An overview of somatic treatment of psychosis during pregnancy and postpartum

Meningocele and ankyloblepharon following in utero exposure to olanzapine

Although atypical antipsychotics are widely used during pregnancy, their safety is not well established. This case highlights the possible teratogenic effect of olanzapine, in which the baby was born with meningocele and ankyloblepharon. It is suggested that olanzapine may interfere with embryonic development at different stages of pregnancy.

Postpartum electroconvulsive therapy: a systematic review and case report

OBJECTIVE

Postpartum depression can have devastating consequences on the mother and child. Prompt treatment is challenging. Whereas electroconvulsive therapy (ECT) is considered to be an effective treatment modality in severe depression and brings about rapid clinical improvement, little is known about ECT during the postpartum period.

METHOD

We systematically reviewed the literature on the use of ECT during the postpartum period using PubMed, Institute for Scientific Information Web of Knowledge and PsycINFO databases until September 2014, using the search terms "electroconvulsive therapy" or "ECT" and "postpartum". Then, we described the successful treatment with ECT and the joint mother-baby hospitalization of a woman with severe depression.

RESULTS

Eight case reports and 8 studies were identified. All of the studies reported that ECT is effective in the postpartum period. It is well tolerated, provides a fast response and allows for breastfeeding. In addition, our case report showed the benefits of the hospitalization of the mother-baby unit.

CONCLUSIONS

Combined ECT and joint mother-baby hospitalization could be a valuable treatment by targeting both the mother-infant relationship and the maternal depressive symptoms.

Structural Effects and Neurofunctional Sequelae of Developmental Exposure to Psychotherapeutic Drugs: Experimental and Clinical Aspects

The advent of psychotherapeutic drugs has enabled management of mental illness and other neurological problems such as epilepsy in the general population, without requiring hospitalization. The success of these drugs in controlling symptoms has led to their widespread use in the vulnerable population of pregnant women as well, where the potential embryotoxicity of the drugs has to be weighed against the potential problems of the maternal neurological state. This review focuses on the developmental toxicity and neurotoxicity of five broad categories of widely available psychotherapeutic drugs: the neuroleptics, the antiepileptics, the antidepressants, the anxiolytics and mood stabilizers, and a newly emerging class of nonprescription drugs, the herbal remedies. A brief review of nervous system development during gestation and following parturition in mammals is provided, with a description of the development of neurochemical pathways that may be involved in the action of the psychotherapeutic agents. A thorough discussion of animal research and human clinical studies is used to determine the risk associated with the use of each drug category. The potential risks to the fetus, as demonstrated in well described neurotoxicity studies in animals, are contrasted with the often negative findings in the still limited human studies. The potential risk fo the human fetus in the continued use of these chemicals without more adequate research is also addressed. The direction of future research using psychotherapeutic drugs should more closely parallel the methodology developed in the animal laboratories, especially since these models have already been used extremely successfully in specific instances in the investigation of neurotoxic agents.

Effects of antipsychotics on the unborn child: what is known and how should this influence prescribing?

The onset of psychosis during pregnancy presents difficult management decisions. A complete and thorough physical and obstetric examination is always warranted to look for possible physiological precipitants. The treatment of pregnant patients with psychotic symptomatology requires close contacts between family members, non-physician professionals involved in the patient's care (e.g. social workers, case managers and home healthcare nurses), and the physicians overseeing the patient's management (e.g. internists, obstetricians and psychiatrists). In mild and less disabling cases it may be possible to avoid medication intervention but this approach risks adverse behaviour consequences resulting from a possible worsening of the patient's symptomatology. Avoiding medication requires an environment in which the patient has strong social supports. Risks are present whether medication is initiated or not, and treatment decisions require a careful assessment of the risks and benefits involved. Initiating medication raises the possibility of obstetric, teratogenic, neurobehavioural and neonatal toxic effects. Research on the risks imposed by antipsychotic drug use during pregnancy is incomplete and raises questions regarding appropriate management. The first trimester represents a period of increased susceptibility to medication-induced teratogenesis. The use of low potency phenothiazines during the first trimester may increase the risk of congenital abnormalities by an additional 4 cases per 1000 (odds ratio = 1.21, p = 0.04) The pharmacological profiles of antipsychotic medications also present adverse effects which need to be considered during pregnancy (hypotension, sedation, etc.). Less is known about the risk of adverse consequences resulting from the use of newer atypical antipsychotic medications. Electroconvulsive therapy is another treatment modality and its use may circumvent the need to introduce antipsychotic medication during pregnancy. It must be stressed that. given current knowledge, no treatment regimen can be considered completely safe. Ultimately many factors must be evaluated when treating psychosis during pregnancy, however, no decision is risk-free.

Psychotropic drugs in mothers' milk: a comprehensive review of assay methods, pharmacokinetics and of safety of breast-feeding

Many mentally ill women want to breast-feed their babies but, if they are taking psychotropic drugs, there is very little systematic data upon which to base decisions about whether or not it is safe to do so. We therefore attempt to provide a comprehensive and critical summary of existing case reports and of studies of breast-feeding in relation to commonly used psychotropic drugs. The literature review focuses on the following drugs: antidepressants: tricyclics and serotonin selective reuptake inhibitors (SSRIs); antipsychotic drugs: chlorpromazine, perphenazine, haloperidol and clozapine; mood stabilizers: lithium and carbamazepine; and benzodiazepines. The research literature consists mainly of single case reports and there have been very few attempts at controlled, longitudinal investigations. Findings are often difficult to compare because of differences in methods or because of lack of key information. Most data are available about the tricyclic antidepressants but even here we have found that the reports cover only a grand total of 66 mother-infant pairs. Dilemmas about whether or not to contraindicate breast-feeding arise most commonly in relation to postnatal depression. The findings to date suggest that provided that infants are healthy at the outset it is likely that the benefits of breast-feeding will outweigh potential hazards if their mothers are taking established tricyclic drugs at recommended dose levels. Much less is known about risks associated with SSRI antidepressants or about antipsychotic drugs such as phenothiazines and butyrophenones or mood stabilizers such as carbamazepine, all of which enter breast-milk. Safeguards are suggested for future single case studies, which, as they accumulate, will provide a platform for mounting controlled prospective studies properly to test for any acute toxic effects and for possible long-term adverse effects of such drugs on infants' development. Appendix 1 is a review of assay methods. Appendix 2 examines pharmacokinetic factors in newborn preterm and sick infants with special reference to contraindications to breast-feeding. Appendix 3 is a review of methods for assessing infant health and development.

Anxiety and depression. Diagnosis and treatment during pregnancy

Anxiety and depression are common disorders that the obstetrician-gynecologist frequently encounters, and they often require consultation with mental health care professionals. Pregnancy offers an unusual challenge because many of the decisions made about the safety of certain drugs are educated guesses. Common sense dictates that no drug should be used unless a serious threat to the mother exists such as suicide. Preconceptional counseling and early referral to and from colleagues in mental health should help the obstetrician guide mother and fetus to a successful pregnancy outcome.

The effects of dual diagnosis on pregnancy and parenting

The desire to give birth and nurture can be significant for women with mental illness and substance-abuse disorders, despite the many internal and external barriers to the effective achievement of these desires. This article provides information on the effect of coexisting mental illness and alcohol or other drug dependency on pregnancy from a medical, obstetric, psychiatric, and psychologic perspective. The article also explores the effect on parenting and highlights the need to assess for parental competency in this population. Treatment planning, including the use of psychotropic medication and the need for collaboration between providers is discussed.

Electroconvulsive therapy during high-risk pregnancy

Pregnancy increases the risk of injury associated with mental illness. The varieties of malnutrition, substance abuse, and aggression that may accompany mental illness can injure the unborn child in more severe ways than the patient herself. Dangers associated with illness-related behavior can outweight the risks of pharmacotherapy, but no psychotropic drug is approved for use during pregnancy. Failure to produce a prompt or lasting remission of psychiatric symptoms also is a significant possibility with medication. The morbidity from continued illness and the incompletely described adverse effects of psychotropic drugs increases the attractiveness of ECT for severely depressed pregnant patients, especially with associated high-risk conditions. This paper discusses physiologic changes occurring during pregnancy and ECT and reviews contemporary monitors of maternal and fetal well-being. Guidelines are suggested for ECT during regular and high-risk pregnancies. The authors conclude that using additional precautions with high-risk pregnant patients permits ECT to be given with relative safety; medical and obstetric risk factors need not prevent its use.

Cocaine abuse during pregnancy: psychiatric considerations

Cocaine abuse is an increasing problem in the obstetric population. It not only poses a health risk to the pregnant woman, but can precipitate premature labor and abruptio placentae, and has been associated with a number of physical and behavioral problems in the newborn. Evaluation and management of the pregnant cocaine abuser is similar in most respects to that of nonpregnant adults, but diagnosis, psychotherapy, and pharmacotherapy is strongly influenced by the pregnancy. This article describes the risks of cocaine use during pregnancy and outlines the evaluation and management of the pregnant cocaine abuser.