Hala Salah Lecturer of psychiatry

 Prenatal Classes  Newspaper articles  Community lectures  Family involvement in the educational process  Routine prenatal screening

-Exercise -Diet: Omega 3 Protein Hydration Vit. (B) -Plan -For women with histories of postpartum depression consider prophylactic antidepressants - For those who were treated during pregnancy

◦ Rest ◦ Proper nutrition ◦ Help with infant and household responsibilities ◦ Family and friends support systems ◦ Avoidance of isolation

 Type of illness (bipolar)  Severity  Medications needed  Infant issues

Quality of mother’s life Benefits of breast feeding Precious baby Risks of drug-induced toxicity in breast-fed infant Individual patient approach is needed

Psychotropics Psychotherapy Social Support ECT

 Psychosocial therapies ◦ First choice for those with mild to moderate symptoms of PPD ◦ Cognitive-behavioral therapy ◦ Interpersonal psychotherapy- focuses on patient’s interpersonal relationship and changing roles

 Group therapy ◦ Helps to increase support network  Family and marital therapy ◦ More rapid recovery ◦ More appreciative of partner’s contribution  Peer-support groups

 Four factors are needed in order to understand problems related to breast-feeding by mothers taking psychotropic medication:  the prescribed dose;  the level of the drug in the mother’s blood plasma;  the level in the breast milk;  and the levels in the infant’s serum.

 Medication’s diffusion across membranes, Molecular weight and its lipophilicity.  The timing of the dose in relation to the infant’s feeding patterns.  Drug’s dosage and frequency, its pharmacodynamics and pharmacokinetics.

Maternal / Infant / Drug Maternal: Drug dosage and duration of therapy Route and frequency of administration Metabolism Renal clearance Blood flow to the breasts Milk pH and composition

Maternal / Infant / Drug Infant: Age of the infant -preterm - full term 3w 8-12w Feeding pattern Amount of breast milk consumed Drug absorption, distribution, metabolism and elimination

 Most drugs are transferred into milk by the passive diffusion processes and hence maternal drug.  Active or carrier-mediated transport occurs for some.  Drugs must pass from the maternal plasma, through the capillary walls, into the alveolar cells lining milk duct.  During the first few days of life there are large gaps between these alveolar cells, which allow most molecules to cross through easily.

 For psychotropics the arbitrary concentration in the infant’s plasma of 10% of the established therapeutic maternal dose is used as the upper threshold where the risks of a particular drug’s side-effects are low and treatment is accepted as safe

 The newborn’s health should be taken into consideration when planning breast-feeding  Preterm immature infants should not be exposed to psychotropics  Infants’ hepatic, renal and cardiac functions should be checked before they are breast-fed by mothers on psychotropic medication

 Infants older than 10 weeks are at a lower risk for adverse effects of tricyclics and there is no evidence of accumulation in the infant  The newborn should be examined regularly for any possible adverse events of medication  All professionals involved in the care of the infant should be informed of psychotropic medication usage

 Increase risk of suicide after initiation of medication  If significant anxiety or insomnia present, consider adding benzodiazepine  Close follow-up

SSRI  SSRI preferred initially.  Drug levels are low to undetectable.  All effective in open trials (Moretti, 2009).  SSRIs such as fluoxetine, sertraline, paroxetine and citalopram are safe during breast-feeding (Berle, 2004).  Sertraline is considered as first line in USA (Altshuler et al. (2001).

 Tricyclics have a less favorable side effect profile and a much higher risk of morbidity and mortality from overdose.  However, it is relatively safer and low levels of drugs are secreted for most tricyclics.  Tricyclics such as amitryptyline, imipramine, nortriptyline and clomipramine are safe during breast- feeding (Becker, 2009).  Doxepin is contraindicated (respiratory depression).

 Trazodone appears to be of lower risk because only 1% passes into the milk, although drowsiness and poor feeding have been reported. Data are limited to a few cases and caution is advised in use of the drug.

- It has been mentioned in certain studies that Mirtazapine can be used as first-line treatment and, because of its action on histamine H 1 receptors, may be preferred in some patients with postnatal depression, when night-time sedation is required (Snellen, 2007)

 Venlafaxine is considered safe (Snellen, 2007).  Bupropion: Few studies found no adverse effects (in one case, it lead to occurance of seizure in the new born) (Becker, 2009).

 Conventional antipsychotics have been used for decades and the accumulated data show that they are safe during breast-feeding (Phenothiazines may increase risk of SIDS).  New information is starting to emerge about some atypical antipsychotics such as olanzapine and risperidone but their safety has yet to be established (Moreeti,2009)

 There is currently no information on quetiapine and amisulpride and therefore it is not safe to expose newborns to these medications  Clozapine accumulates in breast milk and is contraindicated during breast-feeding

 Lithium is contraindicated during breast-feeding (high serum level, but 3 studies recommended its use with caution if no other options available. (Hale, 2004)  There is little evidence of adverse events in infants breast-fed by mothers taking carbamazepine or sodium valproate, although transient hepatic toxicity is possible with the former (Moretti, 2009)  Lamotrigine is considered moderately safe in practice (But with high serum level in infant-be careful of risk of Steven Johnson syndrome) (Becker, 2009).

 It is unsafe to expose infants to repeated doses of long- acting benzodiazepines  Shorter acting agents such as oxazepam, alprazolam and lorazepam are preferred by most authors (Becker, 2009). It must be used for short term.  Buspirone, zaleplon and zopiclone are better avoided because of limited safety data on their use.

 Psychiatric emergency! Inpatient treatment  Mood stabilizers  Antipsychotics  Benzodiazepines  Lithium prophylaxis  Electroconvulsive therapy

 The decision to prescribe antipsychotics to breast-feeding women should depend on individual risk/benefit analysis  The current available research does not allow any absolute and clear recommendation because much of the work on psychotropic medication in breast-feeding is limited to single case reports, small series and naturalistic data collection  Causes and consequences of different adverse events are not yet widely studied

 Berle J.O. The challenges of motherhood and mental health. World Psychiatry. 2004;3(2):p101–102.  Becker M.A, Mayor G.F, Elisabeth J.S. Psychotropic Medications and Breastfeeding. Primary Psychiatry. 2009;16(3):p42–51

-Hale T.W. Drug Therapy and Breastfeeding: Antidepressants, Antipsychotics, Antimanics, and Sedatives. Neo Reviews. 2004;5(10):e Moretti M.E. Psychotropic Drugs in Lactation. Can J Clin Pharmacol. 2009;16(1):p e49–e57. -Snellen M, Galbally M, Udechuku A, Spalding G, Munro C, Drinkwater P. Psychotropic Medication in Pregnancy/Lactation. Revised 2nd Edition. Mercy Health & Aged Care: Melbourne; Pharmacy Department Mercy Hospital for Women. October 2007

Thank you