Mania And Pregnancy: Issues Related To Pharmacologic Treatment And Management Proposal [mania E Gravidez: Implicações Para O Tratamento Farmacológico E Proposta De Manejo]

The management of psychiatric disorders during pregnancy is complex, including clinical decisions which are difficult, and there is no sufficient data regarding this management in medical literature. Bipolar disorder occurs commonly in women during childbearing years, and there is high risk of recurrence during pregnancy and postpartum period. The authors review the existing data regarding the use of psychotropic agents in mania, and the impact on infant and childhood development. It is emphasized that nowadays the use of psychotropic medications during pregnancy is appropriate in many clinical situations, but no decision is risk-free. Moreover, a guideline is presented for psychotropic drug use during pregnancy and for bipolar women who wish to conceive.52297107Altshuler, L.L., Cohen, L., Szuba, M.P., Burt, V.K., Gitlin, M., Mintz, J., Pharmacologic management of psychiatric illness during pregnancy: Dilemmas and guidelines (1996) Am J Psychiatr, 153, pp. 592-606Altshuler, L.L., Hendrick, V., Cohen, L.S., Course of mood and anxiety disorders during pregnancy and the postpartum (1998) J Clin Psychiatry, 59, pp. 29-33Use of psychoactive medication during pregnancy and possible effects on the fetus and newborn (2000) Pediatrics, 105, pp. 880-887(2002) Manual Diagnóstico e Estatístico de Transtornos Mentais - TR, , Porto Alegre: ArtmedPractice guideline for the treatment of patients with bipolar disorder (2002) Am J Psychiatry, 159, pp. 1-50The practice of electroconvulsive therapy: Recommendations for treatment, training, and privileging (1990) Convulsive Therapy, 6, pp. 85-120Baptista, T., Araujo, H., Ruda, P., Hernández, L., Congenital neuroblastoma in a boy born to a woman with bipolar disorder treated with carbamazepine during pregnancy Progress in Neuro-Psychopharmacology & Biological PsychiatryBaugh, C.L., Stowe, Z.N., Treatment issues during pregnancy and lactation (1999) CNS Spectrum, 4, pp. 34-39Bazire, S., Psychotropics in problem areas - Pregnancy (2000) Psychotropic Drug Directory, pp. 200-211. , Bazire S. London: Mark Allen Publishing LtdaBoyd, B.A., Brown, D.W., Electric convulsive therapy in mental disorders associated with childbearing (1948) Journal of Missouri. State Medical Association, 45, p. 573Cohen, L.S., Friedman, J.M., Jefferson, J.W., Johnson, E.M., Weiner, M.L., A reevaluation of risk of in utero exposure to lithium (1994) JAMA, 271, pp. 146-150Dolovich, L.R., Addis, A., Vaillancourt, J.M.R., Power, J.D.B., Koren, G., Einarson, T.R., Benzodiazepines use in pregnancy and major malformations or oral cleft: Meta-analysis of cohort and case-control studies (1998) BMJ, 317, pp. 839-843Ferrill, M.J., Jacsin, J.J., Kehoe, W.A., ECT during pregnancy: Physiologic and pharmacologic considerations (1992) Convulsive Ther, 8, pp. 186-200Finnerty, M., Levin, Z., Miller, L.J., Acute maniac episodes in pregnancy (1996) Am J Psychiatry, 153, pp. 261-263Griffiths, E.J., Lorenz, R.P., Talon, N.S., Acute neurohumoral response to eletroconvulsive therapy during pregnancy (1989) Journal of Reproductive Medicine, 34, pp. 907-911Jacobson, S.J., Jones, K., Johnson, X., Prospective multicenter study of pregnancy outcome after lithium exposure during first trimester (1992) Lancet, 339, pp. 530-533Kallen, B., Tandberg, A., Lithium and pregnancy: A cohort study on maniac-depressive women (1983) Acta Psychiatr Scand, 68, pp. 134-139Kastrup, M., Lier, L., Rafaelsen, O.J., Psychiatric illness in relation to pregnancy and childbirth, I: Methodologic considerations (1989) Nordisk Psykiatrisk Tidsskrift, 43, pp. 531-534Knoppert-Van Der Klein, E.A.M., Kolling, P., Van Gent, E.M., Van Kamp, I.L., Consequences of a bipolar disorder and of use of mood stabilizers for pregnancy management (1997) Ned Tijdschr Geneeskd, 141, pp. 1960-1965Kuller, J.A., Katz, V.L., McMahon, M.J., Wells, S.R., Bashford, R.A., Pharmacologic treatment of psychiatric disease in pregnancy and lactation: Fetal and neonatal effects (1996) Obstet Gynecol, 87, pp. 789-794MacKay, F.J., Pearce, W.G.L., Freemantle, S.N., Mann, R.D., The safety of risperidone: A post-marketing study of 7,684 patients (1998) Human Psychopharmacol Clin Exp, 13, pp. 413-418Marzuk, P.M., Tardiff, K., Leon, A.C., Hirsch, C.S., Portera, L., Hartwell, N., Iqbal, M.I., Lower risk of suicide during pregnancy (1997) Am J Psychiatry, 154, pp. 122-123Miller, L.J., Psychopharmacology during pregnancy (1996) Prim Care Update Ob Gyns, 3, pp. 79-86Moslet, U., Hansen, E.S., A review of vitamin K, epilepsy and pregnancy (1992) Acta Neurol Scand, 85, pp. 39-43Perez, V., Laya, M., Lithium and pregnancy, a review of teratogenic effects of lithium salts (1999) Revis Psicofarmacol, 3, pp. 27-31Rosa, F.W., Baum, C., Computerized on-line pharmaceutical surveillance system (Compass) teratology (1993) Reprod Toxicol, 7, pp. 639-640Rumcau-Roquette, C., Goujard, J., Huel, G., Possible teratogenic effects of phenotiazines in human beings (1977) Teratology, 15, pp. 57-64Saxen, I., Saxen, L., Association between maternal intake of diazepam and oral clefts (1975) Lancet, 2, p. 498Scalco, A.Z., Cabral, A.C.J., Eletroconvulsoterapia na gestação (2000) Indicação e Prática Da Eletroconvulsoterapia, pp. 131-144. , Rigonatti SP, Rosa MA. São Paulo: Lemos EditorialSchick-Boschetto, B., Zuber, C., Alprazolam exposure during early human pregnancy (1992) Teratology, 45, p. 460Schou, M., Goldfield, M.D., Weinstein, M.R., Villeneuve, A., Lithium and pregnancy, I: Report from the Register of Lithium Babies (1973) BMJ, 2, pp. 135-136Scolnik, D., Nulman, I., Rovet, J., Gladstone, D., Czachta, D., Gardner, H.A., Neurodevelopment of children exposed in utero to phenytoin and carbamazepine monotherapy (1994) JAMA, 271, pp. 767-770Shansis, F.M., Cordioli, A.V., Transtorno bipolar do humor (2000) Psicofármacos - Consulta Rápida, pp. 249-261. , Cordioli AV. Porto Alegre: ArtmedSharma, V., Persad, E., Effect of pregnancy on three patients with bipolar disorder (1995) Ann Clin Psychiatry, 7, pp. 39-42Soares, C.N., Viguera, A.C., Cohen, L.S., Mood disturbance and pregnancy: Pros and cons of pharmacologic treatment (2001) Rev Bras Psiquiatr, 23, pp. 48-53St. Clair, S.M., Schirmer, R.G., First trimester exposure to alprazolam (1992) Obstet Gynecol, 80, pp. 843-846Van Gent, E.M., Verhoeven, W.M.A., Bipolar illness, lithium prophylaxis and pregnancy (1992) Pharmacopsychiatry, 25, pp. 187-191Viguera, A.C., Cohen, L.S., Baldessarini, R.J., Nonacs, R., Managing bipolar disorder during pregnancy: Weighing the risks and benefits (2002) Can J Psychiatry, 47, pp. 426-436Viguera, A.C., Cohen, L.S., The course and management of bipolar disorder during pregnancy (1998) Psychopharmacol Bull, 34, pp. 339-346Viguera, A.C., Nonacs, R., Cohen, L.S., Tondo, L., Murray, A., Baldessarini, R.J., Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance (2000) Am J Psychiatry, 157, pp. 179-184Waldman, M.D., Safferman, M.Z., Pregnancy and clozapine (1993) Am J Psychiatry, 150, pp. 168-169Williams, P.G., Hersh, J.H., A male with fetal syndrome and autism (1997) Dev Med Child Neurol, 39, pp. 632-63

Use Of Psychotropic Drugs In Breast-feeding: Review And Management Proposal [uso De Psicofármacos Na Lactação: Revisão E Proposta De Manejo]

The postpartum period is thought to be a relatively high risk period in terms of experiencing a psychiatric disorder. This is particularly important for affective episodes, and for women with preexisting psychiatric illness. Between 5% and 20% of all women will experience a postpartum depression within the first six months, and 1% to 2% will experience a postpartum psychosis. The vulnerability for psychiatric illness during the period after delivery raises the possibility that psychotropic medications will be administered. Most psychotropic medications are excreted into breast milk, but there is great variability in the amount of drug received by the infant. Nevertheless, with the exception of case reports or small case series, there are few data on the safety of psychotropic medications during breastfeeding. The authors made an evaluation of currently published studies, and reviewed the existing data regarding the use of psychotropic agents in breastfeeding, in special its impact on infant's development. They also present guidelines for the use of psychotropic medications during breastfeeding, and emphasize that each case needs to be considered on an individual basis, with a thoughtful analysis of risks and benefits, finally, they present recommendations for management of each specific psychiatric major disorder.526413425Almeida-Filho, N., Mari, J.J., Coutinho, E., Busnello, E., Brazilian Multicentric Study of Psychiatric Morbidity (1997) Br J Psych, 171, pp. 524-529Altshuller, L.L., Burt, V.K., McMullen, M., Hendrick, V., Breastfeeding and sertraline: A 24-hour analysis (1995) J Clin Psychiatry, 56, pp. 243-245The transfer of drugs and other chemicals into human milk (2001) Pediatrics, 108, pp. 776-789Transfer of drugs and other chemicals into human milk (1989) Pediatrics, 84, pp. 924-936Breasfeeding and the use of human milk (1997) Pediatrics, 100, pp. 1035-1039Ananth, J., Side Effects in the neonate from psychotropic agents excreted through breast-feeding (1978) Am J Psychiatry, 135, pp. 801-805Anderson, P., McGuire, G., Neonatal alprazolam withdrawal-possible effects of breast feeding (1989) DICP, 23, p. 614Atkinson, H.C., Drugs in human milk: Clinical pharmacokinetic considerations (1988) Clin Pharmacokinet, 14, pp. 217-240Barnas, C., Bergant, A., Hummer, M., Clozapine concentrations in maternal and fetal plasma, amniotic fluid, and breast milk (1994) Am J Psychiatry, 151, p. 945Baum, A.L., Misri, S., Selective serotonin-reuptake inhibition in pregnancy and lactation (1996) Harv Rev Psychiatry, 4, pp. 117-125Bazire, S., Psychotropics in problem areas: Breast feeding (2000) Psychotropic Drug Directory, pp. 172-177. , Bazire S. London: Quay BooksBennett, P.N., Use of the monographs on drugs (1996) Drugs and Human Lactation: A Comprehensive Guide to the Content and Consequences of Drugs, Micronutrients, Radiopharmaceuticals, and Environmental and Occupational Chemicals in Human Milk, pp. 67-74. , Bennett PN. Amsterdam: ElsevierBezchlibnyk, K.Z., Bredni, S., Desjardins, C., Should mothers on drugs breast-feed their children? (1981) Pharmacy News, 8, p. 4. , Clarke Institute PsychiatryBirnbaum, C.S., Cohen, L.S., Bailey, J.W., Crush, L.R., Robertson, L.M., Stowe, Z.N., Serum concentrations of antidepressants and benzodiazepines in nursing infants: A case series (Electronic Article) (1999) Pediatrics, 104, pp. e11Blacker, K.H., Weinstein, B.J., Ellmann, G., Mother's milk and chlorpromazine (1962) Am J Psychiatry, 119, pp. 178-179Botega, N.J., Dias, M.K., Gravidez e puerpério (2002) Prática Psiquiátrica No Hospital Geral: Interconsulta e Emergência, pp. 285-297. , Botega NJ. Porto Alegre: ArtmedBrandt, R., Passage of diazepam and desmethyldiazepam into breast milk (1976) Arzneimittelforschung, 26, pp. 454-457Brent, N., Wisner, K., Fluoxetine and carbamazepine concentrations in a nursing mother/infant pair (1998) Clin Pediatr, 37, pp. 41-44Brixen-Rasmussen, L., Halgrener, J., Jorgensen, A., Amitriptyline and nortriptyline excretion in human breast milk (1982) Psychopharmacology (Berl), 76, pp. 94-95Buist, A., Norman, T.R., Dennerstein, L., Breastfeeding and the use of psychotropic medication: A review (1990) J Affect Disord, 19, pp. 197-206Buist, A., Norman, T.R., Dennerstein, L., Mianserin in breast milk (1993) Br J Clin Pharmacol, 36, pp. 133-134Burch, K.J., Wells, B.G., Fluoxetine/norfluoxetine concentrations in human milk (1992) Pediatrics, 89, pp. 676-677Burt, V.K., Suri, R., Altshuller, L., The use of psychotropic medications during breast-feeding (2001) Am J Psychiatry, 158, pp. 1001-1009Chambers, C.D., Anderson, P.O., Thomas, R.G., Dick, L.M., Felix, R.J., Johnson, K.A., Weight gain in infants breastfed by mothers who take fluoxetine (Electronic Article) (1999) Pediatrics, 105, pp. e61Chaudron, L.H., When and how to use mood stabilizers during breastfeeding (2000) Prim Care Update Ob Gyns, 7, pp. 113-117Chaudron, L.H., Jefferson, L.W., Mood stabilizers during breastfeeding: A review (2000) J Clin Psychiatry, 61, pp. 79-90Chen, Y., Xu, S., Li, W.X., Artificial feeding and hospitalization in the first 18 months of life (1988) Pediatrics, 81, pp. 58-62Chisholm, C.A., Kuller, J.A., A Guide to the safety of Cns-active agents during breastfeeding (1997) Drug Saf, 17, pp. 127-142Cordioli, A.V., Shansis, F.M., Pádua, A.C., Grever, E.H., Sousa, N.O., Ribeiro, L., Medicamentos: Informações básicas (2000) Psicofármacos - Consulta Rápida, pp. 21-245. , Cordioli AV. Porto Alegre: ArtmedDean, C., Kendell, R.E., The symptomatology of puerperal illness (1981) Br J Psychiatry, 139, pp. 128-135DeVane, C.L., Pharmacokinetics of the selective serotonin reuptake inhibitors (1992) J Clin Psychiatry, 53 (FEB SUPPL.), pp. 13-20Ernst, C.L., Goldberg, J.F., The reproductive safety profile of mood stabilizers, atypical antipsychotics, and broad-spectrum psychotropics (2002) J Clin Psychiatry, 63 (SUPPL. 4), pp. 42-55Field, T., Infants of depressed mothers (1995) Infant and Behavior Development, 18, pp. 1-13Fisher, J.B., Edgren, B.E., Mammel, M.C., Coleman, J.M., Neonatal apnea associated with maternal clonazepam therapy: A case report (1985) Obstet Gynecol, 88, pp. 345-355Goldstein, D.J., Corbin, L.A., Fung, M.C., Olanzapine - Exposed pregnancies and lactation: Early experience (2000) J Clin Psychopharmacol, 20, pp. 399-403Griggs, G.G., Samson, J.H., Ambrose, P.J., Schroeder, D.H., Excretion of bupropion in breast milk (1993) Ann Pharmacother, 27, pp. 431-433Hill, R.C., McIvor, R.J., Wojnar-Horton, R.E., Risperidone distribution and excretion into human milk: Case report and estimated infant exposure during breast-feeding (2000) J Clin Psychopharmacol, 20, pp. 285-286Ilett, K.F., Krinstensen, J.H., Hackett, L.P., Paech, M., Kohan, R., Rampono, J., Distribution of venlafaxine and its O-desmethyl metabolite in human milk and their effects in breastfed infants (2002) Br J Clin Pharmacol, 53, pp. 17-22Iqbal, M.M., Gundlapalli, S.P., Ryan, W.G., Effects of antimaniac mood-stabilizing drugs on fetuses, neonates, and nursing infants (2001) South Med J, 94, pp. 304-322Iqbal, M.M., Sobham, T., Regal, T., Effects of commonly used benzodiazepines in the fetus, the neonate and the nursing infant (2002) Psychiatr Serv, 53, pp. 39-49Ito, S., Blajchenan, A., Stephenson, M., Prospective follow-up of adverse reactions in breastfed infants exposed to maternal medication (1993) American Journal of Obstetrics and Gynecology, 168, pp. 1393-1399Kemp, J., Excretion of doxepin and n-desmethyldoxepin in human milk (1985) Br J Clin Pharmacol, 20, pp. 497-499Kirchheiner, J., Berghofer, A., Bolk-Weischedel, D., Healthy outcome under olanzapine treatment in a pregnant women (2000) Pharmacopsychiatry, 33, pp. 78-80Klier, C.M., Schaeffer, M.R., Schmid-Svegel, B., Lenz, G., Mannel, M., St. John's Wort (Hypericum Perforatum) - Is it safe during breastfeeding? (2002) Pharmacopsychiatry, 35, pp. 29-30Kok, T.H., Taitz, L.S., Bennett, M.J., Drowsiness due to clemastine transmitted in breast milk (1982) Lancet, 1, pp. 914-915Kuhnz, W., Jager-Roman, E., Rating, D., Carbamazepine and carbamazepine-10,11- epoxide during pregnancy and postnatal period in epileptic mothers and their nursed infants: Pharmacokinetics and clinical effects (1983) Pediatr Pharmacol (New York), 3, pp. 199-208Lester, B., Cucca, J., Lynne, A., Flanagan, P., Oh, W., Possible association between fluoxetine hydrochloride and colic in an infant (1993) J Am Acad Child Adolesc Psychiatry, 32, pp. 1253-1255Linden, S., Rich, C.L., The use of lithium during pregnancy and lactation (1983) J Clin Psychiatry, 44, pp. 358-361Llewellyn, A., Stowe, Z.N., Strader Jr., J.R., The use of lithium and management of women with bipolar disorder during pregnancy and lactation (1998) J Clin Psychiatry, 59 (SUPPL. 6), pp. 57-64Mammen, O.K., Perel, J.M., Rudolph, G., Foglia, J.P., Wheeler, S.B., Sertraline and norsertraline levels in three breastfed infants (1997) J Clin Psychiatry, 58, pp. 100-103Matheson, I., Pande, H., Alertsen, A.R., Respiratory Depression caused by n-desmethyldoxepin in breast milk (1985) Lancet, 2, p. 1124McElhatton, D.R., The effects of benzodiazepines use during pregnancy and lactation (1994) Reproductive Toxicology, 8, pp. 461-475Merlob, P., Mor, N., Litwin, A., Transient hepatic dysfunction in an infant of an epileptic mother treated with carbamazepine during pregnancy and breastfeeding (1992) Ann Pharmacother, 26, pp. 1563-1565Fundação Nacional Da Saúde, , http://tabnet.datasus.gov.br, Serviço de Informações Sobre Nascidos VivosMoretti, M.E., Lee, A., Ito, S., Which drugs are contraindicated during breastfeeding? Practice guidelines (2000) Can Fam Physician, 46, pp. 1753-1757Moretti, M., Sharma, A., Bar-Oz, B., Koren, G., Ito, S., Fluoxetine and its effects on the nursing infant: A prospective cohort study (1989) Clin Pharmacol Ther, 65, p. 141Morselli, P.L., Clinical pharmacokinetics in newborns and infants (1980) Clin Pharmacokinet, 5, pp. 485-527Murray, L., Segar, D., Drug therapy during pregnancy and lactation (1994) Emerg Med Clin North Am, 12, pp. 129-149Niebyl, J.R., Blake, D.A., Freeman, J.M., Carbamazepine levels in pregnancy and lactation (1979) Obstet Gynecol, 53, pp. 139-140Ohman, I., Vitols, S., Tomson, T., Lamotrigine in pregnancy: Pharmacokinetics during delivery, in the neonate, and during lactation (2000) Epilepsia, 41, pp. 709-713Oo, C.Y., Jun, R.J., Desai, N., Pharmacokinetics in lactating women: Prediction of alprazolam transfer into milk (1995) Br J Clin Pharmacol, 40, pp. 231-236Patrick, M.J., Telstone, W.J., Reavey, P., Diazepam and breast-feeding (1972) Lancet, 1, pp. 542-543Pinzon, V.D., Pires, R.M., Schüller-Faccini, L., Fármacos psicotrópicos na gestação e na amamentação (2001) Emergências Psiquiátricas, pp. 220-238. , Kapczinski F, Quevedo J, Schmitt R, Chachamovich E. Porto Alegre: ArtmedPiontek, C.M., Baab, S., Reindl, K.S., Serum valproate levels in 6 breast-feeding mother-infant pairs (2000) J Clin Psychiatry, 61, pp. 170-172Prokopczyk, J., Kaminska, E., Drugs and breastfeeding (2002) Med Wicke Rozwoj, 6, pp. 135-144Rivera-Calimlin, L., The significance of drugs in breast milk: Pharmacokinetic considerations (1987) Clin Perinatol, 14, pp. 51-70Schimmell, M.S., Katz, E.Z., Shaag, Y., Pastuszak, A., Koren, G., Toxic neonatal effects following maternal clomipramine therapy (1991) J Toxicol Clin Toxicol, 29, pp. 479-484Schmidt, K., Oleson, O.V., Jenses, P.N., Citalopram and breast-feeding: Serum concentration and side effects in the infant (1999) Biol Psychiatry, 47, pp. 164-165Skauslg, O.B., Schou, M., Breast-feeding during lithium treatment (1977) Ugesler Laeger, 139, pp. 400-401Sovner, R., Orsulak, P., Excretion of imipramine and desipramine in human breast milk (1979) Am J Psychiatry, 136, pp. 451-452Spigset, O., Carreborg, L., Ohman, R., Excretion of citalopram in breast milk (1997) Br J Clin Pharmacol, 44, pp. 285-298Stahl, M.M., Neiderud, J., Vinge, E., Thrombocytopenic purpura and anemia in a breast-fed infant whose mother was treated with valproic acid (1997) J Pediatr, 130, pp. 1001-1003Stowe, Z.N., Cohen, L.S., Hostetter, A., Ritchie, J.C., Owens, M.J., Nemeroff, C.B., Paroxetine in human breast milk and nursing infants (2000) Am J Psychiatry, 157, pp. 185-189Stowe, Z.N., Owens, M.J., Landry, J.C., Kilts, C.D., Ely, T., Llewellyn, A., Sertraline and desmethylsertraline in human breast milk and nursing infants (1997) Am J Psychiatry, 154, pp. 1255-1260Summerfield, R.J., Nilssen, M.S., Excretion of lorazepam into breast milk (1985) British Journal of Anesthesia, 57, pp. 1042-1043Suri, R.A., Altshuller, L.L., Burt, V.K., Hendrick, V.C., Managing psychiatric medications in the breast-feeding women (1998) Medscape Womens Health, 3, p. 1Sykes, P.A., Quame, J., Alexander, F.W., Lithium carbonate and breast-feeding (1976) BMJ, 2, p. 1299Taylor, D.A., McConnell, H., McConnell, D., Kerwin, R., (2001) The Maudsley Prescribing Guidelines, , London: Martin DunitzTomson, T., Ohman, I., Vitols, S., Lamotrigine in pregnancy and lactation: A case report (1997) Epilepsia, 38, pp. 1039-1041Trimble, M.R., Anticonvulsants in children and adolescents (1990) J Child Adolesc Psychopharmacol, 1, pp. 107-124Tunnessen, W.W., Hert, C.G., Toxic effects of lithium in newborn infants: A commentary (1972) J Pediatr, 81, pp. 804-807Viguera, A.C., Nonacs, R., Cohen, L.S., Tondo, L., Murria, A., Baldessarini, R.J., Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance (2000) Am J Psychiatry, 157, pp. 179-184Wesson, D.R., Camber, S., Harkey, M., Diazepam and desmethyldiazepam in breast milk (1985) Journal of Psychoactive Drugs, 17, pp. 55-56Wisner, K.L., Perel, J.M., Serum levels of valproate acid and carbamazepine in breastfeeding mother-infant pairs (1998) J Clin Psychopharmacol, 18, pp. 167-169Wisner, K.L., Perel, J.M., Serum nortriptyline levels in nursing mothers and their infants (1991) Am J Psychiatry, 148, pp. 1234-1236Wisner, K.L., Perel, J.M., Findling, R.L., Antidepressant treatment during breast-feeding (1996) Am J Psychiatry, 153, pp. 1132-1137Wisner, K.L., Perel, J.M., Foglia, J.P., Serum domipramine and metabolite levels in four nursing mother-infant pairs (1995) J Clin Psychiatry, 56, pp. 17-20Yoshida, K., Smith, B., Craggs, M., Kumar, C., Investigation of pharmacokinetics and of possible adverse effects in infants exposed to tricyclic antidepressants in breast-milk (1997) J Affect Disord, 43, pp. 225-237Yoshida, K., Smith, B., Craggs, M., Kumar, C., Neuroleptic drugs in breast-milk: A study of pharmacokinetics and of possible adverse effects in breast-fed infants (1998) Psychol Med, 28, pp. 81-91Yoshida, K., Smith, B., Kumar, R.C., Fluvoxamine in breast-milk and infant development (1997) Br J Clin Pharmacol, 44, pp. 210-21

Transtorno de humor bipolar: diversas apresentações de uma mesma doença Bipolar mood disorder: different occurrences of the same disease

O presente relato tem por objetivo acompanhar a evolução de um caso que se apresentou como mutismo seletivo e evoluiu para transtorno de humor bipolar e chamar atenção para a diversidade de sintomas possíveis no transtorno de humor. Em geral, o mutismo seletivo tem início na idade pré-escolar, porém os sintomas chamam mais atenção na idade escolar. A importância do diagnóstico e tratamento precoces reside na prevenção das complicações, tais como distúrbios no desenvolvimento social e acadêmico e na auto-estima, além da possibilidade de evolução para outros transtornos de ansiedade. O transtorno de humor bipolar é uma doença mental caracterizada por variações extremas no humor. Na criança, prejudica o crescimento emocional e seu desenvolvimento. É confundido com transtorno de déficit de atenção/hiperatividade e transtornos de comportamento, tais como transtorno de conduta e desafiador opositivo. A paciente do sexo feminino, quando avaliada, estava com 5 anos e 9 meses de idade. Concluiu-se o diagnóstico como mutismo seletivo. Foi indicada psicoterapia, com orientações aos pais e à escola, e iniciado o uso de inibidores seletivos de recaptação da serotonina, com boa resposta aos sintomas de ansiedade, mas passou a apresentar piora significativa do comportamento. Foi levantada a hipótese diagnóstica de transtorno de humor bipolar de início precoce. Medicada com estabilizador, apresentou adequação na terceira medicação e evolução satisfatória. O mutismo seletivo, considerado um transtorno de ansiedade na infância, pode ser pródromo para outros quadros psiquiátricos na infância. Há necessidade que os pediatras, médicos que primeiro acessam essas crianças, assim como os psiquiatras da infância, estejam atentos à riqueza de sintomas que pode dar seguimento ao quadro.<br>The purpose of the present case report is to follow the evolution of a child who presented selective mutism and evolved into bipolar mood disorder, and also to draw attention to the diversity of possible symptoms of mood disorders. In general, selective mutism starts at preschool age, although the symptoms are more evident at school age. The importance of an early diagnosis and treatment lies in the prevention of some complications, such as social and academic development and self-esteem, besides the possibility of the development of other anxiety disorders. Bipolar mood disorder is a mental disease characterized by extreme mood variations. In childhood, it hinders the child's emotional growth and development. Selective mutism is mistaken by attention deficit hyperactivity disorder, and behavioral disorders, such as conduct disorder and oppositional defiance disorder. The present case report is about a female patient evaluated at 5 years and 9 months of age. We concluded the case as being a selective mutism disorder. Not only psychotherapy, with parent and school orientation, but also medication was prescribed. The first prescribed medication was use of selective serotonin reuptake inhibitors with good results regarding anxiety symptoms, although the patient started to present significant deterioration in behavior. Because of that, the diagnostic hypothesis came to be bipolar mood disorder with an early start. The patient presented satisfactory evolution only after given a third option of mood stabilizer medication. Selective mutism, which is an anxiety disorder in childhood, can be prodromus to other psychiatric conditions at the same age. It is necessary for pediatricians, who are the doctors that first assess these children, and also child psychiatrists, to be aware of the wealth of symptoms that can give continuation to the condition

Another way of thinking about ADHD: the predictive role of early attachment deprivation in adolescents' level of symptoms.

PURPOSE: Attention deficit and hyperactivity disorder (ADHD) is one of the most frequent disorders in childhood and adolescence. Both neurocognitive and environmental factors have been related to ADHD. The current study contributes to the documentation of the predictive relation between early attachment deprivation and ADHD. METHOD: Data were collected from 641 adopted adolescents (53.2 % girls) aged 11-16 years in five countries, using the DSM oriented scale for ADHD of the Child Behavior Checklist (CBCL) (Achenbach and Rescorla, Manual for the ASEBA school-age forms and profiles. University of Vermont, Research Center for Children, Youth and Families, Burlington, 2001). The influence of attachment deprivation on ADHD symptoms was initially tested taking into consideration several key variables that have been reported as influencing ADHD at the adoptee level (age, gender, length of time in the adoptive family, parents' educational level and marital status), and at the level of the country of origin and country of adoption (poverty, quality of health services and values). The analyses were computed using the multilevel modeling technique. RESULTS: The results showed that an increase in the level of ADHD symptoms was predicted by the duration of exposure to early attachment deprivation, estimated from the age of adoption, after controlling for the influence of adoptee and country variables. The effect of the age of adoption was also demonstrated to be specific to the level of ADHD symptoms in comparison to both the externalizing and internalizing behavior scales of the CBCL. CONCLUSION: Deprivation of stable and sensitive care in infancy may have long-lasting consequences for children's development