Nancy Byatt, DO, MS, MBA

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

To understand the risk differential of pharmacotherapy compared with no treatment during pregnancy and help women make treatment decisions before, during, and after pregnancy.

At the end of this CE activity, participants should be able to:

• Rationalize the need for continued treatment for psychiatric illness during pregnancy

• Explain the risks involved when switching medications during pregnancy and how it affects the fetus

• Discuss the best options for treating psychiatric illness in pregnant women

This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

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Nancy Byatt, DO, MS, MBA, reports that she has received a salary and/or funding support from the Massachusetts Department of Mental Health via the Massachusetts Child Psychiatry Access Program for Moms (MCPAP for Moms). She is also the statewide Medical Director of MCPAP for Moms. Dr. Byatt has served on the Perinatal Depression Advisory Board for the Janssen Disease Interception Accelerator Program, the Perinatal Depression Advisory Board for the Janssen Disease Interception Accelerator Program, the Physician Advisory Board for Sage Therapeutics, and is a Council Member of the Gerson Lehrman Group. She also serves as a speaker for Sage Therapeutics.

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One in 7 women suffers from a mood disorder during pregnancy or in the first year postpartum.

 It is imperative that we, as psychiatric providers, guide each woman to make thoughtful decisions that take into account the effects of the illness and the treatment on her and her baby. Depression, anxiety, and other psychiatric illnesses that occur during pregnancy and the postpartum period have deleterious effects on mom, her child, and her family.

"Sonja," a 26-year-old with a history of postpartum depression and panic disorder reports that she experienced severe postpartum depression and panic disorder within a month of giving birth to her 2-year-old son. The symptoms resolved shortly after she began taking 20-mg escitalopram daily. Three months ago, Sonja and her husband decided that they wanted to have another baby. Her psychiatrist told her that she had to discontinue the escitalopram before attempting to conceive. She followed his recommendations and the depression symptoms and daily panic attacks soon returned. Without the escitalopram, she is completely immobilized and unable to function. She recently saw her psychiatrist, reported the symptoms and her inability to function and requested that he restart the escitalopram. He responded, "You will not take the escitalopram if you care about your baby." She left the psychiatrist's office feeling guilty and inadequate, and that she had no choice but to suffer for the sake of the baby she hoped to conceive.

Sadly, this is just one example of countless similar incidents that occur daily. As this case illustrates, we miss the opportunity to have a trans-generational impact by optimizing maternal mental health, which in turn affects infant and child health. It is a complete fallacy that a woman needs to ignore her mental health or suffer for her baby. Having a baby is extraordinarily challenging. The best thing a woman can do for herself and her baby is get the treatment that she needs and deserves. There are many safe and effective treatment options for pregnant women.

Although there can be adverse effects of psychotropics on the mother and fetus, there are inherent risks of the illness itself. If medications are discontinued in pregnancy, there is a high risk of illness relapse. The duration of and number of depressive episodes pre-pregnancy are the greatest predictors of the same for during pregnancy. Other risk factors include personal or family history of postpartum depression, history of mood changes related to hormonal contraception, and premenstrual dysphoric disorder. Medications should not be automatically discontinued due to pregnancy. It is critical to ask: "What could happen if my patient does not take her medication? How might her illness affect her ability to take of herself and her baby?"Â

The FDA's A, B, C, D, and X categories for medicines used in pregnancy are extremely limited and misleading. For example, the risks of untreated illness are not included. Realizing this, the FDA developed a new approach to replace the risk categories and better support evidence-based decisions.

 The new system, the Pregnancy and Lactation Labeling Rule, uses a narrative model that includes 3 sections on the prescription label for pregnancy-related information: (1) Pregnancy; (2) Lactation; and, (3) Females and males of reproductive potential. Each section summarizes risks to the fetus, illness-related considerations, and available safety data.

Because approximately 50% of pregnancies are unplanned, it is imperative to consider and discuss the possibility of pregnancy with all women of reproductive age. This should include discussing and documenting birth control and the current use of all medications and their risks-especially important with highly teratogenic medications, such as valproic acid. Being aware of interactions between hormonal contraceptives and mood stabilizers is crucial and also needs to be discussed. Some hormonal contraceptives decrease levels of anti-convulsant medications, such as lamotrigine. Conversely, oxcarbazepine and topiramate can decrease the efficacy of hormonal contraceptives. Any discussions and documentation of preconception planning should also include recommendations for prenatal vitamins and folic acid.

Depression during pregnancy is associated with poor health care use, increased use of substances, and poor maternal health care. It is also associated with poor birth outcomes, including low birth weight in preterm delivery. Children of women with maternal depression have also been found to be at increased risk of cognitive delays or behavioral problems.

 Moreover, maternal suicide is a leading cause of death among postpartum women.

 It is critical to educate women about the various options for treating depression during pregnancy. It is also essential that non-pharmacologic treatments and lifestyle changes be included in treatment planning (

). Evidence-based psychotherapy, such as cognitive behavioral therapy and interpersonal psychotherapy, should be considered as first-line therapy when possible. However, many women will need a combination of psychotherapy and pharmacotherapy to achieve full symptom remission. Pharmacotherapy may be the only treatment option for women who do not have access to psychotherapy or who do not see the value of psychotherapy.

"Melissa" is a 32-year-old with a history of severe depression who has 2 children. She is now 14 weeks pregnant. She is currently asymptomatic and taking 300-mg bupropion XL. She notes that she had been severely depressed to the extent that it has affected her functioning and her ability to parent. Once she started taking bupropion, the symptoms resolved. During a visit with her psychiatrist, she reported that she had Googled bupropion because she was concerned about the risks of taking it during pregnancy. As a result of her Google search, she believes that she should stop the bupropion and start sertraline. She notes that the information she found online indicated that sertraline is safer and the best option.

How should her psychiatrist counsel her? Melissa's fetus has already been exposed to bupropion. If bupropion is continued, the fetus will likely experience only a single exposure. While bupropion has less available reproductive safety data than the SSRIs and has been associated with a possible increased risk of congenital heart defects, it is important to consider the risk of switching medications during pregnancy.

If her psychiatrist were to discontinue the bupropion and start sertraline, there is a risk of 3 exposures: her fetus is 14 weeks gestational age and has already been exposed to bupropion; switching would expose the fetus to a second medication (sertraline); and, sertraline may not be as effective as bupropion. Melissa could relapse and expose the fetus to illness. In general, pregnancy is not a good time to switch medications.

To avoid exposure to untreated or undertreated illness and more than one medication, it is best to continue medications with known efficacy. Moreover, the risks of untreated illness need to be considered because the risks of exposure to illness are often as or more important than the risks of exposure to the medication.

There may be a small risk of birth defects when taking antidepressants during pregnancy-the data for paroxetine are most concerning. These findings, however, are inconsistent and the absolute risk of birth defects is small; most meta-analyses have been reassuring.

Antidepressant use during pregnancy has been associated with transient neonatal symptoms. This is a self-limited syndrome that can occur in up to 30% of newborns exposed to antidepressants during pregnancy. It can present as irritability, tachypnea, and/or tremulousness. The syndrome is time-limited and resolves within days; in rare cases it can last 1 to 2 weeks. Discontinuing SSRIs in the third trimester has not been shown to decrease the risk of transient neonatal symptoms.

Although the data are inconsistent, antidepressant use in pregnancy has also been associated with a small increase of risk (baseline rate of 1-2/1000 births) for persistent pulmonary hypertension (PPHN) in the newborn. While there may be a small increased risk (3-4/1000 with antidepressant use during pregnancy), the absolute risk of PPHN appears to be small and more modest than suggested by initial studies.

Antidepressant use during pregnancy has also been associated with preterm labor and low birth weight; changes in IQ or language development have also been seen. However, depression itself has been associated with an increased risk of preterm birth and low birth weight as well as with changes in IQ or language development.

Some studies suggest that the risk of autistic spectrum disorders in the offspring of women with psychiatric illness may be higher with exposure to antidepressants during pregnancy. However, other studies suggest that lack of antidepressant exposure increases the risk of autistic spectrum disorders. Overall, results from available studies do not suggest long-term neurobehavioral effects on children.

The perinatal period is the time of highest risk for first onset or recurrence of bipolar disorder episodes. Bipolar disorder among perinatal women is associated with self-injury, substance use, disruption of mother-child bonding, suicide, and infanticide. Psychotic illnesses have been associated with increased risk of pregnancy complications, including cesarean deliveries, intensive care unit admissions, and higher neonatal morbidity. Moreover, bipolar disorder is the most potent, best-established risk factor for postpartum psychosis.

Lithium is considered the treatment of choice for patients with type 1 bipolar disorder who are pregnant or are of child-bearing age. Preconception levels can be used to guide the therapeutic range of lithium during pregnancy.

Lithium use during pregnancy has been associated with preterm labor, polyhydramnios, polyuria/polydipsia, and lithium toxicity. In addition, babies of mothers who are on lithium during pregnancy may be large for gestational age at birth, have cardiac and neural tube defects, neonatal adaptation symptoms, and changes in long-term neurodevelopment. More recent studies suggest that the risk of major cardiovascular anomalies, such as Ebstein's anomaly, is less than previously thought.

Women who take lithium during pregnancy should be monitored carefully by an obstetrician who is experienced in high-risk pregnancies. A 3D echocardiogram is needed at 16 to 18 weeks gestational age. Lithium should be continued during labor and delivery. To prevent lithium toxicity, patients should be well hydrated during labor and immediately post-partum. Postpartum, infant levels of lithium, thyroid-stimulating hormone, and renal function need to be checked. Consider decreasing the dosage to that of pre-pregnancy in the postpartum period.

Lamotrigine is often considered a first-line medication for women with type 2 bipolar disorder who are pregnant or are of child bearing age. Preconception lamotrigine levels can be used to guide dosing throughout pregnancy with the goal of maintaining the therapeutic preconception level. Postpartum, lamotrigine dose should be decreased to the preconception level.

While early reports suggested an increased risk of cleft lip and palate with first trimester exposure, more recent data are reassuringÃ¢€”lamotrigine has not been associated with an increased risk of neurodevelopmental disorders. However, the following limitations need to be considered before prescribing lamotrigine:

• It can increase cycling at higher dosages

• It needs to be titrated slowly, thus is not ideal for acute treatment

• It needs to be taken consistently because of the need to re-titrate slowly if not taken consistently

Antipsychotics are often indicated for the treatment of mood disorders with or without psychotic features or primary psychotic illnesses. It is important to use antipsychotics that are currently or have previously been effective, while taking into account the relative risk of the medication.

No single malformation has been consistently reported with antipsychotics, although some data suggest a possible association with septal defects. In addition, antipsychotic use during pregnancy has been associated with preterm labor, low and high birth weight, increased risk of postnatal adaptation syndrome, and increased neonatal intensive care unit stays.

There are more data for typical than for atypical antipsychotics. Typical antipsychotics have been associated with a small increase in risk for transient abnormal muscle movement; however, limited long-term data are reassuring. Compared with high-potency agents, low-potency agents have been more strongly associated with teratogenic effects. Atypical antipsychotics have been associated with gestational diabetes and obesity; but the limited data from studies that followed women for up to 12 months are reassuring.

Anticonvulsants such as carbamazepine and oxcarbazepine have been associated with neural tube defects and cognitive deficits among offspring and should be avoided. Valproic acid is highly teratogenic and should be avoided by pregnant women. Supplementation with folic acid is required for women taking an anticonvulsant during pregnancy.

Changes in absorption, distribution, metabolism, and elimination that occur in pregnancy can lower psychotropic drug levels and possibly treatment effects, particularly in mood stabilizers, during the perinatal period. Vigilant monitoring of clinical symptoms is needed for all classes of medications during pregnancy and the postpartum period to assess for symptom recurrence and the need for dose adjustments. Mood stabilizers also require therapeutic drug monitoring in combination with clinical monitoring.

When considering treatment options for pregnant women, there's no such thing as no exposure: there is no risk-free choice. We need to work with our patients to assess the risks of untreated psychiatric illness and the risks and benefits of medication treatment. A detailed and individualized discussion of the risks, benefits, alternatives to medication treatment, and the risks of untreated psychiatric illness is needed. Careful consideration and discussion of risks of treatment and under-treatment or no treatment can help can decrease the risk of decompensation during pregnancy or the postpartum period. And, it will mitigate negative effects on birth, infant, and child outcomes associated with untreated psychiatric illness.

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1. Vesga-Lopez O, Blanco C, Keyes K, et al. Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry. 2008;65:805-815.

2. Ramoz LL, Patel-Shori NM. Recent changes in pregnancy and lactation labeling: retirement of risk categories. Pharmacother. 2014;34:389-395.

3. Forman DR, OÃ¢€™Hara MW, Stuart S, et al. Effective treatment for postpartum depression is not sufficient to improve the developing mother-child relationship. Dev Psychopathol. 2007;19:585-602.

4. Deave T, Heron J, Evans J, Emond A. The impact of maternal depression in pregnancy on early child development. BJOG. 2008;115:1043-1051.

5. Lindahl V, Pearson JL, Colpe L. Prevalence of suicidality during pregnancy and the postpartum. Arch Womens Ment Health. 2005;8:77-87.

6. Byatt N, Deligiannidis KM, Freeman MP. Antidepressant use in pregnancy: a critical review focused on risks and controversies. Acta Psychiatr Scand. 2013;127:94-114.

7. Huybrechts KF, Bateman BT, Palmsten K, et al. Antidepressant use late in pregnancy and risk of persistent pulmonary hypertension of the newborn. JAMA. 2015;313:2142-51.

8. Nulman I, Koren G, Rovet J, et al. Neurodevelopment of children following prenatal exposure to venlafaxine, selective serotonin reuptake inhibitors, or untreated maternal depression. Am J Psychiatry. 2012;169:1165-1174.

9. Cohen LS, Viguera AC, McInerney KA, et al. Reproductive safety of second-generation antipsychotics: current data from the Massachusetts General Hospital National Pregnancy Registry for Atypical Antipsychotics. Am J Psychiatry. 2016;173:263-270.

Articles

Careful consideration and discussion of risks of treatment and under-treatment (or no treatment) can help can decrease the risk of decompensation during pregnancy or the postpartum period.

Lifeline for Pregnant and Postpartum Women Who Are Drowning in Plain Sight

[Acknowledgment-the authors acknowledge Christina Wichman, DO, FAPM and Catherine C. Crone, MD, of the 

 (APM), for helping to bring this article to fruition. The APM is the professional home for psychiatrists providing collaborative care bridging physical and mental health. Over 1200 members offer psychiatric treatment in general medical hospitals, primary care, and outpatient medical settings for patients with comorbid medical conditions.]



Psychiatric symptoms are among the most prevalent perinatal complications. During pregnancy, discontinuing or under-dosing psychotropic medication often results in symptom recurrence. The postpartum period confers heightened risk for expression of depressive disorders, bipolar disorder, generalized anxiety disorder, and obsessive-compulsive disorder.

Recent research has identified interactive influences on vulnerability to perinatal psychiatric symptoms, including genotypes, hormonal fluctuations, neurosteroids, neurotransmitters, inflammatory cytokines, hypothalamic-pituitary-adrenal axis reactivity, stressors, and social role transitions. Studies of epigenetic influences on fetal development have begun to elucidate why maternal antenatal stress and depression increase the risk of preterm birth and heightened stress sensitivity in offspring. The availability of large databases and improvements in study methodology has greatly expanded knowledge of the risks of psychotropic medications during pregnancy. Moreover, new models of integrating mental health care into perinatal care settings have begun to tackle the dilemma of widespread under-detection and under-treatment of perinatal psychiatric problems. 

 highlights some of the challenges surrounding the treatment of women of reproductive age.

Despite considerable expansion of available data, physicians may be reluctant to prescribe psychotropic medication to pregnant patients.

 This may be due, in part, to confusing information regarding the risks of psychotropic medication during pregnancy.

[[{"type":"media","view_mode":"media_crop","fid":"44337","attributes":{"alt":"Â© WAVEBREAKMEDIA/SHUTTERSTOCK.COM","class":"media-image media-image-right","id":"media_crop_2406770500329","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4939","media_crop_rotate":"0","media_crop_scale_h":"183","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Â© WAVEBREAKMEDIA/SHUTTERSTOCK.COM","typeof":"foaf:Image"}}]]This article summarizes clinically relevant advances in the psychiatric care of women during pregnancy and postpartum, including recent changes in how the FDA classifies pregnancy risk for medications, best practices in perinatal psychopharmacology, and innovative models of integrating mental health care delivery with perinatal care to improve access to evidence-based treatments.

FDA final rule on pregnancy/breastfeeding safety labeling

In 1979, the FDA introduced pregnancy risk categories A, B, C, D, and X in response to the thalidomide disaster in the 1960s. Drugs were assigned to a particular category based on the risk of harm to the fetus and newborn (per available animal and human studies) and the potential benefit in pregnancy and breastfeeding. The categories implied increasing risk with each letter. This system was overly simplistic, misleading, and incomplete.

In December 2014, the FDA published the Pregnancy and Lactation Labeling Rule (PLLR), or Final Rule, which will be implemented over the next 3 years.

 The PLLR includes new content and formatting in the form of explanations, based on available and relevant data, across 3 subsections. Each section includes a risk summary and clinical considerations as well as animal and human data:

 Pregnancy: dosing, impact on fetus, and registry information

 Lactation: amount of drug in breast milk and potential effects, if any

 Females and males of reproductive potential: pregnancy testing, contraception, and fertility related to the drug

This has several implications for the clinician. The risk category by letter is being phased out; new safety information will be provided with a focus on risk, individualized consideration of illness, history and circumstances, access to registry information, and data. Conversations with patients will be more informed by evidence. The new format, available at 

, will help orient clinicians and prepare them for the transition.

Best practices in perinatal psychopharmacology

Discussions regarding medication use during pregnancy must take into account the risks of 

 psychiatric disorders in pregnancy. Women with active psychiatric symptoms during pregnancy are at risk for inadequate prenatal care, substance abuse, preterm delivery, low birth weight of the newborn, and other obstetric/ neonatal complications. Domains of reproductive safety include risk of congenital malformation, effect on duration of pregnancy, neonatal toxicity and withdrawal, and long-term neurobehavioral sequelae.

High-quality studies have concluded that, as a group, antidepressants do not increase the risk of congenital malformations above the baseline risk of 2% to 4% in the general population. There are conflicting studies regarding a possible increased risk of cardiovascular malformations with exposure to paroxetine. Serotonergic antidepressants increase the risk of persistent pulmonary hypertension, but the absolute risk remains low. Both antidepressants and untreated depressive symptoms increase the risk of premature labor; gestational age is reduced by about 4 days from exposure to either, and birth weight is lower. These are statistically but not clinically significant. Antidepressant exposure is not associated with an increased risk of autism or other neurodevelopmental problems, although women who take antidepressants may have other risk factors for these problems in their offspring.

 In most cases of moderate to severe psychiatric illness, the benefits of medication used to remit symptoms outweigh putative risks of exposure.

The high recurrence rate of bipolar illness during and after pregnancy complicates an already challenging risk-to-benefit analysis, given that many mood-stabilizing medications are known teratogens. The risk of untreated symptoms may exceed medication-linked risks in individual cases. Valproic acid is strongly contraindicated in pregnancy because it increases the risk of multiple teratogenic effects: for example, a 1% to 6% rate of neural tube defects and high rates of impaired neurocognitive development. Carbamazepine also has multiple teratogenic effects including a 1% risk of neural tube defects. Lithium has a 0.05% to 0.1% increased risk of Ebstein’s anomaly with exposure during the first trimester. However, the risk is much lower than that with valproate or carbamazepine, and much lower than previously thought. Lamotrigine has no increased risk of congenital anomalies after antenatal exposure. Reports of an association with oral cleft defects are conflicting. There are limited data on gabapentin, oxcarbazepine, tiagabine, and topiramate. Atypical antipsychotics may be considered as an alternative for acute mania or maintenance treatment (see below).

 high risk for complications during the perinatal period-nearly double that in the general population. They include higher rates of operative deliveries, neonatal intensive care unit admissions, and neonatal morbidity.

While first-generation antipsychotics have a fairly well described history in pregnancy, with high- potency agents being preferred to low potency, less has been published about second-generation antipsychotics. Overall, no increased risk of congenital anomalies has emerged to date, including recent studies by Habermann and colleagues

 However, metabolic effects, blood dyscrasias, and movement disorders in the mother, fetus, and newborn must be taken into account with the use of these agents.

In summary, some key points to bear in mind in the pharmacological treatment of perinatal women are

• Consider psychotherapy as an initial treatment approach for patients with mild to moderate depression or anxiety and for augmentation as indicated

• Avoid discontinuing medications that provide psychiatric stability

• Maintain patients on previously effective medications at the minimal effective dose with symptom remission as the goal

• Carefully substitute less teratogenic agents if necessary

• Dose requirements may be higher in the second half of pregnancy and should be adjusted accordingly

Although the vast majority of perinatal women are amenable to being screened for depression, screening alone does not improve treatment rates or patient outcomes. Fewer than 30% of women who screen positive for depression attend an initial or subsequent mental health visit, and fewer than 10% adhere to a full treatment course.

Patient, provider, and systemic barriers prevent perinatal women from receiving the mental health care they need. These include

• Stigma, the fear of losing parental rights, and being judged as an unfit mother

• Lack of obstetric provider training in clinical aspects of depression care and communication skills

• An absence of standardized processes and procedures for depression care

• Lack of mental health providers willing or trained to treat women during pregnancy and postpartum

• Inadequate capacity for follow-up and care coordination

In addition to training women’s health providers to be attuned to mental health issues and to have a level of comfort and confidence in diagnosing and managing psychiatric symptoms and syndromes, obstetric practices need supports in place to adequately address depression in their patients.

Translating integrated care models, such as stepped and collaborative care, into obstetric settings could provide a solution. Collaborative models can improve mental and physical outcomes for individuals with mental illness, and they provide a robust framework for integrating obstetric and depression care. Stepped-care models involve interventions appropriate to illness severity, with intensification of care (such as adding case management or specialist consultation) for those with persistent illness. Such programs include mental health training for perinatal care providers, on-site access to prompt evaluation and treatment initiation, integrated social workers or nurses who provide supportive services and follow-up, and access to perinatal psychiatry consultation for perinatal care providers.

In addition to fee for service, funding for such programs can be obtained through grants from state legislatures, private foundations, or Medicaid. As health care reform evolves, accountable care organizations may see the benefit and cost savings of such integration and over time implement changes that would make this the standard of care. 

 describes integrated care models and what clinicians can do to improve outcomes.

Interpreting the rapidly changing field of perinatal psychiatry may be a daunting task for the general psychiatrist, placing patient and provider between Scylla and Charybdis, or a rock and a hard place. The FDA Final Rule, together with a deeper and broader understanding of the effects of mental illness and the role of psychotropics in perinatal outcomes, has diminished polarization in this field and set the stage for evidence-based decisions. Current efforts in health care reform present unprecedented opportunity for the development and implementation of integrated mental health programs in perinatal clinics, which not only lower overall health care costs but improve the quality and impact of care as well.

the authors acknowledge Christina Wichman, DO, FAPM and Catherine C. Crone, MD, of the Academy of Psychosomatic Medicine (APM), for helping to bring this article to fruition. The APM is the professional home for psychiatrists providing collaborative care bridging physical and mental health. Over 1200 members offer psychiatric treatment in general medical hospitals, primary care, and outpatient medical settings for patients with comorbid medical conditions.

Dr Dresner is Director of Wellsprings Health Associates, and Associate Professor of Clinical Psychiatry and Obstetrics Gynecology at Northwestern University Feinberg School of Medicine in Chicago. Dr Byatt is Medical Director of the Massachusetts Child Psychiatry Access Project for Moms, and Assistant Professor of Psychiatry and Obstetrics Gynecology, UMass Memorial Medical Center/UMass Medical School in Worcester, MA. Dr Gopalan is Assistant Professor of Psychiatry and Medical Director of the Psychiatry Consultation-Liaison Service, and Chief of Psychiatry at the Magee-Women’s Hospital at the University of Pittsburgh Medical Center/Western Psychiatric Institute and Clinic in Pittsburgh, PA. Dr Miller is Medical Director of Women’s Mental Health at the Edward Hines Jr. VA Hospital, and Professor of Psychiatry at the Loyola Stritch School of Medicine in Maywood, IL. Dr Sachdeva is Adjunct Associate Professor of Clinical Psychiatry in the Department of Psychiatry and Behavioral Science at the University of Cincinnati Medical School in Cincinnati, OH. The authors report no conflicts of interest concerning the subject matter of this article.

 Byatt N, Biebel K, Debordes-Jackson G, et al. Community mental health provider reluctance to provide pharmacotherapy may be a barrier to addressing perinatal depression: a preliminary study. 

 US Food and Drug Administration. Pregnancy and Lactation Labeling Final Rule. 

http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/Labeling/ucm093307.htm

 Grigoriadis S, VonderPorten EH, Mamisashvili L, et al. Antidepressant exposure during pregnancy and congenital malformations: is there an association? A systematic review and meta-analysis of the best evidence. 

 Vigod SN, Kurdyak PA, Dennis CL, et al. Maternal and newborn outcomes among women with schizophrenia: a retrospective population-based newborn study. 

 Habermann F, Fritzsche J, FuhlbrÃ¼ck F, et al. Atypical antipsychotic drugs and pregnancy outcome: a prospective cohort study. 

 Cohen LS, Viguera AC, McInerney KA, et al. Reproductive safety of second-generation antipsychotics: current data from the Massachusetts General Hospital National Pregnancy Registry for Atypical Antipsychotics. 

. October 6, 2015; [Epub ahead of print].

 Robinson G. Controversies about the use of antidepressants in pregnancy. 

• MGH Center for Womens Mental Health. 

This article summarizes clinically relevant advances in the psychiatric care of women during and after pregnancy, including recent changes in how the FDA classifies pregnancy risk for medications, and best practices in perinatal psychopharmacology.

Nancy Byatt, DO, MS, MBA

Articles

Lifeline for Pregnant and Postpartum Women Who Are Drowning in Plain Sight

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