Drug treatment for mood disorders in pregnancy

Prevalence of benzodiazepines use during pregnancy in Lebanon

Pregnancy is a period of heightened risk period for many psychiatric disorders, particularly anxiety disorders. However, there is limited knowledge regarding the usage of psychotropic medications during pregnancy. Over the past decade there has been a notable increase in the use of medications during pregnancy, with benzodiazepines being the primary choice for alleviating anxiety. It is important to note, though, that benzodiazepines have been associated with various risks for both pregnancy and newborns. In Lebanon, to date, there has been no study estimating the prevalence of the use of benzodiazepines during pregnancy. Our study aims to find the prevalence of benzodiazepines use in a population of pregnant women in Hôtel-Dieu Hospital, a tertiary care center in Beirut, and the medical center of Saint-Joseph University and to compare our results to international literature. To accomplish our objectives we administered questionnaires to over two hundred women who had recently given birth in the gynecology department. These forms encompassed inquiries about benzodiazepine consumption, as well as various medical and socio demographic details. In total, we interviewed 225 women who gave birth at the Hôtel-Dieu de France between the months of December 2019 and February 2020 and between the months of February 2021 and October 2021 in the gynecology department. The questionnaires included socio demographic, medical, and psychiatric information as well as questions about the use of benzodiazepines. We found a significantly lower prevalence of benzodiazepine use among these women compared to the figures reported in international literature. The approval of the ethics committee was obtained on December 19, 2019 after making sure that this study raised no ethical objections. (File number: CEHDF 1533).

Treatment of dissociative identity disorder: leveraging neurobiology to optimize success

INTRODUCTION

Dissociative identity disorder (DID) is a treatable mental health condition that is associated with a range of psychobiological manifestations. However, historical controversy, modern day misunderstanding, and lack of professional education have prevented accurate treatment information from reaching most clinicians and patients. These obstacles also have slowed empirical efforts to improve treatment outcomes for people with DID. Emerging neurobiological findings in DID provide essential information that can be used to improve treatment outcomes.

AREAS COVERED

In this narrative review, the authors discuss symptom characteristics of DID, including dissociative self-states. Current treatment approaches are described, focusing on empirically supported psychotherapeutic interventions for DID and pharmacological agents targeting dissociative symptoms in other conditions. Neurobiological correlates of DID are reviewed, including recent research aimed at identifying a neural signature of DID.

EXPERT OPINION

Now is the time to move beyond historical controversy and focus on improving DID treatment availability and efficacy. Neurobiological findings could optimize treatment by reducing shame, aiding assessment, providing novel interventional brain targets and guiding novel pharmacologic and psychotherapeutic interventions. The inclusion of those with lived experience in the design, planning and interpretation of research investigations is another powerful way to improve health outcomes for those with DID.

Benzodiazepine Concentrations in the Breast Milk and Plasma of Nursing Mothers: Estimation of Relative Infant Dose

Objective: Benzodiazepines are common therapies for mental illness and insomnia, and are used during pregnancy and lactation. Although benzodiazepines have been shown to be transferred into breast milk, the amount transferred is small and compatible with breastfeeding. However, information is not available for all drugs. Therefore, we aimed to determine the milk to plasma (M/P) ratio and relative infant dose (RID), which are used as indicators of drug transfer to breast milk, to determine the safety of such drugs for lactating women and breastfeeding infants. Methods: The study comprised of 11 pregnant women who visited the obstetrics department of Hokkaido University Hospital (approval number: 017-0131) and Tenshi Hospital (approval number: 103) for childbirth. The samples were analyzed using liquid chromatography-tandem mass spectrometry, and the M/P ratio and RID were calculated. The condition of the mother and baby at 1 month after delivery was determined from the clinical information. The target benzodiazepines were alprazolam, brotizolam, clonazepam, clotiazepam, etizolam, ethyl loflazepate, flunitrazepam, and lorazepam. Results: For all drugs, the M/P ratios were <1 and remained constant over time. For drugs other than ethyl loflazepate, the RID values were <10%, which are considered safe; however, even with ethyl loflazepate, it was only slightly >10%. No abnormalities were found in breastfeeding infants whose mothers were receiving these medications. Conclusions: The RID results of this study suggest that drug exposure through breast milk is small; thus, maternal drug treatment and breastfeeding are compatible.

Psychopharmacological Treatment of Obsessive-Compulsive Disorder (OCD)

Background:

Obsessive-compulsive disorder (OCD) is associated with affective and cognitive symptoms causing personal distress and reduced global functioning. These have considerable societal costs due to healthcare service utilization.

Objective:

Our aim was to assess the efficacy of pharmacological interventions in OCD and clinical guidelines, providing a comprehensive overview of this field.

Methods:

We searched the PubMed database for papers dealing with drug treatment of OCD, with a specific focus on clinical guidelines, treatments with antidepressants, antipsychotics, mood stabilizers, off-label medications, and pharmacogenomics.

Results:

Prolonged administration of selective serotonin reuptake inhibitors (SSRIs) is most effective. Better results can be obtained with a SSRI combined with cognitive behavioral therapy (CBT) or the similarly oriented exposure and response prevention (ERP). Refractory OCD could be treated with different strategies, including a switch to another SSRI or clomipramine, or augmentation with an atypical antipsychotic. The addition of medications other than antipsychotics or intravenous antidepressant administration needs further investigation, as the evidence is inconsistent. Pharmacogenomics and personalization of therapy could reduce treatment resistance.

Conclusions:

SSRI/clomipramine in combination with CBT/ERP is associated with the optimal response compared to each treatment alone or to other treatments. New strategies for refractory OCD are needed. The role of pharmacogenomics could become preponderant in the coming years.

Socioeconomic status and treatment of depression during pregnancy: a retrospective population-based cohort study in British Columbia, Canada

Women at the lower end of the socioeconomic distribution have higher rates of depression in pregnancy; however, we know little about the role of socioeconomic status (SES) in determining their treatment. Herein, we investigate the relationships between income and the use of health services for depression in pregnancy. This retrospective cohort study using population-based administrative datasets included all women who delivered a live infant in the province of British Columbia, Canada (population of 4.3 million) between April 1st, 2000 and December 31st, 2009. We restricted to women with an indication of depression during pregnancy and examined their use of health services to treat depression by income quintile. Women in the highest income quintile were significantly more likely to see a psychiatrist for depression during pregnancy and to fill prescriptions for serotonin reuptake inhibitor (SRI) antidepressants than women in the lowest income quintile. Women at the lower end of the income distribution were more likely to have a GP visit for depression. Women at the low end of the income distribution were more likely to end up in hospital for depression or a mental health condition during pregnancy and more likely to receive a benzodiazepine and/or an antipsychotic medication. Our findings suggest a critical gap in access to health services for women of lower income suffering from depression during pregnancy, a time when proper access to effective treatment has the most potential to improve the long-term health of the developing child and the whole family unit.

Psychotropic Medication and Substance Use during Pregnancy by Women with Severe Mental Illness

BACKGROUND

Sociodemographic factors, alcohol and drug intake, and maternal health are known to be associated with adverse outcomes in pregnancy for women with severe mental illness in addition to their use of psychotropic medication. In this study, we describe the demographic characteristics of women hospitalized for severe mental illness along with their use of medication and other drugs during the pregnancy period.

METHODS

A clinical case note review of women with psychosis who were hospitalized at the State Psychiatric Hospital in Western Australia during 1966-1996, gave birth between 1980 and 1992, and received psychiatric treatment during the pregnancy period. The mother's clinical information was available from the case notes and the midwives record. The demographic characteristics of the mothers were described together with their hospitalization pattern and their medication and substance use during the pregnancy period.

RESULTS

A total of 428 mothers with a history of severe mental illness were identified who gave birth during 1980-1992. Of these, 164 mothers received psychiatric care during the pregnancy period. One hundred thirty-two had taken psychotropic medication during this period. Mothers who were married, of aboriginal status or living in regional and remote areas appeared less likely to be hospitalized during the pregnancy period, while older mothers and those with a diagnosis of schizophrenia were more likely to be hospitalized. The number of mothers taking psychotropic medication in the first trimester of pregnancy was reduced compared to the previous 6 months. The decline in the number taking substances over the same period was not significant. In all, 16% of the women attempted suicide during the pregnancy period and 10% non-suicidal self-injury.

CONCLUSION

The women demonstrate a pattern of decreased use of psychotropic medication use from the period before pregnancy to the first trimester of pregnancy. Our data highlight the importance of women with severe mental illness receiving regular ongoing monitoring and support from their psychiatrist during pregnancy regarding the level of medication required as well as counseling with regard to substance use, non-suicidal self-injury, and attempted suicide.

Pharmacotherapy of obsessive-compulsive disorder during pregnancy: a clinical approach

Obsessive-compulsive disorder (OCD) is a relatively common psychiatric disorder in the perinatal period. However, specific pharmacological treatment approaches for patients with OCD during pregnancy have not been satisfactorily discussed in the literature. In addition, there are no randomized controlled studies on the treatment of this disorder during pregnancy. The present paper discusses the pharmacological treatment of OCD in the light of data on the safety of antipsychotics and serotonergic antidepressants during pregnancy and their efficacy in the non-perinatal period. Treatment decisions should be individualized because the risk-benefit profile of pharmacotherapy is an important issue in the treatment of pregnant women with any psychiatric diagnosis.

Prenatal antidepressant exposure and the risk of autism spectrum disorders in children. Are we looking at the fall of Gods?

Recent information suggests that antenatal exposure to psychotropics may impair child neurodevelopment. Thus, aim of this review is to examine systematically available literature investigating potential associations between prenatal use of selective serotonin reuptake inhibitors (SSRIs) and the risk of autism spectrum disorders (ASDs).

METHODS

Medical literature published in English since 1988 identified using MEDLINE/PubMed, EMBASE, SCOPUS, and The Cochrane Library. Search terms: antidepressants, autism (spectrum disorders), childhood, children, neurodevelopment, pregnancy, SSRIs. Searches were updated until March 5, 2015.

RESULTS

Six out of eight reviewed articles confirm an association between antenatal SSRI exposure and an increased risk of ASDs in children. However, the epidemiologic evidence on the link between prenatal SSRI exposure and ASD risk must still be cautiously interpreted, because of potential biases of analyzed research.

LIMITATIONS

Main limitations of reviewed studies include: lack of directly validated clinical evaluation, impossibility to identify women who really took the prescribed medications during pregnancy, no assessment of severity and course of symptoms in relation to the pregnancy, lack of information about unhealthy prenatal lifestyle behaviors.

CONCLUSIONS

Despite such limitations, available data show that some signal exists suggesting that antenatal exposure to SSRIs may increase the risk of ASDs. Thus, there is an urgent need for further, large, well-designed research finalized to definitively assess the existence and the magnitude of this severe risk, thus confirming or denying that we are truly looking at "the fall of Gods", since for many years SSRIs have been considered the first-choice agents for treating antenatal depression (Gentile, 2014; Gentile, 2011a; Gentile, 2005).

Early pregnancy exposure to selective serotonin reuptake inhibitors, risks of major structural malformations, and hypothesized teratogenic mechanisms

INTRODUCTION

Selective serotonin reuptake inhibitors (SSRIs) are commonly used to manage antenatal depression. Hence, the aim of this systematic review is to assess the prevalence of birth defects associated with pregnancy exposure to such agents and summarize the hypothesized teratogenic mechanisms.

AREAS COVERED

Medical literature published in English (1980 - June 2015) was electronically searched to identify all articles reporting an increased prevalence of birth defects associated with prenatal SSRI exposure and hypothesizing teratogenic mechanisms.

EXPERT OPINION

The only recurrent pattern of congenital anomalies associated with antenatal SSRI exposure is heart defects. SSRIs may alter the function of serotonin and related receptors which are involved in the development of the monoamine-dependent cardiac structures. Nevertheless, the magnitude of this increase and, thus, its clinical significance are unclear. Therefore, a cautious approach of using SSRI during pregnancy only in the case of major depressive episodes should be applied. However, this risk should be balanced against the risks associated with the worsening of depressive symptoms, and take into consideration the large number of studies that found no associations between transplacental SSRI exposure and cardiac anomalies. Prenatal ultrasonography and Doppler sonography to detect early cardiac defects are also advisable. Non-pharmacological approaches are preferred for less severe psychiatric disorders.

A pharmacological approach to panic disorder during pregnancy

Anxiety disorders and pregnancy may occur concurrently in some women. Although, several epidemiological or clinical studies about anxiety disorders in pregnancy exist, data on their treatment are very limited. Similar to other anxiety disorders, specific pharmacological treatment approaches in pregnant women with panic disorder (PD) have not been discussed in the literature. An important issue in the treatment of pregnant women with any psychiatric diagnosis is the risk-benefit profile of pharmacotherapy. Therefore, the treatment should be individualized. Untreated PD seems to be associated with several negative outcomes in the pregnancy. When the results of current study regarding the safety of pharmacological agents on the fetus and their efficacy in PD were gathered, sertraline, citalopram, imipramine and clomipramine at low doses for pure PD, and venlafaxine appeared to be more favorable than the other potential drugs. However, controlled studies examining optimum dosing, efficacy of antipanic medications and risk-benefit profile of intrauterine exposure to treated or untreated PD are urgently needed.

Sustained behavioral effects of lithium exposure during early development in zebrafish: involvement of the Wnt-β-catenin signaling pathway

Lithium has been the paradigmatic treatment for bipolar disorder since 1950s, offering prophylactic and acute efficacy against maniac and depressive episodes. Its use during early pregnancy and the perinatal period remains controversial due to reports of negative consequences on the newborn including teratogenic and neurobehavioral effects generally referred as Floppy baby syndrome. The mechanisms underlying lithium therapeutic action are still elusive but exacerbation of Wnt signaling pathway due to GSK-3 inhibition is believed to represent its main effect. In this study we evaluated the impact of lithium exposure during zebrafish embryonic and early development including behavioral and molecular characterization of Wnt-β-catenin pathway components. Wild-type zebrafish embryos were individually treated for 72 hpf with LiCl at 0.05, 0.5 and 5mM. No significant teratogenic and embryotoxic effects were observed. At the end of treatment period western blot analysis of selected Wnt-β-catenin system components showed increased β-catenin and decreased N-cadherin protein levels, without significant changes in Wnt3a, supporting GSK-3 inhibition as lithium's main target. At 10 dpf 0.5 and 5mM lithium-treated larvae showed a dose-dependent decrease in locomotion among other exploratory parameters, resembling lithium-induced Floppy baby syndrome neurobehavioral symptoms in humans. At this later period previously altered proteins returned to control levels in treated groups, suggesting that the neurobehavioral effects are a lasting consequence of lithium exposure during early development. RT-qPCR analysis of β-catenin and N-cadherin gene expression showed no effects of lithium at 3 or 10 dpf, suggesting that protein fluctuations were likely due to post-transcriptional events. Other Wnt target genes were evaluated and only discrete alterations were observed. These results suggest that zebrafish may be a valuable model for investigation of early effects of lithium that may be mediated by effects on the Wnt signaling pathway.

Are Attributes of Pregnancy and the Delivery Room Experience Related to Development of Autism? A Review of the Perinatal and Labor Risk Factors and Autism

Autism is a neurodevelopmental disorder marked by severe deficits in social communication and interactions. It is a complex condition that lacks an established preventive method, warranting a need for research to identify possible environmental triggers. The identification of external factors particularly perinatal risk factors forms the initial critical step in preventing and alleviating risks. We conducted a literature review to assess evidence suggested in the worldwide literature. Perinatal risk factors that have a suggested association include β2 adrenergic receptor agonists, labor induction and augmentation, maternal infection and disease (i.e., antiphospholipid syndrome), antiepileptic drugs, cocaine use, and oral supplements. Smoking has not been found to have a direct association. Pollutants, selective serotonin reuptake inhibitors, artificial insemination, and fertility medications may have a link, but results are often conflicted. Factors related to the delivery room experience may be associated with meconium aspiration syndrome, birth weight, and labor time. Several risk factors during the pregnancy and labor periods have been associated with autism; yet further studies with large populations are needed to establish definitive associations. The fact that several risk factors during the prenatal and labor periods are implicated in autism should prompt the medical community to focus on the pregnancy and labor periods as preventive measures to curb the incidence of autism.

Low-dose imipramine for treatment of panic disorder during pregnancy: a retrospective chart review

Although imipramine is one of the antidepressants that could be effective in the treatment of panic disorder, data on its usage for this diagnosis in the pregnancy period are limited. This report presents the results of 16 pregnant women with panic disorder without comorbid diagnosis who underwent low-dose imipramine (10-40 mg/d) treatment. According to the Clinical Global Impression-Improvement Scale, 12 (75%) of 16 women responded to the treatment. The results suggest that low-dose imipramine may be useful for the treatment of panic disorder during pregnancy.

Patterns of psychotropic medicine use in pregnancy in the United States from 2006 to 2011 among women with private insurance

Background

Psychiatric disorders are equally common during pregnancy as among non-pregnant women, and many of these conditions are treated with psychotropic medicines. Relatively little is known about patterns of use of many these agents during pregnancy, and specifically of how rates may have shifted during the last decade. We aimed to quantify the rate of pregnancy related exposures to categories of psychotropic medicines stratified according to the primary indication for use (antidepressants, antipsychotics, anxiolytics, and psychostimulants), trimester of pregnancy, trends over time and region, and indication for use.

Methods

We conducted a retrospective cohort study of pregnancies among women in the Truven Health MarketScan database (source population 70 million Americans), which captures person-specific clinical use and includes detailed information on filled prescriptions, hospitalizations and outpatient visits for all privately insured employees and their dependents. We classified psychotropic medicines of interest using ATC level 3 accordingly: antipsychotics (N05A); anxiolytics (N05B); antidepressants (N06A); psychostimulants, agents used for ADHD and cognitive enhancement (N06B). We also examined temporal and regional trends in use.

Results

We included 343,299 women who had a live birth between Jan 1, 2006 and Dec 31, 2011, of whom 10.3% were dispensed one or more psychotropic medicines during pregnancy. This rate varied from 6% to 15% between states. The rate of use of psychotropic medicines was relatively stable between 2006 and 2011. The most commonly used psychotropic medicines were selective serotonin reuptake inhibitors (5.1%) and benzodiazepine or benzodiazepine-like medicines (3.9%). Among psychotropic users, the most commonly associated psychiatric diagnosis was depression (25.0%), followed by anxiety disorders (24.4%). Approximately 1.6% of women used more than one category of psychotropic medicine in pregnancy, most commonly an antidepressant and an anxiolytic medicine (1.2%).

Conclusions

Given this relatively high rate of use, the lack of evidence that the most frequently used medications improve birth outcomes and the safety concerns associated with both early and late pregnancy use for many frequently-used medications, there is a need for further study of factors driving psychotropic medication use during pregnancy.

Prescribing of psychiatric medication to bereaved parents following perinatal/neonatal death: an observational study

To examine psychiatric prescribing in response to perinatal/neonatal death, we analyzed data from a cross-sectional survey of 235 bereaved parents participating in an online support community. Of the 88 respondents prescribed medication, antidepressants were most common (n = 70, 79.5%) followed by benzodiazepines/sleep aids (n = 18, 20.5%). Many prescriptions were written shortly after the death (32.2% within 48 hr, 43.7% within a week, and 74.7% within a month). Obstetrician/gynecologists wrote most prescriptions given shortly after loss. Most respondents prescribed antidepressants took them long-term. This sample is select, but these data raise disturbing questions about prescribing practices for grieving parents.

Pharmacological and toxicological effects of lithium in zebrafish

Lithium is the paradigmatic treatment for bipolar disorder and has been widely used as a mood stabilizer due to its ability to reduce manic and depressive episodes, efficiency in long-term mood stabilization, and effectiveness in reducing suicide risks. Despite many decades of clinical use, the molecular targets of lithium are not completely understood. However, they are credited at least partially to glycogen synthase kinase 3 (GSK3) inhibition, mimicking and exacerbating Wnt signaling pathway activation. There has been a great effort to characterize lithium cellular and system actions, aiming to improve treatment effectiveness and reduce side effects. There is also a growing concern about lithium's impact as an environmental contaminant and its effects on development. In this scenario, zebrafish is a helpful model organism to gather more information on lithium's effects in different systems and developmental stages. The rapid external development, initial transparency, capacity to easily absorb substances, and little space required for maintenance and experimentation, among other advantages, make zebrafish a suitable model. In addition, zebrafish has been established as an effective model organism in behavioral and neuropharmacological studies, reacting to a wide range of psychoactive drugs, including lithium. So far only a limited number of studies evaluated the toxicological impact of lithium on zebrafish development and demonstrated morphological, physiological, and behavioral effects that may be informative regarding human findings. Further studies dedicated to characterize and evaluate the underlying mechanisms of the toxic effects and the potential impact of exposure on developing and adult individuals are necessary to establish safe clinical management guidelines for women with bipolar disorder of childbearing age and safety disposal guidelines for pharmaceutical neuroactive compounds.

Effects of maternal psychotropic drug dosage on birth outcomes

BACKGROUND

The aim of this retrospective study was to explore the relationship between psychotropic medication dosage and birth outcomes.

METHODS

A total of 136 women were enrolled, who had an active mental disorder, were taking medication to prevent a relapse, or had a history of postpartum depression or psychosis. Medication use was evaluated for the three trimesters and during labor. Based on the defined daily dose, medication use was classified into three groups. Primary outcome variables included the infant gestational age at birth, birth weight, and Apgar scores at one and 5 minutes.

RESULTS

Our study showed a significantly higher incidence of Apgar score ≤7 at 5 minutes in women taking psychotropic drugs as compared with the group taking no medication, respectively (16.3% versus 0.0%, P=0.01). There was no significant difference between the two groups in Apgar score at one minute or in gestational age and birth weight. The results showed no significant differences in gestational age, birth weight, or Apgar scores for a low-intermediate or high dose of a selective serotonin reuptake inhibitor and for a low or intermediate dose of an antipsychotic.

CONCLUSION

This study does not indicate a relationship between doses of selective serotonin reuptake inhibitors and antipsychotics and adverse neonatal outcomes.

Low-dose mirtazapine in treatment of major depression developed following severe nausea and vomiting during pregnancy: two cases

This report presents the successful use of low-dose mirtazapine in the treatment of major depression that developed following severe nausea and vomiting symptoms during the early gestational weeks in two cases. The psychiatric diagnosis was determined with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Assessments were performed with the Clinical Global Impression-Improvement Scale and the 17-item Hamilton Rating Scale for Depression. Further large-scale studies should be carried out to confirm the useful effects observed in these cases.

Prenatal exposure to carbamazepine reduces hippocampal and cortical neuronal cell population in new-born and young mice without detectable effects on learning and memory

Pregnant women with epilepsy have to balance maternal and fetal risks associated with uncontrolled seizures against the potential teratogenic effects from antiepileptic drugs (AEDs). Carbamazepine (CBZ) is among the four most commonly used AEDs for treatment of pregnant epileptic women. We previously reported that new-born children had a decreased head circumference after in utero CBZ exposure. This study investigates how prenatal exposure of CBZ influences the number of neurons in new-born and young mouse hippocampus, amygdala and cortex cerebri. Clinical studies describe inconclusive results on if prenatal CBZ treatment influences cognition. Here we investigate this issue in mice using two well characterized cognitive tasks, the passive avoidance test and the Morris water maze test. Prenatal exposure of CBZ reduced the number of neurons (NeuN-immunoreactive cells) in the new-born mouse hippocampus with 50% compared to non-exposed mice. A reduction of neurons (20%) in hippocampus was still observed when the animals were 5 weeks old. These mice also displayed a 25% reduction of neurons in cortex cerebri. Prenatal CBZ treatment did not significantly impair learning and memory measured in the passive avoidance test and in the Morris water maze. However, these mice displayed a higher degree of thigmotaxic behaviour than the control mice. The body weight of prenatally CBZ exposed five-week old mice were lower compared to control mice not exposed to CBZ (p = 0.001). In conclusion, prenatal exposure to CBZ reduces the number of neurons dramatically in areas important for cognition such as hippocampus and cortex, without severe impairments on learning and memory. These results are in line with some clinical studies, reporting that CBZ has minor negative effects on cognition. The challenge for future studies are to segment out what possible effects a reduction of neurons could have on different types of cognition, like intellectual ability and social interaction.

The use of psychotropic medication during pregnancy: how about the newborn?

Infants are at risk of developing symptoms of Poor Neonatal Adaptation (PNA) after exposure to psychotropic drugs in utero. Such symptoms are largely similar after exposure to antidepressants, antipsychotics and benzodiazepines and consist of mostly mild neurologic, autonomic, respirator and gastro-intestinal abnormalities. Most symptoms develop within 48 hours after birth and last for 2-6 days. After exposure to Selective Serotonin Reuptake Inhibitors (SSRIs), mirtazapine or venlafaxine in utero, breastfeeding is presumably protective for development of PNA. The dosage of antidepressants does not seem to be related to the risk of PNA. In order to objectify possible symptoms of PNA, observation of mother and child at the maternity ward is advisable. If PNA symptoms do not occur, an observation period of 48-72 hours is sufficient. This applies to all types of psychotropic drugs. When PNA symptoms are present it is advisable to observe the infant until the symptoms are fully resolved. Observation can be performed by trained nurses using the Finnegan scoring list. This observation list should be administered every 8 hours. Interpretation of the scores should be carried out by a paediatrician. In most cases symptoms are non-specific. Therefore other diagnoses, such as infection or neurologic problems, have to be excluded. When there is any doubt on possible intoxications during pregnancy, toxicological urine screening is indicated. Most cases of PNA are mild, of short duration and self-limiting without need for treatment. Supporting measures such as frequent small feedings, swaddling and increase of skin to skin contact with the mother is usually sufficient. In case of severe PNA it is advised to admit the infant to the Neonatal Care Unit (NCU). Phenobarbital is a safe therapeutic option. There seem to be no major long term effects; however, additional studies are necessary in order to draw definite conclusions.

Gynecologic and reproductive health concerns of adolescents using selected psychotropic medications

Psychiatric disorders are common in adolescent girls and may require chronic therapies with psychotropic medications. Antipsychotic medications and mood stabilizers have been increasingly prescribed to and widely used by adolescents for a variety of both "on" an "off" label indications. Studies on the safety and monitoring of these medications in adolescent girls have shown important potential for gynecologic and reproductive adverse effects. The objective of this article is to review the mechanisms for and management of menstrual disorders mediated by hyperprolactinemia associated with antipsychotic medications, hypothyroidism associated with lithium and quetiapine, and the independent association of polycystic ovary syndrome (PCOS) in girls using valproic acid. Beyond their susceptibility to these disruptions in the menstrual cycle, adolescent girls with psychiatric illness also have increased sexual risk behaviors. These behaviors makes it all the more important to review teratogenicity and clinically relevant contraceptive drug interactions in adolescent girls using these psychotropic medications.

Drug treatment developments in schizophrenia and bipolar mania: latest evidence and clinical usefulness

Schizophrenia and bipolar disorder are often highly debilitating with chronic courses, and psychotropic drugs represent cornerstones in the treatment. The primary aim of the review was to summarize the latest evidence with regards to the efficacy and effectiveness of drug treatment of schizophrenia and the manic phases of bipolar disorder. Schizophrenia systematic reviews conclude that antipsychotic drugs are effective in treating overall symptoms of psychosis and in preventing relapse. Some of the newer agents, the second-generation antipsychotics (SGAs), have demonstrated superiority compared with the older first-generation drugs and other SGAs but side-effect differences among the drugs are of a greater magnitude than effect differences. The pragmatic randomized trials of effectiveness have shown a longer time until treatment discontinuation for olanzapine compared with other antipsychotics. Cohort studies have found superiority for the long-acting injection formulations compared with the oral formulations of the drugs, and lower total mortality risk in users of antipsychotics compared with non-users. In bipolar mania SGAs have shown superior antimanic efficacy compared with other mood-stabilizing drugs. In conclusion antipsychotics, in particular some of the SGAs, seem to be drugs of first choice for both schizophrenia and bipolar mania. This perspective review focused on mean effects but the group means may not always be particularly useful as schizophrenia and bipolar mania are biologically heterogeneous disorders with large inter-individual variations in drug response and tolerance. In patients with a prior drug history the different pharmacological and clinical profiles may be exploited in subsequent choices of drugs.

Therapeutic potential of mood stabilizers lithium and valproic acid: beyond bipolar disorder

The mood stabilizers lithium and valproic acid (VPA) are traditionally used to treat bipolar disorder (BD), a severe mental illness arising from complex interactions between genes and environment that drive deficits in cellular plasticity and resiliency. The therapeutic potential of these drugs in other central nervous system diseases is also gaining support. This article reviews the various mechanisms of action of lithium and VPA gleaned from cellular and animal models of neurologic, neurodegenerative, and neuropsychiatric disorders. Clinical evidence is included when available to provide a comprehensive perspective of the field and to acknowledge some of the limitations of these treatments. First, the review describes how action at these drugs' primary targets--glycogen synthase kinase-3 for lithium and histone deacetylases for VPA--induces the transcription and expression of neurotrophic, angiogenic, and neuroprotective proteins. Cell survival signaling cascades, oxidative stress pathways, and protein quality control mechanisms may further underlie lithium and VPA's beneficial actions. The ability of cotreatment to augment neuroprotection and enhance stem cell homing and migration is also discussed, as are microRNAs as new therapeutic targets. Finally, preclinical findings have shown that the neuroprotective benefits of these agents facilitate anti-inflammation, angiogenesis, neurogenesis, blood-brain barrier integrity, and disease-specific neuroprotection. These mechanisms can be compared with dysregulated disease mechanisms to suggest core cellular and molecular disturbances identifiable by specific risk biomarkers. Future clinical endeavors are warranted to determine the therapeutic potential of lithium and VPA across the spectrum of central nervous system diseases, with particular emphasis on a personalized medicine approach toward treating these disorders.

Do psychiatric medications, especially antidepressants, adversely impact maternal metabolic outcomes?

BACKGROUND

Psychiatric illnesses, particularly depression, are some of the most common complications of pregnancy. Accordingly, pharmacologic treatment of these illnesses is prevalent and increasing. Systematic reviews on psychiatric medication use during pregnancy have shown effects on obstetrical and neonatal outcomes and non-systematic reviews of maternal outcomes suggest higher weight gain and an increased risk of gestational diabetes. However, to date there has not been a systematic review of the effects of these medications on maternal metabolic outcomes.

OBJECTIVE

The objective of this study was to assess the relationship between psychiatric medication use during pregnancy and adverse maternal metabolic outcomes [gestational weight gain (GWG), gestational diabetes (GDM) and postpartum weight retention (PPWR)].

STUDY DESIGN

Systematic review and meta-analysis were used. We searched Medline, EMBASE, PsychInfo and references. Two reviewers independently performed each step of the systematic review, following the MOOSE guidelines.

RESULTS

Of 3080 non-duplicate titles and abstracts, 175 articles underwent full text review. Two moderate quality cohort studies were included. No differences were found for GWG, GDM and PPWR.

LIMITATIONS

There were only two studies which met our inclusion criteria, making it difficult to make any definitive conclusions regarding the effects of psychiatric medication on maternal metabolic outcomes.

CONCLUSIONS

Despite the suggestions in non-systematic reviews that psychiatric medication use during pregnancy results in adverse maternal metabolic sequelae, in this systematic review, we found no evidence of an increased risk of GWG, GDM or PPWR in women with psychiatric illness who took psychiatric medications compared to non-medicated women with psychiatric illness. However, more, high quality studies are needed in this area to determine if there is an association between psychiatric medication use and maternal metabolic outcomes.

Perinatal stress, brain inflammation and risk of autism-review and proposal

BACKGROUND

Autism Spectrum Disorders (ASD) are neurodevelopmental disorders characterized by varying deficits in social interactions, communication, and learning, as well as stereotypic behaviors. Despite the significant increase in ASD, there are few if any clues for its pathogenesis, hampering early detection or treatment. Premature babies are also more vulnerable to infections and inflammation leading to neurodevelopmental problems and higher risk of developing ASD. Many autism "susceptibility" genes have been identified, but "environmental" factors appear to play a significant role. Increasing evidence suggests that there are different ASD endophenotypes.

DISCUSSION

We review relevant literature suggesting in utero inflammation can lead to preterm labor, while insufficient development of the gut-blood-brain barriers could permit exposure to potential neurotoxins. This risk apparently may increase in parents with "allergic" or autoimmune problems during gestation, or if they had been exposed to stressors. The presence of circulating auto-antibodies against fetal brain proteins in mothers is associated with higher risk of autism and suggests disruption of the blood-brain-barrier (BBB). A number of papers have reported increased brain expression or cerebrospinal fluid (CSF) levels of pro-inflammatory cytokines, especially TNF, which is preformed in mast cells. Recent evidence also indicates increased serum levels of the pro-inflammatory mast cell trigger neurotensin (NT), and of extracellular mitochondrial DNA (mtDNA), which is immunogenic. Gene mutations of phosphatase and tensin homolog (PTEN), the negative regulator of the mammalian target of rapamycin (mTOR), have been linked to higher risk of autism, but also to increased proliferation and function of mast cells.

SUMMARY

Premature birth and susceptibility genes may make infants more vulnerable to allergic, environmental, infectious, or stress-related triggers that could stimulate mast cell release of pro-inflammatory and neurotoxic molecules, thus contributing to brain inflammation and ASD pathogenesis, at least in an endophenotype of ASD patients.

[Prevention of perinatal depression and anxiety with periconceptional care]

In the public mind, pregnancy, childbirth and newborn care is one of the most wonderful living experiences. However, epidemiological studies have shown that the risks of psychiatric disorders in the perinatal period are multiplying. Pregnancy entails with dramatic physical, mental and social role changing. The birth is a big, irreversible life event, and it should also be nominated as "rite of passage". This process represents a normative crisis during life, which needs new coping mechanisms to be developed. The stress and anxiety during the development of the fetus causes negative consequences in the short and long-term and it causes dangerous complications for the mother, too. During postpartum period, the incidence of major depression is approximately 15-20% that most frequently occurs within 6 months after birth but until the child is 2 years old it can develop any time. Serious risks of the postpartum depression are suicide and infanticide. In addition, it also represents serious teratogenic effects of cognitive and psychomotor development of children. It makes harder to recognize that the symptoms are largely the same as in any other stage of depression occurring during lifetime, but some of the symptoms compliant of normal pregnancy and the postpartum period. In addition, the majorities of women recognize heavily the problem and visit a doctor, because based of social expectations they should feel happiness. After the disclosure of risk factors and securing preventive conditions, preparing to be a mother is effective in prevention of development of perinatal depression. The effective therapy is primarily based on the coaching approach, and requires multi-directional approach.

Selective serotonin reuptake inhibitor exposure during early pregnancy and the risk of birth defects

OBJECTIVE

To assess the methodological value of studies that signaled one or more selective serotonin reuptake inhibitors (SSRIs) as teratogenic agents.

METHOD

Medical literature, published in English (1980-November 2010), was searched using MEDLINE/PubMed, TOXNET, EMBASE, and The Cochrane Library to identify all articles, reporting primary data that suggested any increased rate of congenital malformations following prenatal exposure to SSRIs as a group or single SSRI agents.

RESULTS

Reviewed studies showed some severe methodological limitations, such as data coming from retrospective studies and incomplete information available with reference to timing of exposure and dosages. Further, data continue to be extrapolated from automated databases that do not declare whether the women reported actually used the prescribed medication. Further, it should be noted the distinct lack of research analysis available with reference to the potential impact of non-iatrogenic confounders on pregnancy.

CONCLUSION

In light of such considerations, the hypothesized teratogenicity of SSRIs remains undemonstrated. Hence, further, well-designed research is needed to differentiate definitively the detrimental impact of depression on pregnancy outcomes from potential iatrogenic events.