Psychiatry for GPs Perinatal Mental Health Dr Michael Yousif, Consultant in Psychological Medicine, OUH NHSFT
Perinatal mental health for GPs Diagnosing Prescribing 2
Perinatal mental health for GPs Is this medication safe in pregnancy? Are the risks of this medication justified for this patient? 3
Decision making Risks of medication Infant exposure In utero Lacation Maternal morbidity Risks of not taking Undertreatment Evidence and individual-based Maternal anxiety Evidence-based 4
Key principles: prescribing Baseline 10-20% miscarriage, 2-3% malformations (Henshaw et al 2017) Avoid first trimester prescribing wherever possible Infant outcomes multifactorial Minimise foetal exposure by avoiding drug switching Consider what has worked before for the patient All prescribing is off-label Informed choice paramount Reading material Bumps 5
Key principles: evidence-base Observational studies vs experimental studies Single study associations, open label studies Confounding by indication Association vs causation Relative risks vs absolute risks Statistical significance vs clinical significance Absence of evidence Evidence of absence Few long-term studies 6
Key principles: breastfeeding Most studies are in pregnancy Aim to continue same drug in breastfeeding from pregnancy Lithium, clozapine most risky Placental exposure 5-10x breast milk (Howard et al 2014) Practical considerations Nocturnal sedation, pump and dump, drug half-life 7
Antidepressants Limited direct evidence of efficacy Depressive relapse rate 68% if discontinue meds, 26% if continued (Henshaw et al 2017) Large studies Unlikely to be teratogenic Equivocal evidence of cardiac malformation and PPHN ARI 2/1000 for paroxetine (Henshaw et al 2017) OR ~1.5 spontaneous abortion, inconsistent finding, multiple confounders (Ross et al 2013) OR ~1.5 preterm delivery (days) (Ross et al 2013)
Antidepressants IUGR evidence equivocal Associated with PNAS, lower Apgar scores, NICU admission Withdrawal or SE / toxicity? Definition / measures Likely benign, self-limiting ASD SSRIs, equivocal evidence, confounding by indication Increased risk of speech / language disorders up to age 9 (Brown et al 2016)
Antipsychotics Quetiapine, olanzapine, risperidone, haloperidol best studied Long-term adverse cognitive outcomes, teratogenicity seem unlikely SEs possible in neonate Increased maternal and infant morbidity/mortality, obstetric complication Not due to medication confounding by indication No consistent increase in Maternal outcomes: GDM, HTN, VTE Infant outcomes: prematurity, baby size, NAS More likely to need interventional delivery (Vigod et al 2013) 10
Mood stabilisers Most evidence from epilepsy studies Confounding by indication Valproate, carbamazepine relatively contraindicated (NICE) Craniofacial, cardiac, cognitive, neurodevelopmental, miscarriage Lamotrigine unlikely teratogenic (Chisolm and Payne 2015) Inconsistent evidence about oral cleft Lithium (Chisolm and Payne 2015) Ebstein s anomaly 1/1000 Avoid 1 st trimester foetal heart monitoring Blood volume changes, lithium metabolism, monthly weekly levels Neonatal thyroid problems, arryhthmias Breastfeeding risks 11
Anxiolytics Oral cleft Evidence recently disputed Neonatal withdrawal Floppy baby syndrome Gut atresia Promethazine for insomnia (NICE) but more evidence Z-drugs Chisolm and Payne 2015, Taylor et al 2015, Henshaw et al 2017 12
NICE CG192 TCAs, SNRI, SSRIs for depressive and anxiety disorders Avoid paroxetine Antipsychotics as mood stabilisers Lithium 2 nd line Avoid valproate Promethazine for sleep ECT for severe illness 13
Where to gt help References UKTIS / BUMPS website Maudsley Prescribing Guidelines BAP Guidelines McAllister-Williams et al (2017) Journal of Psychopharmacology 1-34 Services AMHT IAPT OUH Maternity Specialist PMH CMHT 14
References 1. Boukhris et al JAMA Pediatr. 2016;170(2):117-124. 2. Brown et al JAMA Psychiatry. 2016;73(11):1163-1170 3. Chisolm and Payne BMJ 2015; 351:h5918 4. Furu et al BMJ 2015; 350: h1798 5. Howard et al Lancet 2014; 384: 1775-88 6. Henshaw et al RCPsych Modern Management of Perinatal Psychiatric Disorders (2 nd ed.) 2017 7. Jones et al Lancet 2014; 384: 1789-99 8. Myles et al A NZ J Psych 47(11) 1002 1012 9. Reefhuis et al BMJ 2015; 351: h3190 10. Ross et al JAMA Psychiatry. 2013;70(4):436-443. 11. Stein et al Lancet 2014; 384: 1800-19 12. Taylor et al Maudsley Prescribing Guidelines in Psychiatry (12 th ed.) 2015 13. Vigod et al BMJ 2015; 350:h2298 15