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How to plan for pregnancy when you have mental health problems
Starting a family is an exciting and nerve-wracking time for anyone, but having a mental health problem can add an extra layer of planning and anxiety to getting pregnant. Is your medication safe for pregnancy and breastfeeding? How can you keep both yourself and your baby well? And what specialist support is available along the way?
First and foremost, the best advice is to have a conversation with your GP before you start trying to conceive. "Quite simply, the earlier you start thinking about it the better," says Dr Trudi Seneviratne, Chair of the Perinatal Faculty at the Royal College of Psychiatry. "In England we've had a huge expansion of perinatal mental health services in the last three years, and our mother and baby outpatient services now offer specialist pre-conception counselling. Your GP can refer you for a conversation before you fall pregnant," she explains.
"This will usually be for people who've already got a history of mental health problems - which might be depression, anxiety, bipolar disorder, schizophrenia, OCD, whatever it is - and are on medication," Dr Seneviratne adds. "But it could also be for people who are not currently on medication, who just want to think about what support they might need if they do get ill."
Having this conversation with the experts early on will help you make important decisions about your perinatal mental health care plan - which could include continuing, switching or coming off your medication, being referred for talking therapies, and seeing a specialist mental health midwife.
'My midwife would ring every couple of weeks'
31-year-old mother of three Michelle has been on antidepressants for post-traumatic stress disorder (PTSD) since she was 17, but says perinatal mental health support was really lacking when she had her first two children. "I had my son at 22, and I was taking fluoxetine at the time. Nobody could give me any answers about my medication; it was like the blind leading the blind," she says. In the end, with no guidance about what best to do, Michelle continued taking her medication - which, fortunately, had no effect on her son.
Three years later, when she fell pregnant with her second baby, it was a different story. "I was taking citalopram and the attitude was, 'You're pregnant, you don't need to be on antidepressants!' I came off them as soon as I found out I was pregnant; I was so sure everything was going to be okay and I could do it without them. But postnatal depression really hit me after she was born," Michelle says.
"I was just emotionless, like I didn't have any feelings towards her. She'd cry and I'd just look at her, and when she was breastfeeding I just wished she'd hurry up and get off my boob," she adds. "The health visitor was amazing and said, 'Let's get you back on antidepressants before it gets worse', but there really wasn't enough support beforehand."
Fortunately, by the time Michelle had her youngest daughter three years ago, the support on offer had noticeably improved. "This time I asked my GP what to do about the antidepressants and he said, 'I'm not taking you off them; we'll slowly lower the dosage but they won't affect your pregnancy. It was much more supportive," she says. "My midwife would ring me every couple of weeks to check how I was feeling, and to reassure me that I was doing great."
For midwife Sam Nightingale, a researcher for charity Wellbeing of Women, this is the ideal scenario. "Ideally, we'd want women to continue their medications if they need them, and certainly not just suddenly stop them. The key thing is planning in advance, with expert discussion, to decide what's going to be best for them in terms of medication," she says.
"Once they're pregnant we'd want them to book with their midwife by six to eight weeks, really early on, so there can be a full assessment of all of their health needs, physical and mental. Then, if needed, they can be referred on for any appropriate care."
Likewise, Sam adds, continuity of care is really important, and building a relationship with the midwife enables them to ensure both mum and baby are well throughout pregnancy and during the first few weeks after birth.
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Which medications are safe?
It's important to remember that research on medication safety during pregnancy and breastfeeding is ever evolving, so it's always best to discuss it with a psychiatrist, who will be clued up on what the most current research says.
"Of all the groups of antidepressant drugs, some members of the SSRI group [including sertraline, fluoxetine and citalopram] are now used a lot in pregnancy and in breastfeeding, because they seem to be safe enough," Dr Seneviratne explains. "Other antidepressants seem to be a bit more concerning. Things like paroxetine can be linked to hypertension in the lungs for babies, and there are cases with medicines like venlafaxine causing problems. We also wouldn't recommend some of the newer drugs because there hasn't been enough of a body of literature to tell us they're safe enough to use."
Other psychiatric medications which are a definite no-no include sodium valproate, which is used to treat both bipolar disorder and epilepsy, she adds. "We know that is teratogenic and causes birth defects, and can cause longer-term cognitive problems, so if somebody's on that we would suggest coming off it and switching to something else," says Dr Seneviratne.
"With something like lithium, which is a good mood stabiliser, it would be best to be on a different medicine for at least the first 12 weeks of pregnancy, because we know lithium is associated with congenital heart problems. Lithium can be reintroduced after those first 12 weeks if needed, but it can't be used in breastfeeding because there's a risk of the baby becoming lithium toxic," she adds. Likewise, mums taking high doses of antipsychotics should not breastfeed, but it is safe to breastfeed or combination feed on lower doses of certain antipsychotics, like olanzapine and quetiapine.
Weighing up risks and benefits
While deciding what's right for both you and your baby can be fraught with contradictory advice and headlines, Dr Seneviratne says mums-to-be can rest assured that there are safe options if they decide staying on medication is best for them. "If someone needs to take medication for their mental health problems, or to keep them well, we've got enough medicines now that they can and should be taking medication rather than worrying that it's harmful for their child," she says.
"Some women will not want to put anything into their systems regardless. If they do come off medication this should be done slowly, before they fall pregnant, and we'd want to monitor how their mood was doing. Becoming severely depressed or anxious is actually no good for the baby either. That means it's about weighing up the risks of medications that are considered safe enough against the risk that you might suddenly fall seriously ill, and the impact of that on the developing fetus," she explains.
Whatever you decide about medication, Dr Seneviratne adds, you should also have access to additional support throughout your pregnancy and beyond. "It's really important that we're treating individuals in a holistic way," she says. "Treatment can include medication, talking therapies, and things like the importance of eating well, sleeping well, attending antenatal classes, having all the relevant information, and preparing for delivery."