Psychotropic drugs in pregnancy and lactation

The management of psychotropic medications during pregnancy and lactation involves a difficult and complex decision for both patient and provider, particularly due to the many unknown effects medication may have on the infant. Available studies concerning use of psychotropic medications in pregnant and lactating women are limited and there are no universal guidelines. This article reviews the literature on the use of psychotropic drugs, including antidepressants, mood stabilizers, antipsychotics, and benzodiazepines, in pregnant and breast-feeding women and presents relevant data on teratogenic effects, neonatal toxicity, perinatal syndromes, and neurobehavioral sequelae.     

Abrupt discontinuation of psychotropic drugs during pregnancy: fear of teratogenic risk and impact of counselling

OBJECTIVE: To assess the consequences to mother and baby of abruptly discontinuing antidepressant or benzodiazepine medication during pregnancy and to assess the impact of our counselling. PARTICIPANTS: All women who consulted the Motherisk Program between November 1996 and December 1997 and who stopped taking antidepressant or benzodiazepine medication when pregnancy was confirmed agreed to participate in the study. DESIGN AND INTERVENTIONS: Subjects were interviewed, received counselling, and completed a questionnaire 1 month after their initial call and after the birth of their baby. RESULTS: Of 36 women who completed the study, 34 discontinued their medication abruptly for fear of harming the fetus, 28 on the advice of their physician; 26 (70.3%) women reported physical and psychological adverse effects, 11 reported psychological effects only, and 11 reported suicidal ideation (4 were admitted to hospital). After counselling, 22 of 36 (61.1%) women resumed taking their medication, and 4 found that they no longer required it. One woman had a therapeutic abortion and 2 experienced spontaneous abortions; there were therefore 35 healthy babies (including 2 sets of twins) born to 33 women; 14 of 21 mothers breast-fed their babies while taking their psychotropic medication, with no adverse effects reported. CONCLUSIONS: When assessing the risks and benefits of taking psychotropic medication during pregnancy, women and their physicians should be aware that the abrupt discontinuation of psychotropic drugs can lead to serious adverse effects. Counselling is effective in reassuring women to adhere to therapy.     

Side effects on fetus and infant of psychotropic drug use during pregnancy.

Psychotropic drugs are used frequently for the treatment of emotional as well as other disorders. With usage so widespread, many pregnant women receive psychotropic drugs. Maternal ingestion of these drugs may produce, in the fetus, side effects including withdrawal symptoms. Withdrawal signs in the fetus as a result of maternal intake of opiates, hypnotics, analgesics, and tricyclic antidepressant drugs have been reported. Fetal side effects can occur by maternal ingestion of nuroleptic medications, lithium, antidepressants, anxiolytic sedatives, anticonvulsants, and bromides. The author feels that even though these drugs are generally safe, they must only be administered to pregnant women when absolutely needed, and then under vigilance.     

Behavioral symptoms and the administration of psychotropic drugs to aged patients with dementia in nursing homes and in acute geriatric wards

OBJECTIVES: To describe the prevalence of various psychiatric and behavioral symptoms among patients with dementia in nursing homes and acute geriatric wards and to investigate the administration of psychotropic medications to these patients. METHODS: 425 consecutive patients (>70 years) in six acute geriatric wards in two city hospitals and seven nursing homes in Helsinki, Finland, were assessed with an extensive interview, cognitive tests, and attention tests. Of these, 255 were judged to have dementia according to the following information: previous dementia diagnoses and their adequacy, results of CT scans, Mini-mental State Examination (MMSE) tests, Clinical Dementia Scale (CDR) tests, and DSM-IV criteria. Psychiatric and behavioral symptoms were recorded over two weeks for each patient. RESULTS: Psychiatric and behavioral symptoms were very common among patients with dementia in both settings. In all, 48% presented with psychotic symptoms (delusions, visual or auditory hallucinations, misidentifications or paranoid symptoms), 43% with depression, 26% agitation, and 26% apathy. Use of psychotropic drugs was also common: 87% were on at least one psychotropic drug, 66% took at least two, 36% at least three, and 11% four or more psychotropic drugs. Of the patients with dementia, 42% were on conventional antipsychotics, and 34% on anxiolytics despite their known side-effects. Only 13% were on atypical antipsychotics and 3% on cholinesterase inhibitors. The use of selective serotonin reuptake inhibitors (SSRIs) was common (31%) among the patients. A surprising finding was that drugs with anticholinergic effects were also frequently (20%) used. CONCLUSION: Both behavioural symptoms and use of psychotropic drugs are very common among dementia patients in institutional settings. The frequent use of potentially harmful drugs implies a need for education among physicians taking care of these patients.     

Psychopharmacology in patients with hepatic and gastrointestinal disease

Psychotropic drugs often need to be prescribed to patients who also have pre-existing gastrointestinal (GI) and/or hepatic disease. This paper addresses the effect of GI and hepatic disease on the pharmacokinetics of psychotropic drugs, the effect of psychotropic drugs on pre-existing GI and hepatic diseases, the adverse GI and hepatic effects of psychotropic medications, the effects of GI medications on mental status, and the potential drug interactions between commonly prescribed GI medications and psychotropic drugs. Drug selection and dosage modification based on these considerations should allow safe and effective psychotropic treatment for patients with pre-existing GI and/or hepatic disease.     

Variations in the treatment culture of nursing homes and responses to regulations to reduce drug use

OBJECTIVE: The study examined the relationship between treatment cultures of nursing homes and their responses to regulations to reduce use of psychotropic drugs mandated by the 1987 Omnibus Budget Reconciliation ACT: The authors hypothesized that reduction in use of antipsychotic drugs was more likely to occur in homes with a resident-centered culture emphasizing psychosocial care, avoidance of psychotropic drugs, pharmacist feedback, and involvement of mental health workers. The authors also predicted greater reductions in drug use in facilities with a less severe case mix and better capacity for change. METHODS: Data were collected in a stratified random sample of 16 skilled nursing facilities in Wisconsin. Participants included 1,181 residents in the baseline study and 1,650 residents in the follow-up study. Treatment culture was measured with a questionnaire for assessing nurses' beliefs and philosophies of care and their interactions with pharmacists and mental health workers. RESULTS: No significant change was observed in the use of benzodiazepines, antidepressants, or polymedicine (two or more psychotropic medications). However, use of antipsychotic drugs decreased significantly, from 24 percent to 16 percent. The change in use varied dramatically across facilities, from an 85 percent reduction to a 19 percent increase. Findings also revealed significant variability in treatment cultures. Greater reductions in use of antipsychotic drugs were found in facilities with a resident-centered culture, a less severe case mix, and a higher nurse-to-resident staffing ratio. CONCLUSIONS: Future policy and quality improvement efforts must address treatment cultures, staffing, and other organizational barriers to nursing home reform.     

Course of chronic paranoid delusions during pregnancy and post-partum]

In order to analyse the evolution of the mental state of patient suffering from chronic delirium, during their pregnancy and the postpartum period, we researched the medical history of some pregnant women about 50 pregnancies. It appears that the period preceding the birth is calm in the great majority of cases. However the delirium reappears in the days following the birth in a brutal fashion in nearly a third of the cases. No malformation in the child is found, but we should note there was one case of infanticide and one young baby was abandoned in the street. The delirium, often concerning the identity or the theft of the child, has necessitated the hospitalisation. The termination of psychotropic drugs is justified during the months of pregnancy. However it often brings with it, an end to psychiatric follow up and the absence of any return to treatment, which seems necessary to us immediately after the birth.     

Psychotropic effect of antiepileptic drugs

Eighteen controlled studies investigating the psychotropic effect of anti-epileptic drugs are critically reviewed. The neurochemical evidence for existence of psychotropic properties is still speculative. It seems questionable on the basis of this survey that there exist genuine psychotropic effects of antiepileptic drugs, which are not related to antiepileptic efficacy and/or differences in toxicity.     

Congenital malformations with psychopharmacologic agents

Psychopharmacological agents are frequently used and often for a long time because of the chronicity of mental illness. Ayd reports that about 250 million people have taken these drugs.³ This number probably includes a considerable number of pregnant women. The safety of psychotropic drugs for the fetus has not been established with certainty, even though none except thalidomide is incriminated. The conclusive evidence can only be obtained by monitoring of fetal effects. In this paper, the fetal effects, particularly teratogenesis, of the psychopharmacologic agents are reviewed.     

Treatment of mania in the last six months of pregnancy

The management and treatment of psychotic exacerbations of manic-depressive illness during the last six months of pregnancy are discussed and guidelines are given. The author notes that such concerns are covered only superficially in most standard references. The acutely psychotic pregnant patient presents a therapeutic dilemma that has been overshadowed by the attention to teratogenic effects of psychotropic drugs. To date there are no controlled studies on the efficacy of different therapeutic modalities during pregnancy. Citing a case example, the author says second- and third-trimester treatment designs must primarily consider the perinatal aspects of pharmacotherapy in the mother and fetus than teratogenicity.     

Psychopharmacologic interventions in nursing homes: what do we know and where should we go?

Psychiatric symptoms are common among individuals who live in nursing homes, with prevalence rates ranging from 51 percent to 94 percent. Accordingly, psychotropic medications are widely prescribed in this setting and are the subject of considerable debate and regulation. Current regulations arose from public and governmental concerns that psychiatric medications were being prescribed inappropriately to frail patients. Concern has also been raised about the absence of evidence on which to base prescribing decisions. Nursing homes are slowly being recognized as complex health care settings that warrant considerable research attention. This article explores the origins of the regulation of the use of psychotropic drugs in nursing homes, reviews controlled trials of these drugs in nursing homes, examines the role of these agents in adverse drug events experienced by nursing home residents, and proposes policy and research areas that merit consideration.     

Psychotropes, grossesse et adaptation néonatale du nouveau-né. Étude exploratoire (Unité Mère-Enfant, Bordeaux : 2001-2007)

Background

Knowledge about the impact of psychotropic drugs intake during pregnancy on newborns and infant health is limited. The present preliminary study compares neonatal adaptation of babies whose mothers took psychotropic drugs during pregnancy to adaptation of babies whose mothers didn’t, for dyads hospitalized in the Mother-Baby Unit of Bordeaux (UMB-Société Marcé Francophone - Database).

Method

Intake of psychotropic drugs during pregnancy was retrospectively evaluated in a sample of 187 women hospitalized with their baby. Neonatal adaptation of the newborns was evaluated through the APGAR score at 5 minutes of life. Univariate analyses were used for this exploratory study.

Results

APGAR scores of exposed newborns (87) were significantly lower, and specifically for newborns exposed to mood stabilizers and/or antipsychotics. Exposed children were more frequently hospitalized for neonatal cares. The duration of pregnancy was shorter for mothers treated with mood stabilizers and/or antipsychotics and/or benzodiazepines.

Conclusion

This preliminary exploratory study suggests, in spite of its limitations, that newborns whose mothers were hospitalized in post-partum and who used psychotropic medications during pregnancy presented with more neonatal health difficulties than those of untreated mothers.     

The use of psychiatric drugs in pregnancy and lactation

To help determine which drugs can be used with relative safety during pregnancy, we reviewed the literature on the possible teratogenic, perinatal, behavioral or developmental effects of the various groups of commonly used psychiatric drugs, and their effects on lactation. Tricyclic antidepressants, fluoxetine, phenothiazines, and most benzodiazepines are not considered to be teratogenic and may be used during pregnancy. All anti-epileptic drugs seem to have an embryotoxic and teratogenic potential and we recommend, if possible, avoiding these drugs. Lithium administration during the first trimester of pregnancy increases the risk of cardiac malformations, but the risk is not as high as originally reported. Therefore lithium may be continued whenever it seems to be the "drug of choice" if fetal echocardiography and ultrasonography are performed. There is a lack of information on the teratogenic effect of the newer drugs, and in spite of the fact that similar "older" drugs do not seem to adversely affect the fetus, they should be used with care. Although the data on the development of children following in-utero exposure to psychiatric drugs is limited, there seems to be no evidence of any long-term adverse effects on the development of children exposed to most psychotropic medications. However, children exposed in utero to anti-epileptic drugs may exhibit long-term developmental problems. Most of the drugs are detected in breast milk only at low concentrations. In nursing women taking these drugs, breastfeeding is possible. The infant should be carefully monitored for any clinical side effects and whenever observed, nursing should be discontinued. In light of our knowledge today, there seems to be only rarely an indication for pregnancy interruption following maternal exposure to psychiatric drugs during pregnancy.     

Psychological considerations in the use of psychotropic drugs with women patients

The use of psychotropic drugs with women patients raises special considerations. In some settings women are medicated too readily, and in others they have inadequate access to comprehensive care that includes medication. However, judicious use of medications to relieve disabling symptoms frequently promotes productive psychotherapy. Either prescribing drugs or withholding medication may involve special transference and countertransference issues for the woman patient. Women also have special concerns and conflicts about the effects of psychotropic drugs on pregnancy and lactation and about side effects involving sexual functioning and change of appearance.     

Caffeine: The forgotten variable

Although the majority of the population regularly consume caffeine, there are wide variations between individuals in both daily intake and susceptibility to caffeine's effects. These differences are at least partially genetically determined, possibly via variations in adenosine receptors or caffeine metabolism. Caffeine toxicity is well recognized. Tolerance of its effects and withdrawal symptoms have also been described. Both DSM and ICD-10 recognize caffeine as a potential drug of abuse. Caffeine can induce anxiety, exacerbate psychotic symptoms in some patients with schizophrenia and cause insomnia. It can complicate the management of depression by increasing lithium clearance and can also increase seizure length during ECT. Caffeine can inhibit the metabolism of some psychotropic drugs such as clozapine through the competitive inhibition of CYP 1A2 . Potent inhibitors of CYP 1A2 such as fluvoxamine can precipitate caffeine toxicity. Enquiries about caffeine consumption should be made in all patients who have apparently treatment-refractory illness, or seem unusually sensitive to, or tolerant of, psychotropic drugs.