The use of psychotropic medications during breast-feeding.

OBJECTIVE: The authors reviewed the risks and benefits regarding the use of psychiatric medications during breast-feeding as they relate to the health and well-being of mothers and their infants. Strategies are discussed to limit infant exposure to a medication while effectively treating the nursing mother. METHOD: A MEDLINE search of the literature since 1955 was conducted to determine the use of psychotropic medications in breast-feeding women. Search items included each of the categories of psychopharmacologic agents as well as each of the agents in association with nursing, breast-feeding, postpartum, lactation, and breast milk. RESULTS: No controlled studies on the safety of psychotropic medications in nursing mothers were found. Case reports and small case series for each of the different psychotropic medications serve as the basis for suggested treatment guidelines for the management of psychiatric illnesses in breast-feeding women. Thus, each case needs to be considered on an individual basis, with a thoughtful analysis of the risks and benefits of nursing and exposure of the infant to medication. The baseline clinical status of the infant should also be reviewed. CONCLUSIONS: Women are vulnerable postpartum to psychiatric disorders and frequently face the need to decide whether to take psychotropic medications while breast-feeding. Should psychiatric medication be indicated, the parents should be provided with the available information regarding the effects of these medications on the neonate. In this way, an informed decision can be made. When psychotropic medication is used during breast-feeding, it is strongly recommended that the infant's pediatrician be involved in monitoring the infant.

Medication status and polycystic ovary syndrome in women with bipolar disorder: a preliminary report.

BACKGROUND: In patients with epilepsy, polycystic ovary (PCO) syndrome has been reported to be associated with the use of the anticonvulsant divalproex sodium. Whether PCO syndrome is associated with divalproex use in patients with bipolar disorder has not previously been explored. METHOD: Twenty-two female outpatients with a DSM-IV diagnosis of bipolar disorder who were between the ages of 18 and 45 years (inclusive) and who were taking lithium and/or divalproex (10, divalproex monotherapy; 10, lithium monotherapy; 2, divalproex/lithium combination therapy) were evaluated. Patients completed questionnaires about their medical, psychiatric, and reproductive health histories, and body mass indices were calculated. In the early follicular phase of their menstrual cycle, women were examined for hirsutism, given a pelvic ultrasound, and/or assessed for changes in laboratory values such as serum levels of testosterone, free testosterone, estradiol, estrone, dehydroepiandrosterone, dehydroepiandrosterone sulfate, luteinizing hormone, follicle-stimulating hormone, and 17-OH progesterone. RESULTS: All 10 patients on lithium monotherapy, 6 of 10 patients on divalproex monotherapy, and both of the patients on divalproex/lithium combination therapy reported some type of menstrual dysfunction, which, in 4 cases, had preceded the diagnosis of bipolar disorder. Hirsutism was not common in any group, but obesity was prominent in all groups. Ovarian ultrasound revealed an increased number of ovarian follicles in 1 patient taking lithium and in none of the patients taking divalproex. Hormonal screening did not indicate PCO-like changes in any patient. CONCLUSION: In this pilot study of bipolar patients, PCO-like changes were not seen in women receiving divalproex or lithium. However, independent of therapeutic agent used, the bipolar women in this study reported high rates of menstrual disturbances, suggesting that the hypothalamic-pituitary-gonadal axis may be compromised in some women with bipolar disorder.

Chart-recorded psychiatric diagnoses in women giving birth in California in 1992.

OBJECTIVE: Although major advances have been made in the diagnosis and treatment of mental disorders in primary care, few population-based investigations have focused on the obstetrical sector. This study examines the occurrence of chart-recorded psychiatric discharge diagnoses among all women delivering in California hospitals in 1992. METHOD: The authors undertook an archival analysis of the California Health Information for Policy Project data set, which consists of linked hospital discharge and birth certificate data for 580,282 deliveries. Frequencies of ICD-9 psychiatric diagnoses were ascertained. RESULTS: Among all women delivering, 1.5% received psychiatric or substance use diagnoses. Of diagnoses recorded, 75% were substance use disorders, 21% were classified generically as "mental disorder of pregnancy," and other psychiatric disorders accounted for 4%. CONCLUSIONS: The occurrence of psychiatric diagnoses in these women is markedly lower than expected, suggesting an underreporting of psychiatric disorders at delivery. Further investigations into the detection of mental disorders in the obstetrical sector are needed.

Managing psychiatric medications in the breast-feeding woman.

Given the high risk of postpartum psychiatric problems, clinicians need to be prepared to appropriately manage the breast-feeding woman who needs psychotropics. These psychiatric researchers examine the issues and offer guidelines. Following childbirth, many women are at high risk for the onset or recurrence of psychiatric illness. Women who need psychopharmacologic treatment may wish to breast-feed their infants, but the data regarding the degree of drug passage to the infant and the subsequent effects of this exposure on infant growth and development are very limited, leaving clinicians with little guidance for responding in ways that protect the health and well-being of both mother and infant. In general, the less protein-bound, the more lipid-soluble, and the more weakly basic a drug is, the more likely it is to diffuse into breast milk. When a psychotropic medication is administered, the infant's clinical status and serum concentrations, including metabolite concentrations, should be closely monitored. Among the agents that have been the subject of at least limited studies in breast-feeding women are tricyclic antidepressants, selective serotonin reuptake inhibitors, benzodiazepines, and the mood stabilizers lithium, carbamazepine, and divalproex. This article examines the factors that influence infant exposure to psychotropic medication through breast-feeding and includes clinical guidelines for managing the breast-feeding woman on psychotropics as well as protecting and caring for her infant.

Depressive symptoms in the perimenopause: prevalence, assessment, and guidelines for treatment.

This review describes the biological changes occurring in perimenopause and analyzes epidemiological studies that shed light on the relationship between perimenopause and mood. The role of estrogen as a treatment for depressive symptoms is also examined. We found that a positive association may exist between depressive symptoms and the perimenopause, and that a prior history of depression may be associated with such symptoms. In most of the studies reviewed, the use of estrogen in replacement doses appears to improve depressive symptoms in perimenopausal patients who do not have major depression. We suggest an approach to the treatment of middle-aged women presenting with such symptoms. No careful study of the incidence of DSM-IV major depression associated with perimenopause has been done, and the efficacy of estrogen as a primary or adjunctive treatment for the disorder during perimenopause is unclear.

Course of psychiatric disorders across the menstrual cycle.

Women of reproductive age with psychiatric disorders may experience a fluctuating course of illness over the menstrual cycle. Some data suggest an exacerbation of symptoms during the premenstrual and menstrual phases. The usefulness of such reports is limited, however, by the lack of prospective assessments and the small number of patients involved. Additionally, many reports do not specify whether the exacerbations reflect an intensification of the underlying psychiatric disorder or a new onset of symptoms that occur only during certain phases of the menstrual cycle. Because symptomatic intensification has been reported for illnesses including schizophrenia, bipolar disorder, depression, anxiety disorders, bulimia nervosa, and substance abuse, the data bring attention to the importance of assessing the relationship between a female patient's symptomatic exacerbation and the menstrual-cycle phase in which it occurs. We present a review of the literature on the course of psychiatric symptoms across the menstrual cycle and discuss the potential effects of estrogen and progesterone on these symptoms.

Pharmacologic management of psychiatric illness during pregnancy: dilemmas and guidelines.

OBJECTIVE: Given concerns about use of psychotropic medication during pregnancy, the authors reviewed the literature regarding the effects of prenatal exposure to psychotropic medications on fetal outcome. METHOD: A MEDLINE search of all articles written in English from 1966 to 1995 was performed to review information on the effects of psychotropic drug use during pregnancy on fetal outcome. Where sufficient data were available and when methodologically appropriate, meta-analyses were performed to assess risk of fetal exposure by psychotropic medication class. RESULTS: Three primary effects are associated with medication use during pregnancy: 1) teratogenicity, 2) perinatal syndromes (neonatal toxicity), and 3) postnatal behavioral sequelae. For many drug classes there are substantial data regarding risk for teratogenicity. Tricyclic antidepressants do not seem to confer increased risk for organ dysgenesis. The available data indicate that first-trimester exposure to low-potency phenothiazines, lithium, certain anticonvulsants, and benzodiazepines may increase the relative risk for congenital anomalies. However, the absolute risk of congenital malformations following prenatal exposure to most psychotropics is low. CONCLUSION: Exposure to certain psychotropic drugs in utero may increase the risk for some specific congenital anomalies, but the rate of occurrence of these anomalies even with the increased risk remains low. Use of psychotropic medications during pregnancy is appropriate in many clinical situations and should include thoughtful weighing of risk of prenatal exposure versus risk of relapse following drug discontinuation. The authors present disorder-based guidelines for psychotropic drug use during pregnancy and for psychiatrically ill women who wish to conceive.

Breastfeeding and sertraline: a 24-hour analysis.

BACKGROUND: Few reports exist on the levels of antidepressants in breast milk or on observed behavioral effects, if any, of neonates who are breast-fed. Thus, a dilemma exists for women who would like to breast-feed but require psychotropic medications. METHOD: Analysis of sertraline levels was performed on eight samples of breast milk obtained over a 24-hour period, after 3 weeks of breastfeeding, from a lactating patient taking sertraline and nortriptyline. During this same 24-hour period, two serum samples each were taken from mother and child for analysis of sertraline and nortriptyline levels. After 7 weeks of exclusive breastfeeding, an additional serum sample was obtained from mother and child for analysis of sertraline levels. Drug metabolites were not measured. RESULTS: Breast milk levels of sertraline were lowest 1 hour before the ingestion of sertraline and highest 5 to 9 hours after ingestion of the drug. The infant's serum sertraline and nortriptyline levels were nondetectable. CONCLUSION: These data indicate that sertraline levels in breast milk vary substantially over 24 hours and appear to be lowest within the 2 hours before and 1 hour after ingestion of the medication, with the peak probably occurring between Hours 1 and 9 postingestion. However, the absence of detectable serum sertraline and nortriptyline levels in the infant suggests that if either medication is present in infant serum, its concentration would be extremely low. No abnormal occurrences have been noted in the development of the infant. It would be important in future studies to measure metabolites in addition to medication levels since the former have been associated with untoward events in an infant.

Providing residents with a comprehensive educational program in outpatient psychiatry : integrating an outpatient curriculum into outpatient management teams.

As part of their efforts to prepare psychiatry residents for comprehensive, practical outpatient psychiatric practice, the authors have established an organized training program in ambulatory psychiatry. The program consists of outpatient management teams that run from mid-PGY-2 to PGY-4, a specified minimum number of mandatory outpatient hours for continuity patient care, and suggested guidelines for residents' outpatient experiences. An outpatient management team curriculum has been designed for team leaders and trainees that consists of specific topics in outpatient care, associated learning objectives, and readings for each topic. This curriculum, which supplements our previous program of conferences, individual supervision, and a yearlong psychotherapy seminar series, has been refined over the past 5 years. The authors describe the program and the topics included in the curriculum.

A survival guide for aspiring academic psychiatrists : personality attributes and opportunities for academic success.

Many residents in psychiatric residency training are interested in an "academic career" Recognizing that current academic departments require excellent teachers, clinicians, and administrators in addition to researchers, medical schools and their universities are wrestling with titles and tenure as they attempt to provide opportunities via a variety of academic career paths. What constitutes the most suitable career path for the academic aspirant depends on the person's goals, motivations, interests, values, personality style, talents, background, and training, as well as historically and geographically available training, mentoring, and employment opportunities. The authors examine alternative definitions of "academic success," relate these to the variety of personality types and opportunities found in academic settings, and provide some guidelines for advancement along the available career paths.

Outpatient management teams : integrating educational and administrative tasks.

To provide a more structured experience in outpatient psychiatric training, the UCLA Neuropsychiatrie Institute's outpatient department organized outpatient management teams. Each team is supervised by a pair of faculty psychiatrists. PGY-3 and PGY-4 teams also include a psychologist and a social worker. The teams serve to provide comprehensive outpatient psychiatric training, track and review patients seen by the trainees, and ensure quality of care. In this way, the teams have successfully linked educational, clinical, and administrative tasks. The authors review the organization and processes of this outpatient program, now in its third year.

Older psychiatric residents: a pilot study of stresses and strengths.

Residency-related stresses were examined as a function of age or age-related factors in a group of 10 psychiatrists who started psychiatric training at age 32 or older (average age, 36.2). Commonly expressed stresses included feelings of isolation from the group, inflated expectations, and conflicting role obligations. Addressing the stresses on older residents may diminish their anxiety and enhance their morale and overall gratification in the residency program.