Pharmacotherapy of mood disorders and psychosis in pre- and post-natal women

ABSTRACT

Introduction: Untreated mood and psychotic disorders can have substantial adverse impacts on the patient, the fetus and the family, while treatment can ameliorate such problems. To address concerns by clinicians about the risks of psychotropic medications, this review addresses the risk/benefit analysis of somatic therapies for psychiatric disorders during pregnancy and lactation.

Areas covered: All available research was reviewed on the impact on pregnancy and breastfeeding of mood and psychotic disorders, and of antidepressants, mood stabilizers, antipsychotic drugs, and electroconvulsive therapy. References cited in other reviews, case series, formal studies, pharmacologic discussions, and theoretical pieces were added. Available case control and other studies were critically reviewed and diverse explanations for their findings were considered.

Expert opinion: The potential benefits of treatment of mood and psychotic disorders often outweigh the risks after alternative therapies have been considered. Some medications, particularly paroxetine and valproate, pose greater risks during pregnancy, while the teratogenic risks of lithium have probably been overstated. There is more experience with first than with second generation antipsychotic drugs during pregnancy and lactation. Nursing an infant is possible while taking a number of antidepressants, mood stabilizers or antipsychotic drugs.

KEYWORDS:

• Pregnancy
• postpartum
• psychotropic medication
• depression
• bipolar disorder
• schizophrenia
• psychosis
• lactation
• mood disorders

Article highlights

• Mood and psychotic disorders can have direct physiologic effects on the fetus and newborn, as well as indirect effects mediated by nonadherence and poor health behaviors. Medications used to treat these disorders also have the potential for adverse effects during pregnancy and breastfeeding. Yet the data available to guide decision-making are mixed

• Changes in pharmacokinetics during pregnancy involving induction of enzymes for oxidative metabolism and glucuronidation and increased elimination of medications directly excreted by the kidneys such as lithium are well defined, but alterations of response to psychotropic medications during pregnancy has not been studied extensively

• Some prospective data are available, but most information about adverse medication effects comes from retrospective cohort studies, which provide contradictory data on risks such as persistent pulmonary hypertension of the newborn (PPHN) and autism spectrum disorders (ASD) with serotonin reuptake inhibitors (SSRIs), and the risk of Ebstein’s anomaly with lithium. The risk of neural tube defects associated with valproate exposure during pregnancy is much clearer with valproate and to a lesser extent, carbamazepine

• Antipsychotic drugs with high rates of weight gain may be associated with higher newborn birth weight and with neonatal extrapyramidal syndromes

• While having the advantage of large sample sizes, cohort studies of associations of psychotropic medications with adverse outcomes are limited by nonstandardized diagnostic methods with diverse populations, reliance on prescriptions filled without information about adherence, lack of control for relevant behaviors such as smoking, absence of information about severity of illness and treatment response, a need for very large samples to define small medication risks, and inability to extrapolate from aggregate data to a specific patient.

• Future research should include randomized studies that include measures of treatment response and randomized prospective trials in more discrete, carefully diagnosed patients.

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Declaration of interest

B. Smith has received research funding from the Cystic Fibrosis Foundation. S. Dubovsky has received research funding from Otsuka, Sumitomo, Janssen Research, Pfizer, Neurocrine Biosciences, Neurim and Allergan. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.