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Mental health treatment options for women of reproductive age

Marlene Freeman

SAN DIEGO — In a session here, Marlene P. Freeman, MD, associate professor of psychiatry, Harvard Medical School, and associate director of the Center for Women’s Mental Health at Massachusetts General Hospital, discussed the risks and benefits of different pharmacologic treatment options for women of reproductive age with mental illnesses.

“It’s so important to think of women of reproductive potential, not just those who are pregnant or postpartum, because many of the disorders that we treat are chronic or recurrent and start relatively early in life,” Freeman said during her presentation.

Although many women receive psychiatric diagnoses and start treatment early in life, and come into their reproductive years already on treatment, many are treated for the first time during reproductive years, according to Freeman.

“It’s important from the very beginning that we start working with even very young girls and adolescents that we’re thinking about the reproductive safety of the treatments we select. Why that’s so important is because about half of pregnancies in this country are unplanned, so if you remember nothing else this morning, I’d really think about that, especially if you’re a prescriber of medication,” she said. “Every time you are prescribing for a woman of reproductive potential, consider the fact that there’s a good chance that she can become pregnant during the course of her treatment.”

Untreated psychiatric disorders — like antenatal depression and anxiety — carry risks for women and their babies, including low birth weight, prematurity, small for gestational age, lower adherence to prenatal care and impacting long-term central nervous system development, according to the presentation.

According to American Psychiatric Association/American College of Obstetricians and Gynecologists joint recommendations, the first-line treatment for pregnant women with mild-to-moderate major depressive disorder is psychotherapy and the first-line treatment for severe MDD is antidepressants. Clinicians treating women on antidepressants during pregnancy should consider lifestyle components, previous course of illness, patient preferences and safety information, Freeman said.

She explained that selective serotonin reuptake inhibitors are the most common antidepressants used during pregnancy. When controlling for confounding variables, the data shows that SSRI use during pregnancy was not linked to major or cardiovascular malformations. In a prospective study of MDD during pregnancy, nearly 70% of patients who decided not to receive antidepressants during pregnancy relapsed.

The prevalence of postpartum depression is 10% to 15%, according to the presentation. For the child, maternal depression can lead to behavioral problems and childhood psychiatric diagnoses. Treatment recommendations for perinatal depression included considering the risks and benefits of antidepressants, using the lowest effective doses and maximizing non-medication alternatives, such as psychotherapy and adjunctive exercise and nutritional supplements.

Freeman also discussed the importance of Zulresso, (brexanolone, Sage Therapeutics), the first FDA-approved drug for postpartum depression.

The rate of mood episodes postpartum is 70%, according to the presentation. Retrospective and prospective data show that women who discontinue medication are far more likely to relapse.

Freeman discussed postpartum psychosis, which occurs in one to two per 1,000 pregnancies, has a rapid onset within first 2 weeks and poses a high risk of harm to self and infant. While an estimated 4% of women with postpartum psychosis consider infanticide, rates may be underdiagnosed. Freeman warned that postpartum psychosis is different than postpartum obsessive-compulsive disorder, which is categorized by ego-dystonic thoughts, disturbed thoughts, avoiding being with their newborn and low risk of harm to baby.

Lithium has been shown to possibly increase the risk for cardiovascular malformations in the first trimester. However, Freeman discourages patients from breastfeeding on lithium. Valproic acid is the worst teratogen known among psychotropics. The presentation featured early data from an ongoing study at Massachusetts General Hospital Center for Women’s Mental Health, which found that babies exposed to typical antipsychotics during pregnancy had similar rates of major malformations as those in the comparison group.

Most women have sleep dysregulation while pregnant, but when women have sleep disorders, clinicians should consider nonpharmacologic treatments first, such as cognitive behavioral therapy, as well as treat any underlying conditions. Benzodiazepines, commonly prescribed to women in the U.S., should be avoided in the first trimester as should polypharmacy if possible, according to the presentation.

For some women with ADHD, CBT may benefit functioning during pregnancy, according to the presentation. Some research indicated that women taking prescription stimulant medications were at small increased risk for preeclampsia and preterm birth as well as hypertension in pregnancy; however, methylphenidate does not seem to increase the risk of overall major malformations but may increase the risk for cardiovascular malformations.

“For many of the women that we treat, if the treatment is effective, we can really help women lead the lives that they want to be leading and a lot of women want to have children, so being in treatment and being well often means being on maintenance treatment,” Freeman said. “We want to consider the reproductive safety of the medications every time we’re treating someone of reproductive potential.” – by Savannah Demko

References:

Freeman, MP. Perinatal Psychopharmacology. Presented at: Psych Congress; Oct. 3-6, 2019; San Diego.

Disclosures: Freeman reports multiple tied to industry.