*Updated 10/2022
Mental health, psychiatric medications, and pregnancy
According to ACOG, it is estimated that more than 500,000 pregnancies in the U.S. each year involve individuals who have psychiatric conditions that were present before the pregnancy or emerge during pregnancy, and an estimated one third of all pregnant individuals are exposed to a psychiatric medication at some point during pregnancy. It is difficult to find evidence-based information on the management of mental health conditions in pregnancy, especially when the pregnant individual needs medications. Having an obstetrical care provider who is knowledgeable about management of mental health conditions in pregnancy, as well as the medications needed to treat the individual, is crucial.
I sat down with a reproductive psychiatrist, Dr. Kristin Lasseter, for an in-depth conversation on this topic. We discussed the following:
- Impact of maternal psychiatric conditions on a pregnancy
- Consequences of lack of treatment or under-treatment on pregnancy outcomes
- General treatment concepts
- Specific meds for treatment of depression, bipolar disorder, anxiety, schizophrenia, and ADHD
- Recommendations from MFM and psychiatry
Jump to these topics within the conversation:
- 8:13 When to have the conversation with a healthcare provider about pregnancy and psychiatric medications
- 12:22 The consequences of untreated mental health conditions, including depression, bipolar disorder, and schizophrenia
- 17:17 Depression medications and pregnancy
- 22:20 Postpartum depression risk
- 25:00 Tricyclic antidepressants and pregnancy
- 31:45 Lithium and pregnancy
- 41:45 Anxiety disorders and medications
- 46:00 PTSD and treating underlying disorders that lead up to anxiety
- 53:00 Treating ADHD in pregnancy
Stopping psychiatric meds out of "concern for the fetus" is not the answer
As a maternal-fetal medicine specialist, I have heard of other providers telling patients to stop taking their psychiatric medications as soon as they find out they are pregnant. They say this because they are concerned about the effects of medications on the fetus. However, telling a pregnant individual to discontinue their medication(s) likely replaces any fetal or neonatal risks of medication exposure for the risks of an untreated mental health disorder to the pregnant individual. With a pregnancy, there are two people to think of—the pregnant person and the fetus.
If a mental health disorder is under treated or untreated, there are potential consequences to the pregnancy, including:
- poor compliance with prenatal care
- inadequate nutrition
- exposure to additional medication or herbal remedies
- increased alcohol and tobacco use
- deficits in mother–infant bonding
- disruptions within the family environment
As Dr. Kristin Lasseter says in our conversation, “Even if you’re thinking about the fetus, it’s important to remember that the illness itself is actually more risky for the fetus than the medication.”
General treatment concepts
Ideally, multidisciplinary approach to managing the care of a pregnant individual with a mental health condition should involve the obstetrical care provider and mental health clinician.
Some basic rules of prescribing psychiatric meds in pregnancy include:
- A single medication at a higher dose is favored over multiple medications.
- Avoid changing medications if possible.
- The selection of medication should be based on whether or not the patient has responded favorably in the past to that medication, prior exposure during pregnancy, and available reproductive safety information.
- Medications with fewer metabolites, higher protein binding (decreases placental passage), and fewer interactions with other medications are preferred
Resources
Dr. Lasseter recommends using these specific websites to find evidence-based info:
- Mother to Baby: Telephone: 866-626-6847. Mother To Baby, a service of the non-profit Organization of Teratology Information Specialists, is dedicated to providing evidence-based information to mothers, health care professionals, and the general public about medications and other exposures during pregnancy and while breastfeeding. MotherToBaby affiliates support and contribute to worldwide initiatives for teratology education and research.
- PostPartum Support International: 1-800-944-4773. They offer online support groups, loss and grief resources, and multiple other tools.
- Infant Risk Center: Telephone: 806-352-2519. Consumers can call the call center directly to receive information about medications during pregnancy or while breastfeeding. The InfantRisk Center at Texas Tech University Health Sciences Center is a call center based solely on evidence-based medicine and research. They are dedicated to providing current and accurate information to pregnant and breastfeeding mothers and healthcare professionals. They are a training center for medical and pharmacy students and medical residents in the use of drugs in pregnant and breastfeeding mothers.
- Massachusetts General Hospital (MGH) Women ‘s Mental Health: The MGH Library on Women ‘s Mental Health is a repository of useful information and frequently referenced articles compiled into different specialty areas, including psychiatric disorders during pregnancy and postpartum.
- Perinatal Psychiatric Consultation Line at the University of Washington: Telephone: 206-685-2924 Provides free consultation for providers in Washington state about mental health issues during pregnancy and postpartum, including about the impact of psychotropic medications.
Your OBGYN or psychiatrist can call the postpartum support international (PSI) line and get a second opinion about staying on or starting medications during pregnancy. This line offers specific information from those who are specialized in this subject.
Summary of Recommendations and Conclusions from ACOG PB 92: "Use of Psychiatric Medications During Pregnancy and Lactation"
The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):
- Lithium exposure in pregnancy may be associated with a small increase in congenital cardiac malformations, with a risk ratio of 1.2–7.7.
- Valproate exposure in pregnancy is associated with an increased risk of fetal anomalies, including neural tube defects, fetal valproate syndrome, and long-term adverse neurocognitive effects. It should be avoided in pregnancy, if possible, especially during the first trimester.
- Carbamazepine exposure in pregnancy is associated with fetal carbamazepine syndrome. It should be avoided in pregnancy, if possible, especially during the first trimester.
- Maternal benzodiazepine use shortly before delivery is associated with floppy infant syndrome.
The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):
- Paroxetine use in pregnant women and women planning pregnancy should be avoided, if possible. Fetal echocardiography should be considered for women who are exposed to paroxetine in early pregnancy.
- Prenatal benzodiazepine exposure increased the risk of oral cleft, although the absolute risk increased by 0.01%.
- Lamotrigine is a potential maintenance therapy option for pregnant women with bipolar disorder because of its protective effects against bipolar depression, general tolerability, and a growing reproductive safety profile relative to alternative mood stabilizers.
- Maternal psychiatric illness, if inadequately treated or untreated, may result in poor compliance with prenatal care, inadequate nutrition, exposure to additional medication or herbal remedies, increased alcohol and tobacco use, deficits in mother–infant bonding, and disruptions within the family environment.
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
- Whenever possible, multidisciplinary management involving the patient’s obstetrician, mental health clinician, primary health care provider, and pediatrician is recommended to facilitate care.
- Use of a single medication at a higher dose is favored over the use of multiple medications for the treatment of psychiatric illness during pregnancy.
- The physiologic alterations of pregnancy may affect the absorption, distribution, metabolism, and elimination of lithium, and close monitoring of lithium levels during pregnancy and postpartum is recommended.
- For women who breastfeed, measuring serum levels in the neonate is not recommended.
- Treatment with all SSRIs or selective norepinephrine reuptake inhibitors or both during pregnancy should be individualized.
- Fetal assessment with fetal echocardiogram should be considered in pregnant women exposed to lithium in the first trimester.
Learn more from Dr. Lasseter!
- You can learn more from Dr. Lasseter on Instagram at @the.reproductive.psychiatrist. If you are local to Austin, TX, you can also check out her clinic, RPC Austin.
- Go to my "meds" highlight on my instagram page for more resources!
- Electronic resources for information related to the fetal and neonatal effects of psychiatric drug therapy in pregnancy and with breastfeeding include Reprotox and TERIS.