Psychoactive Drug Treatment
PSYCHIATRIC TREATMENT THROUGH ANTIDEPRESSANTS
Treatment of Pregnant and Lactating Women through ‘Antidepressants’
Treatment of Pregnant and Lactating Women through ‘Antidepressants’
A large number of pregnant women suffer from psychiatric problem at some stage in their pregnancies are treated with psychotropic medicines. Prescribing these medicines to pregnant women is a special concern for the gynecologists and the patients due to the several risks involved; like miscarriages, abortions, premature births and infants with birth defects. Gynecologists need to keep in mind the consequences of prescribing psychiatric medicines to the pregnant and lactating women, chances of exposure to their offspring, effects of not treating the psychiatric illness and the alternative solutions like counseling and therapies. Therefore, use of psychiatric medicines for the treatment of pregnant and lactating mothers is a hot and controversial issue these days. The purpose of writing this paper is to discuss this issue in detail and explore the positive and negative outcomes of using antidepressants during pregnancy and lactation in the light of current evidences provided by experts.
Use of Antidepressants during Pregnancy and Lactation
Experts all around the world are emphasizing on the adverse consequences of taking psychiatric medicines, especially antidepressants, during and after pregnancy. Some of the researchers have claimed the increased risk of birth defects due to the use of such medicines in pregnancy. Contrary to this, the experts supporting such medicines point out that treating the problems like depression and fear during pregnancy is very necessary and ignoring it can result in miscarriages and premature deliveries. In addition it also creates other complications like low birth weight of the infant, improper care of the new born by the mother, improper diet and breastfeeding by mother and negligence to infant (Taylor, Paton and Kapur, 2009).
Howland (2009) argued that psychiatric drugs which are used to treat anxiety and depression of women are very safe and therefore can be used during and after pregnancy. For instance drugs like benzodiazepine that are used for treating insomnia or anxiety have very little but considerable risk of birth defects. Therefore antidepressant drugs can be used to treat anxiety or insomnia as they do not harm the mother or child. Howland also suggested that instead of giving psychiatric drugs, patients can be treated with psychotherapy which is probably very good alternative to medication. It helps in treating the women suffering from insomnia, depression and anxiety during the pregnancy.
It is very crucial to treat pregnant women suffering from psychiatric illness because leaving them untreated results in severe problems during pregnancy and on child birth (Howland, 2009). Therefore, it is important that the possible risks and consequences should be considered and chose the best possible available treatment for the patient suffering from mental psychiatric problems during the times of pregnancy and lactation.
Effects of Antidepressants
Pregnancy Induced Hypertension
The problem with taking psychiatric medicines during pregnancy like antidepressants is the increase the level of serotonin. This increase results in the high blood pressure of patient that creates further problems. Selective Serotonin Reuptake Inhibitors (SSRIs) are considered to have increased risk of ‘Pregnancy Induced Hypertension’ (PIH) along with the other risk factors like drinking, smoking, over eating and not exercising.
Experiencing Selective Serotonin Reuptake Inhibitors (SSRIs) in the first trimester of pregnancy result in sudden abortions. However, some experts disagree and consider depression as a complex variable which forced women to get aborted in few studies (Udechuku, 2010).
Persistent Pulmonary Hypertension
All antidepressants coming in SSRIs category result in persistent pulmonary hypertension of the new born baby if taken by the mother in the late weeks of pregnancy. This life threatening syndrome is found in very rare cases and 1 to 2 infants in 1000 live birth cases. However, this risk increases to 3 if mothers have taken SSRIs during entire pregnancy (Kieler et al., 2011).
Transfer of Medicine in Infants in Pregnancy
The most adverse effect of psychiatric medications is the transfer of medicines in the infants in pregnancy. The medicines taken by the mother are transferred to the babies through the amniotic fluid and placenta. The amount of medicine transferred through placenta can unfortunately even be equal to the dose taken by the mother. However, the transfer quantity is different in different cases so the best strategy is to prescribe medicines in pregnancy that transfer in little quantity.
A study was performed on 38 pregnant women to find out the ‘In Utero Exposure’ of medicines in infants. These all women were taking psychiatric medicines and the results showed the presence of metabolite and antidepressants in 87% of the umbilical cord samples. The mean of the serum ratios had ranges from 0.29-0.89 (Hendrick, 2003).
The transfer of medicines in infants results in birth defects in generally 3% of the infants from which 0.5 to 1% children have defects in heart. Infants whose mothers were treated with medicines like paroxetine during pregnancy have increased rate of defects i.e. from 2% – 4%. Therefore, high doses of this medicine should be avoided as much as possible during the first few months of pregnancy.
Louik et al. (2007) discussed a study that was performed by the Sloane Epidemiology Centre to find out the effect of SSIRs in pregnancy regarding birth defects. The results of the study showed that the total risk of a child having affected by the SSRIs used by mother is surprisingly only 0.2%. They also noted that increased risk was associated with three types of birth defects; septal defects, omphalocele defects and heart defects. This study confirms that mothers can use SSRIs during pregnancy as they hardly cause any harm to infants.
However, withdrawal of SSRI in the third trimester of pregnancy can cause the “discontinuation” syndrome in new born babies. The symptoms of this syndrome include variation in the temperature, tachypnea, high drug levels and irritability (Oberlander et al., 2004). The positive aspect of these problems is that these are very mild and can be easily handled by providing supportive care. There are rarely any severe symptoms and so far no birth deaths have been reported due to the SSRI exposure to infants during pregnancy. This syndrome is stressful not only for the baby but also for the mother but the symptoms hardly last for 1 or 2 days and do not require additional treatment. These evidences encourage the use of particular psychiatric medicines like SSRIs during pregnancy.
Transfer of Medicine in Infants via Breastfeeding
Infants are not at risk while in their mother’s womb but they can also be affected by the medicines that their mother’s take during breastfeeding period. However, the exposure is very less compared to the case of exposure during pregnancy. There are a number of medicines that transfer in infants in very small quantities.
Weissman et al., (2004) conducted a meta-analysis of 337 research cases and 67 different studies of measuring antidepressant levels in the breastfeeding babies. The researchers accessed data of 15 antidepressants and their metabolites. Weissman et al. (2004) found that antidepressants were present in the milk of all the 15 antidepressants that they studied. The medicine that produced the highest proportion of increased infant levels and maximum mean infant level was Fluoxetine. Other depressants like Citalopram also showed relatively high results. Three infants in these studies were exposed to paroxetine prenatally and only one had increased paroxetine level compare to all other infants with zero levels. Fleoxetine was found to be more accumulating in breastfeeding children compared to the other antidepressants.
The experts also studied the long-term effects on these 15 antidepressants on the growth of these infants. They found out that little or undetectable concentrations of these antidepressants will not effect on the development of brain but the constant low doses of antidepressants can result in any risky situation. In addition, they concluded that studies of asymptomatic children were encouraging. The antenatal exposure of antidepressants through breast milk was different from case to case but the antenatal data results showed very minute or at all no long-term effects on the development of children. They pointed out that it was necessary to know if there was any exposure during the prenatal stage that has exceeded the exposure from mother milk and therefore has altered the findings of the breast milk.
Therefore, women using antidepressants successfully during their pregnancies can continue same medication during lactation instead of changing and trying new medication in this critical time when the patient is internally weak. The amount of medicine transferred to the child through breastfeeding will be less than it was transferred in-utero. Indeed, taking the same drug during breastfeeding might minimize the symptoms in the baby (Taylor, Paton and Kapur, 2009). However, it is important to closely monitor the new mothers and their symptoms of depression, in case if no changes are made to their psychiatric illness medication.
It can be concluded from this paper that gynecologists should investigate about the family history of the patient regarding any psychiatric problem when a woman becomes pregnant or plans to get pregnant. The doctor should then educate and counsel the patient about the antidepressant medication. In case of depression, alternative options like therapies should be used to handle the initial level problem and antidepressants should only be given if the patient suffers from moderate to severe depression.
This paper further concludes that that the use of psychiatric medicines like antidepressants during pregnancy and lactation can be the most perfect and safe choice for treating mental problems. There are very little risks associated with antidepressants compared to the risk of not treating the depression which may cause greater harms. Therefore, it is better to treat the pregnant and lactating women with right psychiatric medication instead of worrying about the effects of antidepressants.
Hendrick, V. (2003). Treatment of postnatal depression. British Medical Journal, 327, 1003-1004.
Howland, R. (2009). Prescribing Psychotropic Medications During Pregnancy and Lactation: Principles
and Guidelines. Journal of Psychosocial Nursing and Mental Health Services. May 2009
Volume 47 Issue 5: 19-23
Kieler H, Artama M, Engeland A et al. (2011). Selective serotonin reuptake inhibitors during pregnancy and risk of persistent pulmonary hypertension in the newborn: population-based cohort study from the five Nordic countries. British Medical Journal.
Louik, C., Lin, A.E., Werler, M.M., Hernandez-Diaz, S., & Mitchell, A.A. (2007). First-trimester use of selective-serotonin reuptake inhibitors and the risk of birth defects. New England Journal of Medicine, 356, 2675-2683
Oberlander, T.F., Misri, S., Fitzgerald, C.E., Kostaras, X, Rurak, D., & Riggs, W. (2004). Pharamacologic factors associated with transient neonatal symptoms following prenatal. Psychotropic medication exposure. Journal of Clinical Psychiatry, 65, 230-237.
Scottish Intercollegiate Guidelines Network (SIGN). (2012). Management of perinatal mood disorders.
Edinburgh: (SIGN publication no.127) http://www.sign.ac.uk (Accessed 13-11-13)
Taylor D, Paton C, Kapur S. (2009). The Maudsley Prescribing Guidelines in Psychiatry. 10th edition.
Wiley 2009. p 348-60, 446-8
Udechuku A, Nguyen T, Hill R, Szego K. (2010). Antidepressants in pregnancy: a systematic review.
Australian and New Zealand Journal of Psychiatry. 2010;44:978-96
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