Management of postpartum mood disorder

1. Management of postpartum mood disorder HalaSalah Lecturer of psychiatry

2. Postpartum Mood Disorders:Educational Interventions • Prenatal Classes • Newspaper articles • Community lectures • Family involvement in the educational process • Routine prenatal screening

3. Prevention of postpartum mood disorder -Exercise -Diet: Omega 3 Protein Hydration Vit. (B) -Plan -For women with histories of postpartum depression consider prophylactic antidepressants - For those who were treated during pregnancy

4. Management of baby blues • Rest • Proper nutrition • Help with infant and household responsibilities • Family and friends support systems • Avoidance of isolation

5. Management of PPD

6. To breast fed or not? • Type of illness (bipolar) • Severity • Medications needed • Infant issues

7. Individual patient approach is needed Quality of mother’s life Risks of drug-induced toxicity in breast-fed infant Benefits of breast feeding Precious baby

8. Treatment of PP mood disorders Psychotropics Social Support Psychotherapy ECT

9. Treatment • Psychosocial therapies • First choice for those with mild to moderate symptoms of PPD • Cognitive-behavioral therapy • Interpersonal psychotherapy- focuses on patient’s interpersonal relationship and changing roles

10. Group therapy • Helps to increase support network • Family and marital therapy • More rapid recovery • More appreciative of partner’s contribution • Peer-support groups

11. Pharmacokinetics of psychotropics in breast milk • Four factors are needed in order to understand problems related to breast-feeding by mothers taking psychotropic medication: • the prescribed dose; • the level of the drug in the mother’s blood plasma; • the level in the breast milk; • and the levels in the infant’s serum.

12. Other factors • Medication’s diffusion across membranes, Molecular weight and its lipophilicity. • The timing of the dose in relation to the infant’s feeding patterns. • Drug’s dosage and frequency, its pharmacodynamics and pharmacokinetics.

13. Factors affecting excretion in breast milk Maternal / Infant / Drug • Maternal: • Drug dosage and duration of therapy • Route and frequency of administration • Metabolism • Renal clearance • Blood flow to the breasts • Milk pH and composition

14. Factors affecting excretion in breast milk Maternal/ Infant / Drug • Infant: • Age of the infant • -preterm • - full term 3w • 8-12w • Feeding pattern • Amount of breast milk consumed • Drug absorption, distribution, metabolism and elimination

15. Most drugs are transferred into milk by the passive diffusion processes and hence maternal drug . • Active or carrier-mediated transport occurs for some. • Drugs must pass from the maternal plasma, through the capillary walls, into the alveolar cells lining milk duct. • During the first few days of life there are large gaps between these alveolar cells, which allow most molecules to cross through easily.

16. For psychotropics the arbitrary concentration in the infant’s plasma of 10% of the established therapeutic maternal dose is used as the upper threshold where the risks of a particular drug’s side-effects are low and treatment is accepted as safe

17. The follow-up of infants exposed to psychotropic medication • The newborn’s health should be taken into consideration when planning breast-feeding • Preterm immature infants should not be exposed to psychotropics • Infants’ hepatic, renal and cardiac functions should be checked before they are breast-fed by mothers on psychotropic medication

18. Infants older than 10 weeks are at a lower risk for adverse effects of tricyclics and there is no evidence of accumulation in the infant • The newborn should be examined regularly for any possible adverse events of medication • All professionals involved in the care of the infant should be informed of psychotropic medication usage

19. Pharmacologic Therapy • Increase risk of suicide after initiation of medication • If significant anxiety or insomnia present, consider adding benzodiazepine • Close follow-up

20. Treatment of PPDAntidepressants SSRI • SSRI preferred initially. • Drug levels are low to undetectable. • All effective in open trials (Moretti, 2009). • SSRIs such as fluoxetine, sertraline, paroxetine and citalopram are safe during breast-feeding (Berle, 2004). • Sertraline is considered as first line in USA (Altshuler et al. (2001).

21. Tricyclic • Tricyclics have a less favorable side effect profile and a much higher risk of morbidity and mortality from overdose. • However, it is relatively safer and low levels of drugs are secreted for most tricyclics. • Tricyclics such as amitryptyline, imipramine, nortriptyline and clomipramine are safe during breast-feeding (Becker, 2009). • Doxepin is contraindicated (respiratory depression).

22. Trazodone • Trazodone appears to be of lower risk because only 1% passes into the milk, although drowsiness and poor feeding have been reported. Data are limited to a few cases and caution is advised in use of the drug.

23. Mirtazapine - It has been mentioned in certain studies that Mirtazapine can be used as first-line treatment and, because of its action on histamine H1 receptors, may be preferred in some patients with postnatal depression, when night-time sedation is required (Snellen, 2007)

24. Venlafaxine, bupropion • Venlafaxine is considered safe (Snellen, 2007). • Bupropion: Few studies found no adverse effects (in one case, it lead to occurance of seizure in the new born) (Becker, 2009).

25. Antipsychotics and breast-feeding • Conventional antipsychotics have been used for decades and the accumulated data show that they are safe during breast-feeding (Phenothiazines may increase risk of SIDS). • New information is starting to emerge about some atypical antipsychotics such as olanzapine and risperidone but their safety has yet to be established (Moreeti,2009)

26. There is currently no information on quetiapine and amisulpride and therefore it is not safe to expose newborns to these medications • Clozapine accumulates in breast milk and is contraindicated during breast-feeding

27. Mood stabilizers during breast-feeding • Lithium is contraindicated during breast-feeding (high serum level, but 3 studies recommended its use with caution if no other options available. (Hale , 2004) • There is little evidence of adverse events in infants breast-fed by mothers taking carbamazepine or sodium valproate, although transient hepatic toxicity is possible with the former (Moretti, 2009) • Lamotrigine is considered moderately safe in practice (But with high serum level in infant-be careful of risk of Steven Johnson syndrome) (Becker, 2009).

28. hypnotics and anxiolytics during breast-feeding • It is unsafe to expose infants to repeated doses of long-acting benzodiazepines • Shorter acting agents such as oxazepam, alprazolam and lorazepam are preferred by most authors (Becker, 2009). It must be used for short term. • Buspirone, zaleplon and zopiclone are better avoided because of limited safety data on their use.

29. PPP Treatment • Psychiatric emergency! Inpatient treatment • Mood stabilizers • Antipsychotics • Benzodiazepines • Lithium prophylaxis • Electroconvulsive therapy

30. Take home message • The decision to prescribe antipsychotics to breast-feeding women should depend on individual risk/benefit analysis • The current available research does not allow any absolute and clear recommendation because much of the work on psychotropic medication in breast-feeding is limited to single case reports, small series and naturalistic data collection • Causes and consequences of different adverse events are not yet widely studied

31. References • Berle J.O. The challenges of motherhood and mental health. World Psychiatry. 2004;3(2):p101–102. • Becker M.A, Mayor G.F, Elisabeth J.S. Psychotropic Medications and Breastfeeding. Primary Psychiatry. 2009;16(3):p42–51

32. -Hale T.W. Drug Therapy and Breastfeeding: Antidepressants, Antipsychotics, Antimanics, and Sedatives. Neo Reviews. 2004;5(10):e451. -Moretti M.E. Psychotropic Drugs in Lactation. Can J Clin Pharmacol. 2009;16(1):p e49–e57. -Snellen M, Galbally M, Udechuku A, Spalding G, Munro C, Drinkwater P. Psychotropic Medication in Pregnancy/Lactation. Revised 2nd Edition. Mercy Health & Aged Care: Melbourne; 2007. Pharmacy Department Mercy Hospital for Women. October 2007

33. Thank you