Use of psychotropic medications in breast-feeding women: acute and prophylactic treatment

The International College of Neuro-Psychopharmacology (CINP) Treatment Guidelines for Bipolar Disorder in Adults (CINP-BD-2017), Part 3: The Clinical Guidelines

Background

The current paper introduces the actual International College of Neuro-Psychopharmacology clinical guidelines for the treatment of bipolar disorder.

Concept and structure of the guidelines

The current clinical guidelines are based on evidence-based data, but they also intend to be clinically useful, while a rigid algorithm was developed on the basis of firm evidence alone. Monotherapy was prioritized over combination therapy. There are separate recommendations for each of the major phases of bipolar disorder expressed as a 5-step algorithm.

Discussion

The current International College of Neuro-Psychopharmacology clinical guidelines for the treatment of bipolar disorder are the most up-to-date guidance and are as evidence based as possible. They also include recommendations concerning the use of psychotherapeutic interventions, again on the basis of available evidence. This adherence of the workgroup to the evidence in a clinically oriented way helped to clarify the role of specific antidepressants and traditional agents like lithium, valproate, or carbamazepine. The additional focus on specific clinical characteristics, including predominant polarity, mixed features, and rapid cycling, is also a novel approach. Many issues need further studies, data are sparse and insufficient, and many questions remain unanswered. The most important and still unmet need is to merge all the guidelines that concern different phases of the illness into a single one and in this way consider BD as a single unified disorder, which is the real world fact. However, to date the research data do not permit such a unified approach.

Bipolar disorder in pregnancy and childbirth: a systematic review of outcomes

Background

Bipolar Disorder (BD) is a mental disorder usually diagnosed between 18 and 30 years of age; this coincides with the period when many women experience pregnancy and childbirth. As specific problems have been reported in pregnancy and childbirth when the mother has BD, a systematic review was carried out to summarise the outcomes of pregnancy and childbirth, in mother and child, when the mother has BD diagnosed before pregnancy.

Methods

An a priori protocol was designed and a systematic search conducted in PubMed, CINAHL, Scopus, PsycINFO and Cochrane databases in March 2015. Studies of all designs were included if they involved women with a diagnosis of bipolar disorder prior to pregnancy, who were pregnant and/or followed up to one year postpartum. All stages of inclusion, quality assessment and data extraction were done by two people. All maternal or infant outcomes were examined, and narrative synthesis was used for most outcomes. Meta-analysis was used to achieve a combined prevalence for some outcomes and, where possible, case and control groups were combined and compared.

Results

The search identified 2809 papers. After screening and quality assessement (using the EPHPP and AMSTAR tools), nine papers were included. Adverse pregnancy outcomes such as gestational hypertension and antepartum haemorrhage occur more frequently in women with BD. They also have increased rates of induction of labour and caesarean section, and have an increased risk of mood disorders in the postnatal period. Women with BD are more likely to have babies that are severely small for gestational age (<2nd-3rd percentile), and it appears that those women not being treated with mood stabilisers in pregnancy might not have an increased risk of having a baby with congenital abnormalities.

Discussion

Due to heterogeneity of data, particularly the use of differing definitions of bipolar disorder, narrative synthesis was used for most outcomes, rather than a meta-analysis.

Conclusions

It is evident that adverse outcomes are more common in women with BD and their babies. Large cohort studies examining fetal abnormality outcomes for women with BD who are not on mood stabilisers in pregnancy are required, as are studies on maternal-infant interaction.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1127-1) contains supplementary material, which is available to authorized users.

Medications and Breast-Feeding: A Guide for Pharmacists, Pharmacy Technicians, and other Healthcare Professionals Part III

Objective:

To provide a guide for practicing pharmacists, pharmacy technicians, and other healthcare professionals so that they are able to counsel and advise breast-feeding mothers and fellow healthcare professionals on the safety and use of antiinfectives, vaccines, antiepileptics, benzodiazepines, psychotherapeutic drugs, and radiopharmaceuticals during breast-feeding.

Data Sources:

Primary texts used by the breast-feeding community ( Medications and Mothers' Milk, Drugs in Pregnancy and Lactation, Drugs and Human Lactation) were searched, as well as Micromedex, MEDLINE, PubMed, EMBASE, and EMBASE2 (1984–February 2004).

Study Selection/Data Extraction:

Multiple sources were used wherever available to validate the data, and primary articles were used to verify all tertiary source information. Search terms included breast-feeding, lactation, nursing, and medications, as well as specific drug names.

Data Synthesis:

Concerns regarding medication use during breast-feeding have caused mothers to either discontinue nursing or not take necessary medications. Complete avoidance of medications or cessation of breast-feeding is often unnecessary. Although there are drugs that can be harmful to nursing infants, breast-milk concentrations of most drugs are insufficient to cause any harm.

Conclusions:

Having objective and reliable information on medications enables pharmacists, pharmacy technicians, other healthcare providers, and mothers to make educated decisions regarding drug therapy and breast-feeding.

Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder. The third version is based explicitly on the available evidence and presented, like previous Clinical Practice Guidelines, as recommendations to aid clinical decision making for practitioners: it may also serve as a source of information for patients and carers, and assist audit. The recommendations are presented together with a more detailed review of the corresponding evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from these participants. The best evidence from randomized controlled trials and, where available, observational studies employing quasi-experimental designs was used to evaluate treatment options. The strength of recommendations has been described using the GRADE approach. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment. The use of medication is integrated with a coherent approach to psychoeducation and behaviour change.

A prospective cohort study of antipsychotic medications in pregnancy: the first 147 pregnancies and 100 one year old babies

BACKGROUND

Many women diagnosed with varying psychiatric disorders take antipsychotic medications during pregnancy. The safety of antipsychotic medications in pregnancy is largely unknown.

METHODS

We established the National Register of Antipsychotic Medications in Pregnancy in 2005. Women who are pregnant and taking an antipsychotic medication are interviewed every 6 weeks during pregnancy and then followed until their babies are one year old. The baby's progress is closely followed for the first year of life.

FINDINGS

As of April 18 2012, 147 pregnancies had been followed through to completion. There were 142 live births and data is available for 100 one year old babies. 18% of babies were born preterm, with a higher dose of antipsychotic medication correlating to an increased likelihood of premature delivery; 43% of babies required special care nursery or intensive care after birth; 37% had any degree of respiratory distress and 15% of babies developed withdrawal symptoms. Congenital anomalies were seen in eight babies. Most pregnancies resulted in the birth of live, healthy babies. The use of mood stabilisers or higher doses of antipsychotics during pregnancy increased the likelihood of babies experiencing respiratory distress or admission to Special Care Nursery or Neonatal Intensive Care Units.

CONCLUSION

There is a great need for safety and efficacy information about the use of antipsychotic medications in pregnancy. Live, healthy babies are the most common outcome following the use of antipsychotic medication in pregnancy, but clinicians should be particularly mindful of neonatal problems such as respiratory distress.

Evidence-based guidelines for treating bipolar disorder: revised second edition--recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and target of treatment for bipolar disorder. The second version, like the first, is based explicitly on the available evidence and presented, like previous Clinical Practice guidelines, as recommendations to aid clinical decision making for practitioners: they may also serve as a source of information for patients and carers. The recommendations are presented together with a more detailed but selective qualitative review of the available evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. The strength of supporting evidence was rated. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in treatment of episodes, relapse prevention and stopping treatment.

Canadian Mothers’ Perceived Support Needs During Postpartum Depression

OBJECTIVE

To assess the support needs, support resources, barriers to support, and preferences for support intervention for women with postpartum depression.

DESIGN

Multisite, exploratory, descriptive study in which qualitative data were collected on support needs, the availability of resources, perceived barriers to support, and preferences for support of women who have experienced symptoms of postpartum depression.

PARTICIPANTS AND SETTING

Conducted in Alberta and New Brunswick; mothers were interviewed individually (Alberta, n= 24; New Brunswick, n= 17) and in groups (Alberta, n= 5; New Brunswick, n= 6).

RESULTS

For most mothers, one-on-one support was preferred when postpartum depression is recognized. Group support should be available once the mothers start to feel better and are able to comfortably interact with other mothers in a group format. This suite of alternatives needs to be underpinned by concerted public education efforts.

Antipsychotic drugs and pregnant or breastfeeding women: the issues for mental health nurses

Antipsychotic drugs and pregnant or breastfeeding women: the issues for mental health nurses Mental illness can affect up to 10% of pregnant women, and women with a pre-existing psychiatric condition are more likely to experience a relapse of symptoms during pregnancy. Antipsychotic drugs are an important part of the treatment of psychotic illnesses; however, their safety with pregnant or breastfeeding women has not been fully established. Given that these drugs will be ordered for pregnant or breastfeeding women diagnosed with a psychosis or with a pre-existing psychiatric condition, it is imperative that mental health nurses and others administering the drugs, or caring for those taking the drugs, be aware of their consequences. A review of the available evidence, albeit at times contradictory, is presented along with a discussion of the implications for mental health nurses. Recommendations for consideration when administering or counselling women regarding the use of antipsychotic drugs in pregnancy or when breastfeeding, are also included.

Clinical issues in perinatal mental health: new developments in the detection and treatment of perinatal mood and anxiety disorders

OBJECTIVE

This paper presents evidence of new developments in the detection and treatment of perinatal mood and anxiety disorders that have relevance for clinicians.

METHOD

An electronic search was conducted in MEDLINE, CINAHL, PsychINFO and The Cochrane Library Database for the interval 1995-2005 for papers published in English.

RESULTS

New developments were identified as follows: i) Broadening frames of reference within perinatal mental health. ii) Impact of disorders upon offspring. iii) Identifying women at risk of mental health problems. iv) Prevention and early intervention strategies. v) Treatments.

CONCLUSION

Perinatal mental health is a rapidly expanding field that impacts upon the health and wellbeing of all members of families with infants and young children. An evidence base for best practice is slowly emerging but considerable work is still needed in relation to the identification of women at risk, standardisation of diagnostic procedures, reduction of adverse outcomes for women and infants, prevention, early intervention, and treatment of clinical disorders.

Role of omega-3 fatty acids as a treatment for depression in the perinatal period

OBJECTIVES

To consider the possible rationale and utility of omega-3 fatty acids as a treatment for depression in the perinatal period.

METHOD

A review of published and unpublished research was undertaken, using electronic databases, conferences proceedings and expert informants.

RESULTS

Relevant bodies of evidence include an epidemiological link between low fish intake and depression. Laboratory studies show correlations between low omega-3 fatty acid levels and depression, as well as reduced levels of omega-3 in non-depressed women during the perinatal period. Treatment studies using omega-3 in patients with mood disorders further support an omega-3 contribution, as do neuroscientific theories. Research into omega-3 and infant development also highlights potential effects of depletion in the perinatal period and supports infant safety and benefits of supplementation.

CONCLUSIONS

There is a relative lack of knowledge about the safety of standard antidepressants in the perinatal period. There is a clear need for more research into alternative treatments, such as omega-3 fatty acids, in the management of depression in the perinatal period.

Women's views of antidepressants in the treatment of postnatal depression

Little research has been carried out on the treatment of postnatal depression and clinicians must currently rely on general recommendations for the use of antidepressants. Antidepressant medication as the main treatment for depression in general practice has been shown to be effective when used as prescribed. However, research has shown that depressed patients consistently receive either no medication or consistently low doses of medication. This study will investigate women's experiences of taking antidepressant medication for postnatal depression. Thirty-five women with a clinical diagnosis of postnatal depression who had been prescribed antidepressant medication completed a questionnaire detailing their experiences of taking medication. Four open-ended questions and responses were discussed with the women. Of the 35 women who were prescribed medication, 4 chose not to take it because they were breast-feeding. Twenty of the women described finding medication helpful. Although only 4 women directly reported not taking antidepressants as prescribed, the comments made by a further 9 women suggest that compliance may have been poor. This study suggests a need to improve information about medication for postnatal depression. If this information is not provided, women are likely to continue to self-manage medication at a dosage that may be clinically ineffective.

Evidence-based guidelines for treating bipolar disorder: recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and target of treatment for bipolar disorder. They are based explicitly on the available evidence and presented, similar to previous Clinical Practice guidelines, as recommendations to aid clinical decision-making for practitioners. They may also serve as a source of information for patients and carers. The recommendations are presented together with a more detailed review of the available evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. The strength of supporting evidence was rated. The guidelines cover the diagnosis of bipolar disorder, clinical management and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment.

Adverse drug reactions in breastfed infants: less than imagined

Medication use during breastfeeding shortens the duration of breastfeeding often because of overly cautious information given by healthcare providers. No comprehensive review of the literature on infant adverse reactions from drugs in breastmilk has been published. All published studies and case reports on adverse events in infants caused by medications (excluding drugs of abuse) in breastmilk were identified and analyzed. Of 100 case reports evaluated, none were considered to be "definite" using a standard ranking scale; 47% were "probable" and 53% were "possible." Drugs with central nervous system activity accounted for half of all reports. All 3 reported fatalities involved central nervous system depressants, but each had extenuating circumstances. At least 63% of reported cases were in neonates and 78% were in infants 2 months or younger; only 4% of adverse reactions occurred in infants older than 6 months of age. Published studies expand on and generally reinforce the analysis of case reports. By taking a few simple precautions in drug selection and considering the infant's age, breastfeeding rarely needs to be discouraged or discontinued when a mother needs drug therapy.

Sertraline in paired blood plasma and breast-milk samples from nursing mothers

Paired blood and breast-milk samples were collected from 10 nursing mothers receiving sertraline. Samples were collected at steady state when the patients had been taking stable doses of 50-150 mg/day over several weeks. Sertraline concentrations in both fluids were determined using a specific, validated HPLC method. Plasma and milk concentrations showed a wide inter-individual variability for the same dose. Mean plasma concentrations were linearly related to dose, but this was not the case for breast-milk concentrations. An overall milk to plasma ratio of 1.76+/-1.72 was recorded. The average dose to the infants ranged from 1.1 to 31.1 &mgr;g/kg, which is less than 2 per cent of the maternal dose per day. Further studies are necessary to determine if these doses are detrimental to the development of the infant. Copyright 2000 John Wiley & Sons, Ltd.