Atypical Antipsychotic Drug Aripiprazole Appropriate for Pregnancies

March 12, 2018 · Posted in Current Treatments · Comment 

pregnant womanA 2017 systematic review in the Journal of Affective Disorders found that the atypical antipsychotic medication apripiprazole (Abilify) was relatively safe for use during pregnancy and lactation. Researcher Alessandro Cuomo and colleagues reviewed 93 articles from the last two decades of research.

Placebo-controlled research on medications used during pregnancy are uncommon, due to ethical reservations about assigning women randomly to each group when their fetus may be affected. However, Cuomo and colleagues were able to find some large prospective studies and large database studies that shed light on aripiprazole’s safety during pregnancy. They concluded that the data on aripiprazole during pregnancy and breastfeeding were “relatively reassuring” and that the benefits of aripiprazole outweigh the potential risks.

Risks of relapse upon discontinuing a mood stabilizer can be as high as 80%. Illness in the mother conveys risks to the fetus, so the risk-benefit ratio may suggest that staying on effective aripiprazole treatment during pregnancy and lactation makes sense for many patients.

In a comment on the study reported by Reuters Health, Dr. Jennifer L. Payne of the Johns Hopkins School of Medicine said, “The main reason to discontinue aripiprazole for pregnancy…would be if it is not working and the mother is actively ill, or if she insisted on doing so. In my mind, the literature supports the use of aripiprazole during pregnancy in mothers with serious mental illness who are responding well to the medication.”

Management of Unipolar and Bipolar Depression During Pregnancy

March 5, 2018 · Posted in Current Treatments, Potential Treatments · Comment 

pregnancyAt the Maryland Psychiatric Research Society’s continuing medical education conference in November, Lauren Osbourne, Assistant Director of the Women’s Mood Disorders Clinic at Johns Hopkins Hospital, gave a presentation on the management of mood and anxiety during pregnancy and lactation. She had a number of important ideas for physicians and patients to consider in their decision-making process.

According to Osbourne, 60%-70% of pregnant women with unipolar depression who discontinue their antidepressants relapse. Of those with bipolar disorder who discontinue their mood stabilizers, 85% relapse, while 37% of those who stay on their medications relapse.

Something to consider when deciding whether to continue medication while pregnant is that depression in pregnancy carries its own risks for the fetus. These include preterm delivery, low birth weight, poor muscle tone, hypoactivity, increased cortisol, poor reflexes, and increased incidence of attention deficit hyperactivity disorder (ADHD) and other behavioral disorders.

The placenta makes an enzyme 11-BHSD2 that lowers the stress hormone cortisol in the baby. However, this enzyme is less active in depression, exposing the fetus to higher levels of cortisol.

Thus, the decision about whether to continue medications during pregnancy should consider the risks to the fetus of both the mother’s depression and the mother’s medications.

Most antidepressants are now considered safe during pregnancy. There have been reports of potential problems, but these data are often confounded by the fact that women with more severe depression are more likely to require antidepressants, along with other risk variables such as smoking or late delivery (after 42 weeks). When these are accounted for by using matched controls, the apparent risks of certain antidepressants are no longer significant. This includes no increased risk of persistent pulmonary hypertension, autism, or cardiac malformations.

There may be a possible increased risk of Neonatal Adaption Syndrome (NAS) in the first weeks of life in babies who were exposed to selective serotonin reuptake inhibitor (SSRI) antidepressants in the third trimester. This syndrome presumably results from antidepressant withdrawal, and can include respiratory distress, temperature changes, decreased feeding, jitteriness/irritability, floppiness or rigidity, hypoglycemia, and jaundice. There is not yet a robust literature on the syndrome, but Osbourne suggested that it disappears within 2 weeks of birth.

In her practice, Osbourne prefers to prescribe sertraline, which has the best safety data, along with fluoxetine. Sertraline is also OK for breastfeeding. There is less data on bupropion, but it also appears to be safe during pregnancy. Endocrine and enzyme changes in pregnancy typically cause a 40% to 50% decrease in concentrations of antidepressants, so doses of antidepressants typically must be increased in order to maintain their effectiveness.

Osbourne ranked mood stabilizers for bipolar disorder, from safest to most worrisome. Lamotrigine is safest. There is no evidence linking it to birth defects, but higher doses are required because of increased clearance during pregnancy. Lithium is next safest. There are cardiac risks for one in 1,200 patients, but these can be monitored. Carbamazepine is third safest. One percent of babies exposed to carbamazepine will develop spina bifida or craniofacial abnormalities. Valproate is least safe during pregnancy. Seven to ten percent of babies exposed to valproate will develop neural tube defects, other malformations, or developmental delay, with a mean decrease of 9 IQ points. The atypical antipsychotics all appear safe so far.

Alternatives and Adjuncts to Medications in Pregnancy

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