Part 1: Pre-Pregnancy Planning
This post is the first installment of a four part series. In this series, we will follow a patient from the pre-pregnancy planning phase to the postpartum period, and many key points discussed in previous blog posts will be reviewed. Please remember that every patient is different and this case should be viewed as one patient’s experience, rather than an outline of recommended treatment. Every patient must work with her own psychiatric provider to devise a plan that best suits her needs.
Ms. D is a 37-year-old married woman with a history of 4-5 episodes of depression since her college years. She also has a history of anxiety, including panic attacks. She came in for a pre-pregnancy consultation to discuss her options for treatment during pregnancy. At the time of the consultation, she stated that she wanted to become pregnant in the very near future.
Psychiatric History: As a young adult, she was treated with fluoxetine (Prozac) for about 2 to 3 years, which worked quite well for her. Other medication trials included sertraline (Zoloft) and escitalopram (Lexapro), but she did not feel they were effective. She also tried bupropion (Wellbutrin), but noted that she continued to have panic attacks. Lorazepam (Ativan), prescribed for anxiety, was also not helpful. While she did not remember the exact dosages of many of her medications, she stated that she typically has used antidepressants at the lower range of the recommended dosage.
She had been off medication for several years but restarted psychiatric medications about 6 years ago after a recurrence of her depression and anxiety. She was initially treated with fluoxetine for approximately 2 months, but she continued to have residual depressive symptoms and was eventually switched to venlafaxine ER (Effexor). Her symptoms resolved, and she remained well on venlafaxine ER 150mg for about 5 years without any symptoms of depression or anxiety.
At the time of consultation: In preparation for pregnancy, she stopped the venlafaxine abruptly without a taper and had significant withdrawal symptoms for approximately 3-4 weeks. She continued with weekly psychotherapy, and she remained off psychiatric medications for about 8 months before her symptoms of depression and anxiety returned. She restarted venlafaxine ER 150 mg, and her symptoms quickly improved, and after being on the medication for about 3 months, she presented for a pre-pregnancy planning consultation. At the time of the appointment, she noted that aside from some increased distractibility, she no longer had any symptoms of depression or anxiety.
Additional history: The patient denied a history of suicidal ideation, psychiatric hospitalization, or substance use issues. She denied any significant medical or surgical issues. She has had no previous pregnancies. There was no family history of psychiatric illness or substance use issues.
Ms. D was seen in consultation to discuss her treatment options during pregnancy. When reviewing the various options with this patient, there are multiple issues to consider.
Should Ms. D Maintain or Discontinue Her Antidepressant?
Given that she has a history of recurrent depression, Ms. D would be at risk for relapse if she were to come off her antidepressant. The risk is particularly high for Ms. D, as her last episode of depression was fairly recent, within the last year of the initial consultation, a relapse which followed the abrupt medication discontinuation. We have studies to show that there are high rates of relapse in women who discontinue their antidepressant proximate to conception and that rapid discontinuation of an antidepressant may increase her risk of relapse.
After coming off medication, Ms. D continued to receive weekly psychotherapy. While this may be the first intervention to consider for pregnant women with mild to moderate depression, it was not effective for her in terms of preventing a relapse.
What Medication is Best for Pregnancy?
Unfortunately there is sparse data regarding the use of venlafaxine in pregnancy and for that reason, it is typically recommended that patients switch to medications with better established reproductive safety profiles, such as the SSRIs, such as fluoxetine, citalopram, and sertraline. When she recently tried fluoxetine, she had a partial response. Other SSRIs, sertraline and escitalopram, were not effective.
The patient mentioned that she did not recall the dosages of medication she had taken in the past, but she recalled that they were on the lower side of normal. While one option might be remaining on venlafaxine during her pregnancy, she might also consider a re-trial of one of the SSRIs. It is possible that increasing the dose of one of these SSRIs may make the medication more effective for her.
Another factor to consider is the patient’s timeline for the planned pregnancy. This patient is 37 years old and expressed a desire to become pregnant in the very near future. Some patients, particularly younger ones, may be more amenable to changing medications prior to conception and holding off on pregnancy for a period of several months in order to determine how the new medication is working.
Betty Wang, MD