Co-Director Kathryn Emerick, MD
photo: Jamie Manser
One of the most common questions that arises when a patient with a psychiatric history learns that they are pregnant is what to do about current psychiatric medications. Unfortunately, the answer is rarely as simple as understanding the available safety data for a medication. When determining the answer for a specific patient, it may be easier to frame the discussion as less about whether a medication is or isn’t safe in pregnancy and more about what promotes the healthiest possible outcome for both mother and baby.
In perinatal psychiatry, the rule of thumb is that complete remission of psychiatric symptoms with the fewest necessary exposures is likely to be the healthiest path forward. Exposures can include medications themselves, but it also includes exposure to multiple failed medication trials, polypharmacy, withdrawal symptoms, and relapse of illness. There are general risks of untreated psychiatric illness in pregnancy to consider, and there are specific risks an individual faces — their personal history with psychiatric illness, including what has kept them stable, how difficult it has been to find successful medications, how much access to testing/labs/follow-up they have, and the severity of decompensation they experience. Ultimately, medication discussions in pregnancy are best viewed as risk-versus-risk conversations, balancing the known or suspected risks of medication exposure against the very real risks of untreated psychiatric illness to optimize outcomes.
Practically, this may look like considering the following questions:
- How stable is the patient currently?
- Are current medications effective?
- Which medications appear essential for maintaining stability?
- Are there medications that have provided minimal benefit or may no longer be necessary?
- How have prior medication changes gone for this patient?
- How severe is decompensation?
- Is this patient able to complete appropriate medication monitoring during pregnancy?
- What is the gestational age of the baby?
- Has significant medication exposure already occurred?
- What is known about reproductive safety data for each medication and how robust is that data?
All of these questions can help you and your patient work together to determine whether to continue, stop or change medications. It is a complex discussion, and if you need additional support, APAL Perinatal Psychiatrists are here to help. APAL can provide reproductive safety data for medications and can help you think through the risk-risk profile for your unique patient. Please reach out at 888-290-1336 to discuss your case.