Dr. Ascher is a fourth-year resident at Beth Israel Medical Center and a Ginsberg Fellow in the Group for the Advancement of Psychiatry Family Committee. Dr. Snyder completed her residency in June 2012 and is now an attending psychiatrist; she is the Clinical Coordinator of the Women's Mental Health Program at Beth Israel, and is also in private practice. Dr. Leibu is a third-year resident at Beth Israel.
Case: Ms. A is a 25-year-old woman with a longstanding history of schizoaffective disorder who has been stable on a combination of valproic acid and haloperidol over the last three years. Prior to starting this regimen, she had several severe manic and psychotic episodes requiring multiple hospitalizations. Ms. A arrives at her monthly medication management visit and excitedly reports that five weeks ago she stopped all forms of contraception, including her oral birth control, and is hoping to conceive with her boyfriend of six months. She has a regular menstrual cycle, but is ‘thrilled’ that she is now a week late for her menses. Ms. A endorses full adherence with her psychiatric medications to this point. However, based on feedback she received from her boyfriend and mother, and from what she has read on the Internet, she feels that it is probably best to discontinue all psychotropic medications from this point forward to protect her fetus during her pregnancy.
Trainees often feel inadequately prepared to counsel a patient such as Ms. A, and may feel awash with a myriad of emotions, including fear, anger, anxiety, sadness and guilt. Residents should be mindful of the high potential for unplanned pregnancy in women of reproductive age and focus on preventative care in general psychiatry.
Clinicians should routinely ask questions such as, “Are you sexually active?”; “Are you currently using birth control,” and if so, “Which type of contraception do you use?”; “Are you considering becoming pregnant?” and if so, “How do the people closest to you feel about you having a child at this time?” All of the medications and supplements a patient is taking should be reviewed and documented by the clinician. The clinician should also be mindful to medical conditions that may affect or preclude the ability for the patient to become pregnant. It is also important to inform patients that their medication dose may need to be adjusted during the pregnancy and that the clinician will attempt to use the lowest efficacious dose possible to minimize exposure to the fetus while minimizing the risk of relapse in the mother. Psychoeducation on the dangers of illicit use of substances, alcohol, and nicotine also warrants discussion with all patients. Clinicians should have referral options for drug and rehabilitation services and discuss those with the patient if necessary.
The importance of a non-judgmental, empathic and collaborative approach with our patients should be underscored. Ideally, the patient should see their clinician as their advocate and as a source for honest support and understanding. If a patient does become pregnant, care should be coordinated and discussed with her internist and obstetrician. We have found that a team approach helps to facilitate the most efficacious care and address all aspects of pregnancy and options for the mother.
Preventive ethics posits that as clinicians, we are charged with the goal of trying to anticipate possible ethical dilemmas in advance rather than responding after the fact. Discussions with women of reproductive age should begin prior to the initiation of pharmacotherapy and should be revisited periodically throughout the course of treatment . Having a discussion early on in the treatment can help to minimize anxiety for both physician and patient . Clinicians should explain the reasons behind specific recommendations. Residents should carefully and thoroughly discuss the potential risks to the mother and fetus if the maternal psychiatric illness is not treated, as well as the potential risks of exposure to the fetus with specific medications. By empowering a woman with this information in advance of a planned or unplanned pregnancy, she can decide with her physician in a thoughtful way how she wants to proceed rather than doing so alone based on information gathered from mostly uninformed, often biased sources, such as the internet, friends, family or significant others.
Encouraging patients to openly discuss their thoughts, feelings and emotions in regards to their reproductive options is essential. Encouraging patients to bring in their partners and loved ones for a family session can be very beneficial when there is conflict within the family stemming from a patient’s reproductive choices and/or mental illness. While advising patients about the importance of using contraception until they are ready for parenthood, clinicians should work with their patients to develop contingency and safety plans in the event of an unexpected pregnancy. This is particularly pertinent because it has been reported that nearly 50% of pregnancies are unplanned .
In the case of a woman with a history of severe and persistent mental illness, it may be appropriate and is often beneficial for all parties to set up a safety plan while she is stable. This allows her to clearly elucidate her wishes for treatment in the future if she were to lose decision-making capacity during a period of decompensation. She can also expresses her wishes regarding her treatment vis-à-vis possible effects on her pre-viable fetus, in the case of pregnancy. This psychiatric advance directive is called a “Ulysses Contract,” which is recognized by some, but not all states .
When the patient is in the midst of a depressive, manic or psychotic episode, autonomy may be affected by impaired decision-making capacity. It is our job as psychiatrists to evaluate whether the patient is able to comprehend and balance the risks and benefits of utilizing a particular treatment plan. As per the ethical principle of beneficence, we should seek to provide the greatest amount of good over harm to both the pregnant woman and her fetus based on a well-informed clinical perspective. In order for a patient to retain autonomous decision-making capacity, she must demonstrate the ability to absorb, retain, and recall relevant information about a specific issue that the clinician provides. The patient should be able to readily and consistently express her opinion, even if it is at odds with a clinician’s recommendation, while also imparting an understanding of the information provided by the clinician. As physicians, we should strive to provide information in an easy-to-comprehend way so that patients can understand the potential consequences of their decisions. Ultimately, our goal is to embrace an ethically sound approach to counseling and to avoid an authoritative or paternalistic approach .
Supervisors are in the position to encourage residents to think critically about serious mental illness and family planning. A collaborative approach with supervisors will help trainees to develop a shared and mutual understanding of the complexities of a particular case. Supervisors should remind residents to regularly inquire about the potential for pregnancy and the importance of checking human chorionic gonadotropin (hCG) levels if clinically warranted. Supervisors can also educate and encourage trainees to become more aware of the patient’s family and support system. Brainstorming ways on how to initiate and have a realistic and empathic conversation with patients about issues surrounding pregnancy and childcare is indispensable. Supervisors should remind residents to prescribe folic acid for all women of reproductive age to minimize the risk of spina bifida and other congenital anomalies [3,4].
In difficult and high risk cases, residents should feel comfortable and are well advised in seeking supervision and consultation with a perinatal psychiatrist to help broaden the resident physician's understanding of the clinical scenario, to optimize patient care, and to allay any patient fears. As always, meticulous documentation for risk management and medicolegal protection is essential.
The case continues: In collaboration with her physician and adhering to all the principles outlined above, Ms. A agreed to discontinue valproic acid and cross titrate haloperidol to olanzapine. The patient and her family were informed of specific signs and symptoms indicative of a possible relapse of mood disorder, and a safety plan was established. She remains stable at 31 weeks, and has had a healthy pregnancy to date.
For up-to-date information on medications and pregnancy, we have compiled a list of useful and relevant online resources that can be helpful to residents. We also recommend reading one of the seminal papers on ethics and reproductive mental health treatment entitled “Ethical principles in perinatal mental health” by Laura Miller .
· Drugs and Lactation Database (Lactmed)
· The Motherisk Program
· National Women’s Health Information Center
· Massachusetts General Hospital Center for Women’s Mental Health, a perinatal and reproductive psychiatry information center
· Organization of Teratology Information Specialists
1. Pace LE, Schwartz EB. Balancing act: safe and evidence based prescribing for women of reproductive age. Women’s Health 2012;8(4):415-425
2. Coverdale JH, McCullough LB, Chervenak FA, Bayer T, Weeks S. Clinical implications of respect for autonomy in the psychiatric treatment of pregnant patients with depression. Psychiatr Serv 1997;48:209-12.
3. Policy statement: Folic Acid for the Prevention of Neural Tube Defects. Pediatrics 2012; e467-468. E-published ahead of print July 30, 2012. http://pediatrics.aappublications.org/content/130/2/e467.full
4. Wilson RD. et al. Preconception vitamin/folic acid supplementation 2007: the use of folic acid in combination with a multivitamin supplement for the prevention of neural tube defects and other congenital anomalies. Obstet Gynaecol Can 2007;29(12): 1003-26.
5. Wade GH et al. A preconception care program for women in a college setting. MCN Am J Matern Child Nurs. 2012;37(3):164-70.
6. Miller LJ. Ethical issues in perinatal mental health. Psychiatr Clin North Am. 2009;32:259-70
AAP Bulletin – September 2012, Page 6 of 7