Prescribing Psychiatric Medications in Pregnant and Breastfeeding Women

Two comprehensive reviews in the Indian Journal of Psychiatry looked at the use of pharmacologic therapy for psychiatric conditions during pregnancy and lactation. One review looked at mood stabilizers and the other focused on antidepressants, anxiolytics, and hypnotics.

Both reviews are exhaustive and valuable for psychiatrists, looking at entire categories of pharmacologic therapies. The collected studies were conducted in pregnant women and women who were lactating, and examined the potential impacts on children of mothers who are breastfeeding.

This is a growing clinical challenge, both studies pointed out, particularly as the number of pregnancies in women with more severe and chronic mental disorders continues to grow. Untreated perinatal depression and anxiety disorders are known to have significant negative impact on both maternal and fetal health. Yet, definitive answers on the safety and effectiveness of a wide range of psychiatric treatments is scarce.

“For obvious ethical reasons, it is not possible to conduct randomized placebo controlled studies on medication safety in pregnant and lactating women,” notde the authors of the mood stabilizers review. Thus, most of the information known about the reproductive safety of drugs is derived from case reports, case series, and retrospective studies.

The common theme through both studies is a lack of strong clinical evidence on the impacts of even heavily prescribed medications, such as lithium, topiramate, gabapentin, risperidone, diazepam, monoamine oxidase inhibitors, bupropion, and selective serotonin reuptake inhibitors (SSRIs), among many others. While SSRIs have been the most researched antidepressants in pregnancy and lactation, “The available literature is criticized mostly on the lack of rigorous well designed controlled studies as well as lacunae in the methodologies, interpretation of statistical information, knowledge transfer, and translation of information,” the authors wrote in the antidepressant study.

The study on mood stabilizers elucidated a poignant ethical dilemma. Noting the widely accepted and numerous benefits of breastfeeding to both mother and child, the reviewers pointed out the difficulties associated with continuing breastfeeding while taking psychiatric medications. The authors noted a number of potential concerns, including the fact that compared to adults, kidneys of newborn are functionally immature; hence the psychotropic medications that are predominately eliminated through kidney may accumulate.

“Ideally, a risk benefit analysis should be carried out taking into consideration the physiological and psychological benefits of breastfeeding; the potential adverse effect of untreated maternal mental illness on the infant and maternal child bonding; impact of psychotropic medication on the cognitive and behavioral development of the infant, and the consequences of untreated mental illness on the mother,” the reviewers explained.

Both reviews shared the conclusion that the decision to prescribe medications during pregnancy should be taken in light of severity of mental disease and drugs should be prescribed only when the potential risk to the fetus from exposure to medication is outweighed by the risk of untreated maternal disorder.

“Appropriate risk-benefit analysis of untreated mental illness versus medication exposure, tailor-made to each patient's past response and preference within in the context of the available evidence should guide clinical decision making,” the mood stabilizer reviewers wrote.

“A pregnant patient with comorbid mental illness would require a careful evaluation of the risk-benefit assessment of psychotropic drug exposure leading to maternal benefit versus fetal harm and vice versa,” the authors of the antidepressant review concluded. “The available evidence both during pregnancy and lactation does not report gross harm due to drug exposure in pooled data and provides some cautions concerning safety of use of some molecules.”