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Perinatal Mental Health
Dr Michael Yousif, Consultant in Psychological Medicine, OUH NHSFT
www.england.nhs.uk
Perinatal mental health for GPs
- Diagnosing
- Prescribing
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Perinatal Mental Health Dr Michael Yousif, Consultant in - - PowerPoint PPT Presentation
Perinatal Mental Health Dr Michael Yousif, Consultant in - - PowerPoint PPT Presentation
Psychiatry for GPs Perinatal Mental Health Dr Michael Yousif, Consultant in Psychological Medicine, OUH NHSFT Perinatal mental health for GPs Diagnosing Prescribing www.england.nhs.uk 2 Perinatal mental health for GPs Is this
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www.england.nhs.uk
Perinatal mental health for GPs
Is this medication safe in pregnancy? Are the risks of this medication justified for this patient?
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www.england.nhs.uk
Decision making
Risks of medication
- Infant exposure
- In utero
- Lacation
- Maternal morbidity
- Maternal anxiety
Evidence-based Risks of not taking
- Undertreatment
Evidence and individual-based
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www.england.nhs.uk
Key principles: prescribing
- Baseline 10-20% miscarriage, 2-3% malformations (Henshaw et al 2017)
- Avoid first trimester prescribing wherever possible
- Infant outcomes multifactorial
- Minimise foetal exposure by avoiding drug switching
- Consider what has worked before for the patient
- All prescribing is off-label
- Informed choice paramount
- Reading material…Bumps
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www.england.nhs.uk
Key principles: evidence-base
- Observational studies vs experimental studies
- Single study associations, open label studies
- Confounding by indication
- Association vs causation
- Relative risks vs absolute risks
- Statistical significance vs clinical significance
- Absence of evidence ≠ Evidence of absence
- Few long-term studies
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www.england.nhs.uk
Key principles: breastfeeding
- Most studies are in pregnancy
- Aim to continue same drug in breastfeeding from pregnancy
- Lithium, clozapine most risky
- Placental exposure 5-10x breast milk (Howard et al 2014)
- Practical considerations
- Nocturnal sedation, ‘pump and dump’, drug half-life
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www.england.nhs.uk
Antidepressants
- Limited direct evidence of efficacy
- Depressive relapse rate 68% if discontinue meds, 26% if continued
(Henshaw et al 2017)
- Large studies
- Unlikely to be teratogenic
- Equivocal evidence of cardiac malformation and PPHN
- ARI 2/1000 for paroxetine (Henshaw et al 2017)
- OR ~1.5 spontaneous abortion, inconsistent finding, multiple confounders
(Ross et al 2013)
- OR ~1.5 preterm delivery (days) (Ross et al 2013)
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www.england.nhs.uk
Antidepressants
- IUGR evidence equivocal
- Associated with PNAS, lower Apgar scores, NICU admission
- Withdrawal or SE / toxicity?
- Definition / measures
- Likely benign, self-limiting
- ASD – SSRIs, equivocal evidence, confounding by indication
- Increased risk of speech / language disorders up to age 9 (Brown et al 2016)
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www.england.nhs.uk
Antipsychotics
- Quetiapine, olanzapine, risperidone, haloperidol best studied
- Long-term adverse cognitive outcomes, teratogenicity seem unlikely
- SEs possible in neonate
- Increased maternal and infant morbidity/mortality, obstetric complication
- Not due to medication…confounding by indication
- No consistent increase in
- Maternal outcomes: GDM, HTN, VTE
- Infant outcomes: prematurity, baby size, NAS
- More likely to need interventional delivery (Vigod et al 2013)
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Mood stabilisers
- Most evidence from epilepsy studies
- Confounding by indication
- Valproate, carbamazepine relatively contraindicated (NICE)
- Craniofacial, cardiac, cognitive, neurodevelopmental, miscarriage
- Lamotrigine unlikely teratogenic (Chisolm and Payne 2015)
- Inconsistent evidence about oral cleft
- Lithium (Chisolm and Payne 2015)
- Ebstein’s anomaly 1/1000
- Avoid 1st trimester – foetal heart monitoring
- Blood volume changes, lithium metabolism, monthly weekly levels
- Neonatal thyroid problems, arryhthmias
- Breastfeeding risks
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Anxiolytics
- Oral cleft
- Evidence recently disputed
- Neonatal withdrawal
- Floppy baby syndrome
- Gut atresia
- Promethazine for insomnia (NICE) but more evidence Z-drugs
Chisolm and Payne 2015, Taylor et al 2015, Henshaw et al 2017
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NICE CG192
- TCAs, SNRI, SSRIs for depressive and anxiety disorders
- Avoid paroxetine
- Antipsychotics as mood stabilisers
- Lithium 2nd line
- Avoid valproate
- Promethazine for sleep
- ECT for severe illness
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Where to gt help
References
- UKTIS / BUMPS website
- Maudsley Prescribing
Guidelines
- BAP Guidelines
McAllister-Williams et al (2017) Journal of Psychopharmacology 1- 34 Services
- AMHT
- IAPT
- OUH Maternity
- Specialist PMH CMHT
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References
1. Boukhris et al JAMA Pediatr. 2016;170(2):117-124. 2. Brown et al JAMA Psychiatry. 2016;73(11):1163-1170 3. Chisolm and Payne BMJ 2015; 351:h5918 4. Furu et al BMJ 2015; 350: h1798 5. Howard et al Lancet 2014; 384: 1775-88 6. Henshaw et al RCPsych Modern Management of Perinatal Psychiatric Disorders (2nd ed.) 2017 7. Jones et al Lancet 2014; 384: 1789-99 8. Myles et al A NZ J Psych 47(11) 1002–1012 9. Reefhuis et al BMJ 2015; 351: h3190 10. Ross et al JAMA Psychiatry. 2013;70(4):436-443. 11. Stein et al Lancet 2014; 384: 1800-19 12. Taylor et al Maudsley Prescribing Guidelines in Psychiatry (12th ed.) 2015 13. Vigod et al BMJ 2015; 350:h2298
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