I have said for years to my female patients that I will not prescribe medications to them if they become pregnant. I prefer to see that they come off the drugs prior to becoming pregnant. Life, unfortunately, is never so neat and tidy. I stop medications if a patient reports to me she is pregnant and deal with the turmoil that may ensue from abrupt cessation. This is a controversial position amongst physicians and especially Obstetricians. They frequently tell my patients that the SSRI's are safe in pregnancy and that there is no need for discontinuance. I then say if the Obstetrician feels that way then let them prescribe the drug. I have yet to find one willing to do so.

My point in this is that the FDA today released the warning posted in the previous entry regarding Paxil. The reality is that no one can conclusively define the risk of these drugs because that would require a double blind placebo controlled study specifically exposing patients and their fetus to harm from a drug with unknown consequences. So the animal studies are conducted and give some general idea of a drug's potential fetotoxicity but these findings are not always transferable to human models. The next best circumstance is what has happened with Paxil. Cases are reviewed of patients that have taken the drug during pregnancy and evaluated for possible, previously undiscovered fetal abnormalities. This is not good medicine in my opinion and demonstrates the unreliability of animal toxicity studies.

The safety of the fetus is paramount and patients desiring to become pregnant would be wise to slowly decrease their psychiatric drugs before attempting to get pregnant. Coming off medication has to be a strategic part of planning for having a child and physicians need to be fully involved in this process. I will also ask a female patient of child bearing age if they intend to become pregnant and if they do I have a lengthy discussion about how we need to work together on a pregnancy plan that doesn’t include psychotropic drugs. These are critical discussions that physicians/psychiatrists must have with their female patients.