Psychotherapy and psychosocial measures should be considered before prescribing medications and electroconvulsive therapy, particularly if the patient has mild symptoms or is in the early stages of pregnancy when major fetal organ systems are developing. Various forms of psychotherapy including cognitive-behavioral, interpersonal, insight-oriented, supportive, couple's and group therapy may be useful. Clinicians should encourage patients to decrease external stressors; ensure sufficient sleep; and minimize caffeine(Drug information on caffeine), nicotine(Drug information on nicotine) and alcohol(Drug information on alcohol) use.
Women who discover they are pregnant while taking psychotropic medications can be reassured that exposure during the first two weeks of gestation is relatively low risk because the uteroplacental circulation has not been established yet. If a woman has been stable over a prolonged period of time and the probability of relapsing is low, medications can be tapered and discontinued.
Psychotropic medications should be used when nonpharmacological treatments fail to maintain psychiatric well-being and when the risk of mental illness to the mother and fetus outweighs the risk of psychotropic medications. Medications should be considered in all women with severe disease, psychosis, suicidal ideation or poor weight gain. Whenever possible, they should be avoided during the first 12 weeks of pregnancy, the primary period of organogenesis.
The clinician should discuss the risks and benefits of medications during pregnancy with the patient so she can make educated and informed decisions about treatment. Including the patient's partner and obstetrician in the discussion is useful. Clinicians should be aware that the U.S. Food and Drug Administration's Use-In-Pregnancy ratings found in the PDR can be misleading. Treatment should reflect current published clinical data in addition to these ratings. Psychiatrists should help patients understand the limitations of the research, including the scarcity of prospective, double-blind, placebo-controlled studies and the dearth of data on the neurobehavioral sequelae of fetal exposure. Careful documentation of all discussions and treatment decisions is essential. Throughout the pregnancy, the clinician should re-evaluate the risks and benefits associated with medication exposure and continue or change the treatment based on changing clinical status.
When prescribing medications to pregnant women, doses should be as low as possible to maintain clinical efficacy. Of the antidepressant medications, tricyclic antidepressants and fluoxetine(Drug information on fluoxetine) (Prozac) have been studied most extensively and do not seem to increase the risk of miscarriage or gross malformations. The literature for the newer selective serotonin reuptake inhibitors, sertraline (Zoloft), paroxetine (Paxil), fluvoxamine(Drug information on fluvoxamine) (Luvox) and citalopram(Drug information on citalopram) (Celexa), is more limited, but also supports reproductive safety. Monoamine oxidase inhibitors are contradicted in pregnancy because of the risk of hypertensive crisis. In a small study (n=150), the use of venlafaxine (Effexor) during pregnancy did not show an increase in the rates of major malformations (Einarson et al., 2001). Other antidepressant medications, including bupropion (Wellbutrin), nefazodone(Drug information on nefazodone) (Serzone) and mirtazapine(Drug information on mirtazapine) (Remeron), have not been evaluated sufficiently during pregnancy.
Nulman et al. (1997) studied the long-term effects of in utero exposure to antidepressant medications. This study revealed that preschool-aged children exposed to fluoxetine (n=55) and tricyclic antidepressants (n=80) in utero were similar to age-matched, nonexposed children with respect to IQ, language and behavior.
The commonly used mood-stabilizing medications (lithium, valproic acid [divalproex sodium (Depakote)] and carbamazepine(Drug information on carbamazepine) [Tegretol]) are associated with fetal abnormalities when used during the first trimester of pregnancy. Lithium(Drug information on lithium) exposure is associated with a 10 to 20 times increased risk of Ebstein's cardiac anomaly (Altshuler et al., 1996; Cohen et al., 1994). While this increase is substantial, the absolute risk is relatively low (0.1%) compared to the 1% to 5% risk of facial abnormalities and spina bifida associated with valproic acid and carbamazepine (Altshuler et al., 1996). Thus, lithium is the drug of choice when a mood-stabilizing medication must be used in pregnancy.
However, other cardiac malformations, hypotonia, poor suck reflex, hypoglycemia and cyanosis have been related to lithium exposure (Briggs et al., 1997; Cohen et al., 1994; Woody et al., 1971). In addition, there are isolated reports of neonatal goiter and diabetes insipidus, but no apparent neurobehavioral sequelae (Woody et al., 1971). Lithium should be given in multiple daily doses to avoid peaks of fetal exposure when administered during pregnancy. Maternal lithium levels should be monitored closely, as serum concentrations often drop in response to increased extracellular fluid volume and renal clearance. A high-resolution ultrasound at week 18 is advised to assess for congenital anomalies, especially cardiovascular malformations. During the last antepartum month, the maternal lithium level should be no higher than 0.9 mEq/L in order to avoid maternal lithium toxicity secondary to the sudden, large fluid shifts that tend to occur at delivery (Burt and Hendrick, 2001).