Hala SalahLecturer of psychiatry

Prenatal Classes

Newspaper articles

Community lectures

Family involvement in the educational process

Routine prenatal screening

-Exercise-Diet: Omega 3 Protein Hydration Vit. (B)-Plan-For women with histories of postpartum depression

consider prophylactic antidepressants- For those who were treated during pregnancy

◦ Rest

◦ Proper nutrition

◦ Help with infant and household responsibilities

◦ Family and friends support systems

◦ Avoidance of isolation

Type of illness (bipolar)

Severity

Medications needed

Infant issues

Quality of mother’s life

Benefits of breast feeding

Precious baby

Risks of drug-induced toxicity in breast-fed infant

Individual patient approach is needed

Psychotropics

Psychotherapy Social Support

ECT

Psychosocial therapies

◦ First choice for those with mild to moderate symptoms of PPD

◦ Cognitive-behavioral therapy

◦ Interpersonal psychotherapy- focuses on patient’s interpersonal relationship and changing roles

Group therapy◦ Helps to increase support network

Family and marital therapy◦ More rapid recovery◦ More appreciative of partner’s contribution

Peer-support groups

Four factors are needed in order to understand problems related to breast-feeding by mothers taking psychotropic medication:

the prescribed dose; the level of the drug in the mother’s blood plasma; the level in the breast milk; and the levels in the infant’s serum.

Medication’s diffusion across membranes, Molecular weight and its lipophilicity.

The timing of the dose in relation to the

infant’s feeding patterns.

Drug’s dosage and frequency, its pharmacodynamics and pharmacokinetics.

Maternal / Infant / Drug

Maternal:• Drug dosage and duration of therapy

• Route and frequency of administration

• Metabolism

• Renal clearance

• Blood flow to the breasts

• Milk pH and composition

Maternal / Infant / Drug

Infant:• Age of the infant -preterm - full term 3w 8-12w• Feeding pattern

• Amount of breast milk consumed

• Drug absorption, distribution, metabolism and elimination

Most drugs are transferred into milk by the passive diffusion processes and hence maternal drug .

Active or carrier-mediated transport occurs for some. Drugs must pass from the maternal plasma, through the

capillary walls, into the alveolar cells lining milk duct. During the first few days of life there are large gaps

between these alveolar cells, which allow most molecules to cross through easily.

For psychotropics the arbitrary concentration in the

infant’s plasma of 10% of the established therapeutic

maternal dose is used as the upper threshold where the

risks of a particular drug’s side-effects are low and

treatment is accepted as safe

The newborn’s health should be taken into consideration when planning breast-feeding

Preterm immature infants should not be exposed to psychotropics

Infants’ hepatic, renal and cardiac functions should be checked before they are breast-fed by mothers on psychotropic medication

Infants older than 10 weeks are at a lower risk for adverse effects of tricyclics and there is no evidence of accumulation in the infant

The newborn should be examined regularly for any possible adverse events of medication

All professionals involved in the care of the infant should be informed of psychotropic medication usage

Increase risk of suicide after initiation of medication

If significant anxiety or insomnia present, consider adding benzodiazepine

Close follow-up

SSRI SSRI preferred initially. Drug levels are low to undetectable. All effective in open trials (Moretti, 2009). SSRIs such as fluoxetine, sertraline, paroxetine and

citalopram are safe during breast-feeding (Berle, 2004). Sertraline is considered as first line in USA (Altshuler

et al. (2001).

Tricyclics have a less favorable side effect profile and a much higher risk of morbidity and mortality from overdose.

However, it is relatively safer and low levels of drugs are secreted for most tricyclics.

Tricyclics such as amitryptyline, imipramine, nortriptyline and clomipramine are safe during breast-feeding (Becker, 2009).

Doxepin is contraindicated (respiratory depression).

Trazodone appears to be of lower risk because only 1%

passes into the milk, although drowsiness and poor

feeding have been reported. Data are limited to a few

cases and caution is advised in use of the drug.

- It has been mentioned in certain studies that Mirtazapine can be used as first-line treatment and, because of its action on histamine H1 receptors, may be preferred in some patients with postnatal depression, when night-time sedation is required (Snellen, 2007)

Venlafaxine is considered safe (Snellen, 2007).

Bupropion: Few studies found no adverse effects (in one case, it lead to occurance of seizure in the new born) (Becker, 2009).

Conventional antipsychotics have been used for decades and the accumulated data show that they are safe during breast-feeding (Phenothiazines may increase risk of SIDS).

New information is starting to emerge about some atypical antipsychotics such as olanzapine and risperidone but their safety has yet to be established (Moreeti,2009)

There is currently no information on quetiapine and amisulpride and therefore it is not safe to expose newborns to these medications

Clozapine accumulates in breast milk and is contraindicated during breast-feeding

Lithium is contraindicated during breast-feeding (high serum level, but 3 studies recommended its use with caution if no other options available. (Hale , 2004)

There is little evidence of adverse events in infants breast-fed by mothers taking carbamazepine or sodium valproate, although transient hepatic toxicity is possible with the former (Moretti, 2009)

Lamotrigine is considered moderately safe in practice

(But with high serum level in infant-be careful of risk of Steven Johnson syndrome) (Becker, 2009).

It is unsafe to expose infants to repeated doses of long-acting benzodiazepines

Shorter acting agents such as oxazepam, alprazolam and lorazepam are preferred by most authors (Becker, 2009). It must be used for short term.

Buspirone, zaleplon and zopiclone are better avoided because of limited safety data on their use.

Psychiatric emergency! Inpatient treatment Mood stabilizers Antipsychotics Benzodiazepines Lithium prophylaxis Electroconvulsive therapy

The decision to prescribe antipsychotics to breast-feeding women should depend on individual risk/benefit analysis

The current available research does not allow any absolute and clear recommendation because much of the work on psychotropic medication in breast-feeding is limited to single case reports, small series and naturalistic data collection

Causes and consequences of different adverse events are not yet widely studied

Berle J.O. The challenges of motherhood and mental health. World Psychiatry. 2004;3(2):p101–102.

Becker M.A, Mayor G.F, Elisabeth J.S. Psychotropic Medications and Breastfeeding. Primary Psychiatry. 2009;16(3):p42–51

-Hale T.W. Drug Therapy and Breastfeeding: Antidepressants, Antipsychotics, Antimanics, and Sedatives. Neo Reviews. 2004;5(10):e451.

-Moretti M.E. Psychotropic Drugs in Lactation. Can J Clin Pharmacol. 2009;16(1):p e49–e57.

-Snellen M, Galbally M, Udechuku A, Spalding G, Munro C, Drinkwater P. Psychotropic Medication in Pregnancy/Lactation. Revised 2nd Edition. Mercy Health & Aged Care: Melbourne; 2007. Pharmacy Department Mercy Hospital for Women. October 2007

Thank you