The Perinatal Treatment Conundrum

Psychiatric disorders are common during pregnancy. For those women with symptoms prior to pregnancy, symptoms can intensify, placing the mother at risk for continued illness during the postpartum as well as for other psychiatric issues. As there can be differing manifestations of various psychiatric disorders across the perinatal period (e.g., the finding of relative quiescence of schizophrenia-like disorders during pregnancy), treatment decisions regarding medication prior to pregnancy become more complex. Among the factors to consider, experts recommend weighing the potential adverse effects of the illness on the mother and baby against the potential adverse effects and benefits of medication on outcomes, as well as the effects of medication discontinuation when faced with treatment decisions. This is often difficult to do as our understanding of many relevant issues remains incomplete. The dilemma faced by a woman is that her choice does not appear to be without consequence for her, the infant, or family, regardless of the decision she may make. Given just under half of all pregnancies are unplanned, it is imperative to further our understanding. In this issue, Leong et al. provide a piece of the missing information, specifically the lacking population-based Canadian data on all psychotropic drug use during the perinatal period. They used administrative data located at the Manitoba Centre for Health Policy to examine psychotropic medication use across the 12 months prior to pregnancy, during pregnancy, and up to 3 months postpartum in all pregnancies occurring between April 1, 2000 and December 31, 2012 (N 1⁄4 224,762). They report increased rates of psychotropic use from 2001 to 2013, consistent with other reports of increasing prescription rates overall in pregnant women. Moreover, the 1.5-fold increase over time in the 3 to 12 months prepregnancy is comparable to other Canadian data on secular trends in the rate of overall psychotropic prescriptions. Contributors to these rising rates need to be explored. Specifically, are we as health care providers doing a better job at detecting and treating or is prevalence increasing? Is there an increasing tendency to prescribe psychotropics or, perhaps, greater acceptance by patients? These are important questions, but the fact that the timing is around the perinatal period has further implications for practice. Leong et al. found that up to 16% of women used psychotropics in the 3 to 12 months prior to pregnancy; however, of those who used 3 months proximate to pregnancy, only 10% continued use during pregnancy while close to 40% and 20% discontinued prior to the first and second trimesters, respectively, and a further 30% demonstrated intermittent use throughout pregnancy. International studies have also reported high rates of discontinuation of psychotropic medications around pregnancy. With the exception of sedatives/hypnotics, psychotropic medications are typically to be used daily, not intermittently. This highlights the need for increased knowledge of the reasons for discontinuation and/or intermittent use and the consequences of cessation to adequately address treatment needs. Risk perception is a critical componentof the clinical decision-making process, and although there have been numerous reports of fear of adverse effects on the fetus as a factor for discontinuation, some have argued women can overestimate the risk of using drugs during pregnancy. Indeed, decisional conflict does appear to be at play, and risk tolerance may be an important factor as well, although both have not been well studied. There has been a surge of research on the potential adverse effects of psychotropic use lately, particularly for selective serotonin reuptake inhibitors (SSRIs). Poor outcomes, including preterm birth and immediate neonatal outcomes, among others, have been reported in association with prenatal use of SSRIs, benzodiazepines, antipsychotics, and anticonvulsants. However, with the exception of valproate, some of the clinical implications for many of the adverse effects of these drugs have been debated. The literature on