Psychiatric Disorders and Treatment in Pregnancy and PostPartum

1. Psychiatric Disorders and Treatment in Pregnancy and PostPartum Emily Boothe, DO Psychiatrist The Behavioral Health Pavilion of the Virginias Bluefield, WV Adjunct Clinic Faculty Wake Forest Department of Psychiatry Winston Salem, NC

2. PMADs = Perinatal Mood and Anxiety Disorders • Why we need to know about it • 10-15% of women experience PPD, and 50% of their partners may also have PPD • Depression is the most common complication of pregnancy and the postpartum! • This can be a fatal illness. And can certainly be debilitating. • Underdiagnosed and undertreated • Why we aren’t catching it • Stigma • Myth that pregnancy/postpartum is a protected time in a woman’s life • Mistaken for normal mood changes in pregnancy

3. PMADs = Perinatal Mood and Anxiety Disorders • Risk factors • History of mental illness, personal or family • History of PMS or PMDD • Substance use • Lower socioeconomic status • Poor social support • Trauma history • Complications in prior or current pregnancy

4. Depression in pregnancy • Around 10% of women • Persistent depressed mood or persistent anxiety as opposed to typical mood lability that does not persist and is more common in first trimester • Fatigue that is not improved with sleep • Anxious thoughts without a balance of excitement • Disconnected from pregnancy • Poor appetite

5. “Baby Blues” vs Postpartum Depression • Onset of “baby blues” is rapid and resolves quickly • Sleep deprivation? • Major hormonal shift within 48 hours of giving birth • Postpartum depression may develop quickly or come later – even 6 months postpartum and beyond

6. Postpartum Depression • Persistent depressed mood • Anxiety, panic, guilt • Feeling disconnected from the baby • Sleep difficulties – not sleeping even when baby is sleeping • Difficulty with concentration or focus • Grief of ”lost” time • Suicidal thoughts • Poor appetite • Often starts during the pregnancy, can start quickly or later postpartum. May be triggered by cessation of breastfeeding or starting birth control. • Mothers or partners often do not recognize these symptoms as PPD

7. Postpartum Anxiety and OCD • Postpartum Anxiety • Persistent anxiety about the wellbeing of the baby • Persistent anxiety about being a good enough parent • Sleep difficulties – cannot sleep when baby is sleeping • Intrusive thoughts/ruminations • Panic episodes • Postpartum OCD • Intrusive thoughts/obsessions • Usually morbid thoughts of baby being hurt or injured. These are ego-dystonic

8. Screening tools • Edinburgh Postnatal Depression Screen • 10 items • Not somatically focused • Great tool both during and after pregnancy

9. Treatment • Therapy • First line treatment for mild to moderate depression or anxiety • Behavioral Management • Make sure parent is getting enough sleep • Increase support as available • Check on nutrition and activity status • Medication management • Risk vs Benefit • Minimize polypharmacy/multiple exposures if possible • Use what works if possible • Use the minimum effective dose • Worst case scenario = exposure without benefit • Dose increases in second trimester may be necessary

10. Medication Management • Risk vs Benefit Discussion • Randomized double blind studies are not used in pregnant women. Studies are often small and have many confounding variables. We don’t know anything for certain. • Risks of untreated depression or anxiety in pregnancy • Increased risk of low birth weight babies and preterm birth • Risk of neuropsychiatric complications in offspring • Risk of further psychiatric decompensation • Risk of decreased nutrition, self-care • Risk of substance use in pregnancy • Risks of using psychotropic medications in pregnancy • Increased risk of low birth weight babies and preterm birth • Malformation risk with some medications • Possibly increased risk of spontaneous abortionwith some medications

11. Great References

12. SRI’s in pregnancy • Most data collected on these medications in pregnancy • No apparent increased relative risk of malformation and no trend in malformations observed • Sertraline utilizes greater number of cytochrome P450 enzymes • Paxil • Risk for cardiac malformation • Risk for withdrawal syndrome • Tachypnea, tremor, sleep disturbance, GI disturbance

13. Benzodiazepines • Data is variable and limited: some showing no increased risk of congenital malformations and others suggesting this risk is increased • Case reports of overdose on benzodiazepines not causing harm in baby • Risk for NAS • Consider alternative treatments for anxiety, but also consider use if necessary

14. Bipolar disorder and Schizophrenia in pregnancy • Preconception counseling • Increased fertility rates partially due to more medication options that do not cause persistent hyperprolactinemia • Consider increased folate supplementation prior to and during pregnancy • Therapy • Medications: use what works at lowest effective dose, avoid polypharmacy • High risk of mood episode/psychosis during pregnancy • More likely to have other co-morbid psychiatric or medical problems; more likely to have significant poor health behaviors • Both especially in women with schizophrenia • Risk of pregnancy denial in women with schizophrenia • Risk of poor outcomes particularly in women with schizophrenia irrespective of the medication • Increased risk of postpartum psychosis

15. Postpartum Psychosis • Irritability, paranoia, sleeplessness, mania, disorganized thoughts • Develops rapidly • Psychiatric emergency • Risk for suicide and infanticide • Preventable tragedy • Treatment • Treat underlying disorder – is it depression, bipolar disorder, or psychotic disorder • Sleep • Support

16. Mood stabilizers and antipsychotics in pregnancy • Use what works if possible at the lowest effective dose • Some sources advise those TTC and pregnant taking higher doses of folate • Mood stabilizers • More data in regards to treating seizure disorders • Lithium –Ebstein’s anomaly 0.05-0.1% • Lamotrigine – lower rates of malformation • Carbamazepine – facial abnormalities, reduced birth rate • Valproate – highest rate of malformations • Antipsychotics • Less data, many confounding variables related to poor maternal health • Risk of metabolic syndrome, gestational diabetes – increased monitoring • Malformation risk may be low, risk of effect on birth weight, motor problems • Olanzapine has highest placental passage

17. Lactation • SSRIs or SNRIs • Sertraline has very little passage through breastmilk • Fluoxetine and Citalopram have greater concentrations in breastmilk • Benzodiazepines • Considered compatible for breastfeeding • Monitor closely; consider short-acting • Mood stabilizers • Lithium - pumping and dumping at peak levels recommended • LMT – monitor closely; dose reduction needed immediately postpartum due to increased levels • VPA – little passage • Oxcarbazepine and Carbamazepine – data limited; Carbamazepine better safety profile • Antipsychotics • Data limited • Quetiapine and Olanzapine considered safe

18. References • Beck CT. Predictors of postpartum depression: an update. Nursing Research. 2001; 50:275–85 • Blom EA, et al. Perinatal complications increase the risk of postpartum depression. The Generation R Study. BJOG. 2010; 117:1390–8. • Einarson TR and Einarson A. Newer antidepressants in pregnancy and rates of major malformations: a meta-analysis of prospective comparative studies. Pharmacoepidemiology and Drug Safety. 2005; 14: 823–827. • Gaynes BNGN, Meltzer-Brody S, Lohr KN, Swinson T, Gartlehner G, Brody S, Miller WC (2005) Perinatal depression: prevalence, screening accuracy, and screening outcomes. Summary, Evidence Report/Technology Assessment No. 119. AHRQ Publication No. 05-E006-1. • Grote NK, Bridge JA, Gavin AR, Melville JL, Iyengar S, Katon WJ (2010) A Meta-analysis of Depression During Pregnancy and the Risk of Preterm Birth, Low Birth Weight, and Intrauterine Growth Restriction. Arch Gen Psychiatry 67(10): 1012–1024. • Galbally, Snellen, Lewis. Psychopharmacology and Pregnancy: Treatment Efficacy, Risks, and Guidelines. Springer. New York. 2014. Print. • Rahimi R, Nikfar S, Abdollahi M. Pregnancy outcomes following exposure to serotonin reuptake inhibitors: a meta-analysis of clinical trials. Science Direct. Reproductive Toxicology. 2006; 22:571–575. • Kronenfeld N, Berlin M, Shaniv D, Berkovitch M. Use of Psychotropic Medications on Breastfeeding Women. Birth Defects Research. 2017; 109:957–997. • PacchiarottiI, Leon-Caballero J,MurruA,VerdoliniN,FurioMA,PancheriC,ValentiM, Samalin L, Roige ES, Gonzalez-Pinto A, Montes JM, Benebarre A, Crespo JM, de Dios Perrino C, Goikolea JM, Gutierrez-Rojas L, Carvalho AF, Vieta E. Mood stabilizers and antipsychotics during breastfeeding: Focus on bipolar disorder. European Neuropsychopharmacology. 2016 ; 26(10):1562 – 1578.