Psychiatric disorders are common during pregnancy and postpartum. For example, rates of perinatal depression and anxiety are 15-20%. Twenty percent of people with postpartum depression have a bipolar spectrum disorder. In addition, many people have pre-existing psychiatric conditions and are already taking psychotropic medications when they become, or are planning to become, pregnant. The overall goal of treatment during pregnancy is to use the lowest number and dosages of medications possible, while effectively treating the underlying psychiatric disorder(s).
Although the Perinatal PCL receives questions about diagnoses, non-medication treatments, and resources and referrals, many calls are about prescribing and the effects of medications during pregnancy and lactation. Here, we provide some general guidelines about prescribing during the perinatal period and some resources to find information about risks of specific medications.
What are some general guidelines about prescribing during the perinatal period?
1. Consider risks during pregnancy whenever prescribing medication for someone of childbearing potential.
About 50% of pregnancies are unplanned. Considering, and informing people of childbearing potential about, risks of their medication(s) during pregnancy helps to maximize prescribing of safer medications and avoid patients’ suddenly discontinuing needed medication if they find out they are pregnant.
2. Make any medication changes before pregnancy if possible.
This minimizes the number of exposures for the baby and maximizes stability for the parent. Changing a newer medication with less data regarding safety in pregnancy to an older medication with more safety data can be done before pregnancy, if desired. Making this change once the patient is already pregnant involves exposing the baby to two medications instead of one and potentially causing worsening of the parent’s psychiatric condition during pregnancy.
3. Ideally, the patient should be psychiatrically stable for at least 3 months before trying to conceive.
Although this is not always possible, it decreases the risk of relapse and exposure of the baby to risks of untreated/undertreated psychiatric illness.
4. Avoid polypharmacy whenever possible.
Prescribing the fewest medications possible to effectively treat the patient’s psychiatric disorder reduces exposures for the baby. Reviewing the need for each medication is especially important when someone is taking multiple medications and/or more than one medication in a class (e.g., two or more antidepressants, two or more antipsychotics, multiple antianxiety/hypnotic medications, etc.).
5. Avoid Depakote.
Depakote (valproic acid) is a commonly prescribed mood stabilizer for patients with bipolar disorder. Depakote is a known teratogen (rate of malformations elevated in all dosage ranges and 25% at doses above 1450 mg/day) and is associated with significantly decreased IQ in children exposed in utero.
6. Optimize non-medication treatments.
At all times, and especially during the perinatal period, we want to maximize the use of evidence-based non-medication treatments such as psychotherapy. Even if someone requires medication for effective treatment of their condition, non-medication treatments can help minimize numbers and dosages of medications and increase effectiveness of treatment.
7. Remember that an untreated/undertreated psychiatric disorder also poses risks to the parent and the baby.
Untreated/undertreated psychiatric disorders pose significant risks for parents and babies. For example, perinatal depression is associated with higher rates of preterm birth, low birth weight, problems with attachment and bonding, and increased rates of psychiatric disorders in childhood and adolescence. For this reason, it is important to treat psychiatric disorders effectively during the perinatal period.
8. If you are thinking of stopping your patient’s psychotropic medications because they are pregnant, please call us first.
Discontinuing medications abruptly can precipitate relapse (another exposure for the baby and risk for the parent). Also, stopping some medications can cause withdrawal symptoms that are potentially dangerous (e.g., benzodiazepines) or unpleasant (e.g., antidepressants). We would be happy to help you sort out which medications to discontinue and safe tapering schedules.
9. Prescribing during the perinatal period requires a risk-risk discussion.
Informed consent during the perinatal period involves collaborating with the patient in discussing and weighing risks of medication for the fetus/baby, risks of the psychiatric disorder, and possible alternative treatments.
10. Use a patient-centered and team approach.
In addition to collaborative decision-making with, and support of, the patient, this includes involving family members and communicating with other care providers. It is important to educate the partner and/or family members about the risks and benefits of treatment as well as warning symptoms of relapse. Communication with obstetric and pediatric providers minimizes the patient’s hearing conflicting opinions and being confused and concerned.
The Perinatal PCL is a free, state-funded, provider-to-provider consultation line like the Psychiatry Consultation Line (PCL) but focused on behavioral health disorders and symptoms during the perinatal period (pregnancy and the first 12 months postpartum). We are available at 877-725-4666 or by email at ppcl@uw.edu, weekdays 9-5. Like PCL, we also offer scheduled consultations.
Any healthcare provider in Washington State can call us with any behavioral health-related questions about a patient/client who is pregnant, planning pregnancy, postpartum, or who has pregnancy-related complications (e.g., infertility, pregnancy loss). Perinatal PCL is staffed by University of Washington perinatal psychiatrists, an addiction psychiatrist with expertise in the perinatal period, and our program coordinator, who is trained in social work. We offer psychiatric consultation and local perinatal mental health resources. For more information about Perinatal PCL, and to access our online Perinatal Mental Health Care Guide, please visit our website.
Author
Deb Cowley, MD
Board-certified psychiatrist at UWMC-Roosevelt
UW professor of Psychiatry and Behavioral Sciences
Medical director, Perinatal PCL
Dr. Cowley has expertise evaluating and treating women who have mental health issues during pregnancy and postpartum, and throughout their life cycle, including premenstrual and menopause-related psychiatric symptoms. Her clinical interests include anxiety disorders, depressive disorders, obsessive compulsive and related disorders, panic disorder, postpartum depression, evidence-based medicine, maternal mental health and women’s health.
Related Resource
Management of Psychotropic Drugs During Pregnancy
Psychiatric conditions (including substance misuse disorders) are serious, potentially life threatening illnesses that can be successfully treated by psychotropic drugs, even during pregnancy. This review presents an up to date and careful examination of the most rigorous scientific studies on the effects of psychotropic drugs in pregnancy.
Other Resources
InfantRisk for Healthcare Providers
This collection of apps is for healthcare providers and parents about the safety of medications during pregnancy and breastfeeding.
LactMed
This database of drugs and other chemicals provides information about the safety of exposure during breastfeeding.
Reprotox
This database of medications highlights their effects during pregnancy, breastfeeding, and development. (Requires subscription.)
MotherToBaby
These fact sheets are for parents regarding risks of drugs (including non-prescribed drugs) during pregnancy and breastfeeding.
Perinatal Support Washington
This non-profit organization provides a warm line, support groups, peer support, resources, and therapy referrals to support emotional wellbeing for new parents.