Managing Mood Disorders for Pregnant Patients and Their Progeny 6/11/2020

Optimizing treatment intervention for individuals with clinically significant mood disorders during pregnancy can be fraught with conflicting influences and requires careful consideration and sensitivity, as whatever actions you take (or don’t take) for the mother, will also affect the fetus. Following are a number of clinical considerations identified in a recent article published in Psychiatric Times.

  1. Pregnancies happen– and dialogue with all female patients of child bearing ages about the potential impacts of their becoming pregnant should be a routine part of their care and should be documented. In this context, it is far better to explore the individual issues for each patient prior to a pregnancy occurring than to have to respond after the fact.
  2. While there is a very natural impulse to want all pregnancies to be “natural”, a reflex response of stopping all medications is not appropriate, nor is a rigid stance against any changes in treatment —the risks and benefits of continuing meds or stopping meds should be considered carefully and be individualized to each patient. Relapse rates in the face of medication discontinuation can be as high as 70% for women with depression and as high as 85% for those with bipolar depression. This is contrast to reported relapse rates of only 30% when a pregnant patient continues her medication.
  3. A depressed mom means a distressed fetus and it is important to consider the potential impacts of a mother’s recurring or worsening mood disorder on the child. Research shows a clear association between maternal depression and negative consequence such as preterm delivery, low birth weight, poor reflexes in the baby, and both increased risk of preeclampsia and gestational diabetes for the mother.
  4. For a patient whose illness history indicates that discontinuation of medication is likely to be associated with a relapse or significant worsening of symptomatology, the impulse to reduce medication dosage should be carefully reconsidered as fetal exposure to the drug will occur in this scenario and a compromise in the mother’s mood state, with impacts on the fetus, would be anticipated.
  5. With an unanticipated pregnancy it would be highly appropriate to consider switching from an agent such as paroxetine with known fetal risk to another agent if this has not been considered prior to the onset of the pregnancy.
  6. Regardless of the prescription choices made with regard to psychiatric medications, counseling and attention to an expecting mother’s potential use of substances such as tobacco, alcohol, marijuana, opiates and other drugs is always warranted given the documented risks to both mom and child.
  7. Continuing with an antidepressant following pregnancy during the breastfeeding period is another consideration to address with the pregnant mom-to-be and the family in recognition of the very substantial health and emotional benefits of breastfeeding and the limited risks of medication exposure for the infant.
  8. For mood disordered patients with more complicated treatment regimens that have included the use of benzodiazepines prior to the start of a pregnancy, gradual tapering off the benzodiazepine is ideal and a scheduled taper over the course of several weeks is recommended to avoid withdrawal symptoms such as increased blood pressure and pulse, seizures, and heightened anxiety.
  9. For patients with complex co-occurring disorders and symptoms with psychotic symptoms or manic tendencies, careful management of antipsychotic and/or mood stabilizing medications is required in association with enhanced psychosocial and psychotherapeutic supports. Coordinated interventions by a multidisciplinary team for these high risk situations is ideal and the active evaluation and subsequent ongoing management of the potential risks and benefits of psychopharmacologic interventions is necessary. Patients who have required use of mood stabilizer medications such as lithium, valproic acid and carbamazepine will require particular attention as each of these agents have significant potential fetal toxicities.

Reference: Psychiatric Times, March 2020 (p16-17) Common Errors Psychiatrists Make When Managing Mood Disorders In Pregnant Patients

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