Neuroactive steroids or neurosteroids are a new class of medications which appear to have anxiolytic and antidepressant effects and have received a great deal of attention over the past few years.  Most of neuroactive steroids currently under investigation as antidepressants are derivatives of allopregnanolone.  In the human body, the hormone progesterone is metabolized into a variety of active and inactive compounds, including allopregnanolone.  It is hypothesized that these allopregnanolone derivatives ameliorate anxiety and depressive symptoms by modulating the hypothalamic-pituitary-adrenal or HPA axis which mediates the body’s response to stress and is modulated by GABAergic signaling. The first neurosteroid to generate a great deal of excitement was brexanolone which was approved by the FDA for the treatment of postpartum depression.  Zuranolone, ...

In an evidence-based review published in 2012, Laura Wakil, Samantha Meltzer-Brody, and Susan Girdler present a thorough review of premenstrual dysphoric disorder (PMDD), reviewing its diagnosis and treatment options.  The information provided is clear and provides an excellent framework for understanding PMDD.  In addition, this article includes a section on the association between PMS/PMDD and a history of sexual or physical trauma, an important topic that other reviews have typically not included. Although published 9 years ago, there are not many reviews on PMDD out there, and this is a good one.  With regard to treatment and diagnosis, little has changed over the last decade.  PMDD is now classified as a mental illness in the Diagnostic and Statistical Manual of ...

While many women experience physical symptoms prior to the onset of their period or premenstrual syndrome (PMS), a smaller subset of women suffer from Premenstrual Dysphoric Disorder (PMDD), a more severe form of premenstrual syndrome.  PMDD is characterized by significant premenstrual mood disturbance, often with prominent mood reactivity, irritability, and depression. Symptoms of PMDD can emerge 1-2 weeks preceding menses and typically resolve with the onset of menses. This mood disturbance results in marked social or occupational impairment, with its most prominent effects noted in interpersonal functioning.  Serotonergic antidepressants have been established as the first-line treatment option for PMDD; however, some women either do not tolerate or fail to respond to this class of medications.  Some women may benefit from ...

The following post was first published in Current Psychiatry, published September 2017, Vol. 16, No. 9, p. 20-28. Check out the article on Current Psychiatry or listen to Dr. Raffi discuss treatment of menstrual–related mood and anxiety disorders. By Edwin R. Raffi, MD, MPH, & Marlene P. Freeman, MD In an age when psychiatry strives to identify the biologic causes of disease, studying endocrine-related mood disorders is particularly intriguing. DSM-5 defines premenstrual dysphoric disorder (PMDD) as a depressive disorder, with a 12-month prevalence ranging from 1.8% to 5.8% among women who menstruate.1-3 Factors that differentiate PMDD from other affective disorders include etiology, duration, and temporal relationship with the menstrual cycle. PMDD is a disorder of consistent yet intermittent change in mental health ...

Major depressive disorder (MDD) affects approximately 10% to 15% of pregnant patients, causing maternal distress, increased risk of suicide, life-threatening obstetric complications, and lasting neurodevelopmental effects on offspring.1–4 The strongest evidence-based treatments for MDD during pregnancy are psychotherapy and pharmacotherapy, typically with selective serotonin reuptake inhibitors (SSRIs), but these may not always be viable or acceptable options for patients due to symptom severity, the need for rapid symptom resolution, and perceived concerns about the effects of medications on fetal development.1,5 Therefore, non-pharmacologic neuromodulation therapies such as transcranial magnetic stimulation (TMS) have gained interest and research attention. TMS is an FDA-approved, non-invasive, and safe neuromodulation therapy for MDD that uses magnetic pulses to stimulate specific areas ...

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 along with proteinuria or edema during pregnancy, generally in the second half of gestation.  Preeclampsia is more common in women who have not carried a previous pregnancy beyond 20 weeks and in women at either extreme of their reproductive years. Exactly what causes preeclampsia is not fully understood. Because serotonin plays a role in vascular function and the regulation of blood pressure, some have questioned whether the use of serotonin reuptake inhibitor (SRI) antidepressants may affect a woman’s risk for ...

This week has been National Eating Disorders Awareness Week (February 27-March 5). Existing literature has explored the nature of eating disorders among perinatal women. It is well understood that the pregnancy and the postpartum period can be a challenging time for women who also experience body image dissatisfaction or who struggle with disordered eating. As Eating Disorders Awareness Week comes to a close, we wanted to share some of the blog posts that we’ve previously published in this space, in addition to linking resources for anyone who may be struggling or interested in learning more. The National Eating Disorder Association (NEDA) is the largest nonprofit organization dedicated to supporting individuals and families affected by eating ...

Perinatal psychiatry is a field in which we treat vulnerable patients, a mother and her child, where both the illness and the treatments prescribed to treat the illness have the potential to affect pregnancy outcomes. There is a deep and compelling literature documenting the negative impact of postpartum depression upon children, and we are constantly learning more about the short and long-term adverse effects of untreated depression and anxiety during pregnancy on pregnancy outcomes and child development. Treatment decisions during pregnancy must take into account the current status and previous course of illness for the individual patient, as well as the potential risks of treatment to the developing fetus. The calculus is complicated, and often ...

The Journal of Clinical Psychiatry recently published a series of articles on the use of valproic acid in women of childbearing age.  We all agree that valproic acid is a teratogen and is associated with unacceptably high rates of major congenital malformations, including neural tube defects, neurodevelopmental disorders, and other adverse outcomes. Where there seems to be a divergence of opinions, however, is whether or not valproic acid should be used at all in women of childbearing age.  Several other countries have put strict limitations on the use of valproic acid in reproductive aged women; the United States has not. Chittaranjan Andrade, MD, et al: Use of Valproate in Women: An Audit of Prescriptions to ...

Analyzing data from nearly 150,000 children with prenatal antidepressant exposure in two healthcare databases, a recent study finds no association between prenatal exposure to antidepressants and risk for neurodevelopmental disorders. In a recent commentary, Dr. Lee Cohen, notes that over the last 15-20 years, we have collected an enormous amount of data on the use of antidepressants during pregnancy. Data from multiple studies and meta-analyses have demonstrated no increased risk of major malformations in children exposed to antidepressants during pregnancy, including the SSRIs, SNRIs, tricyclic antidepressants and bupropion. “However,” he notes, “for so many clinicians and for patients, the missing piece in the risk-benefit equation has been the issue of long-term neurodevelopmental sequelae in children ...

Neural tube defects (NTDs) are among the most common major malformations in the United States. Daily folic acid supplementation in the periconceptional period significantly reduces the risk of neural tube defects.  However, most women do not receive the recommended daily intake of folate from diet alone; thus, it is recommended that all women of childbearing age should take supplemental folic acid. Since half of all pregnancies in the US are unplanned, the US Preventive Services TAsk Force recommends that all women who are capable of getting pregnant should take a daily supplement or multivitamin containing 0.4 to 0.8 mg (400 to 800 mcg) of folic acid.  In terms of preventing neural tube defects, the critical ...