Fluoxetine and carbamazepine concentrations in a nursing mother/infant pair.
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Adult↗
Biomedical subjects
K L Wisner
Publications and source records attributed to K L Wisner.
Psychobiology of postpartum mood disorders.
Postpartum mood disorders are common. The clustering of mood-disorder episodes after birth compels a search for factors particularly potent during childbearing. In this article, the complex relationships between the dynamic postbirth physiological environment and mood disorder are discussed. Available studies show a lack of evidence that serum levels of gonadal hormones account for mood disturbance in women. However, substantial amounts of data demonstrate their ability to modulate other neuroendocrine systems. Alterations in hypothalamic-pituitary-adrenal (HPA) axis function attributable to childbearing show remarkable similarity to those observed in depressed women. Postpartum women are also at increased risk for hypothalamic-pituitary-thyroidal (HPT) axis dysfunction that may increase affective-disorder vulnerability. A decreased rate of postpartum recovery of HPA- and HPT-axis function may play a more central role than cross-sectional measures. Understanding the etiology of postpartum mood disorders will require integration of multiple psychosocial and biological risk factors. Further research is critically needed.
Adult↗
Effects of the postpartum period on nortriptyline pharmacokinetics.
The objective of this research was to investigate sequential serum levels and level/dose ratios of the tricyclic antidepressant nortriptyline (NTP) through the first 17 postpartum weeks. The initial NTP dose was given immediately postpartum to 16 mothers and increased gradually to 70 mg over the first week. A dose of 75 mg was prescribed until adjustment according to serum levels. Serum levels of NTP and its metabolites Z- and E-OH-NTP were determined. At postpartum Week 2, the women developed a mean level/dose (L/D) ratio for NTP of 1.11 (range 0.37 to 3.23), and subsequently experienced an increase in the L/D ratios which continued through Week 6. At Week 8, the NTP L/D ratios declined, and became relatively stable at Week 11 and beyond. For postpartum women treated with NTP, side effect profiles should be carefully followed during the first 6 weeks after delivery as a clinical marker for elevation of serum levels. Since our highest L/D ratios for NTP occurred at Week 6, a serum level is recommended at this time. If the dose needs to be lowered to maintain a nontoxic level, a repeat serum level should be obtained at Week 11, at which time an increase in dose may be required.
Adult↗
Nortriptyline and its hydroxymetabolites in breastfeeding mothers and newborns.
We previously reported the serum nortriptyline levels of a series of breastfeeding mother-infant pairs. Nortriptyline was below the level of detectability in the infants' sera; however, two young infants aged 10 weeks or less had low concentrations of 10-hydroxy-nortriptyline. Because very young breastfeeding infants are likely to be at increased risk for toxicity, we have focused our study on breastfeeding newborns. We present additional data from six mothers and their infants (4 weeks of age), as well as data from one prematurely born baby. We were able to quantify nortriptyline in one infant and another had higher levels of hydroxymetabolites than previously reported, although still very low. No adverse clinical effects were observed in the infants.
Breast Feeding↗
Phenelzine use throughout pregnancy and the puerperium: case report, review of the literature, and management recommendations.
Little is known about the use of monoamine oxidase inhibitors (MAOIs) during pregnancy and the postpartum period. We present a literature review with what we believe is the second case report of phenelzine exposure throughout pregnancy and the postpartum period. Potential indications for use and principles of the clinical management of the pregnant patient treated with an MAOI are also discussed and include: documenting informed consent, MAOI dose adjusting during pregnancy, monitoring of maternal and fetal outcome, and appropriate analgesia and anesthesia during labor and delivery. Our patient tolerated phenelzine well throughout her pregnancy but experienced recurring depressive symptoms during periods of significant weight gain requiring dose adjustment. Labor, delivery, and the perinatal period progressed without complication for our patient and her infant, in whom no congenital malformation was detected. Additional case reports and animal studies of MAOI use during gestation may help determine safety and refine clinical management guidelines.
Adult↗
Effects of childbearing on the natural history of panic disorder with comorbid mood disorder.
This historical prospective study included 22 women with panic disorder. They experienced 45 pregnancies associated with or after their first lifetime episode of panic disorder. Mood disorder predated or was associated with 32 of these pregnancies. The most common effect of pregnancy was No Change in symptoms from baseline during pregnancy and continued No Change postnatally for both panic attacks (n = 22; 49%) and depression (n = 19; 59%). The pattern of panic attack across gestations was consistent for only 5 of 14 multiparae. An interesting observation was that first lifetime onset of panic disorder was common postpartum (n = 4) or post-miscarriage (n = 2). First-onset depression was also common postpartum (n = 4).
Adult↗
Nortriptyline treatment of breast-feeding women.
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Breast Feeding↗
Antidepressant treatment during breast-feeding.
OBJECTIVE: The primary purpose of this article is to review critically the literature about use of antidepressants during lactation. Strategies for the clinical management of depressed breast-feeding mothers are also suggested. METHOD: The authors conducted a computerized search of MEDLINE for articles. The review includes studies in which serum levels of drugs were obtained from nursing infants. RESULTS: Fifteen published reports were located that provided information for the following nine antidepressants: amitriptyline, nortriptyline, desipramine, clomipramine, doxepin, dothiepin, fluoxetine, sertraline, and bupropion. CONCLUSIONS: Amitriptyline, nortriptyline, desipramine, clomipramine, dothiepin, and sertraline were not found in quantifiable amounts in nurslings, and no adverse effects were reported. Therefore, these are the drugs of choice for breast-feeding women. Adverse effects were described in some young infants whose mothers had been treated with doxepin or fluoxetine during breast-feeding. The collective serum level data suggest that infants older than 10 weeks are at low risk for adverse effects of tricyclics, and there is no evidence of accumulation. Research needs include an expanded database of mother-baby serum levels, behavioral assessments of infants during nursing, and longitudinal developmental evaluation of nurslings. Prescription of an antidepressant for a breast-feeding woman is a case-specific risk-benefit decision.
Age Factors↗
Clinical dilemmas due to the lack of inpatient mother-baby units.
OBJECTIVE: Epidemiologic studies have demonstrated the dramatic increase in the rates of new episodes of psychiatric illness in postpartum women. Mother-Baby joint admission inpatient units serve the needs of women with psychiatric illness related to childbearing in other countries. Such units have been rare experiments in the United States. This article explores the clinical dilemmas that clinicians who treat postpartum women face when mother-baby units are not available. Barriers to the implementation of these units are also discussed. METHODS: A survey of mothers admitted to general adult units was performed to study their satisfaction with the experience. The authors also discuss their extensive clinical experience in the treatment of women with postpartum disorders and provide examples of the clinical dilemmas which occur because of mother-only admissions. RESULTS: Clinical dilemmas were: separation from infants causes mothers to refuse admission, undermines breastfeeding, complicates the diagnostic evaluation, precludes participation of the infant in dyadic psychotherapy, produces longer lengths of hospital stay, and places the responsibility of caring for the baby on the spouse and extended family. Post-discharge readjustment to caring for the baby can contribute to maternal relapse. CONCLUSIONS: Although admission to Mother-Baby units offers significant advantages to mothers and families, firm data to support the cost-effectiveness of these units is not available and is a major barrier to implementation.
Adult↗
Psychiatric episodes in women with young children.
An historical cohort study was performed. Subjects were 118 pregnant women or mothers of children of < 3 years who were assessed at presentation to a psychiatric hospital and 5 years later. The relationship of episode onset to childbearing (during pregnancy or within 3 months of birth) was derived from psychiatric records at presentation and retrospectively determined by interview and life-event charting at follow-up. Determining childbearing status from records yielded an error rate of 30% compared with the status derived from direct interview. A change in diagnosis in the ChildBearing-Related Onset Illness (CBROI) category occurred in 50% of subjects. When Research Diagnostic Criteria were applied retrospectively to the presenting episodes, 95% of women with CBROI had affective disorder diagnoses. Clinicians in our intake setting often missed episodes of mania or hypomania in our subjects' histories.
Adolescent↗
Effects of postpartum psychiatric illnesses on family planning.
OBJECTIVE: We investigated the relationship between postpartum psychiatric episodes and subsequent family planning. Our hypothesis was that women who had a postpartum illness would plan to have fewer children. METHOD: We conducted a mail survey of members of the self-help group Depression After Delivery (DAD). The membership was asked about changes in family planning after a postpartum illness. Two groups were defined: women who took action to prevent further pregnancies after the illness (CHANGE) and women who did not take action to prevent future pregnancies (NO CHANGE). RESULTS: Among respondents 32 percent changed their family plans after suffering a postpartum illness. Fear of recurrence, effects on the family, treatment costs and severity of the episode manifested by suicide or infanticide attempt, hospitalization, and prescribed medication were reasons given for altering plans. CONCLUSIONS: The postpartum illness dramatically changed some women's reproductive plans. Prevention strategies for these illnesses need to be addressed when women are making decisions about having other children.
Adult↗
Serum clomipramine and metabolite levels in four nursing mother-infant pairs.
BACKGROUND: Women with postpartum-onset obsessive compulsive disorder may elect treatment with clomipramine. There is minimal information to guide the clinician who must advise breastfeeding women about clomipramine therapy. METHOD: Four clomipramine-treated breastfeeding mother-infant pairs were assessed for serum concentrations of clomipramine, N-desmethylclomipramine, and corresponding 8-hydroxymetabolites. RESULTS: Although the mothers exhibited a wide range of serum concentrations, the parent drug and metabolites were either nondetectable or below the quantifiable limit in the sera of all infants. No adverse clinical effects were observed. CONCLUSION: This report adds to the growing literature that suggests that tricyclic use during breastfeeding rarely results in measurable drug levels in infant sera.
Adult↗
Symptomatology of affective and psychotic illnesses related to childbearing.
Symptom patterns in women with childbearing-related onset illnesses (CBROI) and nonchildbearing-related onset illnesses (NCBROI) were compared. Women with diagnoses of Affective Disorders and Psychoses (n = 762) were divided into four groups: CBROI with psychosis, CBROI with non-psychotic affective illnesses, NCBROI with psychosis, and NCBROI with non-psychotic affective illness. Principal components analysis of 64 symptoms revealed 9 factors. The most dramatic result was the high score for psychotic women with CBROI on the factor cognitive disorganization/psychosis. Psychotic women with CBROI also reported homicidal ideation more frequently. Symptoms of non-psychotic women with CBROI and NCBROI did not differ.
Adjustment Disorders↗
Marital support and remission of treated depression. A prospective pilot study of mothers of infants and toddlers.
Eighteen married mothers of infants and toddlers were evaluated before and after 12 weeks of antidepressant treatment for major depressive disorder. The women were assessed at baseline on Snyder's marital disaffection and disharmony subscales and on selected clinical measures to evaluate these factors as correlates of remission. Remission was defined as a Hamilton Rating Scale for Depression score < or = 7 at week 12. Twelve women remitted; six did not. Nonremitted women reported high disaffection toward their husband, were in an episode of which the onset was not childbirth related (i.e., onset not within 3 months after giving birth), or their youngest child was older than 6 months. Results showed that initial symptom severity was no different for the nonremitted and remitted women. Thus, the relationships between low disaffection, late onset, and not having a child under 6 months and nonremission appear to be independent of initial severity of depressive symptoms.
Adult↗
Prevention of recurrent postpartum major depression.
OBJECTIVE: Postpartum depression affects between 10 and 15 percent of new mothers. These mothers are apprehensive about recurrence after later births. This study tested the efficacy of antidepressant medication administered during the postpartum period to prevent a recurrence of postpartum depression among women who had suffered a previous episode. METHODS: An open clinical trial was conducted at a university-based outpatient clinic treating pregnant and postpartum women with mood disorders. Study participants were 23 pregnant women who had at least one previous postpartum episode that fit DSM-III-R criteria for nonbipolar major depression without psychotic features. Postpartum monitoring for recurrence of depressive symptoms was compared with postpartum monitoring plus postbirth treatment with either the medication that had been effective for the previous episode or nortriptyline. The first dose was given within 24 hours of birth. The authors assessed recurrence of postpartum major depression by psychiatric examination and use of the Inventory to Diagnose Depression, a reliable self-report instrument. RESULTS: A significantly greater proportion of the women who elected monitoring alone (62.5 percent) suffered recurrence of major depression compared with the women who received monitoring plus medication (6.7 percent) (p = .0086). CONCLUSIONS: Prophylactic antidepressant treatment reduced the recurrence of postpartum major depression.
Antidepressive Agents↗
Relationship of psychiatric illness to childbearing status: a hospital-based epidemiologic study.
Women who presented to a University psychiatric hospital were categorized into those with childbearing-related onset illness (CBROI, n = 168) and compared to those with non-childbearing-related onset illness (NCBROI, n = 1004). Women with CBROI were an average of five years younger. The two groups did not differ in membership across five major psychiatric diagnostic categories. However, women with CBROI were given the specific diagnosis adjustment disorder with depressed mood more frequently. Anxiety disorders were also common in women with CBROI. Most women with CBROI had the onset of illness during the postpartum period compared to during pregnancy or after pregnancy loss.
Abortion, Induced↗
Tricyclic dose requirements across pregnancy.
In a series of eight pregnant women, the authors found that the doses of tricyclic antidepressants required to achieve remission of symptoms and adequate serum levels increased during the second half of pregnancy. During the final trimester, the mean dose required was 1.6 times the mean dose required when the patients were not pregnant.
Adult↗
Nortriptyline in chronic fatigue syndrome: a double blind, placebo-controlled single case study.
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Adult↗