Discussion Post: Treatment Planning in Pregnant and Lactating Women with Depression and Bipolar Disorder

Managing psychiatric disorders in pregnancy and lactation requires careful balancing of maternal mental health with fetal and neonatal safety. Treatment plans must incorporate evidence-based pharmacologic and non-pharmacologic interventions, while addressing unique risks such as teratogenicity, neonatal adaptation syndrome, and breastfeeding safety.

Depression in Pregnancy (Week 5 case)

For a pregnant woman with depression, first-line management would prioritize psychotherapy (CBT or interpersonal therapy) in cases of mild to moderate depression (Yonkers et al., 2020). If symptoms are moderate to severe, pharmacotherapy may be warranted. Among antidepressants, SSRIs are considered safest, with sertraline or fluoxetine most commonly recommended due to favourable safety data (ACOG, 2023).

Depression in Lactating Women

For breastfeeding women, sertraline remains the preferred SSRI because it has the lowest transfer into breast milk and minimal adverse infant effects (Lanza  Scale & Wisner. Fluoxetine, while effective, is less ideal in lactation due to its long half-life and potential for infant irritability. Patient teaching would emphasize adherence, monitoring the infant for feeding difficulties or irritability, and reassurance that untreated maternal depression poses significant risks for both mother and child. APA

Bipolar Disorder in Pregnancy (Week 7 case)

Bipolar disorder presents greater pharmacologic challenges. Lithium, though effective, is associated with increased risk of Ebstein’s anomaly when used in the first trimester, but may be considered if benefits outweigh risks (McKnight et al., 2012). Alternatives such as lamotrigine may be safer, particularly for bipolar depression, though careful dose titration is required due to increased clearance in pregnancy. Valproic acid and carbamazepine should be avoided due to high teratogenicity. Adjunctive psychotherapy and close monitoring are critical.Sertraline and lamotrigine represent safer pharmacologic options, while psychotherapy remains valuable across both conditions. Patient-centered education and safety planning are critical to optimizing both maternal and child outcomes.