• Baseline Risks: Remember that even without medication, pregnancy carries inherent risks. Spontaneous abortion occurs in 10-20% of confirmed early pregnancies, and major malformations occur in 2-3% of newborns.
• Lifestyle Factors: Smoking, poor diet, alcohol use, and pre-pregnancy obesity negatively impact fetal outcomes. Obesity specifically increases the risk of neural tube defects.
• Untreated Illness Risk: Psychiatric illness during pregnancy is itself a risk factor for congenital malformations, stillbirths, neonatal deaths, and negative child outcomes persisting into adolescence. Severe mental illness (SMI) also increases the mother's risk of life-threatening obstetric complications.
• Medication Safety Data: Establishing clear safety profiles for psychotropics in pregnancy is difficult. Ethical constraints prevent robust trials, and observational studies often struggle to control for confounding factors like the illness itself, substance use, smoking, obesity, and other medications. Information evolves as more data becomes available.
• Balancing Risks: The patient's informed view on risks and benefits is crucial. Critically, lack of active treatment, especially psychotropic medication, is associated with perinatal suicides in women with SMI. Withholding necessary medication solely due to pregnancy or lactation status is generally discouraged.

For All Women of Child-Bearing Potential:

• Always discuss the possibility of pregnancy (half are unplanned).
• Avoid drugs known to be harmful (contraindicated) during pregnancy, such as valproate, topiramate, and carbamazepine. If their use is essential, ensure the woman fully understands the risks and has a reliable long-term contraception plan in place.

If Mental Illness is Newly Diagnosed During Pregnancy:

• Prioritise non-pharmacological treatments first.
• If medication is needed, try to avoid it during the first trimester (organogenesis) unless benefits clearly outweigh risks.
• Choose a well-established drug.
• Use the lowest effective dose.
• Regularly review the need for each medication and stop any that aren't effective.

If a Woman on Psychotropics Plans Pregnancy:

• Consider discontinuing treatment only if she is well and has a low risk of relapse, based on a thorough history review.
• For women with SMI and high relapse risk, stopping medication is generally not advisable. Consider switching to a lower-risk drug, but be aware that switching itself can trigger relapse. Changes must be cautious and tailored to her history and treatment response.
• Address potential drug-induced hyperprolactinaemia, as it can affect fertility. Consider switching medication if this occurs.
• Women with SMI should receive pre-conception counselling from a perinatal specialist to discuss relapse risks and plan perinatal care.

If a Woman on Psychotropics Discovers She is Pregnant:

• Do not abruptly stop medication if she has SMI and a high relapse risk. Relapse can be more harmful than continuing effective treatment.

Continue Current Meds vs. Switching

Often, it's better to continue the current effective medication rather than switching upon discovering pregnancy. This minimises relapse risk and limits the number of different drugs the fetus is exposed to.

• Valproate must be stopped immediately.
• Review the treatment plan, as mood can fluctuate significantly in early pregnancy.

If the Patient Smokes:

• Smoking significantly increases risks for poor pregnancy outcomes.
• Strongly encourage switching to Nicotine Replacement Therapy (NRT) and refer to smoking cessation services.
• Vaping is likely safer than smoking but carries risks; NRT is generally preferred.
• Be aware that stopping smoking can increase plasma levels of certain drugs (e.g., clozapine).

General Approach During Pregnancy:

• Involve parents in decisions as much as possible.
• Use the minimum number of drugs necessary, both concurrently and sequentially.
• Use the lowest effective dose.
• Be prepared to adjust doses, especially upwards in the third trimester due to increased blood volume (around 30%) and altered liver enzyme activity (CYP2D6 activity increases, CYP1A2 activity decreases). Plasma level monitoring can be helpful.
• Refer women with SMI to specialist perinatal services.
• Liaise with obstetric services for adequate fetal screening.
• Inform the obstetric and neonatal teams about psychotropic use and potential complications.
• Monitor the newborn for any withdrawal effects.
• Document all decisions and the medication plan clearly.

• Risk of Relapse: Pregnancy does not prevent psychotic relapse. Psychosis during pregnancy increases the risk of postpartum psychosis.
• Postpartum Psychosis Incidence: Occurs in 0.1-0.25% of the general population. The risk is significantly higher (around 1 in 5) for women with bipolar disorder and can be up to 50% for those with a personal or family history of postpartum psychosis, bipolar I disorder, or schizoaffective disorder.
• Impact of Untreated Psychosis: Maternal mental health affects fetal well-being, obstetric outcomes, and child development. Risks range from neglect to infanticide.

First-Generation Antipsychotics (FGAs):

• Overall: Unlikely to be major teratogens, although some specific malformations have been reported with individual agents.
• Historical Data: Early studies potentially confounded by treating hyperemesis gravidarum (itself linked to malformations) with low-dose phenothiazines.
• Large Studies: Generally show no meaningful increase in major or cardiac malformations. A 2023 study confirmed FGAs are not major teratogens but noted a potential safety signal (cardiac malformations) with chlorprothixene needing further investigation.
• Haloperidol: A possible link to limb defects exists based on a few cases, but the risk appears extremely low and hasn't been replicated in larger studies.
• Other Associations: Increased risk of gestational diabetes, possibly preterm birth (one study suggested higher risk than SGAs), increased postpartum bleeding (vaginal delivery), higher placenta-to-birth-weight ratio.
• Neonatal Effects: Reports of neonatal dyskinesia, jaundice (with phenothiazines), withdrawal symptoms (somnolence, jitteriness), neurological issues, and persistent pulmonary hypertension (absolute risk low, effects usually mild/transient). Prolonged neonatal hospital stays have also been reported.

Second-Generation Antipsychotics (SGAs):

• Overall: Unlikely to be major teratogens, although specific malformations reported with some agents.
• Large Studies: Generally show no meaningful increase in major or cardiac malformations. One large study noted a small absolute risk increase with risperidone, suggested as a possible safety signal needing cautious interpretation and further study. A 2023 study confirmed SGAs are not major teratogens but flagged potential safety signals needing further study: olanzapine/oral clefts, and gastroschisis/brain anomalies with SGAs as a class.
• Conflicting Data: One study linked SGA use to specific defects (conotruncal heart, tetralogy of Fallot, anorectal atresia, gastroschisis), but this study had significant confounding factors (higher rates of obesity, substance use, smoking, other medications in the SGA group).
• Prospective Study: Found SGA exposure associated with increased birth weight, a modest increase in cardiac septal defects (potentially due to screening bias or co-exposure to SSRIs), and neonatal withdrawal effects (in 15%).
• Lurasidone: Available data do not suggest it's a major teratogen.
• Olanzapine: Associated with lower birth weight (conflicting data exists), large head circumference, macrosomia, and increased risk of gestational diabetes.
• Clozapine: May have a higher likelihood of neonatal seizures compared to other SGAs. Theoretical risk of fetal/neonatal agranulocytosis exists, but overall pharmacovigilance doesn't suggest it's less safe than other antipsychotics. NICE includes it as an option. One study reported lower adaptive behaviour scores and more disturbed sleep/lability in exposed infants compared to those exposed to risperidone, quetiapine, or olanzapine. Generally, clozapine should be continued during pregnancy if effective. Plasma level monitoring is beneficial, especially if smoking habits change.
• Quetiapine: Has relatively low placental passage. One study (where quetiapine was the most used antipsychotic) linked antipsychotic use to increased postpartum bleeding, prolonged neonatal stay, and higher placenta-to-birth-weight ratio.

Cariprazine Use in Pregnancy

Manufacturer advises against use due to malformations in animal studies; should probably be avoided.

• Cariprazine: Manufacturer advises against use due to malformations in animal studies; should probably be avoided.
• Aripiprazole: May not be associated with increased gestational diabetes risk. A potential safety signal regarding neurodevelopmental disorders requires further study.
• Other Associations: Increased risk of gestational diabetes (potentially highest with clozapine, olanzapine, quetiapine), possibly preterm birth, low birth weight, postpartum bleeding (vaginal delivery). Increased risk of C-section and large-for-gestational-age babies compared to no antipsychotic (and higher than FGAs in one study). Maternal illness and lifestyle are important confounders for metabolic risks.
• Neonatal Effects: Reports of withdrawal symptoms, neurological disorders, and persistent pulmonary hypertension (absolute risk low, effects usually mild/transient).

Antipsychotic Use and Longer-Term Neurodevelopment:

• Overall Effect: Unclear.
• Studies:
  • One small study showed transient developmental delays at 2 & 6 months (gone by 12 months); clinical significance uncertain.
  • A small study found no significant impact on IQ or neurodevelopment in school-aged children.
  • Large cohort studies link increased risk of ADHD and ASD to maternal mental illness, not specifically prenatal antipsychotic exposure.
  • Another study found no increased risk of psychiatric disorders in children born to women who continued antipsychotics.
  • A 2022 study found antipsychotics were not causally associated with neurodevelopmental disorders, though noted a signal for aripiprazole needing further investigation.

• Acknowledge data limitations but emphasize the significant risks of untreated maternal psychosis to both mother and child.
• Advise women maintained on antipsychotics to discuss pregnancy plans early.
• Support risk reduction strategies (smoking cessation, avoiding alcohol/drugs) and refer to appropriate services.
• Address drug-induced hyperprolactinaemia if pregnancy is planned.
• If a woman is stable on an antipsychotic and likely to relapse without it, advise her to continue the medication. Switching carries relapse risks and is generally not advised.
• When starting an antipsychotic, consider the one that worked best previously (after discussing risks/benefits) to potentially minimise dose/exposure needed.
• Use the lowest effective dose and the fewest drugs possible. Stop ineffective medications.
• Advise on diet and monitor for excessive weight gain.
• Monitor for gestational diabetes (e.g., offer an oral glucose tolerance test as recommended by NICE in the UK).
• NICE UK generally advises avoiding depot preparations if planning pregnancy, pregnant, or breastfeeding, unless the woman responds well to a depot and has adherence issues with oral medication.
• Consider fetal anomaly scans (e.g., 13 or 18-20 week ultrasound recommended by COPE Australia for first-trimester exposure).
• Be aware of potential neonatal withdrawal symptoms (agitation, crying, feeding issues) – considered a class effect. Recommend delivery in a hospital with access to paediatric intensive care. Some centres use mixed feeding (breast/bottle) to ease withdrawal.
• Document all discussions and decisions thoroughly.

• Prevalence: About 10% of pregnant women experience depression (either new onset or pre-existing).
• Timing: A significant number (around a third) of postpartum depression cases actually start during pregnancy. There's a notable spike in new psychiatric episodes, especially mood disorders like severe depression, in the first 3 months after delivery.
• Risk Factors: Women with a history of depression (postpartum or otherwise) are at higher risk. The risk is particularly high for women with bipolar disorder, who also face risks of mania or mixed episodes.
• Impact of Untreated Depression:
  • Potential (though small) increased risk of miscarriage, low birth weight, small for gestational age babies, or preterm delivery.
  • Maternal mental health directly affects fetal well-being, birth outcomes, and child development.
  • Risks to the mother include poor self-care, neglecting obstetric appointments, and self-harm.
  • Risks to the baby range from neglect to, in severe cases, infanticide.

• Relapse Risk: Stopping antidepressants during pregnancy significantly increases the risk of relapse, especially for those with severe or recurrent depression. One study showed a 68% relapse rate in those who stopped versus 26% in those who continued. The speed of withdrawal also matters.
• Neurodevelopment: Current data, after accounting for factors like maternal illness, do not suggest a link between prenatal antidepressant use and neurodevelopmental disorders (like ASD or ADHD).
• Potential Benefits of Treatment: Treating maternal depression with antidepressants might actually be beneficial for child behavioural outcomes. Some evidence suggests worse outcomes for children of depressed mothers not taking medication compared to those who are treated. Antidepressant use in pregnancy can be a marker for needing early screening and support.

Tricyclic Antidepressants (TCAs)

• Fetal Exposure: Significant exposure occurs through the umbilical cord and amniotic fluid.
• Historical Use: Widely used in the past without obvious major harm to the fetus.
• Potential Risks:
  • Clomipramine: A weak link to cardiovascular defects cannot be ruled out. Product information warns about neonatal withdrawal symptoms (breathing difficulty, lethargy, colic, irritability, blood pressure changes, tremor/spasms) if taken until delivery. Not recommended during pregnancy or without contraception. Rare cases of neonatal QT prolongation/torsades and Timothy syndrome (with amitriptyline) reported.
  • General TCAs: Associated with increased risk of preterm delivery. Use in the third trimester can cause neonatal withdrawal (agitation, irritability, seizures, respiratory distress, metabolic issues), usually mild and temporary.
• Long-Term Development: Limited data; no clear adverse effects found in small studies. Any observed associations with later affective disorders in offspring are likely due to underlying parental mental health issues, not the drug itself. No convincing link to neurodevelopmental disorders or ASD.

Selective Serotonin Reuptake Inhibitors (SSRIs)

• Teratogenicity: Generally not considered major teratogens.
• Congenital Heart Defects: Data are conflicting. Some studies suggested a link (especially with fluoxetine and paroxetine), but others found no association with any SSRI. Any increased risk might be linked to the mood disorder itself or associated factors like alcohol use.
• Placental Exposure: Sertraline appears to have the lowest placental exposure.
• Pregnancy/Birth Outcomes: May be a small increased risk of preterm birth, low birth weight, lower Apgar scores, and NICU admission (note: maternal depression itself increases these risks).
• Neonatal Issues:
  • Poor Neonatal Adaptation/Withdrawal: Reported symptoms like jitteriness, irritability, feeding difficulties. Risk might be higher with prematurity, higher doses, and possibly SSRIs other than sertraline.
  • Persistent Pulmonary Hypertension of the Newborn (PPHN): May be an increased risk, especially with late pregnancy exposure. The absolute risk is small and may be lower with sertraline.
• Maternal Risks: Small increased risks of gestational hypertension, pre-eclampsia, placental issues, and postpartum haemorrhage have been reported (maternal depression also increases these). The MHRA specifically advises awareness of the small increased risk of postpartum haemorrhage with SSRI/SNRI use in the month before delivery.
• Neurodevelopment: Data are inconclusive and often confounded by maternal illness. While some studies suggested a small increased risk of ASD, larger, better-controlled studies often haven't confirmed this or attribute it to confounding factors. No reliable evidence links SSRIs to ADHD. Some reports mention issues with cognitive, motor, speech, or behaviour, but causality is unclear. Associations with later emotional/affective disorders in offspring are likely due to underlying parental factors. A recent study noted brain morphology changes with SSRI exposure, but the clinical meaning is unknown. Overall, evidence suggests antidepressant use itself doesn't increase neurodevelopmental disorder risk when confounders are managed.

Other Antidepressants

• Venlafaxine (SNRI): Early reports linked it to specific birth defects, but a 2022 meta-analysis concluded SNRIs aren't major teratogens. However, it is associated with neonatal withdrawal/poor adaptation, babies being small for gestational age, and postpartum haemorrhage (MHRA warning applies). Potential PPHN risk exists (low absolute risk).
• Duloxetine (SNRI): May be linked to a small increase in postpartum haemorrhage risk. One case of neonatal withdrawal reported. Otherwise, studies haven't identified specific major risks like malformations or stillbirth.
• Trazodone, Bupropion, Mirtazapine: Limited safety data.
  • Trazodone: One recent study found no higher risk of major anomalies compared to SSRIs.
  • Bupropion & Mirtazapine: Not clearly linked to malformations, but possibly to increased spontaneous abortion (may be due to the underlying illness). Bupropion might have a slightly higher risk of ventricular septal defects and has been linked to increased ADHD risk in exposed children. A 2022 study found no association between mirtazapine and major malformations, abortion, stillbirth, or neonatal death.
• Moclobemide & Reboxetine: Very limited data suggest no teratogenic potential.
• Monoamine Oxidase Inhibitors (MAOIs): Should be avoided due to suspected increased risk of congenital malformations and the risk of hypertensive crisis.

Electroconvulsive Therapy (ECT)

• Considered safe for both mother and fetus, although general anaesthesia carries inherent risks.
• NICE recommends ECT for severe depression, severe mixed/manic states, or catatonia during pregnancy if the physical health of the mother or fetus is seriously threatened.

• Continuing Treatment: If a patient is stable on an antidepressant and has a high risk of relapse, continuing the same medication during and after pregnancy is often the best approach (assuming it's effective and tolerated).
• Starting Treatment: Treat moderate-to-severe depression during pregnancy with antidepressants.
  • Consider previous effective treatments first.
  • If no prior treatment history, sertraline or escitalopram (SSRIs) are reasonable first-line choices (ACOG/COPE recommendations). SNRIs are alternatives.
• Third Trimester Onset: ACOG suggests considering brexanolone.
• Monitoring: Screen for alcohol use. Be vigilant for hypertension and pre-eclampsia.
• Late Pregnancy Considerations: Be aware of the small increased risk of postpartum haemorrhage with SSRIs/SNRIs used in the month before delivery. Inform patients about the (very low absolute) risk of PPHN and the possibility of neonatal adaptation/withdrawal symptoms.
• Newborn Monitoring: NICE advises additional monitoring for newborns exposed to SSRIs or SNRIs during pregnancy.

• High Relapse Risk: Discontinuing mood stabilisers during pregnancy leads to a high risk of relapse. The risk increases dramatically after delivery.
• Impact of Untreated Illness: Maternal mental health affects the fetus/child. Risks include poor maternal self-care, lack of obstetric care, hospitalisation, and potential harm to the baby (neglect to infanticide).

Lithium:

• Exposure: Crosses the placenta freely.
• Risks: Associated with increased congenital anomalies, especially in the first trimester and possibly at higher doses. The link to Ebstein's anomaly (a cardiac defect) is well-known, but recent data suggest the risk is much lower than previously thought and might be linked to maternal mental health generally, not just lithium. Risk period is weeks 2-6 post-conception. Possible increased risk of septal defects. Associated with potential preterm birth, large babies (though data conflict), and neonatal issues (goitre, hypotonia, lethargy, arrhythmia, respiratory symptoms, low Apgar scores). May increase neonatal readmission risk (data conflict).
• Neurodevelopment: Probably does not affect neonatal brain development.
• Management: Avoid if possible, but if essential for maternal stability, inform the patient of risks and continue. Slow discontinuation before conception is preferred if stopping. If continuing, use high-resolution ultrasound/echocardiography. Dose needs increase during pregnancy (due to increased body water) and drop abruptly postpartum – requires careful monitoring (levels every 4 weeks, weekly from 36 weeks). Deliver in hospital for fluid balance management. Stop lithium during labour.

Valproate:

• Risks: Clear causal link to fetal abnormalities, especially neural tube defects (e.g., spina bifida) and others (atrial septal defects, cleft palate, hypospadias, polydactyly, craniosynostosis). Risk of major malformations is high (~10%). Also linked to reduced head circumference. Clear causal link to motor and neurodevelopmental problems (developmental delay in up to 40%, language/memory/speech difficulties, lower IQ, increased ASD diagnosis, learning deficits – potentially dose-related). Associated with decreased school performance. May increase pre-eclampsia risk.
• Management: Strongly contraindicated in women of child-bearing potential unless all other treatments failed and effective long-term contraception is used (UK: requires agreement of two specialists for initiation/continuation). Should be stopped before pregnancy (gradual taper over 2-4 weeks recommended by COPE, with high-dose folic acid). Folate during pregnancy doesn't prevent valproate-induced neural tube defects (neural tube forms early), but pre-conception folate and supplementation during pregnancy is still recommended for potential neurodevelopmental benefits. It's hard to justify its use given the significant risks.

Carbamazepine:

• Risks: Clear link to fetal abnormalities (e.g., neural tube defects), though lower risk than valproate. Teratogenic effect likely dose-related. May require maternal vitamin K if used in the third trimester. Lower Apgar scores reported (low absolute risk).
• Management: Avoid if possible. If essential, use low-dose monotherapy. NICE advises against offering it for mental health problems if planning pregnancy/pregnant/breastfeeding and suggests stopping if possible.

Lamotrigine:

• Risks: Growing evidence suggests it's safer than valproate or carbamazepine. Risk of major malformations appears similar to the general population. Some reports of parental-reported behaviour problems and a possible association with autism risk, but overall effect on neurodevelopment appears not significant.
• Management: Clearance increases significantly during pregnancy and drops postpartum, requiring frequent level monitoring.

Topiramate:

• Risks: Associated with major malformations, specifically orofacial clefts (risk may be higher at doses used in epilepsy). A large study reported increased risk of neurodevelopmental disorders, small for gestational age, and congenital malformations.
• Management: Should not be used in pregnant women. Women of child-bearing age need effective contraception.

Oxcarbazepine:

• Data unclear. A meta-analysis showed a non-significant increased malformation risk and a possible association with fetal/perinatal deaths, but study limitations make conclusions difficult.

Pregabalin:

• Data unclear. A Nordic study showed a small increased risk of major malformations, leading UK MHRA and manufacturers to advise awareness of risk and use of effective contraception.

General Anticonvulsants:

• A large study found anticonvulsant mood stabilisers were not associated with placenta-mediated complications or preterm birth.

• Pre-conception: If stable for a long time, consider switching to a safer drug (e.g., antipsychotic) or withdrawing treatment before conception (especially for the first trimester). Refer to perinatal services for advice. Avoid abrupt discontinuation due to high relapse risk.
• Mood Stabiliser Choice: No mood stabiliser is clearly safe. NICE UK prefers mood-stabilising antipsychotics over continuing traditional mood stabilisers (except potentially lithium in specific circumstances).
• Valproate: Strongly avoid. Discontinue before pregnancy.
• Carbamazepine: NICE advises against its use for mental health problems in this context.
• Lithium: If essential: discuss risks (especially first trimester heart defects). If stopping, do it gradually over 4 weeks (high relapse risk, especially postpartum). If continuing: monitor levels frequently (every 4 weeks, then weekly from 36 weeks), adjust dose, ensure fluid balance, deliver in hospital, stop during labour. Perform detailed fetal ultrasound/echo.
• Lamotrigine: If continuing, monitor levels frequently.
• Acute Mania: Use an antipsychotic first. Consider ECT if ineffective.
• Bipolar Depression: Use CBT for moderate depression. Consider an SSRI for severe depression. Lamotrigine is also an option.

• Commonality: Frequently occur during pregnancy.
• Preferred Treatments: Cognitive Behavioural Therapy (CBT) for anxiety, sleep hygiene measures for insomnia.

Benzodiazepines:

• Risks: Early studies linked first-trimester use to oral clefts, but later studies often haven't confirmed this. Use might be a marker for other risks. Associated with C-section, miscarriage, NICU admission, neonatal ventilation, low birth weight, preterm delivery, small head circumference/gestational age. Third-trimester use linked to "floppy baby syndrome" (hypotonia, lethargy). Use in late pregnancy linked to substantially higher risk of stillbirth and preterm birth (early pregnancy use linked mainly to small for gestational age).
• Neurodevelopment: Available data do not show an association with neurodevelopmental disorders.
• Recommendations: NICE advises against routine use, except short-term for severe anxiety/agitation. Recommends gradual stopping if planning pregnancy, pregnant, or breastfeeding. ACOG advises avoiding or using sparingly.

Z-drugs (Zolpidem, Zopiclone, etc.):

• Risks: Probably not linked to increased congenital malformations. Increased risk of premature birth, low birth weight, small for gestational age reported. Zolpidem may increase likelihood of C-section. Use in late pregnancy linked to substantially higher risk of stillbirth and preterm birth (early pregnancy use linked mainly to small for gestational age).
• Neurodevelopment: Available data do not show an association with neurodevelopmental disorders.

Promethazine:

• Used for severe morning sickness (hyperemesis gravidarum) and appears non-teratogenic, but data are limited.

Methylphenidate & Amfetamines:

• Risks: Probably not major teratogens. Small increased risk of cardiac malformations reported with methylphenidate (not amfetamines). Small increased risk of miscarriage (methylphenidate) or premature birth/low birth weight (amfetamines) possible.
• Neurodevelopment: Available data do not show increased risk of neurodevelopmental disorders in exposed children.

Modafinil:

• Risks: May be associated with increased risk of congenital malformations (cardiac defects, hypospadias, orofacial clefts).
• Recommendations: MHRA advises against use during pregnancy. Women of child-bearing potential must use effective contraception during treatment and for 2 months after stopping.

• Breastfeeding offers significant long-term benefits for a child's physical health and cognitive development.
• Mothers are generally encouraged to breastfeed for at least the first 6 months.
• Concerns about medication safety can influence a mother's decision to breastfeed.

• For most psychotropic drugs, continuing them during breastfeeding is recommended because the benefits of breastfeeding usually outweigh the potential risks, and evidence of harm is often lacking.
• However, there are specific exceptions where breastfeeding should be avoided if that medication is the best or only option for the mother (e.g., clozapine, lithium).
• Information on safety comes mainly from small studies or case reports, focusing on short-term effects. Long-term safety isn't guaranteed. Interpret data cautiously and stay updated.

1. Mother taking psychotropics during pregnancy: Generally, continue the same medication(s) during breastfeeding. This helps prevent withdrawal symptoms in the baby (note exceptions later).
2. Mother starting psychotropics after birth: Decisions are more complex. Refer to the specific drug information below.

• All psychotropics pass into breast milk to some extent.
• Infant plasma levels are the best measure of exposure but are rarely measured.
• Relative Infant Dose (RID): This is often used as an estimate. It's the infant's estimated daily dose (based on milk intake of 150mL/kg/day and drug concentration in milk) compared to the mother's dose, adjusted for weight.
  • RID is expressed as a percentage.
  • An RID below 10% is generally considered compatible with breastfeeding.
  • Infant plasma levels below 10% of the mother's average level are also suggested as a safety threshold.
• Remember, RID values are estimates and can vary widely in studies. Use them as a guide only.

• Plan Ahead: Discuss breastfeeding safety when considering psychotropics for women who might become pregnant. Ideally, discuss this before conception or early in pregnancy. Decisions about pregnancy medication should include breastfeeding plans.
• Avoid Switching: Don't switch medications late in pregnancy or just after birth solely for breastfeeding purposes, as this increases the risk of maternal relapse.
• Continue When Possible: If a mother used a psychotropic during pregnancy, usually continue it while breastfeeding (unless it's a known contraindication like lithium or clozapine) to minimize infant withdrawal.
• Risk vs. Benefit: Always weigh the benefits of breastfeeding for both mother and baby against the risks of infant drug exposure. Consider the baby's overall health and gestational age.
• Prioritize Maternal Treatment: Don't withhold necessary treatment from the mother. If the best drug is contraindicated for breastfeeding, advise the mother to bottle-feed with formula milk. Stopping breastfeeding is usually only necessary if the drug is absolutely contraindicated.
• Starting a Drug Postpartum:
  • Consider the mother's previous response to treatments.
  • Prefer drugs with low reported infant plasma levels or low RID.
  • Be mindful of drug half-lives; long half-life drugs can accumulate in the infant.
• Infant Vulnerability: Neonates and infants (especially premature ones or those with health problems) clear drugs less efficiently than adults and are at higher risk.
• Monitor the Infant: Watch for any drug-specific side effects, changes in feeding patterns, growth, and development.
• Consider Infant Plasma Levels: If you suspect adverse effects or toxicity, check infant drug levels.
• Safe Sleep: Strongly advise mothers on sedating medication not to breastfeed in bed due to the risk of falling asleep and potentially harming the baby.
• Maternal Interaction: Monitor mothers on sedating drugs to ensure sedation doesn't impair their ability to interact with their child.
• Prescribing Strategy:
  • Use the lowest effective dose.
  • Avoid using multiple psychotropic drugs (polypharmacy) if possible.
  • Ideally, continue the same regimen used during pregnancy.

(Remember: Continuing the drug used during pregnancy is usually preferred, except for clozapine and lithium).

• Antidepressants: Sertraline is often considered when starting treatment postpartum. Other options are available (see table below).
• Antipsychotics: Olanzapine or quetiapine may be considered when starting treatment postpartum. Other options are available (see table below). Avoid breastfeeding if taking clozapine (continue clozapine treatment).
• Mood Stabilisers: Mood-stabilising antipsychotics like olanzapine or quetiapine may be considered when starting treatment postpartum. Other options are available (see table below). Avoid breastfeeding if taking lithium (continue lithium treatment).
• Sedatives/Hypnotics: Best avoided. If necessary, choose one with a short half-life.