Prevention of Postpartum Depression
Postpartum depression (PPD) is a relatively common problem, affecting between 10% and 15% of women after delivery. Although it is difficult to reliably predict which women in the general population will experience postpartum mood disturbance, it is possible to identify certain subgroups of women who are more vulnerable to postpartum affective illness. Women who have had one episode of postpartum depression have about a 50% chance of experiencing another episode of PPD after a subsequent pregnancy. The extent to which a history of depression (prior to pregnancy) influences risk is less clear, but some studies indicate that between 30% and 50% will suffer from recurrent depression during the postpartum period. Several investigators have recently explored the potential efficacy of prophylactic interventions in these populations of women at risk.
Is St. John’s Wort Safe in Breastfeeding Women?
Postpartum depression is a relatively common event, affecting 10 to 15% of women after the birth of a child. Many women, however, do not receive treatment, and one of the most common reasons for avoiding or deferring treatment is concern regarding the use of medications while breastfeeding. A preliminary study from Lee and colleagues at the Motherisk Program in Toronto, Canada has investigated the use of St. John’s wort in breastfeeding women.
Long-term Effects of Fetal Exposure to Antidepressants
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 toxic agents throughout pregnancy. While insults that occur early in pregnancy may result in gross abnormalities, exposures that occur after neural tube closure (at 32 days of gestation) may produce more subtle changes in behavior and functioning.
Bupropion and Breastfeeding
Data have accumulated over the last few years on the use of antidepressants in nursing mothers. It appears that all antidepressants are secreted into the breast milk; however, the amount of medication to which the nursing child is exposed appears to be relatively small. We have the most information is available for fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and the tricyclic antidepressants. In general, one should try to choose an antidepressant for which there are data to support its safety during breastfeeding. However, there are often situations where one may choose another antidepressant that has not been as well characterized. For instance, if a woman has not responded well to any of the above medications.
Anticonvulsants During Pregnancy in Women with Bipolar Disorder
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 to these medications during the first trimester of pregnancy. For women who need a mood stabilizer during pregnancy, lithium is the safest option; however, when used during the first trimester, it carries a 0.1% risk of a cardiac malformation called Ebstein's anomaly. Although this is a potentially serious complication, it is important to keep in mind that the risk of malformation is relatively small.
Reevaluating the Pros and Cons of Hormone Replacement Therapy
Each year, more than 1.3 million American women become menopausal in the U.S. The menopausal transition is marked by intense hormonal variability, and frequently accompanied by vasomotor symptoms (e.g., hot flashes, night sweats), sleep disturbance, and altered libido. In addition, as women become estrogen-deprived, they may also experience an increased risk for osteoporosis, cardiovascular disease, cognitive dysfunction, and depressive symptoms.