Managing Medication and Mental Health: Preparing for Pregnancy After Recovery

Q: Managing Medication and Mental Health: Preparing for Pregnancy After Recovery

Hello, Xiao Yu： It seems that you are responding well to the medication, and the tapering process is going smoothly, which is a good start. <br>Here are the responses to your questions： <br>1) There is a possibility of discontinuing the medication, but it is recommended to contin

Medication consultation: After taking Lofepramine and Duloxetine for treatment, it is expected to discontinue medication for pregnancy preparation after recovery?

Hello Doctor, I am currently experiencing severe obsessive-compulsive behaviors, anxiety, and depression that I cannot control.
I have been taking Lexapro (escitalopram) and Emsam (selegiline) for over a month, classified as D and C level medications, respectively.
In the first month, I was prescribed Lexapro 100 mg daily (once in the morning) and Emsam 1 mg daily (0.25 mg taken four times a day: morning, noon, evening, and before bed).
After starting the medication, I became completely stable, with no more obsessive behaviors, and my thoughts became entirely positive and optimistic.

In the second month, the dosage was reduced to Lexapro 100 mg daily (once in the morning) and Emsam 0.5 mg daily (0.25 mg taken twice a day: once in the morning and once in the evening).
After reducing the medication, I experienced vivid dreams during sleep but maintained a stable sleep schedule from around midnight to 7 AM.
There have been no further occurrences of obsessive behaviors, and I have only mild anxiety or tension, which I can manage and accept.
My thoughts remain relatively positive, although I occasionally engage in negative thinking due to concerns about the behavior of those around me.
I have started working with a therapist to adjust my cognitive patterns and am reading related materials.
I plan to begin RTMS (Repetitive Transcranial Magnetic Stimulation) after the third month, in addition to my medication, hoping to gradually improve my mental health and eventually taper off the medication without relapse.
I also intend to start preparing for in vitro fertilization (IVF) due to my age, aiming for February of next year (as I need to take leave and rest).

I have the following questions:
1) With my current medication dosage and treatment plan, is there a chance I could recover and stop medication by the end of December?
2) Would starting RTMS earlier help me recover and stop medication sooner?
3) Given my progress, is it possible to recover and stop medication within three months without relapse? Are there any addiction concerns with these medications, and how can I address them? Would exercise or other methods help?
4) To avoid residual medication affecting the fetus, I plan to stop medication for a month after recovery before using my frozen eggs for IVF.
Is this duration sufficient? How long do you recommend stopping medication before starting IVF?
5) During the IVF process, could hormonal changes pose a risk of relapse? What can be done to manage or control relapse without medication, ensuring it does not affect the fetus?
6) What is the clinical efficacy of RTMS? Is it complementary to medication or a substitute? Thank you, Doctor.

Xiao Yu, 40~49 year old female. Ask Date: 2023/10/02

Dr. Lin Mianzhang reply Psychiatry

Hello, Xiao Yu: It seems that you are responding well to the medication, and the tapering process is going smoothly, which is a good start.
Here are the responses to your questions:
1) There is a possibility of discontinuing the medication, but it is recommended to continue with rTMS and psychotherapy, and to have regular follow-ups with your physician to discuss your current situation.

2) It will be helpful.

3) Since I do not know the severity of your previous depression, anxiety, and obsessive-compulsive symptoms, I cannot directly assess your risk of relapse.
However, based on past studies, women with major depressive disorder who discontinue antidepressants during pregnancy have a relapse rate of 68%, while those who continue taking antidepressants during pregnancy have a relapse rate of 26%.
Given that you will be undergoing rTMS, I believe the risk of relapse should be much lower.
Antidepressants are not addictive, but sedative-hypnotic medications can be (such as Zolpidem).
Therefore, we generally recommend that sedatives be used short-term, while antidepressants can be used long-term.

4) The duration for tapering off medication depends on the drug's half-life, which is the time it takes for the drug concentration in the body to reduce to half of its maximum concentration after reaching peak levels.
Generally, after five half-lives, the drug concentration in the body drops to about 3% of its maximum concentration, which we can consider as nearly completely eliminated from the body.
Both Lexapro and Zolpidem have a half-life of approximately 24 hours, so after five days of discontinuation, the drug concentration will be about 3%, and after seven days, it will be less than 1%.
Therefore, a one-month discontinuation is definitely sufficient!
5) As mentioned earlier, there is a risk of relapse after discontinuation.
Therefore, it is advisable to consider maintenance treatment with rTMS, combined with psychotherapy, and to have regular follow-ups with your physician to discuss your current situation.

6) The efficacy of rTMS can be influenced by many factors, such as the severity of the condition, the parameters of rTMS stimulation, and the location of stimulation.
For treating major depressive disorder, the symptom remission rate is about 30-60%, and the symptom improvement rate is about 60-80%.
Therefore, the efficacy is considered quite good, but due to its high cost, fewer people choose to use rTMS as a standalone treatment; most still combine it with medication.
However, in special circumstances (such as pregnancy) or if financially feasible, using rTMS alone for treatment is also an option.
Wishing you a smooth pregnancy!

Reply Date: 2023/10/02

More Info

Managing mental health during pregnancy is a complex issue that requires careful consideration of both the benefits and risks associated with medication use. Given your current situation, where you are managing severe obsessive-compulsive behaviors, anxiety, and depression, it is crucial to approach your treatment plan with a comprehensive understanding of how medications may affect both your mental health and the health of a potential fetus.

1. Medication and Recovery Timeline: The timeline for recovery and the possibility of stopping medication by December largely depend on your individual response to treatment and the severity of your symptoms. While some individuals may experience significant improvement and be able to taper off medications within a few months, others may require a longer duration of treatment. It is essential to work closely with your psychiatrist to monitor your symptoms and adjust your treatment plan accordingly.
2. RTMS and Recovery: Repetitive Transcranial Magnetic Stimulation (RTMS) is a non-invasive procedure that has shown promise in treating depression and anxiety. Starting RTMS earlier may indeed help accelerate your recovery, as it can enhance neuroplasticity and improve mood regulation. However, the effectiveness of RTMS can vary from person to person, and it is best used as part of a comprehensive treatment plan that includes medication and therapy.

3. Risk of Relapse and Medication Dependence: The risk of relapse after discontinuing medication is a significant concern, especially for individuals with a history of severe anxiety and obsessive-compulsive disorder. While medications like Lexapro (Escitalopram) and other SSRIs are not typically associated with physical dependence, psychological dependence can occur. Engaging in regular exercise, mindfulness practices, and cognitive-behavioral therapy (CBT) can be beneficial in managing anxiety and reducing the risk of relapse.

4. Timing for Fertility Treatments: Regarding your plan to undergo in vitro fertilization (IVF) after stopping medication, it is generally recommended to allow a washout period of at least 4-6 weeks after discontinuing SSRIs before attempting conception. This timeframe helps to minimize any potential residual effects of the medication on the developing fetus. However, the exact duration should be discussed with your healthcare provider, who can tailor advice based on your specific situation.

5. Hormonal Changes and Mental Health: Hormonal fluctuations during IVF and pregnancy can indeed impact mental health. Some individuals may experience an exacerbation of anxiety or depressive symptoms due to these changes. To mitigate this risk, it is essential to have a robust support system in place, including mental health professionals who can provide therapy and coping strategies. Regular monitoring of your mental health during this period is crucial.

6. Effectiveness of RTMS: Clinical studies have shown that RTMS can be effective in treating depression and anxiety, often serving as an adjunct to medication rather than a complete replacement. It can help reduce symptoms and improve overall functioning, making it a valuable tool in your treatment arsenal. Discussing the integration of RTMS with your psychiatrist will help you understand how it fits into your overall treatment plan.

In summary, managing your mental health while preparing for pregnancy involves a careful balance of medication management, therapeutic interventions, and lifestyle modifications. Open communication with your healthcare providers is essential to ensure that you receive the best possible care tailored to your needs. As you approach this significant life change, prioritize your mental health and well-being, and seek support from professionals who understand the complexities of mental health during pregnancy.

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