Pregnant and mentally ill: A complex clinical challenge

Attention to depression and anxiety during pregnancy is much appreciated in the February 2008 issue of Current Psychiatry (“Treating anxiety during pregnancy: Just how safe are SSRIs?” p. 38-52). Although well-meaning, however, Dr. Henry Nasrallah’s comments (“Pregnant and mentally ill: A labor-intensive clinical challenge.” From the Editor, p. 15-16) endorsing FDA pregnancy categories and advising prescribers to “select the lowest-risk agents (Category A) first, and use the lowest efficacious dose” are a disservice and oversimplification.

Most psychiatrists who specialize in treating pregnant patients can outline the shortcomings of the FDA’s rating system. No psychotropic drug is category A; most are C or D—with no clear distinction among ratings, no consideration of the risk of untreated disorder, and inadequate prospective human data on which to base the ratings. The only psychotropic rated B is clozapine, based on almost no human data. The FDA rating scale and the advice in the editorial would list one of the most risky and least studied drugs in pregnancy as a first-line treatment.

The only way to help patients make good choices during pregnancy is to stay current on the evolving and often conflicting literature about risks and benefits of pharmacotherapy for pregnant patients.

Marlene P. Freeman, MD
Director, Women’s Mental Health Center,
Associate professor of psychiatry,
obstetrics, and gynecology
University of Texas Southwestern Medical School
Dallas, TX

Attention to depression and anxiety during pregnancy is much appreciated in the February 2008 issue of Current Psychiatry (“Treating anxiety during pregnancy: Just how safe are SSRIs?” p. 38-52). Although well-meaning, however, Dr. Henry Nasrallah’s comments (“Pregnant and mentally ill: A labor-intensive clinical challenge.” From the Editor, p. 15-16) endorsing FDA pregnancy categories and advising prescribers to “select the lowest-risk agents (Category A) first, and use the lowest efficacious dose” are a disservice and oversimplification.

Most psychiatrists who specialize in treating pregnant patients can outline the shortcomings of the FDA’s rating system. No psychotropic drug is category A; most are C or D—with no clear distinction among ratings, no consideration of the risk of untreated disorder, and inadequate prospective human data on which to base the ratings. The only psychotropic rated B is clozapine, based on almost no human data. The FDA rating scale and the advice in the editorial would list one of the most risky and least studied drugs in pregnancy as a first-line treatment.

The only way to help patients make good choices during pregnancy is to stay current on the evolving and often conflicting literature about risks and benefits of pharmacotherapy for pregnant patients.

Marlene P. Freeman, MD
Director, Women’s Mental Health Center,
Associate professor of psychiatry,
obstetrics, and gynecology
University of Texas Southwestern Medical School
Dallas, TX

Attention to depression and anxiety during pregnancy is much appreciated in the February 2008 issue of Current Psychiatry (“Treating anxiety during pregnancy: Just how safe are SSRIs?” p. 38-52). Although well-meaning, however, Dr. Henry Nasrallah’s comments (“Pregnant and mentally ill: A labor-intensive clinical challenge.” From the Editor, p. 15-16) endorsing FDA pregnancy categories and advising prescribers to “select the lowest-risk agents (Category A) first, and use the lowest efficacious dose” are a disservice and oversimplification.

Most psychiatrists who specialize in treating pregnant patients can outline the shortcomings of the FDA’s rating system. No psychotropic drug is category A; most are C or D—with no clear distinction among ratings, no consideration of the risk of untreated disorder, and inadequate prospective human data on which to base the ratings. The only psychotropic rated B is clozapine, based on almost no human data. The FDA rating scale and the advice in the editorial would list one of the most risky and least studied drugs in pregnancy as a first-line treatment.

The only way to help patients make good choices during pregnancy is to stay current on the evolving and often conflicting literature about risks and benefits of pharmacotherapy for pregnant patients.

Marlene P. Freeman, MD
Director, Women’s Mental Health Center,
Associate professor of psychiatry,
obstetrics, and gynecology
University of Texas Southwestern Medical School
Dallas, TX