MENTAL DISORDERS AND PREGNANCY

• “A mental disorder or mental illness is a psychological or

behavioural pattern that occurs in an individual and is
thought to cause distress or disability that is not expected
as part of normal development or culture”
 There are five types of mental disorders:

Anxiety disorders: Personality disorders.

• Phobia
Psychotic disorders:
• Generalized anxiety disorder
• Schizophrenia
• Social anxiety disorder
• Panic disorder • Delusional disorder
• Agoraphobia • Schizoaffective disorder
• Obsessive compulsive disorder • Schizotypy
• Post-traumatic stress disorder
Eating disorders:
Mood and Bipolar disorders:
• Anorexia nervosa
• Major depressive disorders
• Dysthymia • Bulimia nervosa
• Bipolar disorders
 Depression

• Depression that is left untreated in pregnancy, either

because symptoms are not recognized or because of
concerns regarding the effects of medications, can lead to
• a host of negative consequences

• lack of compliance with prenatal care recommendations,

• poor nutrition and self-care,
• self-medication,

• alcohol and drug use,

• suicidal thoughts
• thoughts of harming the fetus,

• the development of postpartum depression after the baby

is born.
• Treatment

If history of mild or moderate depression;

• - gradual withdrawal of antidepressants
• - switch to psychological therapy (CBT, IPT)

If history of severe depressive episodes or new

• moderate/severe episodes;
• structured psychological treatment.
• antidepressant treatment.
• combination treatment if no response.

In treatment-resistant patients; consider different single drug or ECT before considering

combination drug treatment.
 Panic disorder

• possible effects on mother and fetus are not understood

• thyroid screening may be performed

• Non-pharmacological therapies (CBT, supportive psychotherapy,

relaxation techniques, sleep hygiene, and dietary counseling)
should be considered before pharmacological therapies
(benzodiazepines, antidepressants).
• If new episodes of panic disorder; paroxetine should not be
started and a safer drug should be considered.
 Generalized anxiety disorder

• Difficult to differentiate from normal anxiety during

pregnancy.
• If already on treatment for GAD, switching to CBT should
be considered.
 Obsessive-compulsive disorder

• Several reports suggest that women may be at an

increased risk for the onset of OCD during pregnancy and
the postpartum period.
• Should be treated normally, as usually on psychological
therapy.
• Avoid combination of more than one antidepressant.
 Eating disorders

• The prevalence of eating disorders in pregnant women is approximately

4.9%.
• Studies have suggested that the severity of symptoms may actually decrease
during pregnancy.
• Anorexia nervosa reduces a woman’s fertility.

• Women with bulimia nervosa are more prone to unplanned pregnancy.

• Consider psychological treatment rather than antidepressants.
• Advise against breastfeeding if on fluoxetine.
 Psychoses in pregnancy

• Women with psychoses are less fertile, partly as a result

of hyperprolactinaemia secondary to antipsychotic drugs,
the newer atypical drugs such as clozapine and
olanzapine, do not have this effect.
• The most common manifestations being bipolar illness,
followed by psychotic depression and schizophrenia.
 Bipolar mood disorder

• Pregnant women who are stable on antipsychotic, should be

maintained on antipsychotics with monitoring of weight gain and
diabetes.
• If stopped lithium as a prophylactic treatment, consider
antipsychotics.
• If new episode while on medication consider increase of dose or
change to another antipsychotic.
 Schizophrenia

• Psychosis during pregnancy can have devastating consequences

for both the mother and her fetus, including
• failure to obtain proper prenatal care,

• negative pregnancy outcomes such as low birth weight and

prematurity,
• neonaticide or suicide.
• Women with a history of psychosis require close monitoring by
health care professionals during pregnancy
• Women with schizophrenia who are planning a pregnancy or
pregnant, should be treated according to guidelines except switch
from atypical to typical antipsychotics should be considered.
• Women with schizophrenia who are breastfeeding, should be
treated according to guidelines except that women receiving
depot medication should be advised that their infants may show
extrapyramidal symptoms.
 Psychiatric medications in pregnancy

Antidepressants

- Most tricyclics have a higher fatal toxicity index than selective

serotonin reuptake inhibitors (SSRI’s)
- Fluoxetine is the SSRI with the lowest known risk during
pregnancy
-Imipramine, nortriptyline and sertraline are present in breast milk at
relatively low levels. (unlike fluoxetine)
- SSRI’s after 20 weeks gestation may be associated with an
increased risk of persistent pulmonary hypertension in the neonate

- Paroxetine taken in the first trimester may be associated with foetal

heart rate defects
- All antidepressants carry the risk of withdrawal or toxicity in
neonates – in most cases the effects are self limiting.
Benzodiazepines

- should not be routinely prescribed for pregnant women,

except for short term treatment of extreme anxiety and

agitation.
- Risk to foetus – cleft palate
- Risk to neonate – floppy baby syndrome
Valproate

- Risk of neural tube defects

-If possible convert to another drug (e.g. for bipolar disorder convert
to antipsychotic)
-If no alternative limit to max 1gram per day in divided doses in slow
release format. (Administer 5mg per day folic acid)
Antipsychotic

- Clozapine should not be routinely prescribed for women who are pregnant
– theoretical risk of foetal agranulocytosis in the infant
- Olanzapine – risk factors for gestational diabetes should be taken into account

- Depot antipsychotics and anticholinergic drugs should not be routinely

prescribed to pregnant women because may show extrapyramidal side effects
several months after administration.
Carbamazepine and Lamotrigene

- Carbamazepine increased risk of neural tube defects (6 to 20 per

1000), also risk of gastrointestinal tract problems and cardiac
abnormalities
- Lamotrigene carries risk of oral cleft (9 per 1000 exposed
foetuses).
- Stop if possible
Lithium
- Increases risk of foetal heart abnormalities (8 per 1000 increased
to 60 per 1000)
- Avoid in first trimester and during breast feeding
- Stop if not at high risk of relapse – gradual withdrawal over 4
weeks

- Consider converting to antipsychotic

- Consider stopping for first then restarting in second
trimester if not planning to breast feed

- If continuing check levels every 4 weeks, then weekly from

36 weeks and within 24 hours of childbirth. Adjust dose to
keep at the lower end of the therapeutic range
- Monitor fluid balance in labour – risk of dehydration and
lithium toxicity

– may be necessary to check lithium levels

Electroconvulsive therapy (ECT)
- No evidence available on risk of harm to foetus