Newsletter for Providers
October 2017
Medication and PMADs
Welcome to our first provider-focused newsletter!

This month we introduce our first newsletter especially for providers. This professional-focused  newsletter contains the most up-to-date research, news, resources, and training information to keep you in the know and up to speed. This month we take a in-depth look at medication and PMADs.

(Note that our Parents Newsletter is full of helpful information, resources, community events, and inspiration for families to use to navigate PMADs and parenthood. If you're a provider, this is a great resource to send to your clients!)

We want to make sure you receive only the information you can use. You can choose which newsletter you receive--Parents, Providers, or both--by clicking the Update Profile link at the very bottom of this email.

We always welcome feedback on our newsletters!
In This Issue
Latest News
Updates in prescribing mood stabilizers in pregnancy and postpartum
Amritha Bhat, MD, MPH
In the United States, about 1 in 10 fetuses are exposed to psychotropic medications. It is important to maintain optimal mental and physical health for the mother in the perinatal period, and at the same time ensure a safe environment for fetal growth, and perinatal mental health providers are often faced with the dilemma--to prescribe or not to prescribe?
There are several improvements in the availability of data and the FDA's new Pregnancy and Lactation Labeling rule is more informative than previously defined pregnancy risk categories. But there is still minimal high-quality data to guide the prescribing of medications during pregnancy and lactation.
Here I review recent updates in information on prescribing mood stabilizers in pregnancy and postpartum.
In recent years, lamotrigine has become the preferred medication to treat bipolar disorder during pregnancy. Initial concerns for risk of cleft lip and palate in a baby exposed in utero to lamotrigine have not been supported by recent cohort studies and meta-analyses, and the current consensus is that there is no increased risk of malformation in the fetus if the mother is prescribed lamotrigine during pregnancy. There are reports that when used by breastfeeding mothers, lamotrigine can lead to high concentrations in infant serum. However a review of 122 women with bipolar disorder and epilepsy showed no increase in the number of infant adverse events reported. These data suggest that mothers may continue to take lamotrigine while breastfeeding, and the infant needs to be monitored for possible adverse effects such as rash. A very recent naturalistic cohort study of women with bipolar disorder also suggests that lamotrigine is as effective as lithium in preventing severe postpartum episodes.
For women who require lithium to treat their bipolar disorder, we have new information on lithium dosing strategies based on a retrospective cohort study of a 113 pregnancies. The authors recommend that, as lithium levels drop in the first and second trimesters, lithium should be monitored once every three weeks until 34 weeks gestation and then once a week until delivery. Lithium is excreted by the kidney, and renal functions normalize slowly in the postpartum period, so levels should be monitored twice weekly for the first two weeks postpartum. It is important to obtain preconception lithium levels so that the dose during pregnancy can be adjusted to maintain levels in the therapeutic range. Dosing lithium twice a day can minimize side effects.  Previous recommendations to decrease or discontinue lithium at onset of labor are no longer emphasized as it is possible to continue lithium while closely monitoring levels. In the postpartum period it may be advisable to administer lithium targeting a higher therapeutic level (>0.8mmol/L) in order to reduce the risk of postpartum relapse.
Looking at the data from a Cochrane Database Review published last year, there have been a total of four studies which have included data on children exposed to oxcarbazepine monotherapy. The prevalence of major malformations for children exposed to oxcarbazepine (N = 238) was 2.39%, which did not differ from the prevalence observed in the control groups.
Valproate , of course, should never be prescribed during pregnancy. Although valproate is compatible with breastfeeding, the high teratogenicity and other risks such as polycystic ovarian disease imply that it should not be a medication of choice in reproductive age women.
There is some new information on less frequently used mood stabilizers such as gabapentin, which is associated with increased rates of preterm birth and low birth weight, and topiramate, which is associated with higher risks of oral clefts, hypospadias, and coarctation of aorta. 
There is a new medication on the horizon for the treatment of postpartum depression. Not yet ready for clinical use but showing promise is the intravenous infusion of brexanolone, which is a derivative of a progesterone metabolite. Women with severe depression showed significant improvements within 24 hours of receiving this medication. Stay tuned for updates as the phase three clinical trials for this medication are completed!
Information in this field changes rapidly, and some useful resources for you to access for updated information include ReproTox and LactMed . To speak to a perinatal psychiatrist and obtain consultation on any mental health related question for perinatal patients, you can call the free telephone consultation service for providers, the Perinatal Psychiatry Consultation Line at 206-685-2924.
Medication Management Resources

Medication Overview Chart. 
This is a great chart that includes both generic and brand names of medications.
Medication Overview Chart (2011).
This chart provides information on antidepressants during pregnancy and breastfeeding, including advantages and disadvantages.
ACOG Guidelines on Psychiatric Medication Use During Pregnancy and Lactation (2008).
This chart provides information regarding the FDA Pregnancy Category, AAP Rating, and  lactation Risk Category for psychotropic medications. 
This database allows users to search for a specific medication and receive detailed information regarding the impact of medication on breastfeeding.
Mother to Baby
Telephone: 866-626-6847
MotherToBaby, a service of the non-profit Organization of Teratology Information Specialists, is dedicated to providing evidence-based information to mothers, health care professionals, and the general public about medications and other exposures during pregnancy and while breastfeeding. MotherToBaby affiliates support and contribute to worldwide initiatives for teratology education and research.
Infant Risk Center 
Telephone: 806-352-2519
Consumers can call the call center directly to receive information about medications during pregnancy or while breastfeeding. The InfantRisk Center at Texas Tech University Health Sciences Center is a call center based solely on evidence-based medicine and research. They are dedicated to providing current and accurate information to pregnant and breastfeeding mothers and healthcare professionals. They are a training center for medical and pharmacy students and medical residents in the use of drugs in pregnant and breastfeeding mothers.
Telephone: 877-439-2744
Motherisk provides evidence-based information and guidance about the safety or risk to the developing fetus or infant, of maternal exposure to drugs, chemicals, diseases, radiation, and environmental agents.
Massachusetts General Hospital (MGH) Women 's Mental Health
The MGH Library on Women 's Mental Health is a repository of useful information and frequently referenced articles compiled into different specialty areas, including psychiatric disorders during pregnancy and postpartum.
The Perinatal Mental Health Consultation Service at the University of Illinois
Telephone: 800-573-6121
Provides free clinical consultation to providers regarding all aspects of diagnosis and treatment, including the use of psychotropic medications, during pregnancy and lactation.

Perinatal Psychiatric Consultation Line at the University of Washington.
Telephone: 206-685-2924
Provides free consultation for providers in Washington state about mental health issues during pregnancy and postpartum, including about the impact of psychotropic medications.
Thomas Hale at Texas Tech University
World-renowned expert on lactation and medication and author of Medications and MothersMilk. Provides an open forum for healthcare providers only, and has a searchable database on this subject.
Response to the New York Times Article on SSRIs and Pregnancy: Moving Toward a More  Balanced View of Risk. 
MGH Center For Women's Mental Health on September 5, 2014, in Psychiatric Disorders  During Pregnancy.
Breastfeeding & Psychiatric Medications
Evolving practice in perinatal psychopharmacology: Lessons learned
MGH Center For Women's Mental Health
Meta-Analysis: Antipsychotics and Pregnancy Outcomes
MGH Center For Women's Mental Health
The Use of Antidepressants in Pregnant and Breastfeeding Women: A Review of Recent Studies
Kathleen Kendall-Tackett, PhD, IBCLC, and Thomas W. Hale, PhD
Antidepressant Use During Pregnancy and Breastfeeding
Kathleen Kendall-Tackett, Ph.D., IBCLC

MommyMeds. A consumer-focused application for safety of medications in pregnancy and breastfeeding, based on the research by the InfantRisk Center.

InfantRiskCenter. A provider-focused application on the latest info and research on the safety of medication in pregnancy and breastfeeding.

LactMed. A database of drugs and supplements that may impact breastfeeding.

ReproTox. A membership-based database of the impacts of medications on pregnancy, reproduction, and development. Needs website account ($199).
First Person
Abigail Enelow Myers, MN, ARNP

Abby Enelow Myers, MN, ARNP, based in Seattle, has been in practice for 23 years. PS-WA talked with her about the latest perinatal mood and anxiety disorder (PMAD) trends she has seen in her practice, approaching the idea of medication with families who may be wary about it, and the stigma around the use of medication and of PMADs in general.

Myers said a good encapsulation of her thinking is found in this post by Lee S. Cohen, who is the director of the Ammon-Pinizzotto Center for Women's Mental Health at Massachusetts General Hospital in Boston. It is found on the Women's Mental Health website. It outlines clinical scenarios where there are inconsistencies between clinical practice and the evidence. Cohen lists these key discrepancies:
  1. Using lower doses of antidepressants during pregnancy. Studies show that the dose that "gets them well is typically the dose that keeps them well."
  2. Switching to sertraline in pregnancy/postpartum. If a patient is doing well on another antidepressant and switches to sertraline or another medication, this may put her at risk of recurrence.
  3. Changing to a Category B label drug.
  4. Discontinuing lithium during pregnancy. This is risky, and results in high rate of relapse.
  5. Trying alternative therapies. There is frequent relapse when combined with stopping (effective) antidepressants.
  6. Stopping breastfeeding or deferring antidepressants.
  7. Using non-benzodiazepine sedative-hypnotics.
  8. Pumping and dumping
  9. Failing to bring up contraception.
A big trend that Myers sees is increasing recognition that patients have anxiety, depression, or both during pregnancy, not just postpartum. Providers are beginning to recognize this and to become more knowledgeable about the issue and the safety profiles of medication usage. Some patients report that because they know they have a history of depression and/or anxiety, that this may put them at risk for a perinatal mood disorder. Some women will therefore come in before they get pregnant, she says. Women may also report that their own mothers had unrecognized postpartum depression, which increases their concern about their own risk. Pregnancy is a very fragile time, and Myers says if the patient recognizes that they may be at risk for a PMAD, they are well ahead of the game in terms of prevention.

The stigma around perinatal mood and anxiety disorders continues to occur despite increasing public awareness. Women may be especially reluctant to share their symptoms while pregnant, Myers reports. With this shame, often patients don't want to share with their provider, and if the provider does not ask, the chances for prevention won't occur.

However, across her years of clinical work, Myers sees a decrease in the stigma of taking medication. There are multiple factors for why this may be, some of which include increased media attention, celebrities sharing that medication helped their recovery, and the increase in women sharing their own experiences. In addition there has been a massive increase in research on the safety of medications during both pregnancy and breastfeeding.

It is critical to get moms to meet up with other moms who may share their experiences with treatment-- both counseling and medication. Most of the time, Myers reports that by the time a woman comes in to see her, their distress is such that they just want relief, and so medication is on the table for them.

If a patient is wary of taking medication during pregnancy or postpartum, Myers frames the issue differently, stressing that this is a physiological problem, that neurochemicals are off. She starts by just listening to the mother's report of her experience. She then determines whether supportive counseling is enough. To determine this objectively, she uses the Postpartum Depression Screening Scale, a validated screening tool (PDSS). She finds that this scale is more informative than the Edinburgh Postpartum Depression scale (EDPS) because it gives much more detailed information and helps to determine the severity of the problem. The score can aid in determining whether medications are recommended. She states that often simply sharing the score with the mom will influence her acceptance and willingness to try medication.

As far as approach to treatment, if a patient is pregnant and had been on meds before the pregnancy, Myers will prescribe the lowest dose that is effective, especially in the first trimester of pregnancy, and then watches for any return of symptoms. If the patient does well, she will continue to watch for symptoms returning in the second and third trimesters and increase if needed. But in all cases she recommends increasing the dose a few weeks before delivery to prevent a relapse in the postpartum time period.

If a patient's decision is to stay off meds, Myers really emphasizes using all the support that's available: more help, sleep, support groups, and other networks. She emphasizes that sleep is critically important, and she stresses that patients work on finding a way for the amount of sleep to be maximized. She cites the important standard of getting 5 hours of uninterrupted sleep. Hopefully, she states, the partner will share "shifts" of these blocks of sleep. Although expensive, nighttime doulas can also be an option to help ensure sleep for mom. Extended family may be willing to help defray costs.

One new article of interest for Myers describes the low incidence of PMADs in mothers with no prior psychiatric history. But Myers wonders that if you dig deeper into the woman's background, there may indeed have been some unrecognized psychiatric history, such as chronic low grade depression known as "dysthymia."

Finally, Myers is seeing more and more women struggling with depression related to infertility. Issues such as miscarriage, fertility treatments, and decisions after failure of treatments have a profound effect on a woman and her partner. The grief and loss that inevitably follow must be addressed.
IV Drug for Postpartum Depression in Clinical Trials

At present, there are no drugs on the market specifically identified to treat postpartum depression. However, researchers led by a team at the University of North Carolina School of Medicine recently released results from the second phase of a double blind, multi-site clinical trial of an injectable drug called brexanolone. In the sample group of 21 women, recruited from urban, suburban, and rural settings in the United States, all scored at least 26 on the Hamilton Depression Rating Scale (HAM-D.) Ten women received a 60-hour continuous IV dose of the drug. The other 11 women received a placebo.

The women who received the brexanolone had a mean reduction of 21 points on the HAM-D, compared to an 8.8-point reduction in the placebo cohort. According to the researchers, the drug was well tolerated, with no adverse incidents. And, HAM-D scores for the brexanolone cohort remained lower for a 30-day follow-up period.

A phase 3 clinical trial of the drug is underway at UNC and other sites around the United States.

For more information on the study, please see:

Upcoming Events and Trainings

Consult Groups
PS-WA is partnering with local perinatal specialists to provide Clinical Consult Groups on perinatal mood and anxiety disorders. These consult groups offer a forum to meet with peers and colleagues to confidentially discuss clinic issues. They are suitable for all mental health providers.

The consult groups require a commitment of all 10 monthly consulting meetings. Cost is $75 per meeting.  20 CEUS provided by PS-WA at the completion of the year-long program based on participation: MAs, MSWs, MFTs.

The following group locations are available:
  • ONLINE: 2nd Friday of each month, beginning November 10. 12-2pm Pacific time. Led by Heidi Koss, LMHC. 
  • IN-PERSON (northeast Seattle): 1st Tuesday of each month, beginning November 7. 5:30-7:30 pm. Led by Tricia Spach, ARNP
For more information, see HERE for the online group and see HERE for the in-person group in Seattle.
Let Your Clients Know About Our  Warm Line

Perinatal Support Washington has a toll-free support line for new parents. Leave a message, and a trained volunteer will return your call within 24 hours. The line is staffed by a parent who has experienced a perinatal mood and/or anxiety disorder and has recovered fully, or a licensed therapist with specialized training in perinatal mental health.

We provide warm, understanding, effective, and private support, as well as professional referrals to providers who can help. We also provide details about community support groups and resources and information in the community and online. 

NEW! DADS ON THE LINE! Would it feel more comfortable to talk with a dad who has been through his own perinatal mood or anxiety disorder, or has supported a partner who has? Call our warm line and ask to talk with a dad. 
Apply for Our Provider List
We are working to broaden our database of providers who work with childbearing families experiencing emotional health complications. We seek qualified providers such as therapists, medication prescribers, doulas, IBCLCs, LMPS, and others. We use these provider lists as a referral resource for families who call our warm line or contact us for referrals in their area.

Our provider list is for highly qualified professionals who have specific training and experience working with perinatal mental health complication. Click HERE for detailed requirements and a link to the online application.
Giving to Perinatal Support Washington
Employee Giving
Are you a Microsoft or King County employee or spouse of one?  
Please consider supporting us through your respective workplace giving programs. For King County employees, our code is 9187. Our tax ID is 91-1448669. If you are looking for us, be sure to check our old and new name (Postpartum Support International of Washington) if you don't see us--we are there.

Make Sure You're Getting the Right Newsletter for You
PS-WA is always looking for ways to better provide our subscribers with the information they want and need. We now offer TWO separate newsletters to our community--one directed to parents and one directed to professionals! To start, everyone who has subscribed to our e-newsletter will receive both. If you would prefer to only receive one, please change your preferences by clicking "Update Profile" at the bottom of this email.

Our Parents Newsletter is full of helpful information, resources, community events, and inspiration for families to use to navigate PMADs and parenthood. If you're a provider, this is a great resource to send to your clients!

Our Professional Newsletter contains the most up-to-date research, news, resources, and training information to keep professionals in the know and up to speed.
Warm Line: 1-888-404-7763 (PPMD)

Support Education, Referral
(formerly Postpartum Support International of Washington)