The use of psychotropic agents in pregnancy and lactation

The question of which psychotropic medications are safe during pregnancy is likely to remain unanswered for many years to come. There are ethical limitations to performing the type of prospective controlled studies required to answer a scientific question of this type definitively. At the present time, in all patients with worsening psychiatric illness during pregnancy, be it in the schizophrenic, affective, anxiety disorder, or personality disorder spectrum, outpatient psychotherapy, hospitalization, and milieu therapy should be attempted prior to the routine use of psychotropic medication. Prior to pregnancy, withdrawal of psychotropic medications should be attempted under close supervision. Situations will arise in which hospitalization is not sufficient to avert psychotic decompensation. In both schizophrenic illnesses and acute mania, neuroleptics should be used, especially in the first trimester in preference to lithium. The use of high-potency neuroleptics appears preferable to low-potency agents as the first line of therapy, although subsequent management decisions will depend on ability to control side effects. In depression, TCAs should be used in cases of suicidality or incapacitating vegetative signs after the first trimester if supportive measures fail. There appears to be no rationale for withdrawal of TCAs prior to labor. In the third trimester, use of TCAs, low-potency neuroleptics, or lithium should be accompanied by obstetrical surveillance. In severe anxiety or insomnia following the first trimester, the occasional use of benzodiazepines may be warranted except during labor and the first week postpartum. The chronic use of benzodiazepines during any phase of pregnancy and in breastfeeding women is contraindicated. The importance of close rapport between the treating physician and the pregnant or breastfeeding patient cannot be overstated and will obviate or decrease reliance on psychotropic medication in many cases.