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7 Antidepressants During Lactation
Comments on
usage during
breastfeeding
Possible with
caution
main recommendations
®
not be expected to cause any adverse
effects in breastfed infants. If zuranolone
is required by the mother, it is not a
reason to discontinue breastfeeding.
Monitor infants for excessive sedation
(especially with higher dosages and in
newborns and preterm infants)
Safety
prole LactMed
159
Total
0–10
F
0–1
E
0–2
D
0–1
C
0–1
B
0–2
A
0–2
Safety scores
Adverse
reactions
in infants
Maximum
reported
RID
Antidepressant
class and drug
Zuranolone 0.74% ND 1 2 0.5 0 0 0 3.5 Low Low amounts in milk; zuranolone would
ND no data, RID relative infant dose
160
P. Desaunay et al.
7.5 Conclusion
Pregnant and postpartum women using ADs should benet from additional support to
achieve optimal breastfeeding initiation and duration. All ADs evaluated in this review
can be prescribed to nursing mothers, with sertraline and paroxetine recommended as
rst-line options and others to be considered on a case-by-case basis. Regardless of the
AD used, breastfed infants should be monitored closely, including for weight gain and
neurodevelopment. Finally, larger, methodologically robust safety studies are required
to better understand the implications of AD use during breastfeeding.
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165
Antipsychotics inPregnancy
CarolynBreadon andJayashriKulkarni
8.1 Introduction
The changing patterns of antipsychotic medication use over the past 20years have
resulted in a dramatic shift in the typical prole of the pregnant woman taking these
medications. Several decades ago, the use of rst-generation antipsychotic medication was restricted largely to the treatment of women suffering schizophrenia and
schizophrenia spectrum disorders. In more recent times the use of second- generation
antipsychotic medications has exploded, especially in North America, to treat
patients with mood disorders (including bipolar disorders and major depressive disorders), anxiety spectrum disorders (including PTSD and OCD), ADHD, tic disorders, personality disorders, and intellectual disability and developmental spectrum
disorders.
Additionally, the use of rst-generation antipsychotics in the past may have had
the effect of reducing women’s fertility through elevated prolactin, effectively
arresting the cycle of ovulation. Second-generation antipsychotics do not have this
tendency to the same degree, though case reports and clinical experience suggest
that individual women may be sensitive to this effect even when taking medications
not traditionally considered to be highly active at D2-receptors, such as olanzapine
and quetiapine. Hence women taking antipsychotic medication are more numerous,
more fertile, and suffer a greater variety of underlying conditions which result in
their use of antipsychotic medications in the contemporary era. These women could
be encountered in any area of psychiatric practice.
Teratogenic risks of medications are traditionally considered to be at their highest in the rst trimester of pregnancy, when women are often not aware that they are
pregnant. This means that the care of every woman of childbearing age should
8
C. Breadon · J. Kulkarni (*)
Monash Alfred Psychiatry Research Centre, Monash University, Melbourne, VIC, Australia
e-mail: jayashri.kulkarni@monash.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
F. Uguz, L. Orsolini (eds.), Perinatal Psychopharmacology,
https://doi.org/10.1007/978-3-031-99720-4_8
167
168
incorporate a consideration of the risks of medication prescribed to a potential
unborn child, and psychiatrists must be aware of these risks and communicate them
clearly to their patients.
Once a woman is aware she is pregnant her next consideration is a decision about
the continuation of pregnancy. For this phase of care a woman must be aware of the
risks both to herself in continuing to take a medication throughout pregnancy which
may affect her physical health and her experience of delivery, and the risks to her
child of congenital defects, adverse events at birth, or of later neurodevelopmental delay.
Again, it is the role of her psychiatrist to inform her of the risks of treatment to
her and her baby, balanced against the risks of untreated illness including relapse in
pregnancy or the postpartum. Women taking antipsychotic medications in pregnancy may be more vulnerable to metabolic effects including high rates of weight
gain and gestational diabetes, particularly those taking second-generation antipsychotics. Both weight gain and gestational diabetes have implications for delivery
and neonatal outcomes.
Increasing evidence suggests that most antipsychotic medications do not confer
a greatly increased risk of congenital malformations. However, babies may experience neonatal respiratory difculties and medication withdrawal symptoms at delivery, suggesting that a neonatal ICU or special care nursery should be available.
Available data on neurocognitive development of babies exposed to antipsychotics
in pregnancy seems to suggest that at 1year there are no developmental distinctions
between these babies and their peers.
Emerging evidence relating to risks of neurodevelopmental delay, autism spectrum disorder and attention decit-hyperactivity disorder in babies of women treated
with antipsychotic medications seems to indicate that babies born to women with a
broad range of mental health disorders may be at higher risk of developing these
conditions, and that treatment with antipsychotic medication in pregnancy probably
does not further elevate these risks.
This chapter aims to provide a concise up-to-date summary of the known risks
associated with antipsychotic medication treatment in pregnancy, to aid clinicians in
providing best practice care to their patient (and by extension, to their patient’s
family).
C. Breadon and J. Kulkarni
8.2 The True Cost ofRelapse inPregnancy
andthePostpartum
Women who are prescribed antipsychotic medications face a decision point when
they discover they are pregnant. Anecdotally, many women cease all medications at
this point. Recent evidence suggests that this is also true for women taking antipsychotic medications (Petersen etal. 2014). However, this decision can have serious
consequences for the mother and also for her unborn or newborn child. Elsewhere,
researchers have examined the dollar cost of a relapse of psychosis (Hong etal.
2009). This can’t begin to encompass the multiple problems associated with a
relapse of psychosis for the individual and society more broadly in terms of
8 Antipsychotics inPregnancy
nancial, interpersonal, occupational, and psychological costs. These costs are
magnied and other risks are added in the context of pregnancy and childbirth. In
clinical experience, treating a pregnant woman with psychosis in a general psychiatric inpatient unit provokes anxiety and distress for everyone involved in the woman’s care, including the woman herself and her family. The risks are evident:
fragmented antenatal care, poor attention to nutrition, itinerancy or homelessness,
with all the risks to physical safety and health that these situations entail, including
the need to commence higher doses of medication in hospital to establish, rather
than maintain, a stable mental state.
It has been well established that women are at greater risk of relapse of mood
disorders in pregnancy and in the postpartum, when this can manifest as postpartum
psychosis. Women with a history of bipolar disorder who are untreated in pregnancy
face a very high risk of relapse (Bergink etal. 2012). In the postpartum this relapse
carries the added risks of suicide and infanticide (Wisner etal. 2002), alongside the
more subtle risks to attachment security and bonding which could occur through
separation of mother and baby (Howard 2000) or through the difculties associated
with bonding and psychosis (Howard 2000).
Women living with schizophrenia are perhaps uniquely vulnerable when faced
with the challenges of parenting (Hipwell etal. 1996), especially when allied with
other factors related to mental illness such as poor social support and economic
disadvantage (Göpfert etal. 1996). Howard et al. (2004a) lists the potential pitfalls
for these women as follows: “Psychotic symptoms may affect the mother-infant
relationship through involvement of the child in delusions, hallucinations or passivity experiences, by making the mother unavailable, or through the absence of desirable behaviours resulting in an impoverished environment for the child.” These
authors examined outcomes for unwell women with psychosis admitted to mother
and baby units in the UK, and advocated for early treatment of psychosis in averting
parenting orders and family separation (Howard et al. 2004a).
169
8.3 Evaluating theTrue Risks toWomen andTheir Babies
fromTreatment withAntipsychotic Medication
inPregnancy
The challenge in correctly identifying the true risk to a woman and her baby from
treatment lies in unravelling the risks conferred by a medication from the risks associated with having a serious mental illness. A woman living with schizophrenia or
bipolar disorder may have genetic vulnerabilities shared by her child, and may also
have multiple vulnerabilities and disadvantages arising from the nancial, social,
and occupational costs of living with a major mental illness. Taylor etal. (2015)
succinctly summarised the current state of research into confounding factors, writing “..the prevalence of these modiable risk factors in these women is unclear as
most studies have used clinical data from specialist services with limited generalisability, or have small clinical samples with limited statistical power to investigate
differences between the groups, or have used administrative data of population
cohorts with little detail on clinical characteristics.” In reality, the eld of perinatal