Skip to main content Accessibility help
Hostname: page-component-77c89778f8-vsgnj Total loading time: 0 Render date: 2024-07-18T02:48:51.706Z Has data issue: false hasContentIssue false

Chapter 19 - Psychotropic Prescribing in Pregnancy and Lactation

from Part 3 - Specific Therapeutic Areas

Published online by Cambridge University Press:  29 May 2020

Peter M. Haddad
Hamad Medical Corporation, Qatar
David J. Nutt
Centre for Neuropsychopharmacology, Division of Psychiatry, Department of Brain Sciences, Imperial College London
Get access


The decision to prescribe psychotropic medication is always a matter of weighing up potential risks and benefits but at no time is this more difficult than in pregnancy and the post-partum period. This is because the risks do not only relate to the side-effects for the mother but also potential adverse outcomes for the pregnancy and the child who may be particularly vulnerable during fetal development and breastfeeding. In addition, there is often a degree of uncertainty about what added risks medication may bring compared with no treatment.

Publisher: Cambridge University Press
Print publication year: 2020

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


American College of Obstetricians and Gynecologists (2008). ACOG Practice Bulletin: clinical management guidelines for obstetrician-gynecologists number 92, April 2008. Use of psychiatric medications during pregnancy and lactation. Obstet Gynecol, 111, 10011020.Google Scholar
Baldwin, D, Wieck, A (2018). Withdrawal of, and alternatives to, valproate-containing medicines in girls and women of childbearing potential who have a psychiatric illness. Royal College of Psychiatrists, PS 04/18. Available at: (last accessed 15.8.19).Google Scholar
Bauer, A, Paronage, M, Knapp, M, et al. (2014). The Costs of Perinatal Mental Health Problems. The London School of Economics, Personal Social Services Research Unit. Available at: (last accessed 8.9.19).Google Scholar
Bennett, PN (1996). Use of monographs in drugs. In Bennett, PN, ed., Drugs and Human Lactation. Amsterdam: Elsevier Science Publishers, pp. 6774.Google Scholar
Bodén, R, Lundgren, M, Brandt, L, et al. (2012). Antipsychotics during pregnancy: relation to fetal and maternal metabolic effects. Arch Gen Psychiatry, 69, 715721.Google Scholar
Bonari, L, Koren, G, Einarson, TR, et al. (2005). Use of antidepressants by pregnant women: evaluation of perception of risk, efficacy of evidence based counseling and determinants of decision making. Arch Womens Ment Health, 8(4), 214220.CrossRefGoogle ScholarPubMed
Boyle, B, Garne, E, Loane, M, et al. (2017). The changing epidemiology of Ebstein’s anomaly and its relationship with maternal mental health conditions: a European registry-based study. Cardiol Young, 27(4), 677685. doi:10.1017/S1047951116001025.Google Scholar
Bromley, R, Baker, GA (2017). Fetal antiepileptic drug exposure and cognitive outcomes. Seizure, 44, 225231.Google Scholar
Bromley, R, Weston, J, Adab, N, et al. (2014). Treatment for epilepsy in pregnancy: neurodevelopmental outcomes in the child. Cochrane Database Syst Rev, (10), CD010236. doi:10.1002/14651858.CD010236.pub2.Google Scholar
Casanova Dias, M, Jones, I (2016). Perinatal psychiatry. Medicine, 44(12), 720723. doi: Scholar
Chambers, CD, Hernandez-Diaz, S, Van Marter, LJ, et al. (2006). Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. N Engl J Med, 354, 579587.Google Scholar
Christensen, J, Grønborg, TK, Sørensen, MJ, et al. (2013). Prenatal valproate exposure and risk of autism spectrum disorders and childhood autism. JAMA, 309(16), 16961703.Google Scholar
Cohen, LS, Altshuler, LL, Harlow, BL, et al. (2006). Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA, 295, 499507.Google Scholar
Coughlin, CG, Blackwell, KA, Bartley, C, et al. (2015). Obstetric and neonatal outcomes after antipsychotic medication exposure in pregnancy. Obstet Gynecol, 125(5), 12241235. doi:10.1097/AOG.0000000000000759.Google Scholar
Croen, LA, Grether, JK, Yoshida, CK, et al. (2011). Antidepressant use during pregnancy and childhood autism spectrum disorders. Arch Gen Psychiatry, 68, 11041112.Google Scholar
Dayan, J, Gaignic-Philippe, R, Seligmann, C, et al. (2011). Use of antipsychotics and breastfeeding. Curr Wom Health Rev, 7, 3745.Google Scholar
Deligiannidis, KM, Byatt, N, Freeman, MP (2014). Pharmacotherapy for mood disorders in pregnancy: a review of pharmacokinetic changes and clinical recommendations for therapeutic drug monitoring. J Clin Psychopharmacol, 34(2), 244255. doi:10.1097/JCP.0000000000000087.Google Scholar
Di Florio, A, Forty, L, Gordon-Smith, K, et al. (2013). Perinatal episodes across the mood disorder spectrum. JAMA Psychiatry, 70(2), 168175.Google Scholar
European Medicines Agency (2014). CMDh agrees to strengthen warnings on the use of valproate medicines in women and girls. Press release, 21 November 2014. Available at: (last accessed 15.8.19).Google Scholar
European Medicines Agency (2018). New measures to avoid valproate exposure in pregnancy endorsed. Press release, 23 March 2018. Available at: (last accessed 15.8.19).Google Scholar
Furu, K, Kieler, H, Haglund, B, et al. (2015). Selective serotonin reuptake inhibitors and venlafaxine in early pregnancy and risk of birth defects: population based cohort study and sibling design. BMJ, 350, h1798. doi:10.1136/bmj.h1798.Google Scholar
Gentile, S (2008). Infant safety with antipsychotic therapy in breast-feeding: a systematic review. J Clin Psychiatry, 69(4), 666673.CrossRefGoogle ScholarPubMed
Goodwin, GM, Haddad, PM, Ferrier, IN, et al. (2016). Evidence-based guidelines for treating bipolar disorder: revised third edition recommendations from the British Association for Psychopharmacology. J Psychopharmacol, 30(6), 495553. doi:10.1177/0269881116636545.Google Scholar
Grigoriadis, S, VonderPorten, EH, Mamisashvili, L, et al. (2013). The effect of prenatal antidepressant exposure on neonatal adaptation: a systematic review and meta-analysis. J Clin Psychiatry, 74, e309e320.Google Scholar
Grzeskowiak, LE, Morrison, JL, Henriksen, TB, et al. (2015). Prenatal antidepressant exposure and child behavioural outcomes at 7 years of age: a study within the Danish National Birth Cohort. BJOG, 123, 19191928.Google Scholar
Habermann, F, Fritzsche, J, Fuhlbrück, F, et al. (2013). Atypical antipsychotic drugs and pregnancy outcome: a prospective, cohort study. J Clin Psychopharmacol, 33(4), 453462. doi:10.1097/JCP.0b013e318295fe12.CrossRefGoogle ScholarPubMed
Hale, T (2012). Medications and Mother’s Milk. Amarillo: Hale Publishing.Google Scholar
Huybrechts, KF, Bateman, BT, Palmsten, K, et al. (2015). Antidepressant use late in pregnancy and risk of persistent pulmonary hypertension of the newborn. JAMA, 313, 21422151.Google Scholar
Huybrechts, KF, Hernández-Díaz, S, Patorno, E, et al. (2016). Antipsychotic use in pregnancy and the risk for congenital malformations. JAMA Psychiatry, 73(9), 938946. doi:10.1001/jamapsychiatry.2016.1520.Google Scholar
Hummels, H, Bertholee, D, van der Meer, D, et al. (2016). The quality of lactation studies including antipsychotics. Eur J Clin Pharmacol, 72(12), 14171425.Google Scholar
Jentink, J, Loane, MA, Dolk, H, et al.; EUROCAT Antiepileptic Study Working Group (2010). Valproic acid monotherapy in pregnancy and major congenital malformations. N Engl J Med, 362(23), 21852193.Google Scholar
Jimenez-Solem, E, Andersen, JT, Petersen, M, et al. (2013). Prevalence of antidepressant use during pregnancy in Denmark, a nation-wide cohort study. PLoS One, 8(4), e63034. doi:10.1371/journal.pone.0063034.Google Scholar
Jones, I, Chandra, PS, Dazzan, P, Howard, LM (2014). Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet, 384(9956), 17891799.Google Scholar
Källén, BA, Otterblad, OP (2007). Maternal use of selective serotonin re-uptake inhibitors in early pregnancy and infant congenital malformations. Birth Defects Res A Clin Mol Teratol, 79, 301308.Google Scholar
Kanes, S, Colquhoun, H, Gunduz-Bruce, H, et al. (2017). Brexanolone (SAGE-547 injection) in post-partum depression: a randomised controlled trial. Lancet, 390(10093), 480489.Google Scholar
Koren, G, Pariente, G (2018). Pregnancy-associated changes in pharmacokinetics and their clinical implications. Pharm Res, 35(3), 61. doi:10.1007/s11095-018-2352-2.Google Scholar
Malm, H, Artama, M, Gissler, M, et al. (2011). Selective serotonin reuptake inhibitors and risk for major congenital anomalies. Obstet Gynecol, 118, 111120.CrossRefGoogle ScholarPubMed
Man, KK, Tong, HH, Wong, LY, et al. (2015). Exposure to selective serotonin reuptake inhibitors during pregnancy and risk of autism spectrum disorder in children: a systematic review and meta-analysis of observational studies. Neurosci Biobehav Rev, 49, 8289.Google Scholar
McCrea, RL, Nazareth, I, Evans, SJ, et al. (2015). Lithium prescribing during pregnancy: a UK primary care database study. PLoS One, 10(3), e0121024. doi:10.1371/journal.pone.0121024.Google Scholar
McKnight, RF, Adida, M, Budge, K, et al. (2012). Lithium toxicity profile: a systematic review and meta-analysis. Lancet, 379(9817), 721728. doi:10.1016/S0140-6736(11)61516-X.CrossRefGoogle ScholarPubMed
Meador, K, Reynolds, MW, Crean, S, et al. (2008). Pregnancy outcomes in women with epilepsy: a systematic review and meta-analysis of published pregnancy registries and cohorts. Epilepsy Res, 81(1), 113. doi:10.1016/j.eplepsyres.2008.04.022.Google Scholar
Meltzer-Brody, S, Howard, LM, Bergink, V, et al. (2018). Postpartum psychiatric disorders. Nat Rev Dis Primers, 4, 18022. doi:10.1038/nrdp.2018.22.CrossRefGoogle ScholarPubMed
Myles, N, Newall, H, Ward, H, et al. (2013). Systematic meta-analysis of individual selective serotonin reuptake inhibitor medications and congenital malformations. Aust N Z J Psychiatry, 47(11), 10021012. doi:10.1177/0004867413492219.CrossRefGoogle ScholarPubMed
National Institute for Health and Care Excellence (NICE) (2014). Antenatal and postnatal mental health – clinical management and service guidance. Clinical guideline [CG192]. London: National Institute for Health and Care Excellence.Google Scholar
Patorno, E, Huybrechts, KF, Bateman, BT, et al. (2017). Lithium use in pregnancy and the risk of cardiac malformations. N Engl J Med, 376(23), 22452254. doi:10.1056/NEJMoa1612222.Google Scholar
Peng, M, Gao, K, Ding, Y, et al. (2013). Effects of prenatal exposure to atypical antipsychotics on postnatal development and growth of infants: a case-controlled, prospective study. Psychopharmacology (Berl), 228(4), 577584. doi:10.1007/s00213-013-3060-6.Google Scholar
Petersen, I, McCrea, RL, Osborn, DJ, et al. (2014). Discontinuation of antipsychotic medication in pregnancy: a cohort study. Schizophr Res, 159(1), 218225. doi:10.1016/j.schres.2014.07.034.Google Scholar
Ross, LE, Grigoriadis, S, Mamisashvili, L, et al. (2013). Selected pregnancy and delivery outcomes after exposure to antidepressant medication: a systematic review and meta-analysis. JAMA Psychiatry, 70, 436443.CrossRefGoogle ScholarPubMed
Royal College of Psychiatrists, Centre for Care Quality Improvement (2016). Topic 15a baseline audit report. Prescribing valproate for bipolar disorder. Available at: (last accessed 15.8.19).Google Scholar
Schou, M (1976). What happened later to the lithium babies? A follow-up study of children born without malformations. Acta Psychiatr Scand, 54(3), 193197.Google Scholar
Stein, A, Pearson, RM, Goodman, SH, et al. (2014). Effects of perinatal mental disorders on the fetus and child. Lancet, 384(9956), 18001819.–0.Google Scholar
Tomson, T, Battino, D (2012). Teratogenic effects of antiepileptic drugs. Lancet Neurol, 11(9), 803813. doi:10.1016/S1474-4422(12)70103-5.CrossRefGoogle ScholarPubMed
Toxnet – LactMed (2019). Drugs and Lactation Database – LactMed. Available at: (last accessed 8.9.19).Google Scholar
Veroniki, AA, Cogo, E, Rios, P, et al. (2017a). Comparative safety of anti-epileptic drugs during pregnancy: a systematic review and network meta-analysis of congenital malformations and prenatal outcomes. BMC Med, 15(1), 95. doi:10.1186/s12916-017-0845-1.Google Scholar
Veroniki, AA, Rios, P, Cogo, E, et al. (2017b). Comparative safety of antiepileptic drugs for neurological development in children exposed during pregnancy and breast feeding: a systematic review and network meta-analysis. BMJ Open, 7(7), e017248. doi:10.1136/bmjopen-2017-017248.Google Scholar
Viktorin, A, Uher, R, Reichenberg, A, et al. (2017). Autism risk following antidepressant medication during pregnancy. Psychol Med, 47, 27872796. doi:10.1017/S0033291717001301.Google Scholar
Wesseloo, R, Wierdsma, AI, van Kamp, IL, et al. (2017). Lithium dosing strategies during pregnancy and the postpartum period. Br J Psychiatry, 211(1), 3136. doi:10.1192/bjp.bp.116.192799.Google Scholar
Westin, AA, Brekke, M, Molden, E, et al. (2018). Treatment with antipsychotics in pregnancy: changes in drug disposition. Clin Pharmacol Ther, 103(3), 477484. doi:10.1002/cpt.770.Google Scholar
Wieck, A (2017). Prevention of bipolar episodes with lithium in the perinatal period. Br J Psychiatry, 211, 34.Google Scholar
Wlodarczyk, BJ, Palacios, AM, George, TM, et al. (2012). Antiepileptic drugs and pregnancy outcomes. Am J Med Genet A, 158A(8), 20712090. doi:10.1002/ajmg.a.35438.Google Scholar
Yonkers, KA, Gotman, N, Smith, MV, et al. (2011). Does antidepressant use attenuate the risk of a major depressive episode in pregnancy? Epidemiology, 22, 848854.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the or variations. ‘’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats