Martien Snellen

Management of antipsychotic and mood stabilizer medication in pregnancy: recommendations for antenatal care.

The aim of the present study was to develop recommendations for antenatal care and monitoring for women with bipolar disorder and schizophrenia who are on lithium carbonate, antipsychotic or anti-epileptic medication during pregnancy. A literature search and review of original research, published reviews and guidelines was undertaken for mood stabilizers and antipsychotics in pregnancy and for the management of bipolar disorder and schizophrenia in pregnancy. This information was summarized, condensed and then reviewed by representatives of psychiatry, pharmacy, paediatrics and obstetrics to produce an information booklet and subsequently monitoring recommendations and tables. A model of antenatal monitoring and care for women with schizophrenia, bipolar disorder and related disorders who are maintained on psychotropic medication was developed. This included an online and published booklet for clinicians summarizing psychotropic medication in pregnancy, and lactation and monitoring tables that could be part of patient case files. These were to assist in reminding and educating staff on the need for additional monitoring and assessment above standard antenatal care for women on mood stabilizers and antipsychotic medication. Women with bipolar disorder and schizophrenia have an increased risk of complications in pregnancy from their illness and from the medications they are prescribed. A summary of the risks and a model of suggested additional monitoring during pregnancy have been developed in consultation across a number of clinical disciplines.

Antipsychotic drugs in pregnancy: a review of their maternal and fetal effects

Understanding the risks of antipsychotic medication use in pregnancy is becoming an important clinical concern given the evidence of their increasing rate of prescription in the general population for a range of disorders. Despite antipsychotics being amongst the earliest of psychotropic medications to be introduced, the evidence for their effects secondary to pregnancy exposure is extremely limited. While this review does not identify clear evidence for a risk of malformation, there is evidence for risks associated with pregnancy and neonatal outcomes. Studies identified found risks that included prematurity, low and high birth weight, and gestational diabetes. There have also been studies that suggest neonatal withdrawal and abnormal muscles movements. The longer term neurodevelopmental outcomes for children exposed in utero remain unclear with only four studies identified: two of first generation antipsychotics and two of second generation antipsychotics. When considering the risk of these medications in pregnancy, the risk of untreated maternal illness (particularly schizophrenia and bipolar disorder) on both maternal and child outcomes is relevant. Future research needs to focus on prospective, longitudinal studies with adequate measures of key confounding variables including maternal mental illness, other exposures (such as smoking, alcohol and illicit drug use) and adequate length of follow up where accurate child developmental measures are obtained.

A review of the use of psychotropic medication in pregnancy.

Purpose of review There is increasing awareness within obstetric services of the importance of treating maternal mental illness due to the association with increased maternal mortality, morbidity and poorer child outcomes. However, there is limited research on the risks and benefits of pharmacological treatment of women in pregnancy. This review is focused on studies published in the past 18 months. Recent findings Antidepressants and antiepileptic mood stabilizers are the most frequently studied of the pharmacological treatments for mental illness. There are clear risks of neonatal serotonin discontinuation symptoms associated with antenatal antidepressant use. It remains unclear whether there is an elevated risk of malformations, persistent pulmonary hypertension of the newborn, prematurity, low birth weight and negative child developmental outcomes. Mood stabilizers have been associated with an increased malformation risk and some are associated with poorer neonatal and child developmental outcomes. There are available only limited studies on antipsychotics in pregnancy. Summary Given the limited research on psychotropic medication in pregnancy, each woman, in collaboration with her clinician, needs to consider the risks in the context of her individual circumstances. However, any consideration of the risks of pharmacological treatment must be considered in relation to the risks associated with untreated mental illness.

Borderline Personality Disorder in the perinatal period: early infant and maternal outcomes.

Objective: This study examines pregnancy and early infant outcomes of pregnant women with a clinical diagnosis of Borderline Personality Disorder presenting for obstetric services to a major metropolitan maternity hospital in Victoria, Australia. Method: A retrospective case review of pregnancy and early infant outcomes on 42 women who had been diagnosed with Borderline Personality Disorder via psychiatric assessment using DSM-IV-R criteria was undertaken. Outcomes were compared with a control group of 14,313 consisting of women and infants of non-affected women from the same hospital over the same period of time. Results: Women presenting for obstetric services with a clinical diagnosis of Borderline Personality Disorder experienced considerable psychosocial impairment. They anticipated birth as traumatic and frequently requested early delivery. High comorbidity with substance abuse was found and high rates of referral to child protective services. Mothers with Borderline Personality Disorder were significantly more likely to have negative birth outcomes such as lowered Apgar scores, prematurity and special care nursery referral when compared with controls. Conclusions: These findings offer preliminary evidence to be considered by clinicians in developing treatments and services for the perinatal care of women with Borderline Personality Disorder and their infants. Further research is required in order to develop evidence informed clinical guidelines for the management of women with Borderline Personality Disorder and their infants.

Perinatal mental health services: what are they and why do we need them?

Objective: To review the evidence for perinatal mental health as a sub-specialist area of mental health and describe the development of a service model. Conclusions: Perinatal mental health is emerging as a sub-specialist area of mental health with specific knowledge and expertise in assessment, diagnosis and treatment. It requires services to ensure that women and infants receive optimal care across pregnancy and the postpartum.

Commentary on RANZCP clinical practice guidelines for the management of schizophrenia and related disorders

Australian & New Zealand Journal of Psychiatry, 51(3) focus on familial abuse/neglect, the importance and influence of peer relationships is also critical. Nonetheless, further research is needed to ascertain the appropriate treatment methods. While recent research has delivered promising results using several cognitive behavioural therapy (CBT) techniques, unfortunately these studies are underpowered and in some cases lack control groups (Bendall et al., 2013). However, several challenges integral to ensuring quality clinical outcomes for this population are evident. For example, how best to address trauma and schizophrenia simultaneously in clinical settings remains a medical and psychosocial challenge for mental health clinicians. Restricted access to clinical resources necessitates a clinical focus that remains primarily on clinically addressing illness symptomology. This in turn can limit a clinician’s capacity to address other underlying psychosocial issues related to schizophrenia and trauma. Although health and psychiatric comorbidities related to schizophrenia and trauma can be a significant clinical concern, they remain an underexplored area for both mental health research and psychiatric clinical practice. Thus, determining trauma histories of people with psychiatric disorders can be significant in determining clinical pathways for recovery. However, there remain significant challenges in assessing trauma. For example, there is a need for safe interview environments, access to appropriate trauma measurement tools and the provision of welltrained and experienced clinicians. Most significantly, it is imperative to minimise re-traumatisation and to provide psychosocial supports on discharge from the service for consumers.

Bipolar Disorder, Psychopharmacology, and Pregnancy

The antenatal management of women with bipolar disorder presents a major challenge for both obstetric and mental health services due to the inherent risks associated with both the condition and its treatment: each of which can be considered to be teratogenic in their own right. The possibility of pregnancy in all women of reproductive age should be considered when making treatment decisions from the outset, especially given that unplanned pregnancy is particularly common in this patient group. For all women with bipolar disorder it is essential that specific considerations be attended to, and monitoring systems established and followed perinatally.

Aripiprazole and pregnancy: A retrospective, multicentre study

BACKGROUND Aripiprazole is a second generation antipsychotic medication that has been a useful addition to the treatment of severe mental illness due to its low metabolic and sedation risk profile. Pregnancy is a time of high risk of metabolic complications such as gestational diabetes and the postpartum period is often a time when sedation can compromise infant care. To date there is limited data in pregnancy on the safety of aripiprazole use. While available data do not suggest an elevated malformation risk in pregnancy, there is less information available on pregnancy and neonatal complications. METHODS This study presents preliminary data on pregnancy and neonatal complications on 26 women who took aripiprazole in pregnancy. These women attended at antenatal clinics for women with severe mental illness at two hospitals in Australia. RESULTS Overall aripiprazole was not associated with an increased risk of gestational diabetes. However, use of aripiprazole in pregnancy was associated with an increased risk of pregnancy hypertension, lower birth weight, shorter gestation at birth and higher rates of admission of the neonate than the expected population rates. LIMITATIONS These findings need to be replicated in a larger, well-designed study to ensure they do not reflect confounding factors. CONCLUSIONS Findings demonstrate that aripiprazole is unlikely to pose a metabolic risk in pregnancy but other pregnancy complications including hypertension, need to be examined in further studies.

Pharmacological lactation suppression with D2 receptor agonists and risk of postpartum psychosis: A systematic review

It has been suggested that D2 receptor agonists commonly used postpartum for the physiological suppression of lactation, such as bromocriptine and cabergoline, may increase the risk of illness onset or relapse in women where there is a predisposition for or history of schizophrenia, bipolar disorder or postpartum psychosis. This is based on two lines of reasoning: current models of psychosis assume episodes are triggered by dysregulation of brain dopaminergic activity and treated by medications that universally have D2 receptor antagonist properties; and limited research suggesting these agents may be associated with psychotic episodes in vulnerable individuals outside of the postpartum period.

Pharmacological Management of Major Depression in Pregnancy

Depression is now recognised as a common complication of pregnancy and the postpartum period. If untreated this mental illness has implications for maternal morbidity and foetal, infant and child outcomes. Most treatment guidelines recommend for moderate to severe depression the consideration of pharmacological treatment and this includes guidelines developed for the perinatal period. This chapter will provide an overview of depression in pregnancy, risks and benefits of antidepressant treatment in pregnancy and suggestions for management should pharmacological treatment be instigated or maintained in pregnancy.