Magazine article Clinical Psychiatry News

Evolving Perinatal Psychopharmacology Practice

Magazine article Clinical Psychiatry News

Evolving Perinatal Psychopharmacology Practice

Article excerpt

Over the last 2 decades, interest has been growing in establishing a rich evidence base for treating psychiatric illness in pregnancy and the postpartum period. The goals center on refining knowledge of safe treatments.

Despite these strides, my colleagues and I frequently see a divergence between recommendations in the literature and what is done clinically by those who treat women around reproductive associated psychiatric disturbance--premenstrual dysphoric disorder or psychiatric disorder during pregnancy and the postpartum period. In some cases, evidence has not filtered into day-to-day practice, and some physicians continue to follow practices that, while outdated, make intuitive sense. In other clinical situations, limited evidence is being applied too broadly or data are too sparse to clearly inform practice.


Here is a sample of the scenarios in which we have seen inconsistencies.

1. Discontinuing antidepressants close to conception

It is still common for clinicians to advise women to stop antidepressants while planning a pregnancy or after documentation of a pregnancy, regardless of the severity of the underlying illness. This runs counter to data showing high rates of relapse in women who stop antidepressants near conception, the safety of antidepressants in pregnancy, and the harm to the mother and fetus when depression during pregnancy is untreated.

2. Using a lower dose of antidepressants during pregnancy

It makes intuitive sense to use the smallest dose of medicine like antidepressants during pregnancy. However, multiple studies show that, at least in non-pregnant patients, the dose that gets patients well is typically the dose that keeps them well. One of the quickest paths to relapse in depression is a reduction in the antidepressant dose after someone has gotten well.

3. Switching to sertraline in pregnancy/post partum

Another scenario that we often see is a pregnant patient whose depression previously was well controlled with a particular antidepressant, but whose physician, once she decides to conceive or becomes pregnant, switched her to sertraline.

The idea is that sertraline is the safest antidepressant for pregnant women, because it has robust reproductive safety data and has particularly modest amounts of medication (if detected at all) in the plasma of infants of mothers who breastfeed while using the medicine. We certainly have more safety data on SSRIs that were made earlier, compared with antidepressants that became available later. But we now have data that fail to show a clear signal for teratogenicity across many antidepressants manufactured over the last 2 decades.

4. Changing to a Category B label drug

This is another example of switching a patient to a potentially less effective drug in a somewhat misguided effort at finding a treatment that is safer in pregnancy. The Food and Drug Administration s drug category label system was a step forward, or at least a well-intentioned effort to give women and their clinicians clearer insight into the reproductive safety of medications, but ultimately, the incomplete nature of the information caused the agency to transition to a new system (see the Pregnancy Labeling and Lactation Rule). Switching a woman to a category B medicine with sparse reproductive safety data instead of a category C medicine is not a better choice.

5. Discontinuing lithium

The discontinuation of lithium during attempts to conceive in a woman whose illness has been well controlled is associated with a high risk of relapse. …

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