What are the treatment options for untreated mental illness in pregnancy?

Treatment Options for Untreated Mental Illness in Pregnancy

Treatment of mental illness during pregnancy should prioritize the risks of untreated illness against potential medication risks, as untreated mental disorders are associated with increased risks of spontaneous abortion and preterm birth. 1

Risk Assessment Framework

When considering treatment for mental illness during pregnancy, it's crucial to understand that both treatment and non-treatment carry risks:

• Risks of untreated mental illness:

  • Worse maternal mental health outcomes
  • Significant impairments in functioning
  • Increased risk for spontaneous abortion
  • Increased risk for preterm birth
  • Potential for postpartum exacerbation

• Medication considerations:

  • Placental transfer of medications
  • Potential teratogenic effects
  • Neonatal complications

Treatment Options by Approach

1. Psychotherapy Options

• Cognitive Behavioral Therapy (CBT)

  • First-line non-pharmacological treatment for depression and anxiety
  • Addresses negative thought patterns and behaviors
  • No risk to fetus

• Interpersonal Psychotherapy (IPT)

  • Focuses on interpersonal relationships and social functioning
  • Particularly effective for depression during pregnancy

• Dialectical Behavior Therapy (DBT)

  • Beneficial for ADHD and comorbid conditions
  • Four key modules:
    • Mindfulness skills (addresses poor concentration)
    • Distress tolerance (addresses disorganization)
    • Interpersonal effectiveness skills (improves relationships)
    • Emotion regulation skills (addresses affective lability)
  • Has shown decreased symptoms, improved neuropsychological functioning, and reduction of co-existing anxiety and depression 1

2. Body-Oriented Interventions

• Yoga
• Mindfulness practices
• Exercise therapy
• Can improve self-compassion and parental self-efficacy

3. Alternative Therapies

• Acupuncture
  • Shows moderate reduction in depressive symptoms
  • Non-invasive and generally safe during pregnancy

4. Pharmacological Options

For moderate to severe mental illness, medication may be necessary despite potential risks:

For Depression/Anxiety:

• SSRIs (e.g., Fluoxetine, Sertraline)

  • Important risks to consider:

    • Neonates exposed in late third trimester may develop complications requiring prolonged hospitalization
    • Possible symptoms include respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulties
    • Potential increased risk for persistent pulmonary hypertension of the newborn (PPHN)
    • Increased risk of postpartum hemorrhage (less than 2-fold) 2

  • Benefits of continuing treatment:

    • Women who discontinued antidepressants during pregnancy showed significant increase in relapse of major depression 2
    • Treating depression improves maternal functioning and wellbeing

For ADHD:

• Psychostimulants

  • Amphetamine-based stimulants generally do not show association with major congenital malformations
  • Small potential increased risks for:
    • Gastroschisis (small absolute risk)
    • Preeclampsia
    • Preterm birth (when continued in second half of pregnancy) 1

• Non-stimulant options:

  • Bupropion (norepinephrine and dopamine reuptake inhibitor)
  • Atomoxetine
  • Viloxazine 1

Treatment Algorithm

1. Assessment phase:

   • Evaluate severity of mental illness
   • Determine functional impairment
   • Assess suicide risk
   • Consider previous treatment response

2. For mild symptoms:

   • Begin with non-pharmacological approaches (CBT, IPT, body-oriented interventions)
   • Close monitoring for symptom progression

3. For moderate to severe symptoms:

   • Consider combination of psychotherapy and medication
   • When selecting medication:
     • Use medication with established safety profile
     • Use lowest effective dose
     • Consider splitting doses to avoid peak concentrations
     • Avoid medication changes in third trimester if possible

4. Monitoring:

   • Regular assessment of symptoms
   • For women on medications, monitor for side effects
   • For women on SSRIs, prepare for potential neonatal complications
   • For women on stimulants, monitor blood pressure and fetal growth

Important Considerations and Pitfalls

• Common pitfall: Automatically discontinuing all psychiatric medications during pregnancy without considering the risks of untreated illness
• Caution: Breastfeeding while taking psychiatric medications requires monitoring the infant for potential adverse effects
• Risk communication: Discuss absolute rather than relative risks when counseling patients
• Timing considerations: Medication changes are best made before conception when possible
• Multidisciplinary approach: Involve obstetrics, psychiatry, and pediatrics in care planning

The decision to use medication during pregnancy must weigh the established benefits of treating mental illness against potential risks, made on a case-by-case basis with informed consent and shared decision-making.