Safely Medicating the Stork
Date: July 30, 2009
When psychiatrist Jennifer Payne was thinking of starting a family, she made an appointment with her ob/gyn for reasons not so typical. A prudent woman, Payne wanted to see how early in a pregnancy she’d have to stop her regular asthma medication. “But my doctor laughed when I asked,” she says. “Breathing and oxygen are awfully good for babies,” Payne was told. And on the verge of motherhood, she found herself with a prescription change and an altered inhaler schedule rather than the expected drug holiday.
What happened to her should also be routine for pregnant patients at risk for mood disorders, says Payne, who co-directs Hopkins’ Women’s Mood Disorders Center. “But the misperception about medicating psychiatric illnesses unfortunately continues. People think, just pull up your socks and go on. And what patients see are big spreads in Parade about harming your unborn child if you take an antidepressant. No one writes those guilt-provoking articles when pregnant women take pills for high blood pressure,” she adds.
Guilt may be the least of the damage that Payne wants to counter.
Pregnancy apparently doesn’t change the risk of major depression in the general population. History of a mood disorder, though, raises it. So more than 60 percent of pregnant women who quit their antidepressants suffer relapse, according to one study. That drops to 35 percent at a lowered dose and around 25 percent for those who keep their pre-pregnancy dosages throughout.
Fewer studies exist for bipolar disorder. The consensus, however, is that stopping a mood stabilizer in pregnancy roughly doubles the risk of mood episodes, including depression and mania.
Moreover, mood-affected women often discontinue meds during the first trimester only to resume in the second, after a relapse. “These psychiatric flare-ups are far from benign for babies in utero,” says Payne. Studies tie them to preterm delivery, low birth weight and increased risk of ADHD. And if the mother suffers postpartum depression—also more likely—babies are set for a rocky start.
So Payne is eager to help women at various points on the reproductive road—from preconception through breast-feeding. That’s not always easy considering that the FDA hasn’t approved mood disorder medications for pregnancy. As difficult: No long-term drug safety studies exist for exposed infants. All prescribing, then, is “off-label,” putting a higher-than-usual premium on clinician experience.
So Payne lets her research and learning from the high volume of patients she sees devise rules to sidestep problems. She knows, for example, that the mood stabilizer valproate has a small but real tie to fetal birth defects—a fact that fosters white-knuckle decision-making if that’s the one drug that’s kept a potential mother healthy. And she advises new breast-feeding mothers to take their antidepressants only at night after baby’s asleep: Use formula or stored milk for nighttime feeds.
“If you get paralyzed by the lack of information, you end up harming patients,” says Payne, “and we take an oath to do no harm. In these situations, you tell the parents, the pediatrician, the obstetrician what you know and what you don’t. And you support the mother after her decisions. We’re not about to abandon a patient—or her baby—if what she decides isn’t what we would recommend.”
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Healthy Mom, Healthy Baby
What brought Amy Meacham* face to face with her bipolar disorder was deeply unsettling: It involved police and restraints. But a positive twist, years later, has made Meacham a best case example for patients thinking of parenthood—so much so that psychiatrist Jennifer Payne presented the now-pregnant woman at a recent Psychiatry grand rounds.
Meacham grew up in a loving home where she very much mattered. Aside from a blip of depression in high school, she seemed on track. She graduated with honors from an Ivy League school, was teaching in graduate school, had a boyfriend. But stress and biology made other plans. At 26, she slipped into mania and psychosis. Wandering at dawn, she was picked up by police. One minute she felt at one with all of humanity; the next, she was restrained, sedated and ignored in a large inner city public hospital. “I was terrified,” she says. “It took me six months to grasp reality.”
The shock of that episode gave Meacham the bone-deep resolve to find and hold to the best therapy possible. She settled on lithium for mood stability and Wellbutrin to treat depression—a combination that allowed satisfying work and marriage.
But what pleased Payne most was that Meacham visited Hopkins for planning before pregnancy. Payne switched her off both drugs—lithium has a risk of making babies hypothyroid; Wellbutrin’s in utero effects aren’t clear—and onto Lamictal. The latter drug’s original safe use for epilepsy throughout women’s reproductive years means fewer surprises. “Also, you want to limit the number of drug exposures for unborn children,” says Payne, “if only because nobody’s studied combinations.”
Lamictal was a good match for Meacham. Staying on it for a half-year before she was pregnant, as Payne recommended, wasn’t difficult. A blood test during that waiting period marked a good baseline level for the drug, with continued monitoring during her first two trimesters.
Now well into pregnancy—she gives birth in September—Meacham has already discussed breast-feeding. Since all psychiatric medicine enters breast milk, she’ll take steps to minimize exposure. Also, she’ll stay on lamictal, a tactic so newborns avoid the bump of a switch.
“Healthy mom/healthy baby is our watchword,” Payne says.
* To protect privacy, her name and some details are switched.