Dr. Gise is Clinical Professor, Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii and Staff Psychiatrist, Maui Community Mental Health Center. Dr. Gise has disclosed that she is on the medical advisory board of Medco Health Solutions, a pharmacy benefits manager. She has no significant relationships with or financial interests in any pharmaceutical company.
Over the last several years, we’ve all seen many FDA warnings and cautionary letters from drug companies about the effects of psychotropics in pregnancy. As a result, it’s easy to become a little skittish about prescribing any medication for pregnant women.
I have worked in the field of women’s mental health for more than 25 years, and over this time I have developed certain common-sense practices that have served most of my patients well.
Assess the possibility that your patient is pregnant. When presented with a distressed patient, we don’t always think of the risk of pregnancy. But half of pregnancies are unintended, so we must assess the risk of pregnancy for all women of childbearing age. For example: Is she trying to get pregnant? Is she doing anything not to get pregnant? Did she have her tubes tied? This gives us the opportunity to discuss psychotropics before pregnancy or when psychotropics are first prescribed.
Every patient requires an individual risk/benefit analysis. No psychotropics are safe in pregnancy, so I never use the word “safe.” None have been tested or approved by the Food and Drug Administration for use during pregnancy, and the FDA ratings are not useful because they are based on missing data. What I talk about is which medications we have more experience with and the rates of problems that have been reported. I also inform my patients that untreated psychiatric problems pose their own risks to fetal well-being, and that this must be balanced against the risks of medications.
Try to avoid any medications during the first trimester of pregnancy. During the first 13 weeks of pregnancy, the major organs systems are actively growing and differentiating, and the risk of malformations is highest. So I try to avoid prescribing any medication during this period. If insomnia is a problem, I discuss sleep hygiene with my patients and hand them a list of practices such as using the bed only for sleep, going to sleep at the same time each night, avoiding stimulating foods and beverages before bedtime, using relaxation exercises, etc. For depression or anxiety, I recommend psychotherapy, especially problem-focused techniques such as cognitive behavioral therapy or interpersonal therapy.
My favorite medication for depression or anxiety in pregnancy is sertraline (Zoloft). But pregnancy is not a time to experiment. So if a woman is stable on an antidepressant, I consider keeping her on it. We have the most data on sertraline, in both pregnancy and breastfeeding, and for this reason it is often my first choice when medication is needed (for an excellent review, see Wisner KL et al., Am J Psychiatry 2000;157(12)1933-1940). Fluoxetine (Prozac) has been taken by more women in pregnancy, but fluoxetine’s long half-life is a disadvantage. First, with unintended pregnancy, if a woman decides to discontinue fluoxetine, the drug and its active metabolites will stay in the bloodstream for up to five weeks, while sertraline will be gone within 5 days. Second, for planned pregnancies, if we decide to taper before delivery to avoid neonatal withdrawal (see below), fluoxetine presents the same long half-life difficulty.
Nortriptyline is also on my short list of preferred medications, simply because we have 50 years of experience with it with no reports of teratogenicity. I prescribe it in low doses of 12.5 mg to 25 mg QHS for sleep or in higher doses (50 mg to 75 mg QD) for anxiety and depression.
If a patient on medication discovers that she is pregnant, I always try to reduce the dose of the medication. While I acknowledge that lowering the dose of medication risks triggering relapse, I would prefer to expose the fetus to the lowest level of a medication that is consistent with keeping my patient well. Often, over the course of this taper, we find that the patient can discontinue medication entirely, which is the best possible outcome.
I recommend continuing SSRIs until delivery. In 2005, the FDA required that all antidepressant makers insert a warning about the risk of a neonatal withdrawal syndrome of respiratory distress, jitteriness, and irritability. Since then, many patients have asked me if they should discontinue their medications one to two weeks before their due dates. I don’t recommend this. I point out to patients that the symptoms are rarely serious, and that affected babies inevitably do fine once they go home. On the other hand, if the mother suffers a depressive relapse around delivery, she may develop full-blown postpartum depression, which can have drastic consequences for the baby’s earliest experiences.
My Plan A for all patients on medications is to not breastfeed; Plan B is to use sertraline (Zoloft) over other antidepressants. Yes, breastfeeding is valuable, in terms of both optimal nutrition and mother-child bonding. But, particularly during the first month of life, medications in breast milk can pose unknown risks to an immature and developing brain. Furthermore, an immature liver and kidneys are poorer at eliminating even tiny amounts of medication. I believe these risks outweigh the benefits. For mothers on antidepressants who insist on breastfeeding, sertraline (Zoloft) has the most published data during breastfeeding (Altshuler L et al., J Clin Psychiatry 1995;56:243-245).
Breastfeeding should be discussed as soon as pregnancy is discovered, and the decision is whether or not to breastfeed, not whether or not to take medication. If the woman needs medication, she should take it.
Document. Psychotropic medications are both over-prescribed and under-prescribed in pregnancy. Many psychiatrists fear lawsuits and won’t prescribe to pregnant women on that basis alone, although I have never heard of a successful lawsuit over an adverse pregnancy outcome related to psychotropics. The best defense against lawsuits is to have a risks-benefits discussion with the woman and her partner and to document this in the chart.