Affective disorders: A question of continuing treatment during pregnancy (Review)

Abstract

Fetal development, especially in the first trimester, has proven to be heavily influenced by external factors, such as chemical intake of medication. Chronic psychiatric treatment might interfere with the anatomical and physiological wellbeing of the fetus, because psychotropic medication proceeds past the placenta, into the amniotic fluid, and can enter breast milk. Hence some of the medications prescribed for mood disorders should be reconsidered during pregnancy, without sub-optimally treating when it is needed. A literature review is presented which systematically collects modern data and synthesizes previous interdisciplinary research findings on the safety of psychiatric treatment for affective disorders during pregnancy (term-based) and lactation. Antidepressants and mood stabilizers, fundamental strategies in treating affective disorders, have been classified by the FDA as C respectively D drugs pertaining to their risk, with some exception. Most guidelines recommend pharmacologically treating moderate-severe depression, preferably with SSRIs. Evidence advocates that drugs should be used during pregnancy only if clearly needed and the benefit outweighs the risk to the fetus. However, guidelines the American College of Obstetricians and Gynecologists state that antidepressants are a preferred first course of treatment and does not take into account the severity of the depression. Among mood-stabilizers, lithium is considered to be the safest option for pregnant women. Anticonvulsants have a higher risk of teratogenicity compared with lithium, with lamotrigine being the safest one. All mood stabilizers should be recommended in the lowest effective doses. There is controversy regarding the safety of second-generation antipsychotics during pregnancy and further research is required. Several case reports and meta-reviews have been published in order to emphasize the safety of electroconvulsive therapy (ECT) during pregnancy, but practitioners still stigmatize this procedure. Evaluating the overall risk-benefit ratio should be assessed by the medical care provider, taking into consideration current findings.

Psychotropic medication in pregnancy and lactation and early development of exposed children

“…With this study, we added original data to the seriously understudied topic of safety of psychotropic medication in the peripartum. It is a wide consent that the use of psychotropic medication needs a balancing of risks and benefits and that alternative treatments (e.g., psychotherapy) should be (additionally) considered (e.g., Trifu et al 31 …”

“…It is a wide consent that the use of psychotropic medication needs a balancing of risks and benefits and that alternative treatments (e.g., psychotherapy) should be (additionally) considered (e.g., Trifu et al 31 ). During pregnancy, a continuous TDM can be a guidance for clinicians to monitor drug alteration patterns, which are likely to occur due to physiological pregnancy-associated changes in pharmacokinetics.…”

Gene Environment Interactions in the Etiology of Neural Tube Defects

“…A robust literature that has developed over the last 50 years succinctly documents the apparent teratogenicity of all the frontline ASMs commonly used to manage seizure disorders ( Dansky and Finnell, 1991 ). These ASMs include phenytoin ( Hanson and Smith, 1975 ; Hanson et al, 1976 ; Buehler et al, 1990 ) trimethadione ( Zackai et al, 1975 ), carbamazepine ( Ornoy and Cohen, 1996 ; Hill et al, 2010 ; Kohl et al, 2019 ), lamotrigine ( Hernandez-Diaz et al, 2012 ; Tomson et al, 2019 ; Trifu et al, 2020 ), levetiracetam ( Tomson et al, 2015 ; Kuo et al, 2020 ), VPA ( Wyszynski et al, 2005 ; Koren et al, 2006 ; Kluger and Meador, 2008 ; Gerard and Meador, 2015 ), and topiramate ( Veroniki et al, 2017 ; Vajda et al, 2020 ). More alarming is the fact that many of these compounds are now widely prescribed to women of reproductive age for the management of more common afflictions, including neuropathic pain, migraine headaches, mood disorders, obesity, and psychiatric disorders, adding significantly to the number of women of reproductive age who are exposed to these important medications.…”