Canadian Network for Mood and Anxiety Treatments 2024 Clinical Practice Guideline for the Management of Perinatal Mood, Anxiety, and Related Disorders: Guide de pratique 2024 du Canadian Network for Mood and Anxiety Treatments pour le traitement des troubles de l'humeur, des troubles anxieux et des troubles connexes périnatals

Treatment Recommendations

• Options are classified into first-line, second-line and third-line treatment recommendations for each PMAD.
• Lines of treatment were created by initially considering the placement of individual agents in non-perinatal treatment guidelines, and then by adding, removing, or moving agents up or down in lines of treatment based on evidence for their safety and efficacy in pregnancy and in lactation. For example, if 2 medications were similarly effective and tolerated in non-perinatal populations, but safety data in pregnancy and lactation were more reassuring for one medication, that agent would be placed in a higher line of treatment.
• Within lines of treatment, agents are listed alphabetically. A justification for placement column contains the rationale for placing the medications within that line of treatment. Clinicians and patients can use this information to help select which agent(s) to try first within each line of treatment. Such decisions may be based on prior history or response/tolerability with previous treatments and/or how patients value the potential benefits and risks associated with specific agents.
• Although CANMAT recommends that agents listed in a higher line of treatment be tried first, there may be specific reasons for choosing an agent in a lower treatment line such as patient preference, prior treatment response or non-response, or other clinical features. Specifically: In individuals on medication(s) whose symptoms are well-controlled, the medication(s) should not usually be changed to another one based on its placement in the rankings, unless the current agent is listed as “not recommended.” Switching medication may lead to clinical worsening. If a medicine is taken in pregnancy, it is generally preferable to continue it postpartum to reduce the risk for clinical worsening. Significantly less medication enters breastmilk than passes through the placenta, so there would be few benefits of stopping or switching medications immediately post-delivery. Changes do not usually need to be made for lactation unless the patient is doing poorly clinically, or the medication is causing significant adverse effects in the patient or infant.
• In individuals on medication(s) whose symptoms are well-controlled, the medication(s) should not usually be changed to another one based on its placement in the rankings, unless the current agent is listed as “not recommended.” Switching medication may lead to clinical worsening.
• If a medicine is taken in pregnancy, it is generally preferable to continue it postpartum to reduce the risk for clinical worsening. Significantly less medication enters breastmilk than passes through the placenta, so there would be few benefits of stopping or switching medications immediately post-delivery. Changes do not usually need to be made for lactation unless the patient is doing poorly clinically, or the medication is causing significant adverse effects in the patient or infant.