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

These types of symptoms can lead to stigma feelings of shame and therefore make it hard for a woman to feel comfortable disclosing her symptoms to her doctor, to avoid feeling judged.

The U.S. Preventive Task Force, the American Academy of Pediatrics and the American College of Obstetrics and Gynecology all recommend screening women in the postpartum period for depression. The Edinburgh Postnatal Depression Scale and Postpartum Depression Screening Scale are useful screening tools. The key to detect as many cases of PPD as possible is to have repeated screenings. More than 10% of women who have a negative screen at 4-12 weeks postpartum were found to be high risk 6-12 months later. And it is important to conduct the screening in an open and comfortable way, helping mothers understand that PPD is very common and that it is not the mothers; fault.

The other piece that is important is making sure that women with a positive screen go on to have a complete assessment to determine if they do indeed have PPD and then are linked to appropriate treatment. Many identified cases of PPD end up being lost to follow up because of lack of linkage or, again, the mother’s worry about stigma and judgment. One option that is growing in popularity is co-location of behavioral health in the primary care setting.

It can be scary and confusing to mothers who do not feel depressed early on in the postpartum period to go on to develop symptoms of PPD (depressed mood, lack of interest in activities that they normally enjoyed, constant worry and fatigue, to name a few common ones) later in the postpartum period. But is not uncommon. And it argues the point that it is important to conduct screenings at intervals throughout the postpartum period.

Medication can be an important treatment for antepartum and postpartum depression (PPD), if the symptoms are moderate-severe and/or not responding to non-medication approaches. The selective serotonin reuptake inhibitors (SSRIs) are the first line agents, in particular sertraline because of its relatively short half-life and availability of low doses (can be dosed as low as 12.5 mg per day). Paroxetine is pregnancy category D because of there is evidence that it increases the risk of birth defects, including rare cardiac and CNS effects. While these birth defects are very serious, it is important to keep in mind that they are very rare at baseline and that the increase in absolute risk from SSRI use is very minimal and depends on the SSRI being considered. There is also a possible connection between SSRI use in the third trimester of pregnancy and development of persistent pulmonary hypertension of the newborn in infants. There have been reports of newborns experiencing temporary discontinuation symptoms at birth, including jitteriness and irritability when a woman is treated with antidepressants during pregnancy. Other antidepressants, like the SNRIs and tricyclic antidepressants, are not typically recommended during pregnancy.

The SSRIs are also the first line medication treatment in the postpartum period for patients for whom medication might be indicated. Of the SSRIs, sertraline and paroxetine are the least detectable in breast milk, because of their relatively short half-lives. Several case reports note an association between fluoxetine and citalopram use in lactating women and infant irritability, poor sleep, poor feeding, crying, and restlessness. This might be related to these medications’ relatively longer half-life. Other case reports have not noted any adverse effects in infants of mothers taking fluoxetine and citalopram.  If one is considering treating PPD with a medication, sertraline is a good first line agent because of its relatively shorter half-life and ability to dose in smaller doses, as low as 12.5 mg per day. The peak level of sertraline in breast milk is between 7-10 hours after taking the medication, which can be kept in mind to determine the optimal time for the patient to take the medication. If a woman is already on an antidepressant like fluoxetine with a good response, it is okay to continue with the medication and monitor closely for side effects in the mother and infant.

The important take home point for treating depression related to pregnancy is to first consider a non-medication treatment. If it is determined medication is needed, it is important to have a careful discussion about the risks and benefits and to try to use the smallest possible dose for the shortest length of time, with sertraline being a good first choice for both the antepartum and postpartum period. 

Website: www.pc2education.org

Postpartum Blues: Symptoms of mood lability, irritable mood, interpersonal hypersensitivity and tearfulness are common in the postpartum period and are commonly known as the postpartum “blues”. The incidence is up to 75% and the symptoms typically arise and resolve within 7-14 days after the delivery.

The following conditions are of more concern: depression during pregnancy (known as antepartum depression), postpartum depression (PPD) and postpartum psychosis.

Antepartum depression: The prevalence of depression during pregnancy ranges from 10-15% and it may persist into the first postpartum year. Depression during pregnancy is linked to birth complications like pre-eclampsia, low birth weight, premature delivery, and small for gestational age infants.

Postpartum depression: The prevalence of PPD is 10-15%. The postpartum year is one of the highest risk periods for first-onset depression for women with approximately 50% of women experiencing their first episode of depression during that time. In addition 25% of women with a history of Major Depressive Disorder will experience PPD and 50% of women who have had PPD will have a recurrence. The Edinburgh Postnatal Depression Scale and Postpartum Depression Screening Scale are useful screening tools. In addition to depressive symptoms, women with PPD typically also present with prominent anxiety symptoms that involve distressing and intrusive thoughts about infant safety and feelings of guilt and inadequacy about mothering. Infants of depressed mothers have been found to be less responsive and more irritable than infants of non-depressed mothers. Infants of depressed mothers are also more likely to develop an insecure attachment because of (unintentional) maternal rejection of the baby. If one suspects PPD it is important to rule out medical conditions, like thyroid dysfunction and iron-deficiency anemia, as these are more common during pregnancy and in the postpartum period.

Postpartum psychosis: Postpartum psychosis is rare and occurs in 1-2 women per 1000. The onset is typically within 2 weeks of delivery. The psychotic symptoms typically accompany affective symptoms of depression and anxiety, rather than represent a psychotic first break. Postpartum psychosis is more common in women who have a history of bipolar disorder. In addition to auditory and visual hallucinations, patients may present with cognitive impairment, confusion, and olfactory and tactile hallucinations. Many mothers are distressed because they experience command hallucinations to harm their infants. If postpartum psychosis is suspected, it is important to seek immediate psychiatric attention and to consider psychiatric hospitalization for the mother for her safety and for the infant’s safety. Antipsychotic medications are helpful for treating postpartum psychosis but it is more appropriate for the treatment to take place in a psychiatric hospital.

Treatment considerations for depression related to pregnancy will be discussed in the next e-Weekly.

Attached are a JAMA article about the timing of symptoms and the  Edinburgh Postnatal Depression Scale (EPDS) screening tool.

http://jamanetwork.com/journals/jamapsychiatry/fullarticle/1666651

https://pc2education.files.wordpress.com/2012/05/edinburghscale.pdf