Tough Decisions Surround Rx in Pregnancy: The Child Will Be Exposed to Illness or Treatment, and 'Some Decisions Are Far Worse Than Others.'

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KOLOA, HAWAII -- Labeling typically doesn't support the use of psychotropic drugs in pregnant women, but the drugs might be needed during pregnancy, according to an observational study done at Emory University, Atlanta.

"What I want you to recognize is that you're going to expose the child to something, be it illness or treatment, and in the context of that, some decisions are far worse than others," lead author Dr. Zachary N. Stowe said at the annual meeting of the American College of Psychiatrists. "Abruptly stopping or changing treatment at knowledge of conception is an effort on your part to reduce your anxiety. It doesn't change outcome. In fact, it probably worsens outcome."

The need for treatment cannot be ignored. A large number of women who become pregnant have a mental health problem. "We're talking about [400,000] or 500,000 women every year with a neuropsychiatric illness that" begins before family planning, or that might have been treated or needed to be treated during family planning, said Dr. Stowe, who is director of the women's mental health program at Emory University.

And with 4 million U.S. deliveries per year, he pointed out, "over 50% of pregnancies are unplanned."

Studies of antenatal depression and its consequences led the American College of Obstetricians and Gynecologists to issue the following guideline statement in November 2007: "Maternal psychiatric ill-ness, if inadequately treated or untreated, may result in poor compliance with prenatal care, inadequate nutrition, exposure to additional medications or herbal remedies, increased alcohol and tobacco use, deficits in mother-infant bonding, and disruptions within the family environment."

Other antenatal depression study findings include increases in suicide, postpartum depression, premature birth, low birth weight, neonatal complications, and fetal demise, Dr. Stowe said.

In the observational study that he and his colleagues conducted, pregnant women who had depression decided for themselves whether to discontinue their antidepressant medication. Of the women who discontinued, 68% became "sick" before delivery, Dr. Stowe said. The other 32% were able to stop taking their antidepressant safely, but 25% who stayed on their antidepressant still became sick.

Among women with bipolar disorder who discontinued their mood-stabilizing medication, 85% became sick before delivery.

A big problem, of course, is the typical drug labeling statement that "use in pregancy is not recommended unless the potential benefits justify the potential risks to the fetus," which Dr. Stowe called "handwashing."

There's no question that psychotropic drugs will reach the fetus. Psychotropic medicines are designed to get past the blood-brain barrier and reach the brain, which means they will likely pass through the placental barrier without any difficulty. His own unpublished research has supported this, but he won-dered whether it is always harmful. "You can actually statistically argue that antidepressants reduce your risk of birth defects," he said. "To date, we have no confirmed evidence of increased birth defects on our antidepressants."

In some psychotropic categories, however, some drugs are better than others--or much worse. …