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USE OF ANTIDEPRESSANTS TO TREAT PERINATAL PSYCHIATRIC DISORDERS
HOW TO DO IT EASILY, SAFELY, AND EFFECTIVELY!
THE PROBLEM
- 20 % of women will develop perinatal psychiatric disorders (PPD)
- less than 15% will receive any treatment
- untreated maternal depression leads to;
- Increased severity of the illness in the mother
- Severe impairment of the newbornęs cognitive and behavioral development
- Disruption of marital and family life
- Chronicity
DEPRESSIVE PSYCHOSIS, SUUICIDE, AND INFANTICIDE
THE ROLE OF PRIMARY CARE
- Assuming the time arrives that these patients are routinely identified, the best choice to manage treatment is the primary caretaker
- These can be OB/GYNs, Pediatricians, nurse midwives, nurse practitioners, physician assistants etc
- All can be trained to provide effective, safe medication
MANAGEMENT OF THE RANGE OF DIAGNOSTIC ENTITIES
- Perinatal Psychiatric Disorders can range from relatively mild, such as dysthymia, to Puerperal Psychosis, Bipolar Disorder Mania, or Depressive Psychosis
- The severe mental disorders, schizophrenia, bipolar disorder, and depressive psychosis should be referred for specialist care
- The full range of other anxiety and mood disorders can be managed in a primary care setting
RISK/BENEFIT
- The embryo is at risk for malformation for only three weeks after conception and there is some question that there is any risk at all
- The most dangerous medicines, i.e. lithium, only increase the risk from the normal rate of malformation, 1/1000 births to 4/1000 during the vulnerable period
- Most first prenatal visits are at 6 weeks or the first sonogram. Withholding medication from that time on is locking the barn door after the horse has left
- Depression damages both mother and child
TREATMENT SNAGS
- Patients, in general, are so reluctant to take antidepressants that over 40% of them never get a refill of their first prescription
- Patientęs are afraid that they will become addicted or dependent on the medication
- Anti-depressants are analogous to the use of insulin in diabetes as they replace a necessary body component
- Fear of side effects, or in the case of mothers, fears for effects on their babies hold them back
- Many women fear that taking medication while they are breastfeeding will harm their baby
- There is absolutely no convincing evidence of that
- What we do know is the effect of a motheręs untreated depression on her baby, significant other, and other children
STATEGY FOR SUCCESS
ESTABLISHMENT OF A TREATMENT ALLIANCE
- With the patient
- With the husband or family
- Patient education (both ways)
- Time invested in explanations at the outset more than pays for itself
- Patient should be encouraged to ask questions and report problems
THERAPEUTIC ALLIANCE
- You and the patient are on the same team
- If she doesnęt understand the problem or agree with the plan,
there is no way to "make her" do anything
- Explain why the patient should want to take the medicine
- It is not to make her "happy", but to stop the debilitating
symptoms of depression and anxiety; i.e. uncontrollable crying,
intrusive thoughts of harming the baby or inability to work
THE PROMISE
- 2/3 of the patients will get much better on the first medicine they try. The success rate goes way higher with a second attempt
- That unpleasant side effects will go away either with time or change in dose
- That these medicines are safe not only for the mothers themselves but for their babies as well
- They are effective if taken for a long enough period of time (6 weeks)
THE COMMITMENTS
- Ask the patient to promise herself that if she is going to start medication she will remain on it for a year
- That before she makes the decision to stop taking a medicine she will consult with you
- Offer to be available if and when she has questions
- Have your patient or their relative promise to stay in touch with you or your practice daily
- If you do not hear from your patient for a day, you or a member of your staff has to contact them
PITFALLS
- Delayed onset of benefit
- Patients need to know that they cannot expect positive results for 2-3 weeks
- Because of this, their symptoms may get worse, instead of better at first
- It is a time of higher risk for suicidal ideation
- Need to follow up is increased but is managed by the commitment to keep in touch daily
- Any changes before 2-3 weeks are either side effects or placebo effect
A UNIVERSAL PITFALL
- Patients feel so much better by 6-8 weeks they don't believe
they need the medicine anymore and stop it
- Many patients feel that taking medicine is an admission of weakness, so that, as soon as it seems they can do without it, they stop
- This invariably leads to a relapse, after days or weeks
- The good news is that this relapse will convince the patient that they need to stay the course on their own
WHICH MEDICINE?
- All antidepressants are equally effective
- They differ in side effect profiles
- Drug companies will tout the idea that their product is faster.
Drug trials deal with far more severely ill populations than
you are likely to see. So the patient's chance of success is
greater than what is described in the scientific literature.
- Early relief is a pleasant surprise if the patient does not expect it
SIDE EFFECTS
- Vary by medication
- Newer preparations that aim for only the active stereoisomer tend to have lower side effects and may have quicker onset of action
- Side effects are worse in the beginning
- They are usually dose dependent
- If they are not so unpleasant that the patient will stop taking the medication, they are acceptable
SEXUAL SIDE EFFECTS
- These are often ignored at first, as they seem almost irrelevant
- They become much more important as the patient improves in other parts of her life
- They occur with almost all the old SSRIs
- They are minimal with Lexapro and Wellbutrin
- The time to talk about them is at the first visit
DOSAGE I
- The target is a complete recovery
- The majority of patients will respond to the smallest standard dose recommended by the manufacturer
- One size does not fit all
- The most common prescribing error is too small a dose
DOSAGE II
- A marginal response means the medicine is working. It requires more time
- The dose can be increased repeatedly
- Dosage is limited by side effects
- Some patients, especially with OCD, tolerate 4-5 times standard doses
DOSAGE III
- The best long range treatment for anxiety disorders is, in fact, antidepressants
- Anxiety disorders occur frequently, with or without overt depression
- Patients with panic disorder are usually very sensitive to medicine and require fractional doses
- By contrast, OCD patients are refractive to treatment and require doses anywhere from 3 to 6 times the usual recommendation
FOLLOW UP
THE SHORT-TERM
- The period immediately after treatment begins is particularly worrisome
- This is the period where the suicide and infanticide risks increase temporarily as the medicine has not had a chance to work, or has allowed a patient with no energy to improve enough to act
- As stated above, the patient or their relative should promise to call you or a delegated member of your staff daily for a couple of weeks until they are actually feeling better. This is the best suicide prevention
THE LONG TERM
- After a year of treatment, 50% of first time cases will no longer need medication
- Depression is a relapsing illness
- Lifetime treatment is justifiable on the same basis as the lifetime need for insulin
- It is not an addiction
- Subsequent pregnancies can be managed with timed prophylactic use of psychotropic medication
SUMMARY
- Medication is a powerful weapon against PPD
- Its use is straightforward, safe, and effective
- If used in combination with psychotherapy, over 90% of patients will have an excellent result
REFERENCES
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