What are the best psychotropic medications, such as Selective Serotonin Reuptake Inhibitors (SSRIs), for treating a pregnant patient?

Best Psychotropic Medications for Pregnant Patients

For depression and anxiety in pregnancy, sertraline is the preferred first-line SSRI, followed by citalopram, based on the best safety profile and minimal excretion in breast milk. 1, 2

SSRIs for Depression and Anxiety

First-Line Agents

• Sertraline is the preferred SSRI due to its minimal excretion in breast milk (providing the infant <10% of maternal daily dose normalized for weight) and low infant-to-maternal plasma concentration ratios 1
• Citalopram is an acceptable alternative as a first-line agent alongside sertraline 2
• Both medications should be continued at the lowest effective dose during pregnancy, as withdrawal may have harmful effects on the mother-infant dyad 1

Important Safety Considerations

• No adverse neurodevelopmental outcomes have been identified in several recent reviews of infants with prenatal SSRI exposure 1
• Paroxetine requires special consideration: While it has the lowest infant-to-maternal plasma concentration ratio (<0.10) during breastfeeding 1, it was classified as FDA pregnancy category D in 2005 due to concerns about cardiac malformations, though more recent evidence suggests this link may not exist 1
• Third-trimester exposure to SSRIs can cause neonatal adaptation syndrome (continuous crying, irritability, jitteriness, tremors, feeding difficulty, respiratory distress) that typically resolves within 1-2 weeks 1

Clinical Management

• Arrange early follow-up after hospital discharge to monitor for neonatal withdrawal symptoms appearing within hours to days after birth 1
• Monitor infants for irritability, feeding difficulties, sleep disturbances, and respiratory symptoms during the first week of life 1
• In severely affected neonates, a short-term course of chlorpromazine may provide symptom relief 1

ADHD Medications in Pregnancy

Stimulant Options

Methylphenidate and amphetamines do not appear to be associated with major congenital malformations or significant adverse developmental outcomes 1

• Methylphenidate: Overall reassuring safety profile with possible small increased risks for cardiac malformations (absolute risk 1.7%) and preterm birth that appear minimal 1
• Amphetamines (mixed salts, dextroamphetamine): No association with major congenital malformations or cardiac defects; possible small increased risk for gastroschisis (absolute risk extremely low given population prevalence of 0.05%) and preterm birth 1
• Discontinuing stimulants during pregnancy can lead to worse mental health outcomes and significant functional impairment, which may negatively impact the developing fetus through increased risks of spontaneous abortion and preterm birth from untreated ADHD 1

Breastfeeding Considerations

• Amphetamines: Hale lactation risk category L3; breastfeeding does not appear to adversely affect infants when used therapeutically 1
• Monitor infants carefully for irritability, insomnia, and feeding difficulty 1

Non-Stimulant Alternatives

• Bupropion: A norepinephrine and dopamine reuptake inhibitor shown to be more effective than placebo for ADHD in adults 1
• Atomoxetine and viloxazine: Alternative non-stimulant options, though atomoxetine crosses the placenta in animal models 1

Critical Decision-Making Framework

Risk-Benefit Analysis

The risks of untreated psychiatric illness during pregnancy must be weighed against medication exposure risks 1, 3

• Untreated depression is associated with premature birth, decreased breastfeeding initiation, and tragic outcomes including suicide and infanticide 1, 3
• Untreated ADHD increases risks for spontaneous abortion and preterm birth 1
• Most psychotropic drugs are relatively safe in pregnancy, and not using them when indicated poses greater risk to both mother and child 3

Hepatic Impairment

• Use sertraline with caution in liver disease; consider lower or less frequent dosing 4

Common Pitfalls to Avoid

• Do not routinely discontinue psychiatric medications when pregnancy is discovered or planned, as this is associated with high relapse rates 1, 3
• Avoid abrupt cessation of SSRIs; taper gradually if discontinuation is necessary to minimize withdrawal symptoms 4
• Do not mix sertraline oral concentrate with anything other than water, ginger ale, lemon/lime soda, or orange juice 4
• Avoid valproate and carbamazepine for bipolar disorder in pregnancy as they are contraindicated 2