Psychopharmacology and Pregnancy: Treatment Efficacy, Risks, and Guidelines

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Psychopharmacology and Pregnancy: Treatment Efficacy, Risks, and Guidelines

edited by Megan Galbally, Martien Snellen, and Andrew Lewis. Springer-Verlag Berlin, Heidelberg, Germany, 2014, 232 pages, $59.99 (hardcover).

Pregnancy or planned pregnancy in persons with mental illness who need or want to stay on psychotropic medications can pose a complicated situation for both clinicians and patients. Clinicians may only rarely treat patients who are pregnant or planning to be pregnant and may be unfamiliar with the current state of the literature and what can and cannot be concluded from it. Patients may be anxious about using medications and need details about the risks, benefits, and alternatives. Psychopharmacology and Pregnancy: Treatment Efficacy, Risks, and Guidelines is a clear and concise guide to the treatment of mental illness and pregnancy that provides expert guidance for clinicians and thus allows them to confidently counsel their patients on what is and is not known about the use of psychotropics in pregnancy.

The second chapter discusses informed consent, a particularly important topic when prescribing for this population. Interestingly, this chapter points out that there may be circumstances in which the interests of the fetus or unborn child and the mother may not be the same and that the clinician has an ethical duty to both entities. Because of the nature of the decision, the authors also encourage the father to be involved in the decision making. Very helpful is section 2.11, “What to Make of It All?” which gives 10 steps to both provide optimal consent and decrease medicolegal risk.

Chapter 3 provides a critical evaluation of the literature, especially a literature that is composed mostly of observational studies and very few placebo-controlled clinical trials. There are remarkably few controlled clinical trials in this area because of ethical concerns about giving a placebo to someone who is pregnant and whose untreated mental illness may jeopardize the fetus or unborn infant. An equal argument could probably be made that it is just as unethical not to apply the gold standard of the placebo-controlled trial to this special population. Regardless, this chapter goes on to describe the special problem of this literature in that much of it is from administrative databases, which are set up for administrative claims, not pharmacologic research, and national birth registries, which may not collect the information needed to answer any particular question. One other major source of data in this area, not discussed in the book, is data collected by helplines like Motherisk. They collect data only on those who call into the helpline, potentially introducing a source of bias toward those who are perhaps either more proactive about their health care or more anxious. Since these are the major sources of research data in this area, it is not surprising that our conclusions about treatment and its side effects are limited.

The book also has several chapters about the data on management of specific disorders including depression, anxiety, sleep, bipolar disorder, schizophrenia, borderline personality disorder, eating disorders, and substance abuse. The chapter on depression discusses the problem, even in controlled clinical trials, of sorting out the side effects of treatment versus the actual potential side effects of untreated mental illness. In the example of depression, a woman who receives no treatment for depression does not put the fetus at risk of harm from the medication, but depression may have an adverse effect on her health and the infant’s health through multiple potential mechanisms, for example, an inability to care for herself or to prepare or care for her baby. Treating the mother with medications may expose the baby to their side effects but can increase maternal well-being and reduce risk of side effects of depression itself. Also very helpful is the chapter on treating anxiety and sleep, which is clinically probably seen as much or more in pregnant women than other forms of mental illness.

Chapter 10 reviews the diagnosis and treatment of postpartum psychosis, which is fortunately rare (0.1%-0.2%) but very concerning. It helps by differentiating the so called “maternity” or “baby blues,” which up to 50% of mothers may experience, from postpartum depression and the rare occurrence of postpartum psychosis or mania. The chapter emphasizes that postpartum psychosis is a clinical emergency that warrants hospitalization, medical evaluation, and interventions that may include antipsychotics, lithium, or even electroconvulsive therapy.

Complementary and alternative therapies are discussed in chapter 13. Modalities discussed include bright light therapy, SAMe, cranial electrical stimulation, essential fatty acids, folate/folic acid/l-methylfolate, and vitamin D. This chapter is particularly helpful, as clinicians may be less familiar with these modalities, struggling to discuss them with even their nonpregnant patients. One thing that is missing from this chapter and the book in general is at least a brief discussion of psychotherapies, individual or group, and other supportive mechanisms such as home visitors. One of these may be all that is needed, especially in persons with less severe forms of mental illness, and are good options in women who choose to use no medications for any reason. The book ends with a chapter on the pros and cons and techniques of electroconvulsive therapy in pregnancy.

In short, Psychopharmacology and Pregnancy: Treatment Efficacy, Risks, and Guidelines provides guidance on the psychopharmacologic treatment of both pregnant women and women considering pregnancy, and it addresses several important topics to keep in mind when treating this special population, including consent procedures, ongoing critical review of the literature, and available alternative treatments. It would be a valuable reference to any clinician who may potentially treat peripartum women.

Annette M. Matthews, MD

[email protected]

Author affiliations: Oregon Health & Science University School of Medicine, Portland.

Potential conflicts of interest: None reported.

J Clin Psychiatry 2015;76(6):e840 (doi:10.4088/JCP.15bk09799).

© Copyright 2015 Physicians Postgraduate Press, Inc.