Mental Illness in Pregnancy and Lactation

Question 1

Women’s reproductive life stages

Answer 1

Pre-menstrual
childbearing
Perimenopausal
Post menopausal

Question 2

Estrogen

Answer 2

-Produced in the ovaries, fat cells and adrenal glands
-Estrogen stabilizes mood

Question 3

What happens to estrogen levels throughout the trimesters of pregnancy?

Answer 3

First Trimester:
Second Trimester:
Third Trimester:

Question 4

What happens to Hormone Levels throughout the menstrual Cycle?

Question 5

Progesterone

Answer 5

-Produced in the ovaries
-Increases MAO activity, boosting serotonin and GABA levels
-Inhibits neurotransmission
-Thickens lining of uterus to prepare for fertilization -“Pregnancy hormone”
-Progesterone is thought to be “excitotoxic” in the absence of estrogen (e.g. post-menopausal women, pregnancy)
-Destabilizes mood if levels low (e.g. irritability, anger or rage)

Question 6

Follicle Stimulating Hormone

Answer 6

Increases oestradiol production

Question 7

Luteinizing Hormone

Answer 7

Stimulates production of estrogen and progesterone

Question 8

What happens to rates of depression with Menarche?

Answer 8

Depression rises with onset of menarche

Question 9

Premenstrual syndrome

Answer 9

Physical and emotional distress
Occurs 5 days prior to menstruation
Treated by PCP

Question 10

Premenstrual Dysphoric Disorder

Answer 10

-Severe, debilitating form of physical and emotional distress
-1-2 weeks before menstruation occurs
-Treated in psychiatry(www.aafp.org)

Question 11

Premenstrual Symptoms

Answer 11

Irritability
Feelings of sadness
Lack of motivation
Aggressiveness
Problems focusing and concentrating
Distress
Depression mixed with cognitive changes

Question 12

Treatment of premenstruall symptoms

Answer 12

SSRIs
SNRIs
Quetiapine
Oral Contraceptives

Question 13

Perimenopausal symptoms.

Answer 13

-Possible recurrence of depression and anxiety
-Higher risk of symptoms with history of premenstrual symptoms
-Abrupt Hormone levels fluctuate – Reduction of Estrogen
- “Domino effect”-Years of dysphoria with pre-menopause
– Dysphoric mood, sleep disturbance, fatigue, insomnia, hot flashes and multiple somatic
Complaints, memory problems, sexual dysfunction.
Mood changes are similar to pre-menstrual presentation but more persistent

Question 14

Prescribing Psychotropics during pregnancy and lactation:

Answer 14

-Rates of depression vary during pregnancy and during the postpartum period
-Pregnant women with depression ( and the fetus) face many risks, with or without treatment.
-Consider Risks/ benefits on a case by case basis
-Major precautions should taken
-Estrogen changes during childbearing increase depression
-Fetal effects may occur with psychotropics
e.g. congenital malformations, fetal abnormalities, fetal withdrawal symptoms etc.

Question 15

Treating depression during pregnancy and lactation.

Answer 15

-No firm guidelines that can be generalized for this population
-Assess risks and benefits case by case
-Psychotherapy is a good option for mild depression
-Antidepressant use may outweigh the risks
-Treatment is encouraged for high-risk patients

Question 16

Presribing guidelines during pregnancy and lactation.

Answer 16

Identify concerns
Consultation is recommended
PMHNPs should not make the decisions for the woman
A mentally competent woman should make the decision about treatment

Question 17

Role of the PMHNP during pregnancy and lactation years.

Answer 17

The roles of PMHNPs may include:
To provide as much information as possible for the woman and partner
Drug Information must be evidence-based
Support the woman/partner in the decision making process
Support the woman’s final decision

Question 18

Prescribing for the fertile woman pre-pregnancy

Answer 18

Baseline information about the woman
Medication choice may be adjusted depending on the woman’s wishes
Choosing a safer drug
Medical evaluation

Question 19

Prescribing for the woman that wants to become pregnant. The roles of PMHNPs may include:

Answer 19

-Obtain baseline information
-Try a period of medication discontinuation
-Choosing medications with faster half-life
-Discuss pros and cons of medications
-Address potential complications that could arise
-Discuss the effects of not prescribing any medications
-Assess for any potential habits/behaviors
-Detailed documentation is important
-Careful considerations during first trimester.
-Consider non-pharmacological interventions
-Consider electro convulsant therapy (ECT)
-Use lower doses if needed
-Involve partner as necessary
-Avoid polypharmacy
-Avoid high risk medications

Question 20

Current Pregnancy and Lactation Labeling

Answer 20

Narrative
Risk Summary
Clinical Considerations
Data
No longer using A,B,C,D,X

Question 21

Treating depression during pregnancy

Answer 21

Consider certain TCAs and SSRIs
Avoid prescribing Paroxetine (Paxil)
Consider ECT
Hospitalization

Question 22

Treating anxiety during pregnancy and lactation.

Answer 22

-Treat with non-pharmacological methods (e.g. psychotherapy)
-If necessary, benzodiazepines may be used
-Avoid benzodiazepines during the first trimester due to cleft anomalies in babies
-Clonazepam may be a good choice
-Gradual discontinuation is required

Question 23

Treating bipolar during pregnancy and Lactation.

Answer 23

-Emphasize effects of mood stabilizers
-Avoid fetus exposure to mood stabilizers in first trimester
-Exposure to Lithium in first semester can lead to Ebstein’s anomaly
-Lithium, Carbamazepine and Valproic acid must be avoided in first trimester
-High risk of fetal malformations such as spina bifida and neural tube defects
-If necessary, they may be used in second and third trimesters
-Folate supplementation is recommended
-Frequent monitoring is required
-Limited data available with Lamotrigine and Topiramate

Question 24

Treating psychotic disorders during pregnancy and lactation:

Answer 24

-Several antipsychotics have not been studied. But the potential benefits outweigh the risks.
-Typical antipsychotics are recommended (e.g. Haloperidol, Chlorpromazine and Trifluoperazine)
-Olanzapine, quetiapine, risperidone, clozapine associated with low weight babies and abortion
-According to the FDA, Clozapine has the lowest risk to the fetus
-Atypical antipsychotics have been linked to gestational diabetes

Question 25

Considerations during the Post-partum period:

Answer 25

Monitor for signs of post partum depression/psychosis
If mood stabilizers were discontinued during pregnancy, re-start medications
All psychotropic medications enter the breast milk
High risk time for women d/t large drop in estrogen levels
Assess for prior history of depression
High incidence of “baby blues”
Moderate to low incidence of depressive or psychotic episodes

Question 26

Prescribing antidepressants during post-partum period

Answer 26

Antidepressants may be used
Sertraline and Paroxetine are desired choices
Avoid Fluoxetine
Limited data available on other antidepressants
Many newer antidepressants have case reports demonstrating safety
Low-dose monotherapy, is the safest approach

Question 27

Untreated depression risks:

Answer 27

-Suicide/infanticide
-Malnutrition
-Poor infant care, neglect
-Neonatal irritability
-Poor bonding/attachment
-Possible increased risk for maternal substance abuse

Question 28

Prescribing anti-anxiety drugs during post-partum period.

Answer 28

Consider risk/benefits:
-Increased incidence during pregnancy rather than post-partum
-Use of antidepressants vs. benzodiazepines

Benzodiazepines
-Diazepam can cause oral defects
-Lorazepam and clonazepam are safer
-Neonatal withdrawal syndrome common-taper medication prior to delivery

Lactation Case Reports:
Reports of sedation, hypotonia, withdrawal after stopping breastfeeding

Question 29

Mood stabilizer prescribing in the post-partum period.

Answer 29

Treatment may be required for bipolar disorder
Several mood stabilizers have been linked to potential complications
Carbamazepine has been associated with liver problems
Valproic acid may be a safer option
Lithium is contraindicated d/t cardiac effects: Epstein’s anomaly
Depakote and Tegretol can cause neural tube defects
Can supplement with folate and Vit K
Use of antipsychotics is recommended rather than these agent

Question 30

Prescribing antipsychotics during the post-partum period.

Answer 30

-Consider risk/benefits
-Typical antipsychotics have been used
-Olanzapine and Risperidone may be used
-Clozapine is contraindicated
-Risk for teratogenicity high in the first trimester
-May want to taper prior to delivery
-High-potency formulations minimize side effects

Question 31

Assessing risk vs. Benefit ratio in pregnancy and lactation.

Answer 31

Case report evidence:
– Up to 1/3 or women receive psychotropics during pregnancy
– Non-pharmacologic interventions should be the first line of treatment
– If off medications for pregnancy-may start prophylactic treatment if post-partum relapse
– Some medications should be tapered 3 weeks prior to delivery to prevent withdrawal in newborn

Lactation:
– Less protein bound and more lipid-soluble-more likely to pass into breast milk

Question 32

Risk of psychopharmacology during pregnancy and Lactation:

Answer 32

• Spontaneous abortion or premature labor
  – Toxicity or withdrawal symptoms in neonate
  – Alterations in physiology of mother
  – Morphological teratogenicity
  – Behavioral teratogenicity
  -Risks are weighed with the untreated mental illness risks