Medication Considerations for Pregnant and Postpartum Women
By Yaprak Harrison, MD, PhD
The consequences of untreated mental illness in pregnant and postpartum women can be devastating, yet many women hesitate to pursue medication as a treatment option due fear of negative outcomes for themselves or their babies. There is an abundance of incomplete and misleading information in the media related to psychiatric medications which puts women in an impossible situation when considering their treatment: “Should I risk my own mental health? Or risk harming my baby?” Many women, trying to put their baby’s needs first, choose to forgo medication and wind up feeling hopeless about getting better and shameful about their experience.
Pregnancy can be one of the most emotionally charged periods in a woman’s life. Women are actually more vulnerable to mental health disorders during pregnancy due to the many physiological, hormonal and psychological changes that take place during that time. In fact, about a third of women are expected to have at least one mental health disorder during their pregnancy and in the postpartum period.
Postpartum depression is now a relatively well-known condition and is considered one of the most common complications of pregnancy. But there are several other mental health disorders associated with the perinatal period (“perinatal” refers to events occurring during pregnancy or in the postpartum period) that can also lead to significant harm in both mothers and their children if left untreated. Some of these conditions include anxiety disorders, bipolar disorder, obsessive compulsive disorder, post-traumatic stress disorder and psychosis. Therefore, it is important to be aware of these conditions and quickly seek appropriate care.
Neglecting the mental health needs of a mother comes with an enormous cost and it can have multigenerational consequences. With that said, there is good news, perinatal mental health disorders have a good prognosis. With treatment, women can get better! Appropriate treatment will be determined by your medical and mental health providers, but often includes both medication and psychotherapy. The goal of this article is to equip you with some basic information that may help you feel more comfortable pursuing treatment for you and your baby’s well-being.
This article is NOT a substitute for seeking your medical provider’s opinion. On the contrary, at BHD we encourage open and transparent collaboration with your medical provider and value their expertise. Talking to your medical provider, as well as educating and monitoring yourself, are the first steps in taking care of yourself during pregnancy and in the postpartum period.
Making an Informed Decision about Medications
So how could a woman make an informed decision about whether or not to take medication during pregnancy and which medication to take?
One of the most common questions asked of medical providers is, “Is this medication safe to take in pregnancy?” In order to answer this question, medical providers also consider the risks of untreated mental health conditions and explore the following questions:
What are the risks and benefits of taking this medication?
Is there another way to treat these symptoms?
What are the risks of untreated mental illness during pregnancy and the postpartum period
What would happen if you stop taking this medication?
Do the benefits of this medication outweigh the risks of the untreated mental health condition?
As a woman is trying to make a decision about a medication, it’s important to know the risks and benefits of both sides of the equation (e.g., what is the risk of untreated mental illness compared to the risk of taking medication). Research has shown that even though there may be a relative risk associated with the use of medications during pregnancy, there are also significant risks associated with the untreated mental health conditions in the mother.
The Risk of Untreated Mental Health Conditions in the Peripartum Period
Some risks of untreated perinatal depression are listed below:
Negative impact on prenatal medical care and maternal weight
Increased obstetrics complications like cesarean delivery, pre-eclampsia and long peripartum hospital stay
Problems with bonding with the baby
Suicide, postpartum depression, psychosis
Increased use of alcohol and other harmful substances
It is not only the mother that suffers when mental health concerns go untreated, but also their babies. Some consequences for the baby that have been shown are:
Increased risk of preterm birth
Increased risk of low birth weight
Attachment problems
Behavioral problems
Long term negative impact on cognitive functioning
Increased risk of abuse or neglect
Childhood psychiatric diagnosis and symptoms
What does the research say?
Let’s look at some of the most commonly used medications for mental health disorders and what we know about their relative safety in pregnancy. When reviewing the literature, it is important to remember that many times the published studies showing possible risks of these medications have not been able to do rigorous evaluation of maternal illness as a potential contributing factor. Therefore, it is often difficult to determine if the medication or the mental illness is causing the problem.
Selective Serotonin Reuptake Inhibitors (SSRIs):
SSRIs have been one of the most extensively studied classes of medication in pregnancy. They are used for the treatment of depression and anxiety as well as other mental health disorders, and are very commonly prescribed.
Most rigorous studies have shown that the overall risk of birth defects in children exposed to SSRIs in utero is no different from children that were not exposed. No association between SSRIs and birth defects has been seen.
One of the more plausible concerns with the use of SSRIs in pregnancy has been the association with what has been called “a neonatal adaptation syndrome,” which has been reported in up to a quarter of babies – these symptoms include fussiness and jitteriness, which are usually temporary and resolve with basic or minimal medical attention . The interesting finding is that stopping the medication later in pregnancy does not decrease the rate of these symptoms, which suggests that perhaps other factors, including the untreated maternal illness, may be contributing to these symptoms as opposed to the medication itself.
Several years ago, Persistent Pulmonary Hypertension of the Newborn, a serious but rare condition related to the inflation of the lungs became a news item when some studies suggested a possible association between SSRIs and the condition in newborns. However, several later studies did not confirm this association and it was concluded that if there was any potential increase in PPHN, the absolute risk was small.
Looking at the whole of the literature, the majority of studies do not suggest major long-term neurodevelopmental adverse effects of exposure to antidepressants in utero.
Other Medications:
There are several other antidepressants that are also commonly used in the treatment of mental health disorders (1) Selective Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) such as venlafaxine, desvenlafaxine, and duloxetine, (2) bupropion (Wellbutrin), and 3) Mirtazapine, There has not been as much research conducted on these medications as that has been on SSRIs; but overall the findings are generally reassuring.
Second Generation Antipsychotics: These are medications that are used effectively in the maintenance of bipolar disorder (e.g. quetiapine, olanzapine, aripiprazole). They are also used as adjunct medication for the treatment of depression. New data is gradually accumulating on the reproductive safety of these medications and the preliminary findings are encouraging about their overall safety.
Summary and Take Away
Having a healthy pregnancy in which mother and baby’s well-being are prioritized is the most important step in preventing postpartum mental illness and fostering a positive attachment between mother and baby. Medications are considered one of the most important tools that are available to women suffering from perinatal mental health conditions. If you are reading this article wondering if you should seek treatment for a mental health concern, please talk to your medical provider and discuss appropriate medication and psychotherapy treatment options. You are not alone! Treatments for these conditions do work and you can feel well again.
References:
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Huybrechts et al. 2016, JAMA Psychiatry 73:938-946
Jarde, A et al. JAMA Psychiatry, 2016, 73(8): 826-837
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Margiotta, C et al. Health Issue Brief, March 2021, mathematica.org
Ohaka, H. et al. Psychiatry & Clinical Neuroscie., 2014, 68(8): 631-39
Sujan AC et al. 2017, JAMA, 317:1553-1562
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