Reproductive Psychopharmacology 1 st Annual Bay Area Maternal Mental - - PowerPoint PPT Presentation

Reproductive Psychopharmacology

1st Annual Bay Area Maternal Mental Health Conference Saturday, September 10, 2016 Anna Glezer MD

Disclosures

 None

Fear of Medication in Pregnancy

Pregnant patients use medication!

 Dichotomy between what is beneficial for mom versus baby  Forgetting to weigh risks of untreated illness versus medication rather than just use versus nonuse of medications  Pregnant patients are #1 under-represented patient population in medical research  2/3 take at least one prescription medication  1/3 take psychotropic medication

Medication Discontinuation Effects

 Relapse

 Rates of recurrent are high!  Consequences of recurrence are serious

 Withdrawal

Safety Across Stages

 Malformations (1st trimester) or miscarriage  Obstetric and neonatal outcomes  Long term neurodevelopmental consequences

Most commonly prescribed psychotropic in pregnancy: SSRI

 Indications: mood, anxiety  Well tolerated w/r/t SEs  Most available safety information in pregnancy  Mechanism of action

SSRIs and Malformations or Miscarriage

 No increased risk of malformations  No increased risk of miscarriage

SSRIs and PPHN

 Lower than initially believed  Risk attenuated when depression accounted for

SSRIs and Autism

 No causal relationship has been proven

SSRIs and Neonatal Adaptation

 Poor Neonatal Adaptation: Jittery, tremulous, respiratory difficulty, tremor, difficulty feeding, irritable.  20-30% of infants  Taper?

SSRIs and Development

 No cognitive differences  Possible non-clinically significant differences in gross motor development and language  Age 7

SSRIs and Breastfeeding

 Crossing into milk at <1-8%  Levels low in infants if detectable

Other antidepressants/antianxiety agents

 SNRIs  Bupropion  Trazodone  Mirtazapine  TCAs

Sleep Aids

 Zolpidem  Diphenhydramine  Melatonin  Benzodiazepines

Mood Stabilizers: Lamotrigine

 Registry data: No increased risk of malformations, except for one older North American registry suggesting increased risk of oral clefts (absolute risk

• f 0.9% according to that data)

 Well tolerated, few side effects, weight neutral  Baseline level and repeat 3rd trimester  Postpartum dose adjustment  High rate of crossing into breast milk  Interaction with contraceptives  Long-term data

Other Mood Stabilizers

 Lithium  Carbamazepine/oxcarbazepine  Valproic acid  Lesser used: gabapentin, topiramate

Antipsychotics

 Typicals  Older atypicals  Newer atypicals

Stimulants

 Prescribed stimulant medications versus methamphetamine  No malformations  Obstetrical outcomes

Complimentary medications

 Folic acid  Omega-3s  Placenta encapsulation

Novel treatments

 SAGE 547  Preliminary, pilot study noted significant improvement in symptoms of postpartum depression  Affects GABA  Next step: placebo controlled drug trials

Take Home Points

 For many women, psychotropic medication is an important part of treatment during pregnancy and postpartum  For each woman, it is an individual discussion about her particular risks, benefits, and alternatives of taking versus not taking medication

Resources

 Mind Body Pregnancy  MGH Women’s Mental Health Center  Lact Med  MothertoBaby.org