Atypical antipsychotic medications are commonly used for the treatment of schizophrenia and bipolar disorder.  Despite the increasing use of these medications in women of child-bearing age, there is still relatively little data addressing the reproductive safety of these medications.
Newham and colleagues studied a group of infants with in utero exposure to atypical antipsychotic medications (n=45) [...]

Although the risks of smoking tobacco while pregnant are well documented and well publicized to the general population, women continue to smoke cigarettes during pregnancy. Smoking cigarettes is known to increase a woman’s risk of having a low-birth weight baby and increases the risk of preterm delivery.  While clinicians often ask about and discourage tobacco [...]

A clinician asks:  “Is there any data on the use of the Emsam patch in pregnancy?”
There is very little information on the reproductive safety of the MAOI-B inhibitor, selegiline, which is the active ingredient of the Emsam patch.  While animal studies have failed to reveal any evidence of teratogenicity, the medical literature includes [...]

Anxiety often results in the activation of the sympathetic nervous system. This activation is commonly known as the “fight or flight response”; symptoms may include increased heart rate, shortness of breath, perspiration, chest pain, and nausea or diarrhea. Activation of the fight or flight response is also associated with the activation of numerous other responses [...]

In 2006, Chambers and colleagues published an article linking SSRI use during late pregnancy to an increased risk of persistent pulmonary hypertension in the newborn (PPHN). Since that time, several other reports have been published which have examined the association between SSRI antidepressants and PPHN.  Here is a summary of the findings to date:
Chambers et [...]

While anticonvulsants, such as lamotrigine (Lamictal), topiramate (Topamax), and gabapentin (Neurontin), are being used with increasing regularity for the treatment of women with bipolar disorder, we have limited information with respect to the reproductive safety of the newer anticonvulsant agents.  In 2006, we reported on preliminary data indicating an increased risk of oral clefts among [...]

Postpartum psychosis is rare, occurring in about 1 to 2 per 1000 women after delivery.  While there appears to be a strong link between postpartum psychosis and bipolar disorder, it is estimated that about half of women who present with postpartum psychosis have no psychiatric history prior to delivery, making it difficult to identify those [...]

There have been multiple studies suggesting that depression during pregnancy increases the risk for preterm labor.  Most studies do not attribute this increase in risk to antidepressant exposure, but to the effects of the depression itself.  The mechanism is believed to be related to increased levels of corticotropin releasing hormone (CRH) which is triggered by [...]

Ms. A is a 27-year-old woman who is seven weeks pregnant and is currently taking duloxetine (Cymbalta).  She has a history of recurrent major depressive disorder (MDD) and has had a good response to duloxetine at 60 mg per day.  She has had four previous episodes of major depressive disorder (most untreated) and has been [...]

Hypertension in pregnancy is generally defined as a diastolic blood pressure of 90 mm Hg or greater or a systolic pressure at or above 140 mm Hg.  Preeclampsia is defined as the development of hypertension with proteinuria or edema induced by pregnancy, generally in the second half of gestation.  It is more common in women [...]

The lifetime prevalence rate of obsessive-compulsive disorder (OCD) has been consistently estimated to be 2%-3% in the general adult population throughout the world, making OCD one of more common psychiatric diagnoses; however research on OCD in pregnancy and peurperium has been limited.
Although most studies have not been designed to estimate the prevalence of pregnancy-related OCD [...]

About 15% of women suffer from depression during pregnancy, and many reports have suggested that depression during pregnancy may have negative effects on the fetus.   A new study from researchers at the University of Michigan indicates a link between depression during pregnancy and infant sleep problems.
This study examined sleep patterns in 18 healthy, full-term infants [...]

Women with bipolar disorder are at increased risk for recurrence of illness during pregnancy.  Therefore, many women with bipolar disorder elect to continue treatment with medications during pregnancy after weighing the risks and benefits of various treatment options with their physicians.  Lamotrigine (Lamictal) is an anticonvulsant used to treat bipolar disorder. While the safety data [...]

There have long been concerns regarding the use of the anticonvulsant valproate (Depakote) during pregnancy.  First trimester use of valproate has been associated with a 3-5% risk of neural tube defects, as well as an increased risk of other malformations affecting the heart, limbs, and genitals. A recent report published in the New England Journal [...]

Over the last several years, a number of studies have indicated that exposure to antidepressants near the time of delivery may be associated with poor neonatal outcomes. A recent prospective study from Dubnov-Raz and colleagues published in the journal Pediatrics found an association between QTc interval prolongation in neonates and antenatal exposure to selective serotonin [...]

We invite your comments as we post more cases and clinical scenarios to our blog.  Treatment decisions in the field of women’s mental health are often not straightforward, and we would like to encourage discussion among clinicians on these issues.  You are welcome to leave your name, but comments may also be submitted anonymously.  Please [...]

As more research is conducted within the field of women’s mental health, there are times when recommendations may change depending on the available data.   We will discuss a case here to illustrate this point.
The patient is a 32 year old woman with a history of anxiety who was first evaluated by this clinician in early [...]

Maguire and Mody’s report, GABAA R Plasticity during Pregnancy: Relevance to Postpartum Depression, in the July 2008, Neuron, provides evidence that an abnormal Gamma-aminobutyric acid (GABAA) receptor subunit in pregnant mice may be a useful model for postpartum depression.  The report describes how GABAA receptors, specifically, the delta-subunit-containing GABA receptor, are a preferred target for [...]

Our Perinatal and Reproductive Psychiatry team often discusses clinical cases in Rounds, a confidential forum in which we can get advice and consultation from peers who also work in the area of Women’s Mental Health.  We discussed a patient’s situation recently that highlighted the controversial area about how to prevent mood episodes in a woman [...]

Most obstetricians are now familiar with the potential for what has become known as neonatal distress syndrome (or “adaptation” syndrome) following third trimester exposure to SSRIs.  Some patients still worry about the possibility of their baby developing neonatal distress syndrome, especially if anything unusual happened during the post-delivery experience of an earlier pregnancy.  Women may [...]

A study published in the Archives of General Psychiatry shows that children of women who experience the death of a close relative may have an increased risk of developing schizophrenia later in life.  This study was conducted with records of children born in Denmark between 1973 and 1995, which were then linked to the central [...]

Mood disorders and symptoms during pregnancy and the postpartum period are not uncommon and affect women across the world.  In spite of relatively high rates of depression among childbearing women, there are often inadequate resources for treatment, particularly in poorer countries. In countries lacking resources, health care is often managed by community health workers or [...]

Happy holidays from the Center for Women’s Mental Health! As we finish up 2008, we thank you for your support and interest in our program over the past year.
The following are the ten most widely read posts from our blog over the past six months:
1. Use of Wellbutrin (Bupropion) During Pregnancy – February 20, 2007
2. [...]

Earlier this year, Dr. Lee S. Cohen, Director of the MGH Center for Women’s Mental Health, spoke with Dr. Mehmet Oz from Oprah.com and a woman with bipolar disorder about mood disorders during pregnancy and weighing the risks of treatment options.
Click here to listen to the interview on Oprah.com.

Exercise plays a vital role in achieving and maintaining good health.  Along with numerous other health benefits, recent studies have shown that exercise alleviates symptoms of depression and may be useful in treating mild to moderate major depressive disorder (MDD).  A study by Dunn and colleagues (2005) examined the efficacy of exercise as a treatment [...]

Despite efforts over the last decade to increase awareness regarding the negative effects of alcohol and other drug use during pregnancy, substance abuse among pregnant women continues to be a significant problem in the United States.  The 2003 National Household Survey on Drug Use and Health indicated that 9.3% of pregnant women used alcohol and [...]

Given recent discussions within our group and with our colleague, Lewis Holmes, MD, chief of the Genetics and Teratology Unit at Massachusetts General Hospital for Children and director of the North American AED (Antiepileptic Drug) Pregnancy Registry, I wanted to expand upon a previous blog post.  In the initial post, I wrote that women who [...]

A new study reported in Human Reproduction supports what many other studies have found, that untreated depression during pregnancy increases the likelihood of delivering before 37 weeks gestation.
In this prospective cohort study from by De-Kun Li and colleagues at the Kaiser Foundation Research Institute, women were screened for depression during the first trimester, at approximately [...]

In 2006, Chambers and colleagues published an article linking SSRI use during late pregnancy to an increased risk of persistent pulmonary hypertension in the newborn (PPHN). Based on the results of this analysis, the authors estimated the risk of PPHN to be about 1% in infants exposed to SSRIs late in pregnancy (after 20 weeks). [...]

Infertility and its treatment have been shown to be a trigger for both depression and anxiety.  Women with pre-existing histories of depression and anxiety who have been stable on medication may find themselves with worsening symptoms brought on by the stress involved in the process of infertility treatment.  Many women find the process an emotional [...]

A recent population-based case-control study published in the American Journal of Obstetrics & Gynecology used Washington State birth certificates linked to hospital discharge data to evaluate the association between hospitalization for a psychiatric illness before delivery and risk of postpartum suicide attempt. The study compared women hospitalized for a postpartum suicide attempt (n [...]

St. John’s wort (Hypericum perforatum) is an herbal preparation which has been shown, in some studies, to be effective for the treatment of mild to moderate depressive symptoms. St. John’s wort is now one of the most commonly used herbal products in the United States and is widely used in Europe.
Despite the prevalence of [...]

The link between maternal depression and anxiety during pregnancy and adverse neonatal outcome has been well-documented in the medical literature and reviewed on our website. A recent study published in the journal Early Human Development suggests that a mother’s stress during pregnancy may also negatively affect her baby’s sleep patterns.
In this longitudinal, prospective study, [...]

Previous studies have suggested that prenatal stress may be associated with a spectrum of adverse pregnancy outcomes, including preterm birth and low birth weight (reviewed in Hobel et al, 2008). A recent study from Danish researchers has investigated the impact of psychological stress on risk for stillbirth.
In this prospective cohort study, data from a [...]

Recently, the Massachusetts House of Representatives passed the Mental Health Parity House Bill 4423, which mandates that insurers and government programs cover mental health in the same capacity that they cover physical health. The Bill was introduced by Representative Ruth Balser (D-Newton).
This bill builds on the first Mental Health Parity House Bill (2000) which [...]

We commonly see women in our consultation service who have histories of depression and are planning pregnancy. They frequently have questions about alternative treatments for depression while pregnant. Given that many women are taking omega-3 fatty acids prior to pregnancy, the question arises whether they should discontinue them during pregnancy. An additional question [...]

The U.S. Food and Drug Administration (FDA) has proposed major revisions to prescription drug labeling in order to provide more accurate and helpful information on the effects of medications used during pregnancy and breastfeeding. As it stands, the current system used by the FDA classifies the reproductive safety of medications using five risk categories (A, [...]

Many women experience some degree of sleep disturbance during pregnancy. For a significant number of women, the sleep disruption may be so severe as to require some type of intervention. In a previous post, we discussed the use of different types of medications to treat insomnia during pregnancy. While these drugs are [...]

It has been postulated that psychological stress in the mother, if present at a critical time of brain development, can permanently alter a child’s response to stress and may have long-term negative consequences.  In response to stress, blood flow to the uterus is restricted and the fetus receives fewer nutrients, which may result in lower [...]

The British Medical Journal recently published a brief, but comprehensive review of eating disorders in pregnancy by Veronica Bridget Ward. Eating disorders (anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified) most commonly occur in women of reproductive age and may be influenced by pregnancy and its associated weight gain and change [...]

In 2006, GlaxoSmithKline (GSK) elected to change product label warnings for the antidepressant paroxetine (Paxil), advising against the use of this drug by women who are pregnant. This decision was based on preliminary studies which suggested an increase in the risk of cardiovascular malformations among infants exposed to paroxetine in utero. A recent [...]

Up to 25% of women experience migraine headaches during their reproductive years; often migraine headaches may be triggered or exacerbated by hormonal changes. It has been estimated that 7-14% of women experience migraines only during the premenstrual or menstrual phase of their cycles. Another 52-70% experience headaches throughout the month but note increased [...]

Q. I am currently talking Remeron for depression. I am about 16 weeks pregnant and doing well. I recently started working with a new psychiatrist, and my new doctor suggested that I switch to Prozac because he thought it would be safer for the baby. I am a little worried about making a change; I [...]

Over the past few years, multiple reports have raised questions regarding the safety of selective serotonin reuptake inhibitor (SSRI) antidepressants during pregnancy. Chambers and colleagues reported that exposure to SSRIs late in pregnancy may be associated with an increased risk of persistent pulmonary hypertension of the newborn (PPHN). In the general population, PPHN affects about [...]

Over the past 15 years, multiple studies have addressed the reproductive safety of various antidepressants. Data on the overall teratogenicity of SSRIs has come from relatively small prospective observational studies, larger international birth registries, managed health care databases, and case series; these data have cumulatively supported the reproductive safety of fluoxetine and certain other SSRIs. [...]

Depression during pregnancy is common. While concerns have been raised regarding the potential teratogenic and long-term neurobehavioral effects of psychotropic drug use during pregnancy, what is often overlooked is the fact that untreated maternal depression may also put the unborn baby at risk.
Maternal depressive symptoms during pregnancy have been shown to be associated with a [...]

As many of the traditional mood stabilizers used to treat bipolar disorder, including lithium and valproic acid, carry some teratogenic risk and the reproductive safety of other medications, including the atypical antipsychotic agents, has not been well-characterized, many women with bipolar disorder decide to discontinue their treatment during pregnancy. A new study from Dr. Adele [...]

Epidemiologic studies suggest that about 10% to 15% of women suffer from clinically significant depressive symptoms during pregnancy. Little is known, however, about the prevalence of depression among women with high risk pregnancies. A recent study published online in the Journal of Clinical Psychiatry suggests that this population may be at significant risk for [...]

At our clinic we have the opportunity to see patients at various stages of pregnancy. When we evaluate a patient while she is still in the planning stages, we may recommend changing medications to those that have a better studied safety profile during pregnancy and see how she does on those medications prior to [...]

A few weeks ago, January 7-13, 2008, was National Folic Acid Awareness Week at the Centers for Disease Control (CDC), therefore we wanted to take the opportunity to remind women of the importance of folic acid in the prevention of birth defects. Folic acid can prevent from 50-70% of neural tube defects, which are [...]

Electroconvulsive therapy (ECT) is one of the most effective treatments for depression, with response rates that are consistently higher than those observed in clinical trials of antidepressants. Furthermore, ECT may be more effective than medications for treatment-refractory depression. The American Psychiatric Association (APA) recommends ECT for patients who have had previous positive response [...]

Are you an expectant mother? Do you have questions about bipolar disorder and antidepressants or mood-stabilizers during pregnancy? If you are pregnant and diagnosed with bipolar disorder (or manic depression), you may be eligible for this research study. Participants meet with research coordinators and psychiatrists who specialize in bipolar illness during pregnancy. For more information [...]

Both antidepressant medications and cognitive therapy have been shown to be effective for the treatment of depression; however, the question remains as to whether one treatment is preferred over the other. Subjects enrolled in The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study (men and women with major depression, ages 18-75) were initially treated [...]

Most women experience some degree of sleep disturbance during pregnancy, and for a significant number of women sleep disruption may be quite severe. There are many different causes for sleep disturbance during pregnancy, and choosing the appropriate intervention relies on an accurate diagnosis of the problem.
Certain sleep disorders, such as restless leg syndrome and [...]

Recent reports have raised questions regarding the use of selective serotonin reuptake inhibitors (SSRI) during pregnancy. To date, no professional medical association has issued formal guidelines regarding the use of SSRIs during pregnancy. However, in December the American College of Obstetricians and Gynecologists ACOG published an opinion paper on this topic that is noteworthy for [...]

While it appears that many women with eating disorders may experience a remission of their symptoms during pregnancy, a new study from researchers at the University of North Carolina, Chapel Hill and the University of Oslo, Norway suggests that binge eating disorder may be triggered during pregnancy.
The study included 41,157 women who self-reported eating disorder [...]

While there have been concerns regarding the reproductive safety of psychotropic medications, it must be recognized that withholding or withdrawing pharmacologic treatment for depression or anxiety during pregnancy may not always be the safest option. Untreated psychiatric illness in the mother cannot be considered a benign event, and a number of studies have indicated that [...]

Depression is common during pregnancy, affecting 10% to 15% of women. While psychotherapy is an attractive option for the treatment of depression during pregnancy, all women do not respond to this intervention and many require pharmacotherapy. Thus far, no antidepressants have yet been approved by the FDA for use during pregnancy. Although data accumulated over [...]

There are data to support the use of certain antidepressants during pregnancy. Most of the research over the last decade has focused on the selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (Prozac) and the older tricyclic antidepressants, but there is some new data supporting the use of bupropion during pregnancy.
The most recent information from the [...]

Over the last decade information has accumulated regarding the safety of antidepressants taken during pregnancy. While much research has addressed the effect of antidepressant drugs on risk for congenital malformation, less research has focused on the long-term effects of prenatal antidepressant exposure.
In a landmark study from Irena Nulman and her colleagues at the Mortherisk program [...]

While pregnancy has traditionally been considered a time of emotional well-being, recent data indicate that about 10% to 15% of women experience clinically significant depressive symptoms during pregnancy. Furthermore, women with a history of major depression appear to be at high risk for recurrent illness during pregnancy particularly in the setting of antidepressant discontinuation. In [...]

Q. I have been taking antidepressants on and off for the last ten years, and I am now planning a pregnancy. I am now on Effexor, and my psychiatrist recommended switching to Prozac and staying on it up until the end of the second trimester. He said that antidepressants should be avoided later on in [...]

Driven by concerns regarding fetal exposure to psychotropic medications, many women with psychiatric illness attempt to discontinue their pharmacologic treatment during pregnancy; however, recent studies indicate that this approach may not be appropriate for all women. Dr. Adele Viguera and her colleagues at the Center for Women’s Mental Health have reported that among pregnant women [...]

Early reports suggested that women with bipolar disorder may be at lower risk for onset or relapse of this disorder during pregnancy and that some women may be able to remain well during pregnancy despite medication discontinuation. However, more recent studies have suggested that recurrence of affective illness during pregnancy is relatively common among women [...]

Q. I have taken Paxil for about six years for depression and obsessive-compulsive disorder. I have tried several times to stop the medication but the symptoms come back within a few weeks of stopping the medication. My husband and I are now planning a pregnancy, and my obstetrician tells me that I cannot take Paxil [...]

A recent report suggests that newborns exposed to selective serotonin reuptake inhibitors (SSRI) antidepressants such as Prozac, Zoloft, Celexa and Paxil may be at risk for developing withdrawal symptoms after delivery (Levinson-Castiel 2005). However, the investigators also noted that the symptoms usually disappeared within 48 hours and did not require medical intervention.
In this study, published [...]

Over the last decade, the number of reproductive-age women treated for depression has increased significantly. Given the incomplete information available regarding the reproductive safety of many antidepressant medications, many women choose to discontinue pharmacologic treatment during pregnancy. However, several studies estimate that about 10 to 15% of women suffer from depression during pregnancy (O’Hara et [...]

Literature accumulated over the last decade supports the use of certain selective serotonin reuptake inhibitors (SSRIs) and the older tricyclic antidepressants during pregnancy, indicating no increased risk of congenital malformation in children exposed to these medications during the first trimester of pregnancy. Still, questions remain regarding the purported risk for “toxicity” in newborns exposed to [...]

Over the past 15 years, multiple studies have addressed the reproductive safety of the selective serotonin reuptake inhibitors (SSRIs). Data on the overall teratogenicity of SSRIs come from relatively small cohort studies and larger international programs, and they have cumulatively supported the reproductive safety of fluoxetine (Prozac) and certain other SSRIs. However, several recent studies [...]

Although primarily used to treat schizophrenia and other psychotic disorders, the newer “atypical” antipsychotic agents are now used widely to treat a spectrum of psychiatric disorders, including major depression, bipolar disorder, PTSD and other anxiety disorders. While the reproductive safety of the older typical antipsychotic drugs, such as haloperidol (Haldol) and perphenazine (Trilafon), is supported [...]

About 10-15% of women suffer from depression during pregnancy. The rates are probably even higher among those women who have histories of depression prior to pregnancy. Thus, many women with recurrent illness make the decision to remain on antidepressant during pregnancy. While there have been many studies supporting the reproductive safety of certain antidepressants, including [...]

Q. I have a long history of depression and have been taking Wellbutrin (bupropion SR) for several years now. Every time I try to come off the medication, the depression comes back. I am planning to get pregnant within the next year and was wondering if it is safe to use Wellbutrin.
A. While there is [...]

In October, the Food and Drug Administration (FDA) ordered drug manufacturers to include warnings in the packaging inserts regarding the use of certain antidepressants, including the selective serotonin reuptake inhibitors (SSRIs) and venlafaxine (Effexor), during pregnancy. The labels now describe a spectrum of adverse events in newborns exposed to these drugs late in the third [...]

Depression during pregnancy is relatively common, affecting about 10 to 15% of women. While there is a growing body of literature supporting the reproductive safety of certain antidepressants, our understanding of how these psychotropic medications affect the developing fetus remains incomplete. For this reason, many women and their physicians would prefer to avoid the use [...]

The increasing number of reproductive-age women taking antidepressants has raised concerns about the potential risks of using these medications during pregnancy. Literature accumulated over the last decade supports the use of certain selective serotonin reuptake inhibitors (SSRIs) and the older tricyclic antidepressants during pregnancy, indicating no increased risk of congenital malformation in children exposed to [...]

Although data accumulated over the last 30 years suggest that some medications may be used safely during pregnancy, our knowledge regarding the risks of prenatal exposure to psychotropic medications is incomplete. Because neuronal migration and differentiation occur throughout pregnancy and into the early years of life, the central nervous system (CNS) remains particularly vulnerable to [...]

Unfortunately the mood stabilizers most commonly used to treat bipolar disorder (including lithium and valproic acid) can increase the risk of certain types of congenital malformations in children exposed [...]

Depression during pregnancy (antenatal depression) is relatively common, affecting about 10% of women. While there is a growing body of literature supporting the reproductive safety of certain antidepressants, our understanding of how these psychotropic medications affect the developing fetus remains incomplete. For this reason, antidepressants are typically avoided during pregnancy; thus, there is a clear [...]

Although most people tend to think of pregnancy as a time of emotional well-being, depression is relatively common, affecting about 1 in 10 women. While there are obvious concerns related to the use of antidepressants during pregnancy and the effects of these medications on the developing fetus, less attention has focused on the impact of [...]

For women with bipolar disorder who are planning a pregnancy, it is common practice to discontinue mood stabilizers prior to attempts to conceive, since the mood stabilizers most commonly used to treat [...]

The data regarding the use of the benzodiazepines (including Klonopin, Xanax, Ativan, and Valium) during pregnancy are somewhat controversial. Studies suggest there may be an increased risk of cleft lip and palate [...]

Most women and their doctors try to avoid using medications during pregnancy. Of greatest concern is that a medication used during pregnancy may in some way harm the developing fetus or, at the [...]

Unfortunately the mood stabilizers most commonly used to treat bipolar disorder (including lithium and valproic acid) can increase the risk of certain types of birth defects or congenital malformations [...]

Women who take antidepressants for their depression must make a difficult decision when they plan to become pregnant. Should they continue their medication during pregnancy? Or should they stop? Although [...]

It is relatively common for women with panic disorder to experience recurrent anxiety and panic symptoms during pregnancy. This is especially true for women who have been stabilized on an anti-panic medication prior to conception and abruptly discontinue the medication after becoming pregnant. [...]