PERINATAL MOOD DISORDERS: Updates in Treatment Maya Bulman, MD Maine Medical Center April 29, 2011.

PERINATAL MOOD PERINATAL MOOD DISORDERS: DISORDERS:

Updates in TreatmentUpdates in Treatment

Maya Bulman, MDMaya Bulman, MDMaine Medical CenterMaine Medical Center

April 29, 2011April 29, 2011

Updates in Treatment Updates in Treatment During PregnancyDuring Pregnancy

DepressionDepression Bipolar DisorderBipolar Disorder PsychosisPsychosis InsomniaInsomnia

DEPRESSION DURING DEPRESSION DURING PREGNANCYPREGNANCY

Between 10-20% of Between 10-20% of women will experience women will experience significant depression significant depression during pregnancyduring pregnancy

This will be a first episode This will be a first episode for one thirdfor one third

Course of Depression During Course of Depression During PregnancyPregnancy

Women from 3 specialty centers stable on Women from 3 specialty centers stable on antidepressants for at least 3 months prior to antidepressants for at least 3 months prior to pregnancy :pregnancy :

43% relapsed43% relapsed

26% who continued meds relapsed (50% in first 26% who continued meds relapsed (50% in first trimester)trimester)

68% who discontinued meds relapsed68% who discontinued meds relapsed (50 % in the 1st trimester, 90% by the end of the 2(50 % in the 1st trimester, 90% by the end of the 2ndnd

trimester)trimester)

Cohen LS, et al.Cohen LS, et al. JAMA JAMA. 2006:295;499-507.. 2006:295;499-507.

Time to Relapse in Patients Who Time to Relapse in Patients Who Maintained or Discontinued Maintained or Discontinued

AntidepressantsAntidepressants

Cohen LS, et al. JAMA. 2006:295;499-507.

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Maintained (N = 82)

Discontinued (N = 65)

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CONCLUSIONS:CONCLUSIONS:

Pregnancy puts women with a history of depression at Pregnancy puts women with a history of depression at higher risk of recurrence and is not protective.higher risk of recurrence and is not protective.

Pregnant women stable on antidepressants need to be Pregnant women stable on antidepressants need to be aware of the relapse risk with stopping medsaware of the relapse risk with stopping meds

This should be discussed when weighing the risk/benefit This should be discussed when weighing the risk/benefit ratio of using antidepressants during pregnancyratio of using antidepressants during pregnancy

Cohen LS, et al.Cohen LS, et al. JAMA JAMA. 2006:295;499-507. 2006:295;499-507..

APA/ACOG GuidelinesAPA/ACOG Guidelines

““The Management of Depression The Management of Depression During Pregnancy: A Report from During Pregnancy: A Report from the American Psychiatric Association the American Psychiatric Association and The American College of and The American College of Obstetricians and Gynecologists,”Obstetricians and Gynecologists,”

Obstetrics & Gynecology Obstetrics & Gynecology (September (September 2009)2009) and and General Hospital General Hospital Psychiatry Psychiatry (September/October (September/October 2009).   2009).   

Pregnant women currently on Pregnant women currently on medication:medication:

Those who wish to stay on medication, consult with Those who wish to stay on medication, consult with psychiatrists and OB/GYN to discuss the riskspsychiatrists and OB/GYN to discuss the risks

Stable women may attempt discontinuation depending on Stable women may attempt discontinuation depending on their history. Women with a history of recurrent depression their history. Women with a history of recurrent depression are at a high risk of relapse if medication is discontinued.   are at a high risk of relapse if medication is discontinued.  

Women with recurrent depression or who have symptoms Women with recurrent depression or who have symptoms despite their medication may benefit from psychotherapy to despite their medication may benefit from psychotherapy to replace or augment medicationreplace or augment medication

Women with severe depression (with suicide attempts, Women with severe depression (with suicide attempts, functional incapacitation, or weight loss) should remain on functional incapacitation, or weight loss) should remain on medication. If a patient refuses medication, alternative medication. If a patient refuses medication, alternative treatment and monitoring should be in place, preferably treatment and monitoring should be in place, preferably before discontinuationbefore discontinuation

Pregnant and not currently on Pregnant and not currently on medication for depression:medication for depression:

Psychotherapy may be beneficial in women Psychotherapy may be beneficial in women who prefer to avoid antidepressant who prefer to avoid antidepressant medication. medication. 

For women who prefer taking medication, For women who prefer taking medication, risks and benefits of treatment choices risks and benefits of treatment choices should be evaluated and discussed, should be evaluated and discussed, including factors such as stage of gestation, including factors such as stage of gestation, symptoms, history of depression, and other symptoms, history of depression, and other conditions and circumstances (eg, a smoker, conditions and circumstances (eg, a smoker, difficulty gaining weight).difficulty gaining weight).

All pregnant women:All pregnant women:

Regardless of circumstances, a Regardless of circumstances, a woman with suicidal or psychotic woman with suicidal or psychotic symptoms should immediately symptoms should immediately see a psychiatrist for treatment.  see a psychiatrist for treatment. 

Antidepressant Drug Treatment Antidepressant Drug Treatment During PregnancyDuring Pregnancy

SSRI’s most commonly usedSSRI’s most commonly used Largest sample size exists for Largest sample size exists for

Fluoxetine (Prozac) and it is first Fluoxetine (Prozac) and it is first lineline

Then Citalopram/Escitalopram Then Citalopram/Escitalopram (Celexa/Lexapro), then Sertraline (Celexa/Lexapro), then Sertraline (Zoloft) and TCA’s (favored are (Zoloft) and TCA’s (favored are nortriptyline and desiprimine)nortriptyline and desiprimine)

Non-SSRI’s During Non-SSRI’s During PregnancyPregnancy

• More limited reproductive safety data available for SNRI’s compared to SSRI’s, i.e.. venlafaxine, duloxetine

• Data on bupropion includes growing number of exposures ( >1000) supporting absence of increased risk for malformation (overall and cardiac)

http://www.gsk.com/media/paroxetine/ingenix_study.pdf Chun-Fai-Chan B, Koren G, et al. Am J Obstet Gynecol, March 2005. 192(3).Cole JA, Modell JG, Haight BR, et al Pharmacoepidemiol Drug Saf. 9 August 200612

First Trimester Use of Selective Serotonin-First Trimester Use of Selective Serotonin-Reuptake Inhibitors and the Risk of Birth DefectsReuptake Inhibitors and the Risk of Birth Defects

Retrospective study:Retrospective study:

Compared 9849 infants with and 5860 Compared 9849 infants with and 5860 infants w/o birth defects for associations infants w/o birth defects for associations with 1with 1stst trimester SSRI use trimester SSRI use

SSRIs overall show no increased risk of SSRIs overall show no increased risk of craniosynostosis, omphalocoel, heart craniosynostosis, omphalocoel, heart defectsdefects

Individual SSRIs may confer some Individual SSRIs may confer some increased risks for specific defects which increased risks for specific defects which are rare and the absolute risks are smallare rare and the absolute risks are small

Louik et al. NEJM June 28,2007Louik et al. NEJM June 28,2007

Risk for PPHN Associated With Late Risk for PPHN Associated With Late Trimester Exposure to SSRITrimester Exposure to SSRI

Inconsistent Findings:Inconsistent Findings:

• One report showed increased risk by 6-fold (Chambers 2006)One report showed increased risk by 6-fold (Chambers 2006)• Lower association seen with Källén and Olausson, 2008Lower association seen with Källén and Olausson, 2008• NO association seen by Andrade.et al., 2009NO association seen by Andrade.et al., 2009

Limitations:Limitations: Small number of SSRI exposuresSmall number of SSRI exposures Recall bias with respect to early versus late SSRI exposureRecall bias with respect to early versus late SSRI exposure Recent data suggests lower risk than Chambers et al Recent data suggests lower risk than Chambers et al PPHN correlated with cesarean section, race, body mass index, PPHN correlated with cesarean section, race, body mass index,

and other factors not related to SSRI use**and other factors not related to SSRI use**

** Hernández-Díaz S, et al. Pediatrics. 2007;120:e272-e282. Kallen , August 2008 ; Pharmacoepidemiol Drug Safety Chambers CD, et al. N Engl J Med. 2006;354:579-587. Hernández-Díaz S, et al. Pediatrics. 2007;120:e272-e282

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““Poor Neonatal Adaptation” and Poor Neonatal Adaptation” and SSRI Use During PregnancySSRI Use During Pregnancy

Consistent data: Late trimester exposure to SSRIs Consistent data: Late trimester exposure to SSRIs is associated with transient irritability, agitation, is associated with transient irritability, agitation, jitteriness, and tachypneajitteriness, and tachypnea

Studies do not control for maternal mental health Studies do not control for maternal mental health condition, blinding of exposure in neonatal condition, blinding of exposure in neonatal assessmentsassessments

Effectiveness of discontinuing or lowering the Effectiveness of discontinuing or lowering the dose late in pregnancy aimed at reducing the risk dose late in pregnancy aimed at reducing the risk of neonatal toxicity has not been studiedof neonatal toxicity has not been studied

Lowering the dose of antidepressants does, Lowering the dose of antidepressants does, however, increase the risk for maternal post however, increase the risk for maternal post partum depressionpartum depression

Levinson-Castiel R, et al. Arch Pediatr Adolesc Med. 2006;160:173-176.Chambers CD, et al. N Engl J Med. 2006;354:579-587. 15

No correlation between measures of No correlation between measures of umbilical cord levels of SSRIs and risk of umbilical cord levels of SSRIs and risk of developing neonatal symptomsdeveloping neonatal symptoms

No difference in symptoms between two No difference in symptoms between two groups compared: infants born to groups compared: infants born to mothers who had taken SSRIs but mothers who had taken SSRIs but tapered 2 weeks prior to delivery vs. tapered 2 weeks prior to delivery vs. those who discontinuedthose who discontinued

This phenomenon may represent This phenomenon may represent serotonergic dysfunction rather than serotonergic dysfunction rather than medication withdrawalmedication withdrawal

LONGTERM LONGTERM NEUROBEHAVIORAL EFFECTSNEUROBEHAVIORAL EFFECTS

Two studies demonstrating absence of Two studies demonstrating absence of neurobehavioral differences with TCAs versus neurobehavioral differences with TCAs versus fluoxetine in exposed vs nonexposed children fluoxetine in exposed vs nonexposed children

Children ages 1 1/2 to 6 years exposed to Children ages 1 1/2 to 6 years exposed to antidepressants (Fluoxetine or TCAs) in utero antidepressants (Fluoxetine or TCAs) in utero had similar IQ’s language development, had similar IQ’s language development, behavioral development, temperament, mood, as behavioral development, temperament, mood, as those not exposedthose not exposed

No difference between those exposed during No difference between those exposed during just the first trimester or throughout the just the first trimester or throughout the pregnancypregnancy

However, depression in the mother was associated However, depression in the mother was associated with lower cognitive and language achievementwith lower cognitive and language achievement

Nulman I, et al. Nulman I, et al. N Engl J MedN Engl J Med. 1997;336:258-262. Nulman I, et al. . 1997;336:258-262. Nulman I, et al. Am J PsychiatryAm J Psychiatry. 2002;159:1889-1895. . 2002;159:1889-1895. Oberlander TF, et al. Oberlander TF, et al. J Clin PsychiatryJ Clin Psychiatry. 2004;65:230-237. Oberlander TF, et al. . 2004;65:230-237. Oberlander TF, et al. Arch Pediatr Adolesc Arch Pediatr Adolesc MedMed. 2007;161:22-29. Misri S, et al. . 2007;161:22-29. Misri S, et al. Am J PsychiatryAm J Psychiatry. 2006;163. 2006;163

If a woman is already on an SSRI If a woman is already on an SSRI antidepressant that is working well, continue antidepressant that is working well, continue her on that one. her on that one.

TCA’s are safe, with nortriptyline being TCA’s are safe, with nortriptyline being preferredpreferred

Use an adequate dosage, this often increases Use an adequate dosage, this often increases during the pregnancy (There is no fetal during the pregnancy (There is no fetal benefit to decreasing dose prior to delivery, benefit to decreasing dose prior to delivery, and this may increase risk of PPD in mother)and this may increase risk of PPD in mother)

Consider ECT for severely depressed or Consider ECT for severely depressed or psychotic women –it is safe and very effectivepsychotic women –it is safe and very effective

Cohen LS, et al. JAMA. 1994;271:146-150.Steer RA, et al. J Clin Epidemiol. 1992;45:1093-1099; Orr ST, et al. Am J Prev Med. 1996;12:459-466; Suppes T, et al. Arch Gen Psychiatry. 1991;48:1082-1088; Faedda GL, et al. Arch Gen Psychiatry. 1993;50:448-55; Baldessarini RJ, et al. Clin Psychiatry. 1996;57:441-448.

Pharmacologic Treatment of Pregnant Pharmacologic Treatment of Pregnant Women with Bipolar Disorder: Women with Bipolar Disorder:

Weighing the RisksWeighing the Risks

Commonly used antimanic agents Commonly used antimanic agents are either known teratogens or are either known teratogens or limited available reproductive limited available reproductive safety datasafety data

Risks of untreated psychiatric Risks of untreated psychiatric illnessillness

Risk of discontinuing maintenance Risk of discontinuing maintenance psychotropic medicationspsychotropic medications

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Cohen LS, et al. JAMA. 1994;271:146-150.

Lithium and TeratogenicityLithium and Teratogenicity

1970s Lithium Baby Registry—risk 1970s Lithium Baby Registry—risk for specific cardiovascular for specific cardiovascular malformation high; Ebstein’s malformation high; Ebstein’s anomalyanomaly

Revised risk based on meta-Revised risk based on meta-analysis: 1/1000 to 1/2000 (0.05%)analysis: 1/1000 to 1/2000 (0.05%)

Relative risk 10 to 20 times the rate Relative risk 10 to 20 times the rate in general population (1/20,000)in general population (1/20,000)

Absolute risk vs relative riskAbsolute risk vs relative risk

Summary of Findings Across Pregnancy Summary of Findings Across Pregnancy RegistriesRegistries

Valproic acid (VPA) is associated with the highest risk for all Valproic acid (VPA) is associated with the highest risk for all major malformations major malformations Risk estimates around 10% and higherRisk estimates around 10% and higher11

Risk appears to be dose-dependent (>1000 mg/d); may be with LTGRisk appears to be dose-dependent (>1000 mg/d); may be with LTG2,32,3

Folic acid supplementation may Folic acid supplementation may notnot be protective against VPA- be protective against VPA-associated neural tube defectsassociated neural tube defects

Risk is highest with anticonvulsant polytherapy, specifically with Risk is highest with anticonvulsant polytherapy, specifically with VPAVPA4,5, 4,5,

Carbamazepine (CBZ) and LTG are associated with lower risk than Carbamazepine (CBZ) and LTG are associated with lower risk than VPA VPA

1. Wyszynski DF, et al. Neurology. 2005;64:961-965.2. Morrow J, et al. J Neurol Neurosurg Psychiatry. 2006;77:193-198.3. Cunnington M, et al. Epilepsia. 2007;48:1207-1210.4. Meador KJ, et al. Neurology. 2006;67:407-412.5. Holmes LB, et al. Arch Neurol. 2004; 61:673-678.

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Neurobehavioral Teratogenicity and Neurobehavioral Teratogenicity and AnticonvulsantsAnticonvulsants

Data from several studies suggest Data from several studies suggest VPA exposure is associated with VPA exposure is associated with increased risk for adverse cognitive increased risk for adverse cognitive and neurodevelopmental effects and neurodevelopmental effects compared with other anticonvulsantscompared with other anticonvulsants

Neurobehavioral risk with LTG Neurobehavioral risk with LTG unknownunknown

Adab N, et al. J Neurol Neurosurg Psychiatry. 2004;75:1575-1583.Adab N, et al. J Neurol Neurosurg Psychiatry. 2001;70:15-21. Vinten J, et al. Neurology. 2005;64:949-954. Gaily E, et al. Neurology. 2004;62:28-32.22

Lamotrigine (LTG) Monotherapy Lamotrigine (LTG) Monotherapy Exposure: Increased Risk for Oral Exposure: Increased Risk for Oral

CleftsClefts Overall risk for major malformations with LTG Overall risk for major malformations with LTG

approximately 2.7% across several studiesapproximately 2.7% across several studies1,21,2

North American Antiepileptic Pregnancy Registry North American Antiepileptic Pregnancy Registry showed an increased incidence of a specific showed an increased incidence of a specific malformationmalformation Oral clefts: 8.9/1000 vs baseline 0.37/1000Oral clefts: 8.9/1000 vs baseline 0.37/100033

Finding not corroborated in other registries; further Finding not corroborated in other registries; further data needed data needed

Absolute risk remains smallAbsolute risk remains small1. Cunnington M, et al. Neurology. 2005;64:955-960.2. Meador KJ, et al. Neurology. 2006;67:407-412. 3. Holmes LB, et al. Abstract presented at the 46th Annual Meeting of the Teratology Society. June 24-29, 2006; Tucson, Arizona.

Treatment of Bipolar Disorder in Treatment of Bipolar Disorder in PregnancyPregnancy

Mild to moderate bipolar disorder:Mild to moderate bipolar disorder:

Gradual taper and discontinuation of Gradual taper and discontinuation of antimanic prophylaxis (lithium, sodium antimanic prophylaxis (lithium, sodium valproate) prior to pregnancy can be valproate) prior to pregnancy can be consideredconsidered

Reintroduce mood stabilizer as needed Reintroduce mood stabilizer as needed or during second trimester; except for or during second trimester; except for sodium valproate given data suggesting sodium valproate given data suggesting behavioral teratogenicity.behavioral teratogenicity.

Cohen LS, J Clin Psychiatry 2007;68 ( suppl 9).

Moderate to severe bipolar disorder:

• Lithium may be the safest alternative for women dependent on mood stabilizers

• For lithium nonresponders consider lamotragine monotherapy

• Consider lamotrigine and typical or atypical antipsychotic if lamotrigine monotherapy ineffective

Altshuler LL, et al. Am J Psychiatry. 1996;153: 592-606 Yaeger D, et al. Am J Psychiatry. 2006;163:2064-2070..McKenna K, et al. J Clin psychiatry. 2005;66:444-449. Kulkarni J, et al. Aust N Z J Psychiatry. 2008;42:38-44

Antipsychotic Use During PregnancyAntipsychotic Use During Pregnancy

Typicals and teratogenic risk:Typicals and teratogenic risk:

Data support safety of typical antipsychotics Data support safety of typical antipsychotics with respect to teratogenicitywith respect to teratogenicity

Atypicals and teratogenic risk:Atypicals and teratogenic risk: Postmarketing surveillance data for atypicals , case reportsPostmarketing surveillance data for atypicals , case reports

No increased risk for major malformationsNo increased risk for major malformations

Conclusions regarding reproductive safety of Conclusions regarding reproductive safety of these agents not possible with currently available these agents not possible with currently available

data, data, though no sign of teratogenicity is evident based on though no sign of teratogenicity is evident based on limited studies limited studies

Antipsychotic Use During Antipsychotic Use During PregnancyPregnancy

Largest dataset documenting outcomes of Largest dataset documenting outcomes of use of Atypicals in Pregnancy use of Atypicals in Pregnancy

Examined 713 pregnancies in women who Examined 713 pregnancies in women who were receiving Risperidone during were receiving Risperidone during pregnancypregnancy

21 cases of withdrawal-emergent syndrome 21 cases of withdrawal-emergent syndrome including jitteriness, irritability, feeding including jitteriness, irritability, feeding problems and somnolenceproblems and somnolence

No increased rate of spontaneous abortions, No increased rate of spontaneous abortions, structural malformations and fetal structural malformations and fetal teratogenic risk above that of the general teratogenic risk above that of the general population. population.

Evaluating the postmarketing experience of risperidone use during pregnancy: pregnancy and neonatal outcomes.Evaluating the postmarketing experience of risperidone use during pregnancy: pregnancy and neonatal outcomes.Drug Saf. 2007;30(3):247-64.Drug Saf. 2007;30(3):247-64.

Antipsychotic Use During Antipsychotic Use During PregnancyPregnancy

On 2/22/11, the FDA issued a warning On 2/22/11, the FDA issued a warning against use of antipsychotics during against use of antipsychotics during pregnancy, citing increased risk of pregnancy, citing increased risk of withdrawal symptoms and EPSwithdrawal symptoms and EPS

Data obtained from FDA’s Adverse Event Data obtained from FDA’s Adverse Event Reporting System up to 10/08, including Reporting System up to 10/08, including use of typicals and atypicals (mostly use of typicals and atypicals (mostly typicals)typicals)

A majority of the cases were confounded by A majority of the cases were confounded by other factors, such as malformations, other other factors, such as malformations, other medications, prematurity and complicationsmedications, prematurity and complications

Antipsychotic Use During Antipsychotic Use During PregnancyPregnancy

““The symptoms of EPS and withdrawal in The symptoms of EPS and withdrawal in newborns may include agitation, newborns may include agitation, abnormally increased or decreased muscle abnormally increased or decreased muscle tone, tremor, sleepiness, severe difficulty tone, tremor, sleepiness, severe difficulty breathing, and difficulty in feeding. In breathing, and difficulty in feeding. In some newborns, the symptoms subside some newborns, the symptoms subside within hours or days and do not require within hours or days and do not require specific treatment; other newborns may specific treatment; other newborns may require longer hospital stays.”require longer hospital stays.”

FFFDA Drug Safety Communication: Antipsychotic drug labels updated on use during pregnancy and risk of abnormal muscle movements and withdrawal sFDA Drug Safety Communication: Antipsychotic drug labels updated on use during pregnancy and risk of abnormal muscle movements and withdrawal symptoms in newbornsymptoms in newborns

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Sleep Disturbance in Sleep Disturbance in PregnancyPregnancy

25% of women in 125% of women in 1stst trimester trimester 75% in 375% in 3rdrd trimester trimester Poor sleep is strongly correlated with Poor sleep is strongly correlated with

depressiondepression Insomnia is more prevalent in depressed Insomnia is more prevalent in depressed

women who are untreated vs. women who are women who are untreated vs. women who are treated in week 20 treated in week 20

There is no difference at week 36, meaning There is no difference at week 36, meaning most women experience sleep disturbance in most women experience sleep disturbance in the 3the 3rdrd trimester trimester

Speaks to the importance of treating underlying Speaks to the importance of treating underlying mood disordermood disorder

Field 2007, Katherine Wisner, MD, PhDField 2007, Katherine Wisner, MD, PhD

Zolpidem Use in Zolpidem Use in PregnancyPregnancy

Large Taiwanese study looked at 2,497 Large Taiwanese study looked at 2,497 women without a history of mental illness, women without a history of mental illness, who used Zolpidem during pregnancy for at who used Zolpidem during pregnancy for at least 30 days (with an age matched least 30 days (with an age matched comparison group)comparison group)

This study showed increased rates of This study showed increased rates of adverse pregnancy outcomes including: low adverse pregnancy outcomes including: low birth weight, preterm delivery, small for birth weight, preterm delivery, small for gestational age babies and increased rates gestational age babies and increased rates of C-section deliveries. of C-section deliveries.

There was no increase in congenital There was no increase in congenital anomaliesanomalies

Zolpidem Use in Zolpidem Use in PregnancyPregnancy

Hypothesis include: Hypothesis include: Zolpidem causes the pituitary to release Zolpidem causes the pituitary to release

vasopressin and oxytocin resulting in vasopressin and oxytocin resulting in uterine vasoconstrictionuterine vasoconstriction

GABAergic agonists cause respiratory GABAergic agonists cause respiratory depressiondepression

Highest risk of adverse outcome in Highest risk of adverse outcome in women who took Zolpidem >90 dayswomen who took Zolpidem >90 days

Wang LH,  Lin HC, Lin CC , Chen YH & Lin HC. Wang LH,  Lin HC, Lin CC , Chen YH & Lin HC. Increased Risk of Adverse Pregnancy Outcomes in Women Receiving Increased Risk of Adverse Pregnancy Outcomes in Women Receiving ZolpidemZolpidem

During Pregnancy During Pregnancy. Clin Pharm Ther 88:3, 369-374 (2010).. Clin Pharm Ther 88:3, 369-374 (2010).

Treatment of Sleep Treatment of Sleep Disturbance in PregnancyDisturbance in Pregnancy

Due to these findings, the authors suggest Due to these findings, the authors suggest avoiding use of Zolpidem in pregnancy avoiding use of Zolpidem in pregnancy when possible. Other medication options when possible. Other medication options for sleep with safety data in pregnancy for sleep with safety data in pregnancy are the tricyclic antidepressants and are the tricyclic antidepressants and the benzodiazepines. Other options for the benzodiazepines. Other options for addressing sleep problems during addressing sleep problems during pregnancy include cognitive behavioral pregnancy include cognitive behavioral therapy, improving sleep hygiene and therapy, improving sleep hygiene and addressing underlying mood disorders.addressing underlying mood disorders.

Summary of Summary of Treatment of Mood Disorders During Treatment of Mood Disorders During

PregnancyPregnancy

Thank YouThank You

Questions?Questions?