Women face difficult choices when deciding whether or not to continue psychiatric medications during pregnancy. This choice can be especially difficult for women taking newer medications which lack adequate reproductive safety data.
It is not uncommon for women on newer medications with less reproductive safety data available to attempt to change to a better studied medication when planning for pregnancy. A recent case (with identifying details changed) illustrates the complicated nature of this decision.
A 30-year-old woman, Mrs. Brown, with a history of recurrent major depression treated with duloxetine (Cymbalta) came for perinatal consultation. Even though Mrs. Brown had been doing well on duloxetine for two years, she wanted to change medications prior to conceiving given the lack of available safety data on duloxetine during pregnancy.
Mrs. Brown had tried several antidepressants in the past. Her first episode of depression had been treated with paroxetine followed by mirtazapine. A second episode of depression had been treated with venlafaxine.
She decided to change to fluoxetine (Prozac) before conceiving due to the abundance of information on this medication during pregnancy. Fluoxetine is one of the first SSRIs to come on the market in the United States. Therefore, there is a relatively large amount of information about the outcomes of infants exposed to this medication in utero.
Several weeks after cross-tapering from duloxetine to fluoxetine, Mrs. Brown began experiencing intense anxiety, difficulty sleeping, depressed mood and difficulty concentrating. Her symptoms began interfering with her ability to work, and she therefore decided to postpone pregnancy and restart duloxetine. After restarting duloxetine her mood improved and she was once again able to enjoy time with her husband and function at her previously high level at work. She became pregnant on duloxetine, elected to maintain treatment with this medication, and delivered a healthy baby boy.
Mrs. Brown’s story illustrates the careful consideration and planning that many women put into decisions regarding the use of medications during pregnancy. The risks of continuing a medication during pregnancy must be considered in the context of the risks of experiencing a relapse of symptoms if medication is discontinued. Staying well during pregnancy is important as depression during pregnancy has been found to be the strongest predictor of postpartum depression (Beck 2001, Robertson 2004) and may also be associated with poorer neonatal outcomes (reviewed in Bonari et al, 2004).
Mrs. Brown took time prior to attempting to conceive in order to make a medication change. While it was unfortunate that she experienced a relapse in her symptoms, it is fortunate that she had made these changes prior to becoming pregnant. She was able to restart a treatment that worked well for her prior to conceiving.
Julia Wood, MD
Beck CT. Predictors of Postpartum Depression: An Update. Nurs Research. 2001 Sep/Oct;50(5):275-285.
Robertson E, Grace S, Wallington T, Stewart DE. Antenatal risk factors for postpartum depression: a synthesis of recent literature. Gen Hosp Psychiatry. 2004 Jul-Aug;26(4):289-95.