When a woman considers pregnancy, she naturally has a whole host of questions to answer and decisions to make. For women who have experienced mental illness, however, pregnancy brings up another important decision: should I continue my medication?
While the decision around treatment often centers on the risks to the fetus of exposure to a medication, there are additional risks to both mother and child if mental illness is left untreated. The time during and after pregnancy is a high-risk period for recurring symptoms in women who have had previous experience with psychiatric disorders.
Women must also consider that untreated mental illness, either during pregnancy or the post-partum period, also poses risks to the child. These risks may include slower fetal body and head growth, pre-term delivery, and increased risk for operative delivery. Pregnant women with untreated depression or anxiety are less likely to have adequate prenatal care and nutrition and are more likely to abuse substances. For these reasons, even from the point of view of protecting the child, it may not always be the best choice to discontinue psychiatric medications or to withhold treatment during pregnancy.
There are treatment options during pregnancy that go beyond medications. Psychotherapy, usually in weekly sessions, has been shown to be effective for some conditions. Increased support from partners, family members, friends, and medical care providers can be important as well. Pregnancy is also a time to focus on overall health, including exercise, nutrition, and sleep. Speaking with your doctor about improvements you can make in these areas may be helpful for mood and anxiety symptoms.
Given all the considerations mentioned above, the decision as to whether or not to take or continue a psychiatric medication during pregnancy is a difficult one. The decision is further complicated by the lack of available evidence to guide the process. (For obvious reasons, it is not ethical to conduct research which exposes pregnant women and fetuses to experimental medications and under blinded conditions.)
In lieu of randomized clinical trials, we instead study outcomes from women and babies exposed to medications under naturalistic conditions. This makes it hard to draw clear conclusions, as uncontrollable, complicating factors can affect the data. Nonetheless, researchers are continually making efforts to learn more about the risks of exposure during pregnancy to psychiatric medications. In general, the outcomes studied fall into three categories:
- The risk of birth defects or malformations, or the risk of affecting fetal growth
- The risk to a newborn of “withdrawal” or perinatal syndromes
- Longer-term effects on a child’s development or behavior
Women whom I counsel often focus on the first categories, wondering whether exposure to psychiatric medications can affect a fetus’s growth or organ development. Given that there are too many available psychiatric medications to discuss each of them in sufficient detail, I have provided the resources listed below to learn more about a specific medication.
Although each medication carries its own particular risk, we use a few general principles when guiding women:
- The first is to try to plan for pregnancy in advance, allowing time to focus on stabilizing symptoms before pregnancy.
- A second principle to remember is that all medications cross the placenta, and a developing fetus will be exposed to any medication the mother takes. As a result, the safest situation is to use the fewest number of medications possible at the lowest effective dose. When a pregnancy is planned, a prospective mother may have time to experiment with her own medications, to find the optimal combination of lowest dose and the fewest number of medications. However, even with an unplanned pregnancy, it is not advisable for a woman to stop her medications abruptly, as this can often lead to a relapse of symptoms. Rather, she should contact her doctor for advice, and together they can determine what is best for her.
- Another related principle is to try to use the medications we know the most about, as there are more accumulated data to guide treatment decisions. In pre-conception planning, a woman may elect to switch her current medication to a medication with a better-known safety profile. However, a woman who discovers she is pregnant while taking medications may elect to stick with an effective medication rather than risk relapse by switching to an alternative.
- Treatment decisions should always be open for discussion. A woman may at any time elect to change her mind about the treatment course, and she and her doctor should make decisions collaboratively. Often, medications may need to be altered later in pregnancy, as a woman’s metabolism changes or as her symptoms evolve.
- Finally, even though it will be many months away, a woman and her doctor should have a discussion about whether to plan for breastfeeding. Many medications are found substantively in breast milk, and paradoxically, some that are considered relatively safe in pregnancy may not be as safe for a breastfeeding infant. Given that the post-partum period– with its hormonal changes, lack of sleep, and challenges of breast-feeding– increases the risk for recurrent or worsening symptoms, it is often the wrong time to abruptly switch or stop medications. Instead, considering a mother’s intention to breastfeed early on in the pregnancy may better guide the treatment decisions and provide more stability during the vulnerable post-partum period.
The decisions about psychiatric medications in pregnancy are difficult, personal, and complicated by many other factors. I always remind patients that no decision is permanent, and the discussion can remain open throughout the pregnancy and post-partum period, as she gauges her state of mind and her response to the various conditions of pregnancy, breast-feeding, and motherhood.
For more information, please seek the advice of your psychiatrist or your primary care doctor. Other resources include:
- MGH Center for Women’s Health
- Postpartum Progress
- The National Institute of Mental Health
- The National Alliance on Mental Illness