Treatment of mental state disorder during pregnancy: These 12 methods are questionable

Pathogenesis

Patient women, 37 years old, suffered from recurrence of depression disorders. At present, the new antidepressant drugs are stable.

Patients have had a poor response to the classic SSRI in the past and were treated twice in the hospital. One of them occurred after serious suicide attempt.

If you are her doctor, how would you suggest?

The management of mental disorders during pregnancy is very difficult: patients and children are facing risks regardless of medication; there are many existing documents, but they conflict with each other and it is difficult to guide clinical clinical.

As an expert in the field of psychiatry period, Dr. Jennifer L. Payne, director of the Female Mental Standards Center of Johns Hopkins University in the United States, recently wrote an article on the management of mood disorders during the period of mood during production:

1. Discontinue all psychiatric drugs

Discontinuation of psychotropic drugs during pregnancy is suitable for some patients, but it is not suitable for many other people and even dangerous.If drugs are discontinued during pregnancy, the recurrence risks of patients with depression and bilateral disorders can reach 70%and 85%, respectively; if the medicine is not stopped, the recurrence risk is only one -third.

2. Underesting the risk of mental illness during pregnancy

Psychiatric disorders (especially depression) during pregnancy are related to a series of neonatal adverse turn, including premature birth, low birth weight, exercise tension and decreased activity, increased cortisol levels, weakening reflection, etc.Poor, risk of signs of eclampsia and gestational diabetes.

The adverse impact of postpartum depression on children includes low IQ, slow language development, and paying attention to the risk of defective dysfunction (ADHD) and behavioral problems.

Regardless of pregnancy or after delivery, children’s mental illness exposed to mothers is more prone to adverse consequences.Evaluate whether the pregnancy is discontinued during pregnancy, in addition to drug teratogenicity, the above factors should also be considered.

3. Insufficient treatment for mental illness during pregnancy

Although some female patients have not stopped drugs during pregnancy, they have not reached an effective dose.Another case is that the patient has recurred, but the dose of the drug has not been adjusted accordingly.In this case, patients and children are exposed to the risk of drugs and mental illness at the same time.If you don’t effectively control the condition, what else do you do?

4. Eager to change the medicine during pregnancy

Generally speaking, psychiatrist during the perinatal period recommends the use of old medicines earlier in the market during pregnancy instead of new drugs that have just been listed, because we know more about the safety of the pregnancy of old drugs.However, if the patients who are using new drugs are already pregnant, the child is exposed to the new drug at this time. Instead of old medicine, it will not only face the risk of recurrence, but also expose the child to the second drug.Therefore, if you want to change the medicine, you will be replaced during pregnancy before pregnancy.

5. Eager to change medicine during breastfeeding

The original intention of using a drug that is rarely entered with milk during breastfeeding is undoubtedly good, but it also increases the risk type of baby exposure -medication during pregnancy, breastfeeding, and recurrence of mothers’ diseases.In theory, only in the following three cases, it is reasonable for breastfeeding.

▲ Some drugs should not be used during pregnancy, but it can be used during breastfeeding, such as propyrine;

▲ Some drugs can be used during pregnancy, but it should not be used during breastfeeding, such as chloropapatosis and lithium salt in some cases;

▲ Symptoms recur.

6. Adults for older women’s preparation during pregnancy

Before pregnancy, the patient’s medication was "eliminated", and the drugs with more evidence and knowing the bottom are usually meaningful.However, with the increase of maternal age, the risk of genetic malformations in future generations is also increasing, and it may be unfavorable to spend too much time adjustment and exploration.Against this background, patients’ mission and informed consent are particularly important.

7. Superstition of FDA pregnancy safety B -level drugs

Drugs using FDA pregnancy security B may reflect a misunderstanding.The hierarchical system has long been eliminated and was replaced by the FDA pregnancy and lactation information label.

Many people think that B -level drugs must be safer than Class C or D drugs;Drugs of human security or risk data.

8. Based on the phenyl nitrogen pyrine

Many doctors are nervous about the use of benzodiabenzine during pregnancy, especially accidental pregnancy, and then refuse to prescribe such drugs for patients.However, the arrest of bon nitrogen is easy to induce abstinence syndrome, such as blood pressure, unstable heart rate, and even epilepsy, which is not good for patients, children and pregnancy processes.

A more scientific approach is to try to gradually reduce the suspension of benzodzine and control its conventional use to the minimum.For patients with a power reduction motivation and good support system, you can consider switching to a longer -length benzodzine, and then reduce the amount by 20%every 24 hours.Many patients may need a slower reduction speed, and you can consider the amount of reduction every 3-7 days.

9. Ignore the problem of abuse of maternal material abuse

The author of this article has evaluated many such pregnancy patients: on the one hand, they are deeply concerned about the safety of psychotropic drugs, and on the other hand, they continue to smoke, drink alcohol, use marijuana or opioids.

It is very important that these substances are known as high -risk factor for adverse pregnancy. If they do not pay attention, the risk is quite clear.In contrast, most of the risks of psychotropic drugs (not all) are not so certain.

10. Refuse to use anti -psychiatric drugs for patients who have symptoms of mental illness

Many patients stopped the appropriate anti -psychiatric drug treatment due to pregnancy.The doctor is out of good intentions to avoid the fetus exposed to the drug; however, the risk of mental illness itself, as well as the unhealthy and unpredictable behavior of the mother, is obvious.In fact, rarely physical diseases during pregnancy can be dangerous enough to interrupt the treatment, and the same is true of mental illness.

11. Avoid the use of lithium salt during pregnancy

Lithium salts are poorly reputable for pregnancy, because early research shows the risk of lithium salts that can increase the three -pointed migration deformity (EBSTEIN Anomaly).However, new data shows that the incidence of this deformity is less than 1%, and the recurrence risk of 85%-100%is 85%-100%.

For patients with good lithium salt efficacy and severe past two -phase disorders, lithium salt should still be regarded as one of the treatment options of pregnancy.Clinically, you can also consider switching to atypical anti -psychiatric drugs, but if the patient has a good response to the lithium salt in the past, the change of medicine may increase the risk of recurrence.

Whether the lithium salt can be used during lactation is currently controversial.Although there are cases of lithium salt, for patients who have a disorderly behavior or cannot recognize the child dehydration of the baby, lithium salt is not recommended during breastfeeding.

12. For women in the age of childbearing age, prescribe propiner acid and Kamasiping under the absence of contraceptive plan or pregnancy -free drug management plan

What needs to be clarified is that the author of this article does not suggest that all women who may be pregnant should not use propyrine or Kamasipipipin; what the author really suggests is that these drugs should be ensured when prescribing these drugs.These drugs should not be used during pregnancy unless they are extremely special; if they are used for women with pregnancy potential, these patients should be clearly understood that these drugs should not be used during pregnancy, and any pregnancy should be planned.Use other drugs.

For patients using propyrine or Camari Ping, they should discuss the choice of contraceptive methods and encourage them to start the contraceptive plan.In addition, the correlation between propyrine and polycystic ovary syndrome (PCOS) and the decline in fertility should also be discussed.

Overall, the author of this article recommends that only when other more safer drugs (such as lithium salt or atypical anti -psychiatric drugs) fail in treatment, they can consider propion acid and Camari Ping for women’s prescriptions for childbearing age.

discuss

Back to the initial case -the patient’s previous condition was serious enough to be hospitalized, there was a history of attempted suicide, and the response to SSRI was not good; we are currently using a newer antidepressant drug, and we know the safety of the drug’s pregnancy.Still not much.

One choice is to replace the vermiculine to a old medicine we know better, as long as it is not SSRI, because the patient has a poor response to SSRI.

However, considering that the patient is 37 years old, it takes a lot of time to change the medicine, and at the same time risk the risk of recurrence (especially the previous condition is very heavy), it may not be the best choice for patients.It is recommended to discuss the treatment options with patients in detail in the principle of weighing the advantages and disadvantages, including the risk of psychotropic drugs during pregnancy, the risk of another drug, and the risk of patients, pregnancy and children during pregnancy diseases.

If you add another limited condition, that is, "the patient is currently pregnant", the recommendation will be different: at this time, changing the medicine is not very much, and it will only expose the fetus to the risk of recurrence of a drug and condition.At this time, it is best to continue to use a clear and effective drug for patients and try to reduce the risk of fetal exposure.

Xinyuan: Payne Jl. Common Errors Psychiatrist Make When Managing Mood Disorders in Pregnant Patients. Psychiatric Times. March 11, 2020 2020

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