstract NR706]

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