Pharmacological management and ECT in childbearing women with psychiatric disorders

The medical treatment of a woman with mental illness who wishes to conceive or is pregnant requires more careful consideration than in any other clinical situation. It is important to take a particularly detailed history of the patient’s illness episodes, triggers for recurrences, associated risks to herself and others, and responses to treatment, and to corroborate this with information from hospital case notes and informants. If the illness is relatively mild or the risk of recurrence is low, the best course may be to withdraw medication gradually. When the likelihood of recurrence or its associated risks to the pregnancy and the woman’s health is high, medication often needs to be continued. The available literature suggests that the offspring’s health is not affected significantly by exposure to most commonly used antidepressants and to several antipsychotics during pregnancy and nursing, although the possibility of more subtle effects later in the child’s development cannot be ruled out. Conversely, there is increasing evidence of long-term harm to mother and child from mental illness in pregnancy. Because of their teratogenic potential, the mood stabilizers lithium and carbamazepine should not be used routinely in women in pregnancy or preconceptually. Although the teratogenic risk for lamotrigine is low, similar caution should be taken with lamotrigine because it may also cause severe cutaneous reactions in the child. Valproate appears to be associated with particularly high risks to the foetus and should be used only if there are no alternatives and following specialist perinatal advice. There are as yet few clinical observations and data on serum concentrations in infants breast-fed by mothers treated with psychotropic agents.