Alternative Tx for psychiatric disorders. (Drugs, Pregnancy, and Lactation).

A common scenario seen on our consultation service is a woman with an anxiety or mood disorder who is stabilized on a drug and who wants to switch to an alternative medicine during pregnancy or while trying to conceive. The compounds people ask the most about are St. John's wort, SAMe (S-adenosyl-L-methionine), and omega-3 fatty acids. We also get questions about the use of kava supplements as an alternative treatment for anxiety.

Many women make the intuitive leap that some of these widely used complementary or alternative therapies represent a more "natural" and therefore safer alternative to a more standard pharmacologic treatment during pregnancy or while they are trying to conceive. The problem is that we have very little, if any, reproductive safety data on these natural compounds. Many of these products do not contain just the specific herbal compound, but fillers and other components used for compounding, about which we know very little.

Moreover, efficacy data for many of the herbals are limited. For example, there is still an ongoing debate about the efficacy of St. John's wort for depression. Although there are no data indicating that it's dangerous, not much is known about the reproductive safety of hypericum, its active ingredient.

While omega-3 fatty acids are not presumed to be teratogenic, the data supporting their efficacy in patients with bipolar disorder have been based primarily on adjunctive use with other mood-stabilizing medications. There are very little data on monotherapy; even the experience with adjunctive therapy was based on an extremely small sample of people.

Based on these uncertainties, an arbitrary switch to an alternative treatment may represent a failed risk-benefit decision, exposing a pregnant woman to both an unknown reproductive safety risk and an increased risk for relapse. A woman therefore will not be in a much better position regarding safety with one of these products than with a drug for which there are only limited reproductive safety data but which is known to be effective.

The growing array of newer antidepressants and anticonvulsants increases the possibility that more women will be successfully treated, although not much is yet known about their reproductive safety. More is known about the older medications, like lithium and divalproex sodium (Depakote), which are known to be teratogenic.

Some antidepressants, including ...