Top 12 Mistakes in Perinatal Psychiatry

Psychiatric illness, especially depression, during pregnancy has been associated with multiple negative outcomes for the exposed baby including: preterm delivery, low birth weight,⁴ decreased motor tone and activity in the baby, higher cortisol levels in the baby,^5-8 poor reflexes in the baby as well as overall worse health status⁹ and higher rates of preeclampsia and gestational diabetes.¹⁰ There is also an extensive literature on the negative effects of postpartum depression on exposed babies including: lower IQ, slower language development, and higher rates of ADHD, behavior problems and psychiatric illness.¹¹ Thus, exposure to maternal psychiatric illness either during pregnancy and/or during the postpartum time period can lead to undesirable and negative outcomes for the exposed child.

A common scenario is that a woman’s medication is continued during pregnancy but at a lower dose than what was needed to get her well or, conversely the medication is continued but not increased or changed in the setting of illness recurrence. In this case, the woman and her baby are being exposed to both the medication and psychiatric illness. The better approach is to treat to wellness; otherwise why use the medication in the first place?

In general, perinatal psychiatrists recommend using older medications that we know more about in pregnancy as compared to newer ones about which we know little to nothing in pregnancy. However, this rule of thumb applies to treatment planning before pregnancy. Once a woman is pregnant, the infant is already exposed to the newer medication and switching risks relapse of the illness as well as exposure to the second medication. So, if you’re going to make changes, do so before pregnancy.

This well-intentioned practice also actually increases the number of exposures for the infant: to the medication used in pregnancy (note that the exposure in utero is far larger than the exposure in breastfeeding), to the medication used in breastfeeding and potentially to psychiatric relapse. Switching should be undertaken if the woman has relapsed on the current psychiatric medication(s) but not for the purposes of limiting exposure during breastfeeding.

When a woman is older, her risk of genetic malformations such as Down syndrome increases with each passing year. In the spirit of treating the whole patient, taking time to change a medication regimen and risk relapse and spend time finding a medication regimen that is helpful may not make sense.

Category B combines medications that have reassuring animal data but no human data, with medications that have demonstrated an adverse effect in animals but have no demonstrated risk in humans. Many Category B classified medications simply have no human data at all and therefore are not preferable over medications that we have safety and risk data for in humans.

Sudden discontinuation of benzodiazepines can precipitate withdrawal symptoms including unstable changes in blood pressure and heart rate, and even result in seizures, none of which are particularly good for the patient, her baby or the pregnancy. Attempting to taper and minimize the regular use of benzodiazepines during pregnancy is a more reasonable approach that supports the health of both mother and baby.

It is important to address these known risk factors for negative pregnancy outcomes and emphasize that these substances have very clear risks if continued during pregnancy, while most (but not all) psychiatric medications do not.

Providers have the good intention of not exposing the developing baby to psychiatric medications- however they have neglected the very real risk of exposure to psychiatric illness and unhealthy and unpredictable maternal behaviors. Further, there are very few medical illnesses for which we withhold treatment during pregnancy and psychiatric illness should not be an exception.

Recent data reveal that the risk of Ebstein’s anomaly in lithium-exposed infants is actually less than 1%,¹² while the risk of relapse of Bipolar I disorder with discontinuation of lithium for pregnancy is approximately 85% to 100%.^2,3 Therefore, lithium should be considered as a possible treatment option during pregnancy for patients who respond well to lithium and have a history of severe bipolar illness.

If valproic acid or carbamazepine are to be used in a woman who has the potential to become pregnant, it is important that she clearly understand that she should not take these medications during pregnancy and that any pregnancy should be a planned one, with other medications to be used during the pregnancy. Discussion of contraception choices should be carried out and initiation of contraception should be encouraged and if possible undertaken.

Dr Payne is Associate Professor of Psychiatry, Associate Professor of Gynecology and Obstetrics, Director, Johns Hopkins Women’s Mood Disorders Center, Johns Hopkins School of Medicine, Baltimore, MD. She reports no conflicts of interest concerning the subject matter of this article.