A bump in the road: Overcoming fear associated with psychotropic treatment during pregnancy

While I was out on maternity leave knee-deep in dirty diapers, I returned to find that I would serve as the primary editor for a Mental Health Clinician issue focused on psychotropic medication use during pregnancy and lactation. Ironically, I couldn't help but cringe. I was immediately reminded of my days spent as a psychiatric pharmacy resident. During residency training, each time a pregnant patient was admitted to the inpatient psychiatry unit, a feeling of trepidation overcame me. I frantically searched for articles on PubMed to enlighten myself on the use of medications in this patient population. I knew the medical team would look to me for guidance, since it is often difficult, even for psychiatric pharmacists and psychiatrists, to stay abreast with new warnings and evidence surfacing in this area. As a medical team, together we struggled to optimize medication therapy while attempting to prevent any adverse effects to the fetus. We not only needed to consider the use of psychotropics during pregnancy, but also had to anticipate their use during lactation. Ensuring the safety of both the mother and baby seemed like a daunting task.Some prescribers may automatically choose to discontinue all psychotropic medications during pregnancy out of fear that the medication will adversely affect the fetus; however, the consequences of untreated mental illness during pregnancy must be carefully weighed against the potential for adverse effects associated with psychotropic medications. Untreated mental illness during pregnancy can negatively impact both the mother and fetus.1 Adverse pregnancy outcomes, including preterm delivery, low birth weight and intrauterine growth retardation have been associated with untreated depression.1 Bipolar disorder, as well as schizophrenia, have also been associated with neonatal complications including prepartum hemorrhage, placental abnormalities, fetal distress, preterm birth, low birth weight, and small for gestational age babies.1 Childbirth itself has been identified as a risk factor for postpartum recurrence of an acute bipolar episode.1 Thus, early identification and effective management of mental illness is essential for the well-being of both the mother and baby.1A few factors that must be considered when initiating psychopharmacologic treatment in the pregnant patient include gestational age, available data supporting the pregnancy and lactation risk category of the medication, pregnancy registry information, and potential withdrawal effects or toxicity that may occur in the neonate.2 Additionally, important aspects to evaluate prior to initiating a psychotropic agent include the relative risk of the medication compared to other psychotropic agents used for the same condition, alternative non-pharmacologic therapies, concomitant medications, and disease states that may negatively affect pregnancy outcomes.2 Concerns with the use of psychotropic medications during pregnancy focus on adverse effects related to pregnancy outcomes (i.e., abortion, still-birth, preterm delivery), birth weight, fetal status at birth (i.e. Apgar score), malformations, and infant/child development.1 The benefits and risks associated with each medication and its effects on the mother and fetus must be carefully evaluated and discussed with the patient to enable her to be incorporated into the decision-making process.3 General treatment recommendations provided by the American College of Obstetricians and Gynecologists include: 1) utilizing a single medication at a high dose rather than multiple medications for a psychiatric condition whenever possible, 2) minimizing exposure to multiple psychotropic medications (i.e. avoid switching medications during pregnancy) and 3) choosing medications with few metabolites, higher protein binding (decreased placental transfer), and fewer drug interactions.3 Thus, treating the pregnant or breastfeeding patient goes beyond simply identifying the pregnancy risk and lactation category associated with each agent.For readers who struggle with determining how best to treat this patient population, the August issue of the Mental Health Clinician is dedicated to reviewing selected topics related to the use of psychotropics during pregnancy and lactation. Additionally, the risks of untreated mental illness will be discussed along with limitations to the current FDA pregnancy risk categories. A unique and innovative practice setting, a perinatal psychiatry unit, will be described and a variety of other important topics related to medication use during pregnancy will be highlighted.