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

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 (2009) outline some general principles about prescribing and taking medication for mental illness during pregnancy -

  • prospective parents should be fully involved in all discussions regarding the pregnancy
  • the lowest effective dose should be used
  • the drug with the lowest risk to the mother and foetus should be used
  • as few drugs as possible should be prescribed at the same time 
  • parents-to-be should try receive adequate 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 minimal risk of causing malformations in the unborn baby. Evidence from research into the more modern atypicals is still growing, with most information on olanzapine. Olanzapine seems to be relatively safe in terms of malformations in the unborn baby, although it has been associated with other problems such as lower birth weight. Limited information says suggests that risperidone and quetiapine do not have a high risk of producing malformations in the unborn child. There is little information on any other atypical antipsychotics.

Antidepressants
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.

Mood stabilizers
The risk to women with bipolar disorder of relapsing before or after birth is high if drug based treatment is stopped.

No mood stabilizer is completely safe – lithium should be avoided in pregnancy if possible. This would preferably be by discontinuing it slowly before conceiving rather than coming off it abruptly. Valproate and carbamazepine have some known links to foetal abnormalities. They should be avoided in pregnancy if possible.

After the birth

The risk of psychosis after giving birth is much higher in women with a history of bipolar disorder.

 Women with a history of depression have a higher risk of experiencing further episodes during or after pregnancy (the risk is highest in women with a history of bipolar disorder). There is an increased risk for new mothers developing depression for the first time within 3 months of birth. 10% of pregnant women will go on to develop a depressive illness. 

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.

General principles of prescribing psychotropics in breast-feeding

  • benefits to mother and infant of breast feeding must outweigh the risk of drug exposure to the infant
  • some infants are at a greater risk than others from exposure to medications; these groups include premature babies and 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 baby's feeding time in order to avoid times when excretion of the drug is likely to be at its peak