Pregnancy & mental illness

Pregnancy can be one of the most exciting times for all parents-to-be, but for people with mental illness it can also bring added concerns. As the body changes through pregnancy, mental health can be affected in different ways and day to day management of symptoms through medication may no longer be possible or advisable.
This is because some types of medication used to treat mental illness can present a risk to an unborn baby. But you can take steps to minimize the risk to yourself and to your baby by understanding the complexities of pregnancy and mental illness.

Medication & pregnancy

Research shows that women who suffer from a psychotic illness are at an increased risk of relapse during pregnancy, often as a result of suddenly stopping their medication when they find out that they are pregnant. Also, several psychotropic drugs carry a small risk of birth defects if taken during pregnancy. But medication accounts for only a small proportion of the total number of birth abnormalities; it has been shown that people with schizophrenia are more likely to have minor physical anomalies than the general population, some apparent from birth, others not till later on in life.

If you are taking medication for mental illness and wish to become pregnant you should discuss your plans with your doctor.

If you are on medication and you find out that you are pregnant, you should contact your doctor immediately. In general, it is desirable to minimise or avoid the use of medication during pregnancy and a plan should be drawn up for you and your doctor to monitor your mental health throughout the pregnancy.

The Maudsley Prescribing Guidelines (2005) outline some general principles about prescribing and taking medication for mental illness during pregnancy -

  • doctors should treat with drugs only when absolutely necessary, where potential benefit outweighs potential harm – mentally ill women who are pregnant are very likely to require treatment, especially those who have had repeated relapses
  • prospective parents should be fully involved in all discussions regarding the pregnancy
  • women with mental health problems should consider the risk of relapse if thinking about stopping treatment – having a relapse as a result of stopping treatment may result in having to take a higher dose than would otherwise have been necessary
  • it’s best to avoid, where possible, using drugs in the first three months of pregnancy – this is the time when the baby’s major organs are being formed
  • use established drugs at the lowest effective dose
  • avoid multiple drug treatments (polypharmacy) where possible
  • parents-to-be should try to make full use of available screening procedures during the pregnancy
  • the baby should be monitored after birth in order to check for any signs of withdrawal effects
  • all decisions should be accurately documented by the medical team

Antipsychotics
The older antipsychotics (typicals) are generally thought to have a very small risk of causing malformations in the unborn baby. Evidence from research into the more modern atypicals is still being collected, although Olanzapine is widely used in the UK.

Recommended - sulpiride or olanzapine

Antidepressants
Treatment with antidepressant drugs for women who develop depression during pregnancy should only be used when psychological management techniques have not worked.

The older ‘tricyclic’ antidepressants have been widely used for many years without any apparent negative effects on the unborn baby, although some babies of mothers who have used these drugs in the last three months can show signs of withdrawal effects after birth.

The more modern SSRIs also appear not to be linked with causing abnormalities when used during pregnancy.

But MAOIs should be avoided in pregnancy because of a suspected increase in the risk of congenital malformations, and the risk of increasing blood pressure to dangerously high levels.

Recommended - paroxetine or sertraline

Mood stabilizers
The risk to women with bi-polar disorder of relapsing before or after birth is very high if drug based treatment is stopped abruptly, so they are likely to be advised not to stop their treatment. For women who have had a long period of stability and are planning a family, it may be possible to stop treatment before conception and for at least the first three months. This should be discussed by the parents-to-be and their doctor.

No mood stabilizer is safe – Lithium has an association to cardiac malfunction although this is low (1 in 1000), Valproate, which has some known links to foetal abnormalities, carbamazepine and combinations of mood stabilisers should be avoided if possible.

Recommended - Avoid if possible, valproate if essential

After the birth

There is an increased risk for new mothers developing depression, or having a new psychiatric episode within 3 months of birth – 10% of pregnant women will go on to develop a depressive illness. This risk is highest for women with bipolar disorder. Ideally women should not be separated from their babies during hospitalisation. Special mother and baby units or designated beds on maternity wards are the recommended options for new mothers with mental health problems.

If you are worried you are at risk of this you could discuss what you would like to happen in such events with your doctor.

Breastfeeding whilst on medication

If you are planning to breast-feed you should be aware that small amounts of some medications pass into breast milk. The potential benefits and risks of breast-feeding your baby while taking psychotropic medication should be discussed with your doctor, who should also be able to let you know the specifics related to the particular medication(s) you are taking.

Alternatively you may like to discuss in more detail a particular drug, with the Maudsley Medication Helpline 0203 228 2999 11am-5pm Monday to Friday

General principles of prescribing psychotropics in breast-feeding

  • benefits to mother and infant must outweigh the risk of drug exposure to the infant
  • some infants are at a greater risk than others; these groups include infants with renal, hepatic, cardiac or neurological impairments
  • infants with mothers taking psychotropic drugs should be monitored for adverse effects, and any change or impact on their feeding patterns or development
  • treating the mothers mental illness should be given priority over stopping treatment in order to allow for breast-feeding
  • where possible doctors should ensure that the lowest effective dose is being used and avoiding polypharmacy where possible
  • it can be possible to plan the babys feeding time in order to avoid times when excretion of the drug is likely to be at its peak