Psychopharmacology for Perinatal Psychiatry

A joint meeting of the Section of Perinatal Psychiatry and the Psychopharmacology Special Interest Group was held on 22nd November 2007, Royal College of Obstetricians and Gynaecologists, London: Psychotropic Prescribing in Pregnancy, Striving to “first do no harm.”
At the end of the meeting there was a "Round Table Discussion," arising from which it was suggested that a document recording the consensus views from this regarding "do not's" in terms of psychotropic prescribing in pregnancy and lactation be produced, and put on a blog, for discussion. This is available here:

Consensus views from Round Table Discussion at Joint Meeting of the Section of Perinatal Psychiatry and the Psychopharmacology Special Interest Group: Psychotropic Prescribing in Pregnancy, Striving to “first do no harm,” 22nd November 2007, Royal College of Obstetricians and Gynaecologists, London.


Do not:
• Forget to discuss with all women of reproductive age who
have serious mental illness (particularly bipolar disorder and
schizophrenia) their plans to reproduce, the problems to their mental health if they become pregnant or have a baby and the potential problems to a developing pregnancy related to their current medication
• Fail to recognise that women with bipolar disorder or a schizophrenia spectrum disorder will be at increased risk of gestational diabetes and should hence have appropriate monitoring (including serial BMIs and fasting glucoses where possible, or random glucoses or urine dipsticks where the former are not pragmatic)
• Forget to raise the issue of effective contraception if a woman is taking
clozapine, lithium, anticonvulsant mood stabilisers
• Prescribe anticonvulsant mood stabilisers or lithium in pregnancy unless there is no alternative
• Consider the possible adverse consequences of not prescribing a particular medication regime, especially antepartum
• Fail to take into account individual factors for each patient
• Use new drugs with currently insufficient safety data unless there are no alternatives
• Forget about appropriate supplementation, e.g. high-dose folate
• Fail to liaise and refer to other relevant disciplines, e.g. Neonatology and Paediatrics, and employ shared care protocols where possible
• Fail to use the National Teratology Information Service
• Discontinue or change medication in a postpartum breast-feeding mother (or in the immediate antepartum period) without adequate reason for doing so
• Oversedate a woman postpartum
• Prescribe clozapine to a breast-feeding mother
• Fail to monitor the newborn for blood dyscrasia should pregnancy have occurred on clozapine

Aitchison KJ, Baldwin D & Oates M: Document for discussion, 2008

In addition, text from Dr Baldwin's presentation at this conference (representing extracts from College Report CR142) are available here:

Unlicensed prescribing in pregnancy (from College Report CR 142)

• Wherever possible, women receiving psychotropic medication should carefully plan their pregnancies and discuss with their GP and psychiatrist prior to conception whether to continue, change or stop their medication. This is particularly important for women receiving treatment for serious mental illness and where there may be a significant risk of relapse following cessation of medication.

• Unless there are positive reasons not to do so, medication should be changed prior to conception to that which has the best safety profile in pregnancy.

• In general, because they have been in use for many years, there is more information available about the effects of older drugs compared to newer ones.

• Wherever possible, medication should be avoided in the first trimester. However, if women conceive whilst taking psychotropic medication it should not be abruptly withdrawn. A relapse may involve increased risks through a need to treat the relapse.

• Mild non-psychotic conditions are common in pregnancy and wherever possible psychological treatments are preferable to psychotropic medication. The threshold for prescribing psychotropic medication in pregnancy should be high and based on clear indications.

• Whilst the incidence of serious mental illness in pregnancy is lower than at other times, when these illnesses occur they should be treated energetically. The risk to mother and unborn child of not treating the illness may be higher than the potential risks of the medication.

• Pregnancy is not protective against a relapse of serious mental illness, particularly if medication has been stopped. Continuing medication is therefore in both the mother’s and the infant’s best interests. However particular attention needs to be paid to the choice of individual antipsychotic and mood stabilising agents.

• Psychiatrists, obstetricians and neonatal paediatricians should be aware of the potential of withdrawal effects in neonates if the mother has been taking antidepressants or antipsychotic medication prior to delivery.

• Doctors prescribing psychotropic medication to pregnant and breastfeeding women should ensure that they have the most up to date information possible. A good source of balanced and regularly updated information can be obtained from The National Teratology Information Service

• The lowest dose possible should be used in divided dosage and poly-pharmacy avoided.

• Doctors should always work in partnership with the women and their partners and be able to discuss the risks and benefits of their medication in a way that is easily understood.

• When prescribing medication in pregnancy or lactating women, the psychiatrist should clearly document the reasons why the medication is being prescribed, an indication that the risks and benefits have been addressed, that the woman has been involved in the decision and a note made of any advice or information received that has influenced the decision and choice of medication.


Further considerations when prescribing:

• Doctors might wish to discuss individual practice relating to unlicensed prescribing in their continuous professional development peer groups.

• Trusts might wish to audit local prescribing to gain information on the extent of, and reasons for, prescribing for unlicensed applications in individual patients.

• Doctors may wish to collaborate in evaluating the benefit and acceptability of prescribing for unlicensed applications in their practice, and submit the results of these assessments for publication in scientific journals.

• Faculties of The Royal College of Psychiatrists may wish to convene Faculty-specific working groups to consider in more detail the issue of prescribing for unlicensed applications in their patient groups.

• Research Unit of The Royal College of Psychiatrists may wish to commission large-scale research into prescribing for unlicensed applications in psychiatric practice.


Use of licensed medicines for unlicensed applications: Summary

• forms part of routine clinical practice in psychiatry

• is particularly common in certain patient groups

• can be done safely, without conferring additional risks

• can be a reflection of overall knowledge and competence

Recent Papers of Interest

An open trial of Omega-3 fatty acids for depression in pregnancy Freeman MP, Hibbeln JR, Wisner KL, et al.
Acta Neuropsychiatrica, Volume 18, Issue 1
http://dmmsclick.wiley.com/click.asp?p=4221094&m=14807&u=218261

Randomized dose-ranging pilot trial of omega-3 fatty acids for postpartum depression Freeman MP, Hibbeln JR, Wisner KL, et al.
Acta Psychiatrica Scandinavica, Volume 113, Issue 1
http://dmmsclick.wiley.com/click.asp?p=4221094&m=14807&u=218266

Gentile, Salvatore. Infant Safety With Antipsychotic Therapy in Breast-Feeding: A Systematic Review. (2008). J Clin Psychiatry. 69(4):666-73.

Abstract can be found at: http://www.ncbi.nlm.nih.gov/pubmed/18370569