Psychotropic Prescribing in Pregnancy: Balancing Teratogenic Risk and Relapse Prevention

Veerle Bergink, MD, outlined her clinical session at APA focused on the pharmacological management of severe mental illness during pregnancy and the postpartum period, with emphasis on relapse prevention.

Bergink identified the perinatal period as one of the highest risk intervals for psychiatric relapse, particularly for patients with bipolar disorder and psychotic disorders.¹ She framed the core clinical challenge as balancing maternal and fetal risk when selecting psychotropic agents, noting that many treating psychiatrists find this period particularly difficult to navigate. She noted that "the postpartum period is an extremely high risk period for relapse, for getting sick, especially for bipolar patients," and emphasized that preventing postpartum episodes should be a primary treatment objective.

On pharmacotherapy, Bergink was unequivocal in recommending against valproate for women of reproductive age given its high teratogenicity.² Carbamazepine was similarly discouraged. Lithium, while teratogenic in higher doses during the first trimester, was described as often indispensable for mood stability, with the practical recommendation to reduce the dose during the first trimester based on individual risk profiles. Antipsychotics were characterized as nonteratogenic but lacking robust efficacy data for the perinatal period; clinicians should avoid polypharmacy and excessive dosing, and monitor for obstetric complications including gestational diabetes and excessive weight gain, she said.

Bergink closed by addressing the dual risks of overtreatment and undertreatment. She noted that while rising rates of psychotropic prescribing in the general population have resulted in some women entering pregnancy on medications they may safely taper, others with genuine chronic mental illness (like depression, anxiety, obsessive-compulsive disorder, and bipolar disorder) are being undertreated or abruptly discontinuing medication out of fear, despite deriving clear clinical benefit from continuation.

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. Liu X, Smout S, Mahjani B, et al. Risk of relapse in psychotic and bipolar disorders after prenatal antipsychotic discontinuation. JAMA Netw Open. 2026;9(3):e260682.

2. Fietz AK, Onken M, Padberg S, et al. Impact of maternal first trimester treatment regimen on the outcome of valproate exposed pregnancies: an observational Embryotox cohort study. Sci Rep. 2024;14:674.