Mass General Hospital

Harvard Medical School



Can Women Taking Lithium Breastfeed Their Infants?

It is clear that women with bipolar disorder are at high risk for relapse during the immediate postpartum period (Viguera 2000). There is evidence that the resumption of lithium prior to or within 24-48 hours of delivery can significantly reduce the risk of postpartum illness (Cohen 1995). While this intervention is the current standard of care for this high risk population, women have historically been instructed to avoid breastfeeding while taking lithium based on early reports suggesting high levels of lithium in the breast milk and several cases of lithium toxicity in nursing infants (Schou 1973). While the American Academy of Pediatrics guidelines are less restrictive in their current recommendation, they do urge caution. However, systematic studies regarding the levels of exposure to lithium in nursing infants and the potential risks of this exposure have been lacking.

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Oral Contraceptives for the Treatment of Premenstrual Mood Symptoms in Women with Depression

About 3-5% of women of reproductive age suffer from premenstrual dysphoric disorder (PMDD), where they experience depressive symptoms, anxiety or irritability during the last one to two weeks (the premenstrual phase) of their menstrual cycle. In addition, many women who suffer from depression, including those who have been effectively treated with an antidepressant, report worsening of their depressive symptoms during the premenstrual phase of the menstrual cycle. Although this may be a consequence of sensitivity to fluctuating hormone levels, little is known about the efficacy of hormonal interventions, including oral contraceptives (OCPs), in the treatment of premenstrual worsening of depressive symptoms.

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Should SSRIs Be Discontinued Prior to Delivery?

About 10-15% of women suffer from depression during pregnancy. The rates are probably even higher among those women who have histories of depression prior to pregnancy. Thus, many women with recurrent illness make the decision to remain on antidepressant during pregnancy. While there have been many studies supporting the reproductive safety of certain antidepressants, including Prozac and the tricyclic antidepressants, during pregnancy, concerns have emerged as to whether antidepressants, including the selective serotonin reuptake inhibitors (SSRIs), may increase the risk of adverse events in the newborn.

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Recent Antidepressant Label Changes

In October, the Food and Drug Administration (FDA) ordered drug manufacturers to include warnings in the packaging inserts regarding the use of certain antidepressants, including the selective serotonin reuptake inhibitors (SSRIs) and venlafaxine (Effexor), during pregnancy. The labels now describe a spectrum of adverse events in newborns exposed to these drugs late in the third trimester, including jitteriness, irritability, hypoglycemia (low blood sugar), feeding difficulties, respiratory distress, abnormal muscle tone, and constant crying. Complications requiring “prolonged hospitalization, respiratory support and tube feeding” are also mentioned.

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Acupuncture for Depression During Pregnancy

Depression during pregnancy is relatively common, affecting about 10 to 15% of women. While there is a growing body of literature supporting the reproductive safety of certain antidepressants, our understanding of how these psychotropic medications affect the developing fetus remains incomplete. For this reason, many women and their physicians would prefer to avoid the use of antidepressants during pregnancy; thus, there is a clear need for effective non-pharmacologic treatments for women who suffer from depression during pregnancy. In a recent study from Dr. Rachel Manber and her colleagues at Stanford University, the use of acupuncture is assessed in a group of pregnant depressed women.

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Venlafaxine (Effexor) for Postmenopausal Hot Flushes

During the menopausal transition, up to 85% of women experience vasomotor symptoms of hot flushes and night sweats. For many women, hot flushes may be severe; they can interfere with work and other daily activities and affect sleep quality. Hot flushes may be associated with fatigue, poor concentration, and depression. Given the recent data from the Women’s Health Initiative regarding the risks associated with long-term use of estrogen, many peri- and post-menopausal women are understandably reluctant to take menopausal hormone therapy for the treatment of hot flushes, despite its proven efficacy. Given these concerns, there is a clear need for alternative non-hormonal therapies for the treatment of hot flushes and other menopause-related symptoms.

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Pregnancy and SSRIs: Is There a Risk to the Newborn?

The increasing number of reproductive-age women taking antidepressants has raised concerns about the potential risks of using these medications during pregnancy. Literature accumulated over the last decade supports the use of certain selective serotonin reuptake inhibitors (SSRIs) and the older tricyclic antidepressants during pregnancy, indicating no increased risk of congenital malformation in children exposed to these medications during the first trimester of pregnancy. Still, questions remain regarding the purported risk for “toxicity” in newborns exposed to antidepressants around the time of labor and delivery. These concerns are not new. Twenty years ago, case reports suggested that maternal use of tricyclic antidepressants near the time of delivery was associated with problems in the newborn such as difficulty feeding, restlessness, or jitteriness.

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Paroxetine and Cognitive-Behavioral Therapy (CBT) for the Treatment of Postpartum Depression (PPD)

Postpartum depression (PPD) is relatively common, occurring in about 10 to 15% of women after delivery. Non-pharmacologic interventions, including interpersonal psychotherapy, have been shown to be effective for the treatment of PPD. In addition, several reports have documented the efficacy of selective serotonin reuptake inhibitors (SSRIs) and the serotonin norepinephrine reuptake inhibitor venlafaxine (Effexor). In a recent report, Misri and colleagues have evaluated whether the addition of Cognitive-Behavioral Therapy (CBT) to standard antidepressant treatment improves outcomes in women with postpartum depression and co-morbid anxiety.

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Infertility Treatment: A Trigger for Depression and Anxiety

While several studies have demonstrated high levels of psychological distress among women pursuing infertility treatment, few studies have assessed the prevalence of psychiatric illness in populations undergoing infertility treatment using standardized diagnostic instruments. In a recent study from Taipei Veterans General Hospital, a university-affiliated medical center in Taiwan, women attending an assisted reproduction clinic were assessed using the Mini-International Neuropsychiatric Interview (MINI) (Chen 2004) Of the 112 participants, 40.2% met criteria for a psychiatric disorder. The most common diagnosis was generalized anxiety disorder (23.2%), followed by major depressive disorder (17.0%) and dysthymic disorder (9.8%). Participants with a psychiatric disorder did not differ from those without illness in terms of age, education level, income, or years of infertility.

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