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General approach to treating women during pregnancy and lactation

By Vivien K Burt, MD, PhD (bio)

Professor Emeritus of Psychiatry, The David Geffen School of Medicine, University of California at Los Angeles

Founder and Co-Director, The Women’s Life Center, Resnick UCLA Neuropsychiatric Hospital 


On this page, I will discuss a general approach to how non-specialist mental health clinicians may think about treating pregnant and lactating women. Other articles on this website related to specific aspects of treating mental health problems during pregnancy and lactation are linked to under Related Pages below.

Pregnant depressed woman


Important for ALL clinicians who prescribe psychotropic medications

The topic of prescribing psychotropic medications during pregnancy and the postpartum period is important not only for clinicians who specialize in this area but for ALL clinicians who prescribe psychotropic medications. There are several reasons for this.

– Nearly half of all pregnancies are unplanned/ unintended (Finer and Zolna, 2016). This means that women under the care of any clinician could become present.

– The use of psychotropic medications in women of childbearing age is common. For example, in the US, close to 10% of women who are between 20 and 39 years old take an antidepressant medication (Huybrechts et al., 2014).

– Pregnancy and the postpartum are particularly vulnerable times for women with a history of mental health.

For these reasons, ALL mental health clinicians who prescribe medications to women of childbearing age, even to women who are NOT pregnant, should be prepared to address the impact of psychotropic medications on pregnancy and have at least some understanding of how to treat pregnant women with mental disorders.

This puts prescribing clinicians who do not routinely treat pregnant women in a difficult position. It is extremely difficult for them to stay up-to-date on the potential risks to pregnant women and their babies of all the psychotropic medications they prescribe just in case one of their patients becomes pregnant.

Misinformation spread by the print media, TV, and the internet about psychotropic medications during pregnancy or the postpartum only makes the problem worse for all concerned.


On this page and elsewhere on this website, we will provide advice and important information to mental health clinicians who are not specialists in perinatal psychiatry and who do not routinely treat women who are pregnant or lactating.


Two key general principles

Maternal mental health affects others too

An important general principle for treating clinicians to remember is that when treating women during the perinatal period, the goal should be to prioritize maternal mental health. This is important not only to ensure maternal stability and but also to optimize the health of the newborn and of other family members, especially young children in the family.

Perceived risk and treatment preferences

Another general principle that is important to remember is that patient preference is a particularly important consideration when treating perinatal mental disorders. No two women are the same, and any report of a possible adverse outcome, even if the data is limited and flawed, may be perceived as acceptable by one patient and unacceptable by another.


Three treatment models

Option A

The non-specialist mental health clinician can refer the patient to a perinatal psychiatrist for management during pregnancy and in the postpartum period. After that, the patient can return to the original clinician for follow up.

Option B

Another option is for the non-specialist mental health clinician to refer the patient to a perinatal psychiatrist for a consultation including evaluation and treatment recommendations specific for that particular patient. A high-quality consultation from a perinatal psychiatrist should include the options regarding medications, justifications for each option, and at least some reference to data supporting each option.

The non-specialist mental health clinician can then discuss the recommended treatment options with the patient and proceed to manage the patient in accordance with the recommendations of the perinatal psychiatrist.

If possible, the patient should check in with the perinatal psychiatrist at least once in each trimester and once after delivery.

In addition, the perinatal psychiatrist may be consulted on an as-needed basis throughout the pregnancy and in the postpartum period.

Option C

Frequently, neither Option A (management by a perinatal psychiatrist throughout pregnancy and the postpartum ) nor Option B (consultation with a perinatal psychiatrist followed by collaborative treatment) is possible due to financial or geographical constraints.

Mental health clinicians who treat women of childbearing age who are likely to be in such a situation should learn about managing mental disorders during pregnancy and the postpartum on their own. Importantly, they should know where to be able to look up the most up-to-date information about a particular medication when needed.


Resources

Non-specialist mental health clinicians should start by knowing the following top priority things:

– Which psychotropic medications are known to be teratogenic

– Where to look up up-to-date information about the safety of various psychotropic medications during pregnancy and lactation. For resources on this, please see the following two pages on this website:

Pregnancy and psychotropic medications: Online resources

Lactation and psychotropic medications: Resources

You can also look at this publication from my colleagues and me:

Burt VK, Rasminsky S, Murphy-Barzilay E, Suri R. Caring for special populations: Women. In: The American Psychiatric Association Publishing Textbook of Psychiatry, Seventh edition (2019). Eds: Roberts LW, Hales RE, Yudofsky SC.


Related Pages

Bright light therapy for depressive disorders during pregnancy?

Repetitive transcranial magnetic stimulation (rTMS) for depressive disorders during pregnancy?

Pregnancy and psychotropic medications: Online resources

Lactation and psychotropic medications: Resources

Pregnancy registries

Are you about to prescribe a medication that could lead to unwanted pregnancy?

Tips on using lithium during pregnancy

Is the use of lamotrigine during pregnancy safe?

Serious dangers to avoid if it is essential to physically restrain a pregnant woman

Pregnancy and psychotropic medications: Online resources

Lactation and psychotropic medications: Resources


References

Burt VK, Rasminsky S, Murphy-Barzilay E, Suri R. Caring for special populations: Women. In: The American Psychiatric Association Publishing Textbook of Psychiatry, Seventh edition (2019). Eds: Roberts LW, Hales RE, Yudofsky SC.

Finer LB, Zolna MR. Declines in Unintended Pregnancy in the United States, 2008-2011. N Engl J Med. 2016 Mar 3;374(9):843-52. doi: 10.1056/NEJMsa1506575. PubMed PMID: 26962904; PubMed Central PMCID: PMC4861155.

Huybrechts KF, Palmsten K, Avorn J, Cohen LS, Holmes LB, Franklin JM, Mogun H, Levin R, Kowal M, Setoguchi S, Hernández-Díaz S. Antidepressant use in pregnancy and the risk of cardiac defects. N Engl J Med. 2014 Jun 19;370(25):2397-407. doi: 10.1056/NEJMoa1312828. PubMed PMID: 24941178; PubMed Central PMCID: PMC4062924.


Copyright © 2019, Simple and Practical Medical Education, LLC. All rights reserved. May not be reproduced in any form without express written permission.

Disclaimer: The content on this website is provided as general education for medical professionals. It is not intended or recommended for patients or other laypersons or as a substitute for medical advice, diagnosis, or treatment. Patients must always consult a qualified health care professional regarding their diagnosis and treatment. Healthcare professionals should always check this website for the most recently updated information.

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