Promoting Maternal Mental Health During and After Pregnancy 2 3 4 5 6 Perinatal depression is the most common complication of pregnancy http://www.acog.org/Womens-Health/Depression-and-Postpartum-Depression Perinatal depression is twice as common as gestational diabetes Depression 10-15 in 100 Diabetes 3- 7 in 100 Gavin et al. Ob Gyn 2005, Vesga-Lopez et al. Arch Gen Psychiatry 2006. ACOG Practice Bulletin 2013. Perinatal depression affects mom, child & family Poor health care Substance abuse Preeclampsia Maternal suicide Low birth weight Preterm delivery Cognitive delays Behavioral problems Bodnar et al. J Clin Psych 2009. Cripe et al. Pedi &Perinatal Epid 2011. Forman et al. Dev & psych 2007 Two-thirds of perinatal depression begins before birth Pregnancy 33% Before pregnancy Postpartum 40% 27% 10 Wisner et al. JAMA Psychiatry 2013 Perinatal depression is under-diagnosed and under-treated Treated Women Untreated women 11 Byatt N, et al. Obstetrics and Gynecology. 2015. 855-Mom- Care Education MCPAP Coordination Telephone Consultation Obstetric Family Psychiatric Primary care Pediatric providers/ Medicine providers providers providers Midwives 1-855-Mom-MCPAP Telephone Consultation Obtain and document patient consent before sharing PHI with MCPAP for Moms 14 1-855-Mom-MCPAP Telephone Consultation Obtain and document patient consent before sharing PHI with MCPAP for Moms 15 www.mcpapformoms.org Management of perinatal psychiatric disorders Pregnancy Guiding principles Depression & Anxiety Bipolar & Psychosis Postpartum Think pregnancy for ALL reproductive aged women Half of pregnancies are unplanned Finer & Zolna Contraception 2011. Document preconception discussion Document contraception Discuss risks of teratogenic medication Avoid valproic acid Note interaction between hormonal contraception and mood stabilizers - Birth Control Pill can decrease lamotrigine levels - Oxcarbazepine can decrease BCP efficacy Risk depends on stage of pregnancy The U.S. FDA pregnancy risk categorization is limited Not consider risks of maternal illness Not consider Unclear benefits of categories medication Does NOT inform decision making No choice is completely free of risk Need to balance and discuss the risks and benefits of medication treatment and risks of untreated mental illness Management of perinatal psychiatric disorders Pregnancy Guiding Principles Depression & Anxiety Bipolar & Psychosis Postpartum High risk of relapse during pregnancy in woman discontinuing antidepressants preconception Continue Discontinue *If tapering medication prior to conception, continue to follow women during pregnancy. Cohen et al. JAMA 2006 . Yonkers et al, Epidemiology 2011. Past depression is the # 1 risk factor for perinatal depression Reproductive Related RF General RF • Personal history of • Younger age postpartum depression • High neuroticism • Childhood trauma • Family history of • Sexual abuse postpartum depression • Psychosocial stress • Domestic violence • History of mood • Chronic medical condition changes related to hormonal changes • Race Melville et al OBGYN 2010 ; Meltzer-Brody et al, Arch Women MH2013 Education about various treatment and support options is imperative Case of Ms. Y No decision is risk free Vs. SSRIs are among the best studied class of medications in pregnancy Byatt et al. Acta Psych Scand 2013. Same prescribing principles for preconception, pregnancy and breastfeeding Use what has previously worked (considering available reproductive safety information) Use lowest EFFECTIVE dose Minimize switching Monotherapy preferable Be aware of need to adjust dose with advancing pregnancy Discourage stopping SSRIs prior to delivery Most data does not support increased risk of birth defects Data is inconsistent, paroxetine has been most controversial Byatt et al. Acta Psych Scand 2013. Possible transient neonatal symptoms with exposure to antidepressants Transient and self-limited syndrome that may occur in up to 30% of neonates Data does not support taper in third trimester Moses-Kolko et al JAMA 2005, Warburton et al. Acta Psychiatr Scand 2010. Absolute risk of persistent pulmonary hypertension (PPHN) appears small Baseline rate of 1-2 per 1000 births, may increase to 3-4 in 1000 births Chambers et al. NEJM 2006, Kallen et al. Pharmacoepidemiol Drug Saf 2008, Andrade et al. Pharm Drug Saf 2009. Possible association with preterm labor & low birth weight Depression also a risk factor for preterm labor & low birth weight Huybrechts, N Engl J Med. 2014; Ross JAMA Psychiatry 2013 Limited studies do not suggest long-term neurobehavioral effects on children Postpartum depression is associated with negative neurobehavioral effects on children Nulman et al. AJP 2012, Croen et al. AGP 2011, Rai et al BMJ 2013. When possible, slowly taper benzodiazepines, with goal to be on lowest possible dose Possible risks Cleft lip/palate Preterm birth Low birth weight Neonatal withdrawal syndrome/rare risk of floppy infant Guidelines Monotherapy preferable to polypharmacy, so optimize SSRI first Fewer/no active metabolites (lorazepam) may be safer Try to avoid longer-acting benzos, e.g. diazepam 35 Management of perinatal psychiatric disorders Preconception Pregnancy Depression & Anxiety Bipolar & Psychosis Breastfeeding Imperative to address bipolar disorder Bipolar Disorder 23% Unipolar Depression Other 7% 69% Wisner et al. JAMA Psychiatry 2013 During pregnancy medication discontinuation increase risk for recurrence of bipolar disorder 120 100% 100 80 62% 60 40 20 0 Abrupt Discontinuation > 14 day taper Yonkers et al. AJP 2004 High risk of relapse for bipolar disorder after medication discontinuation postpartum Viguera et al. AJP 2000 Bipolar Disorder in pregnancy is associated with negative outcomes Pregnancy does not protect against mood episodes Bipolar (like depression) is associated with - low birth weight, - preterm <37wks - small for gestational age Increased rate of C-section Mood elevation can lead to behaviors with known perinatal risk (eg Substance use, high risk driving, hypersexuality) Mei-Dan et al, AM J OB Gyn 2015, Boden Et al, BMJ 2012 Bipolar disorder increases risk of postpartum psychosis 1-2/1000 women >70% bipolar disorder 24 hrs – 3 weeks postpartum Mood symptoms, psychotic symptoms & disorientation R/o medical causes of delirium Psychiatric emergency 4% risk of infanticide with postpartum psychosis 41 Wesseloo et al AJP 2016, Manic Depression Illness, Goodwin and Jamison, 2007 Preventing decompensation among women with bipolar disorder is critical Prophylaxis with mood stabilizer A birth plan Close monitoring Collaboration with newborn medicine Plan for infant feeding Support adequate sleep Limit stress Support maternal-infant bonding wesselloo 2015 Risk of harm to baby when mother has thoughts of harming baby OCD/anxiety/depression Postpartum Psychosis • Good insight • Poor insight • Thoughts are intrusive • Psychotic symptoms and scary • Delusional beliefs or • No psychotic symptoms distorted reality present • Thoughts cause anxiety Low risk High risk 43 Many mood stabilizers can be used during pregnancy Lower Emerging Avoid risk reassuring data (if possible) Typical Atypical Carbamazepine/ Antipsychotics Antipsychotics Oxcarbamazepine Lamotrigine Lithium Valproic Acid Lithium use in pregnancy as been associated with risks to mother and baby Preterm labor Large for gestational age Polyhydramnios Cardiac defects (Epstein’s anomaly) Polyuria/polydipsia Neural tube defects (possible small) Lithium toxicity Neonatal adaption/floppy baby Long-term developmental issues? Wesselloo BJP, 2017 Pharmacokinetics of lithium (and most other meds) changes during pregnancy Blood flow Respiratory ∆s ∆s ↑ cardiac ↓ albumin output ↑ plasma ∆ in drug ↑ GFR volume conc Monitor lithium levels closely during the perinatal period Preconception 1st 2nd 3rd Birth Postpartum Obtain Check level q3 weeks until Continue Li at onset of baseline week 34 labor level Check level weekly after week 34 ↓ dose to preconception level within 2-3 weeks Likely ↑ dose Check levels 1-2x/w after Twice daily dosing delivery *Maintain a narrow therapeutic index of 0.6-1.2mEq/L Wesseloo et al. Br J Psych. 2017. Additional monitoring is necessary when using lithium during pregnancy Patient needs high-risk Ob Fetal echocardiogram at 16-18 wks GA Monitor: Infants’ lithium serum levels, TSH, renal function Monitor for interactions: Increase Li levels NSAIDS, diuretics (HCTZ), ARBs ACE-I Decrease Li levels Caffeine and theophylline Galbally et al, Aus NZ J Psychiatry 2010, Wesseloo et al. Br J Psych. 2017 Use antipsychotics that work, while taking into account relative risks of medications No single malformation consistently reported (some data suggests may ASDs/VSDs) Preterm labor Low and high birth weight Increased risk of postnatal adaptation symptoms Increase risk of NICU stays Coughlin et al, OB GYN 2015; Tosato et al J Clin Psyc 2017, Ennis et al, Basic Clin Pharmacol Toxicol. 2015; Huybrechts et al, JAMA Pscy 2016; Cohen et al AJP2016, Vigod et al, BMJ 2015 Second generation antipsychotics have an increasing role in treatment FGA SGA Antipsychotics Antipsychotics Small risk of transient Gestational diabetes & abnormal muscle movement obesity Long-term data reassuring Limited data to 12 months though limited 2/2 indication somewhat reassuring Vigood et al, BMJ 2015, Cohen et al, AJP, 2015, Huybrechts et al, JAMA Psychiatry 2016. Minimize stimulant use and optimize behavioral interventions during pregnancy Premature birth Smaller size Neonatal withdrawal symptoms Postpartum