Decision-Making and Risk Assessment in Perinatal Psychopharmacology

Veerle Bergink, MD, discussed psychotropic medication management during pregnancy, focusing on clinical decision-making, care coordination, and postpartum relapse prevention planning.

Bergink characterized public discourse around medication use in pregnancy as unhelpfully polarized, cautioning against both extremes. She emphasized that the message urging wholesale medication discontinuation is "a very harmful and stigmatizing message," while also noting that blanket continuation is equally unjustified given that medications cross the placenta and reach the developing brain.¹ She advocated instead for individualized, evidence-informed shared decision-making: "it is best to be well informed…discuss this with the woman involved, make a plan, and stick to it during pregnancy and the postpartum period."

Bergink placed particular emphasis on prospective care planning for high-risk patients, noting that women with bipolar disorder or a history of postpartum psychosis face a 1-in-2 to 1-in-3 risk of severe postpartum illness.² Because delivery is not always predictable, she highlighted that a clearly documented treatment plan—like specifying which agents to initiate immediately postpartum, thresholds for adding sleep medication, and arrangements to protect maternal sleep by relieving night feeding responsibilities—should be established well in advance and shared across all treating providers. She noted that psychiatrists and obstetricians are often not present at the every clinical encounter, making written coordination essential.

Bergink encouraged clinicians to approach knowledge gaps without shame, noting that even she actively searches for the latest evidence on specific compounds for individual patients, and recommending that providers research medication safety together with their patients as a collaborative process.

Dr Bergink is a professor of psychiatry and director of the Women's Mental Health Center at the Icahn School of Medicine at Mount Sinai.

References

1. Ewing G, Tatarchuk Y, Appleby D, et al. Placental transfer of antidepressant medications: implications for postnatal adaptation syndrome. Clin Pharmacokinet. 2015;54(4):359-70.

2. Friedman SH, Reed E, Ross NE. Postpartum psychosis. Curr Psychiatry Rep. 2023;25(2):65-72.