Psychopharmacological treatment of schizophrenia during pregnancy and lactation

Long-acting antipsychotic treatments: focus on women with schizophrenia

Effective management of schizophrenia (SZ) requires long-term treatment with antipsychotics (APs) to prevent clinical relapse, attain remission and improve patients' personal and social functioning, and quality of life. Although APs remain the cornerstone treatment for patients with SZ, despite their potential benefits, long-acting injectable APs (LAI-APs) remain underused, most notably in women with SZ. The efficacy and tolerability of APs differ significantly between men and women, and some of these differences are more noticeable depending on the patient's age and the stage of the disorder. Although sex differences may influence treatment outcomes in SZ, their pertinence has been insufficiently addressed, especially regarding the use of LAI-APs. Some biological and social experiences, such as pregnancy, lactation, contraception and menopause, are specific to women, but these remain under-researched issues. Implications of this disorder in parenting are also of special pertinence regarding women; therefore, taking sex differences into account when treating SZ patients is now recommended, and improving personalized approaches has been proposed as a priority in the management of psychosis. In this narrative, critical review, we address some aspects specific to sex and their implications for the clinical management of women with SZ, with a special focus on the potential role of LAI-AP treatments.

Guide de prescription psychiatrique pendant la grossesse, le postpartum et l’allaitement

Perinatal psychopharmacology is an emerging specialty that is gradually developing alongside perinatal psychiatry. The management of psychiatric disorders during the perinatal period is a challenge for perinatal practitioners due to the multiple changes occurring during this crucial period. This little-known specialty still suffers from inappropriate considerations on the impact of psychotropic treatments on the mother and the infant during pregnancy and postpartum, which can promote a deficiency in perinatal psychic care. However, the risks associated with insufficient management of mental health are major, impacting both the mental and physical health of the mother and the infant. In this paper, we propose a perinatal psychopharmacology prescription guide based on available scientific evidence and international and national recommendations. We thus propose a decision-making process formalized on simple heuristics in order to help the clinician to prescribe psychotropic drugs during the perinatal period.

A systematic review of maternal and infant outcomes after clozapine continuation in pregnancy

OBJECTIVE

While there is a general lack of evidence of the safety of antipsychotic medications in pregnancy, there is a specific reluctance to continue clozapine in treatment resistant patients who become pregnant. Our aim is to systematically review adverse maternal and infant outcomes following clozapine use during pregnancy.

METHOD

A systematic review of all observational and intervention studies which highlighted adverse maternal and infant outcomes following clozapine continuation in pregnancy was undertaken. Article selection and quality were independently assessed and PRISMA guidelines adhered to.

RESULTS

Of 481 studies identified only two studies met the inclusion criteria. Both were rated as poor quality. The first found no significant increase in any adverse maternal or infant outcomes associated with antipsychotic exposure, except an increased rate of low birth weight in antipsychotic exposed babies. The number of patients exposed to clozapine was too small for separate statistical analysis. The second study found higher APGAR scoring at one minute for the clozapine group, but the scores were not statistically different at five-minutes.

CONCLUSION

Limited evidence was found to show significant adverse maternal and infant outcomes in pregnancy following clozapine continuation.Key messagesLimited evidence to show that clozapine has adverse effects on mother and infant when used during pregnancy.Risk/benefit analysis should be done thoroughly for each individual patient regarding clozapine continuation when pregnancy is confirmed.Close monitoring of mother and infant during perinatal period when clozapine is continued.Further research is needed to more clearly define the effects of clozapine on mother and infant during pregnancy and into the postnatal period.

Serious mental illness in women

PURPOSE OF REVIEW

Psychiatric illnesses are very prevalent in the United States and impact women and men differently. In this review, we will explore some gender differences in the expression of psychopathology, discuss the most common serious mental illnesses (SMI) affecting women, and review treatment options according to specific life stages. We hope to raise awareness of these issues and consequently improve outcomes for women with serious mental illness.

RECENT FINDINGS

SMI have different rates and are manifested differently in women and men because of biological, psychological, social, and cultural factors. Some SMI are more prevalent in women whereas others uniquely affect them during particular life stages. Even in disorders that have a similar prevalence in men and women or are more prevalent in men, the presentation, course, management, and repercussions can vary significantly between the two genders. Medical and psychiatric comorbidities, which directly influence treatment, prognosis, and disability, are more common in women.

SUMMARY

Several differences in the gender expression of SMI have not yet been fully described. It is important to become familiar with important characteristics of SMI in women, including biological determinants, treatment differences, and psychosocial aspects. Recognizing gender biases, cultural considerations, and adaptive responses can help identify women at risk, promote early recognition of symptoms, and prompt interventions that may lead to improved outcomes.

[Antipsychotics during pregnancy: a systematic review]

BACKGROUND

The benefits and risks of treatment with antipsychotics during pregnancy must be weighed up carefully and individually because antipsychotics can penetrate the placental barrier and prescription is off-label.

OBJECTIVE

Evaluation of the risks and benefits of administering antipsychotics during pregnancy or for women who wish to become pregnant regarding teratogenic effects, risk of fetal death and stillbirths, perinatal complications, persisting postnatal impairments or disorders and gestational diabetes.

METHODS

A systematic review of the literature is provided to aid the selection of psychotropic drugs during pregnancy and in determining whether to begin, continue or switch an antipsychotic treatment during pregnancy.

RESULTS

Large, well-designed and controlled studies are missing; however, most studies suggest that the group of antipsychotics seem to be safe in terms of teratogenicity during pregnancy, at least in monotherapy.

CONCLUSION

Treating mental illnesses during pregnancy requires an individual assessment of the benefits and risks. The risk of an untreated mental illness versus the benefit of a suitable treatment with antipsychotics and the potential harm to the infant must be evaluated. If certain rules are observed and a suitable antipsychotic is selected the risk to the newborn child and/or mother during pregnancy can be minimized, however, a decision about subsequent medication can only be indirectly made from the results of this study.

Women with Schizophrenia over the Life Span: Health Promotion, Treatment and Outcomes

Women with schizophrenia show sex-specific health needs that differ according to stage of life. The aim of this narrative review is to resolve important questions concerning the treatment of women with schizophrenia at different periods of their life—paying special attention to reproductive and post-reproductive stages. Review results suggest that menstrual cycle-dependent treatments may be a useful option for many women and that recommendations re contraceptive options need always to be part of care provision. The pregnancy and the postpartum periods—while constituting vulnerable time periods for the mother—require special attention to antipsychotic effects on the fetus and neonate. Menopause and aging are further vulnerable times, with extra challenges posed by associated health risks. Pregnancy complications, neurodevelopmental difficulties of offspring, cancer risk and cognitive defects are indirect results of the interplay of hormones and antipsychotic treatment of women over the course of the lifespan. The literature recommends that health promotion strategies need to be directed at lifestyle modifications, prevention of medical comorbidities and increased psychosocial support. Careful monitoring of pharmacological treatment has been shown to be critical during periods of hormonal transition. Not only does treatment of women with schizophrenia often need to be different than that of their male peers, but it also needs to vary over the course of life.

Antipsychotic Exposure in Pregnancy and the Risk of Gestational Diabetes: A Systematic Review and Meta-analysis

BACKGROUND

We have limited knowledge about the effects of antipsychotic exposure on the development of gestational diabetes mellitus (GDM). Aim of this study is to perform a systematic review and meta-analysis to assess GDM risk associated with antipsychotic exposure in pregnancy.

METHODS

Systematic literature search was performed using PubMed, Science Direct, Scopus, and Web of Science databases up to August 22, 2018. No restrictions to language or date were applied. Randomized, controlled trials, case-control, or cohort studies reporting GDM risk in antipsychotic-exposed, healthy controls or antipsychotic-ceased patients were included in the meta-analysis. The primary outcomes were study defined GDM, including number of events, odds ratios, and/or risk ratios (RR) with confidence intervals (CI).

RESULTS

Ten studies were included in the meta-analysis. The total number of subjects was 6213 for the antipsychotic-exposed group, 6836 for antipsychotic-ceased control group, and 1 677 087 for the healthy control group. Compared with the healthy controls, the unadjusted cumulative RR for GDM associated with antipsychotic use was 1.63 (95% CI = 1.20-2.22). Adjusted risk for GDM was significantly higher in antipsychotic exposure group than in healthy controls (RR = 1.30, 95% CI = 1.023-1.660). The adjusted RR for GDM was similar between the antipsychotic-exposed group and the antipsychotic-ceased group (RR = 0.78, 95% CI = 0.281-2.164). No significant association was found between study quality, smoking, alcohol use, gestational age, and cumulative GDM risk.

DISCUSSION

Our results indicate an increased risk of GDM with antipsychotic exposure in pregnant women, who may benefit from close pregnancy monitoring, early testing for GDM, targeting modifiable risk factors, and lifestyle modifications.

A practical guide to the use of psychotropic medications during pregnancy and lactation

The use of psychotropic medications during the perinatal period is often met with fear and discomfort on the part of both clinicians and patients. There is a great deal of misinformation about the risks of medication use during pregnancy and lactation. The risk of untreated or undertreated mental illness during this time is an important consideration when making treatment recommendations. This paper serves as a practical guide for clinicians who may be treating patients with psychotropic medication during the perinatal period. A heuristic tool for making treatment decisions will be introduced, and coverage of specific psychiatric disorders and medication classes will be provided.

Men and women respond differently to antipsychotic drugs

BACKGROUND

Because women are often perceived as having better outcomes than men in psychotic illnesses such as schizophrenia - women are less often in hospital, have a lower suicide rate, are less often involved with the law, enjoy better relationships with family and friends - the question arises as to whether or not this apparent advantage is attributable to a gender difference in antipsychotic response.

OBJECTIVE

The aim of this paper is to critically review the quantitative and qualitative literature on gender difference in antipsychotic response sourced mainly from medical databases of the last ten years.

FINDINGS

There are theoretical reasons why women's effective doses of antipsychotics might need to be lower than guidelines recommend for men, especially as regards olanzapine and clozapine, but, because there are so many variables that impinge on antipsychotic response, it is difficult to provide definitive guidance. What is evident is that some antipsychotic side effects, weight gain for instance, are more worrisome for women than for men. It is also evident that, after menopause, women need an increase in their antipsychotic dose; other reproductive stages in women's lives require special prescribing considerations as well.

CONCLUSION

There is a science, and an art, to prescribing antipsychotics, which needs to take gender into account. This article is part of the issue entitled 'Special Issue on Antipsychotics'.

Women who suffer from schizophrenia: Critical issues

Many brain diseases, including schizophrenia, affect men and women unequally - either more or less frequently, or at different times in the life cycle, or to varied degrees of severity. With updates from recent findings, this paper reviews the work of my research group over the last 40 years and underscores issues that remain critical to the optimal care of women with schizophrenia, issues that overlap with, but are not identical to, the cares and concerns of men with the same diagnosis. Clinicians need to be alert not only to the overarching needs of diagnostic groups, but also to the often unique needs of women and men.

Resources for Psychiatric Clinicians Working With Breastfeeding Mothers

In today's health care-focused climate, in which encouraging breastfeeding is part of national and international health care initiatives, clinicians in any field should have resources available for breastfeeding mothers. The current article provides information for psychiatric clinicians on how breastfeeding may affect women with psychiatric conditions, the type of lactation counselor likely to be best prepared to collaborate with psychiatric clinicians, and resources available regarding maternal psychiatric medications safe for breastfeeding infants. These resources can assist informed choices that support the mother's breastfeeding goals while providing the psychological care the nursing mother requires. [Journal of Psychosocial Nursing and Mental Health Services, 56(8),37-46.].