To assess the evidence regarding safety and efficacy of psychiatric medications to treat mental health conditions during pregnancy and lactation. The conditions reviewed include depression, anxiety and anxiety-related disorders, bipolar disorder, and acute psychosis. For information on screening and diagnosis, refer to American College of Obstetricians and Gynecologists (ACOG) Clinical Practice Guideline Number 4, “Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum” 1.
Pregnant or postpartum individuals with mental health conditions with onset that may have predated the perinatal period or may have occurred for the first time in pregnancy or the first year postpartum or may have been exacerbated in that time.
This guideline was developed using an a priori protocol in conjunction with a writing team consisting of one specialist in obstetrics and gynecology and one maternal–fetal medicine subspecialist appointed by the ACOG Committee on Clinical Practice Guidelines–Obstetrics and two external subject matter experts. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.
This Clinical Practice Guideline includes recommendations on treatment and management of perinatal mental health conditions including depression, anxiety, bipolar disorders, and acute postpartum psychosis, with a focus on psychopharmacotherapy. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.
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Fig. 1. Starting treatment for perinatal mental health conditions. FDA, U.S. Food and Drug Administration; GABA-A, gamma aminobutyric acid type A; IV, intravenous; mg, milligrams; PTSD, posttraumatic stress disorder; qAM, every morning; qHS, every bedtime. Modified from Byatt N, Mittal LP, Brenckle L, Logan DG, Masters GA, Bergman A, et al. Lifeline for Moms Perinatal Mental Health Toolkit. University of Massachusetts Medical School; 2019. Accessed March 20, 2023. https://www.umassmed.edu/lifeline4moms/products-resources/toolkits-and-apps/2019/11/lifeline4moms-perinatal-mental-health-toolkit/
Fig. 2. Follow-up treatment of perinatal mental health. EPDS, Edinburgh Postnatal Depression Scale; GAD-7, Generalized Anxiety Scale 7; mg, milligrams; PC-PTSD, Primary Care Post Traumatic Stress Disorder; PCP, primary care physician; PHQ-9, Patient Health Questionnaire-9. Modified from Byatt N, Mittal LP, Brenckle L, Logan DG, Masters GA, Bergman A, et al. Lifeline for Moms Perinatal Mental Health Toolkit. University of Massachusetts Medical School; 2019. Accessed March 20, 2023. https://www.umassmed.edu/lifeline4moms/products-resources/toolkits-and-apps/2019/11/lifeline4moms-perinatal-mental-health-toolkit/
Table 1. General Approach to Risk Counseling for Depression Psychopharmacotherapy
Table 2. Perinatal Safety Outcomes Associated With Psychopharmacotherapy Exposure in Pregnancy
