Treatment with both medication and psychotherapy is often necessary for moderate to severe perinatal symptomatology. If a patient has many active and distressing symptoms, finds it difficult to care for herself or the baby, or is suicidal, medication is usually required. It can be used together with the non-pharmacological treatments described earlier. Table 1 outlines medications for the perinatal population.
Antidepressants are the most common class of drugs used in the perinatal period and are effective first-line treatments for depression and anxiety disorders. Selective serotonin reuptake inhibitors (SSRIs) have high response and remission rates for perinatal women and are commonly used, but other classes of antidepressants may also be effective. Patients often require more than one psychotropic medication: Benzodiazepines, other medications for insomnia or antipsychotic medications may be added.
Clinical Considerations in Medication Management
Before starting psychotropic medication with patients who are pregnant or nursing, there are various issues you need to consider and discuss with patients.
Weighing medication risks and benefits
There is no perfectly risk-free decision about using medication during pregnancy. The decision requires weighing the risks and benefits of treatment versus non-treatment or inadequate treatment:
If a woman stops psychotropic medication during pregnancy, there is a risk of relapse or recurrence of symptoms, especially if she has had several previous episodes or a recent episode. She may also experience uncomfortable discontinuation effects that mimic depression or anxiety with abrupt discontinuation of medication.
There does not appear to be a substantially increased risk of malformations for babies exposed to SSRIs in utero, or for persistent pulmonary hypertension of the newborn. (The rate of malformations in the general population is 2 to 3 per cent. Paroxetine has been associated with possibly slightly increased risk of cardiac malformations, but these findings are inconsistent.) Birth complications, including spontaneous abortion or stillbirths, are not increased with in utero exposure.
Studies of the long-term effects on children who were exposed in utero to SSRIs do not indicate an increased risk of cognitive, emotional, language or behavioural effects on children. There is no significant increased risk of autism spectrum disorders among children exposed to antidepressants in utero.
Neonatal withdrawal from antidepressants occurs in 15 to 30 percent of babies. Symptoms include jitteriness, respiratory distress and excessive crying, but these are self-limiting and should resolve within 48 to 72 hours. There is no evidence of long-term effects. No specific treatments are required, but supportive care can help. Evidence does not support stopping medication late in pregnancy to avoid this effect.
Common initial side-effects of SSRIs may include gastrointestinal upset, headaches, dry mouth and jitteriness, but these may resolve within one to two weeks of use. Longer-term side-effects include anorgasmia, weight gain and vivid dreams or insomnia.
The antidepressant dose often must be increased as pregnancy progresses due to increased blood volume and altered hepatic metabolism. Patients should take the dose that works for their symptoms. There are no data to show that higher doses lead to increased risk of fetal or neonatal effects.
There is no specific first-choice antidepressant. Medication should be chosen based on safety profile, previous response, response in close family members, side-effect tolerance, drug interactions and existence of other medical problems. Benefits may be felt quickly, but full effectiveness may take four to six weeks at a therapeutic dose.
For less severe or first episodes, treatment guidelines suggest continuing medication for at least six to 12 months after remission. Usually, it is advisable to continue pharmacotherapy until at least one year postpartum. At that time, slowly taper off medication, as long as sleep is intact and there are limited external stressors. Women with a lengthier or more complex psychiatric history may require longer or ongoing treatment.
Considerations Around Antidepressant Use While Nursing
The decision to take antidepressants is not incompatible with nursing, as many women commonly believe. Discuss these considerations with your patient:
- Exposure to antidepressants via breast milk is five to 10 times lower than in utero exposure.
- Most commonly used psychotropic medications are compatible with breastfeeding. Medications are deemed acceptable for nursing if the infant is exposed to less than 10 percent of the maternal dose via breast milk.
- Patients should continue medications that were effective during pregnancy because changing medications may cause relapse.
- Many new mothers have complicated and conflicted feelings around breastfeeding, so discuss and respect individual choices and preferences.
Self-Care and Health Promotion Strategies
Evidence supports encouraging new parents to implement self-care strategies in conjunction with pursuing mental health care. Self-care strategies address sleep deficits, and they also include exercise, healthy eating, relaxation and finding time for oneself. Advise new parents to avoid alcohol and other substances, including cannabis, because they may worsen depression and increase anxiety.