Mental health articles

the pregnant and postpartum woman with mental illness Despite the risks outlined above, women with mental illness most often thrive as
mothers. For many women, motherhood and bonding with a new baby can bring much meaning to their lives and identities. By being sensitive to the experiences of the pregnant woman with mental illness and warning signs, families and clinicians can intervene before illness exacerbations take full hold. Understanding the environment and assessing parenting capacity can guide interventions including referrals to community resources, positioning of added supports, and the introduction
of psychoeducational tools to enhance parenting capacity. Lastly, the
relationships between treatment team and expectant and new mother can serve as a corrective emotional experience and template for supportive healthy relationships in growing families.
There are significant challenges to the approach of treatment of the pregnant and postpartum woman with mental illness. Much fear and stigma surrounding psychiatric diagnosis continues to exist, oftentimes leading women to delay seeking care.
Social, familial, and logistical barriers to care exist and are reinforced as women shift into role of primary caretaker, including pressures in early motherhood to tend exclusively to the needs of the newborn and family. Any attempts for a woman to care for or take time for herself may be seen as “selfish” or ungrateful. This is compounded with the expectation, in both mother and family, that pregnancy and the postpartum period are periods in life to be relished and enjoyed without ambivalence. Logistics in seeking care are notoriously difficult to arrange; the fear of stigma and child protection involvement likewise inhibit women from
seeking care. The barriers to care are simple, multi-tiered, blatant, and nuanced—all at once.
One onerous challenge is the lack of consensus about treatment or consolidated treatment guidelines. This is generally attributable to the fact that data evaluating the safety and efficacy of treatments in pregnant/postpartum women are notoriously difficult to generalize and apply usefully. The data that exists is generally based on
results of case studies, registries, and other non-empirically gathered means. There is a lack of prospective, high quality, well-controlled trials since randomized design in studies evaluating pharmacologic treatment of depression during pregnancy is generally not considered ethical. Data continues to be largely dependent on animal studies, case studies, and retrospective reviews. Historically, research in reproductive
psychiatry has been predominantly observational and retrospective with small study populations, making results vulnerable to selection and recall bias, and the effects of other clinical confounders. Though imperfect, studies can provide useful information which requires the clinician’s critical evaluation of both methodology and conclusions.
In 1979, the FDA adopted the Pregnancy Category System in an attempt to provide physicians and patients with a readymade analysis of the data to serve as guidance in the planning of pregnancy, before fetal exposure had occurred. This system has proven difficult to apply clinically as it rests on the assumption that pregnant women generally do not need medication, without consideration of the risks of untreated illness, or the consideration of the reality that unintended pregnancies (and hence, exposures) do occur .Further, it does not account for changes in pharmacokinetics and metabolism during differing stages in
pregnancy or a sophisticated consideration of the applicability of animal data. The category system is sometimes interpreted as a grading system where the risk increases as one progresses through grades A through X, without consideration of the potential benefits of treatment. Fortunately, the FDA is currently considering a new system of reporting pregnancy and lactation data to provide clinicians and patients with a more clinically useful classification system.Until this time, clinicians and patients are left to interpret risk using an understanding of each patient’s history, the sparse literature on risk and treatment, and the current category system to address the treatment needs of patients.
An approach to consideration of treatment of mental illness in pregnancy
requires a collaborative analysis between clinician and client in weighing the risk of untreated illness with the risk of medication exposure. It is favorable for exposure be kept to a minimum and if possible, to one agent at its lowest effective dose. Selection of medications must be based on an understanding of the patient’s history of success with medication treatment, prior experience of the patient with exposure and illness in previous pregnancies, and available safety information. It is
advisable to maximize non-pharmacologic options to help minimize exposure when possible, with an understanding of the evolving nature of mood and psychotic illness in the pregnancy and the postpartum period. Due to the enormity and complexity of the topic, the use of specific medications during pregnancy and the perinatal period will not be broached here, and readers should utilize the resources
section at the end of this chapter for further information.
In approaching the evaluation and treatment of the perinatal patient, the
diagnostician’s task is to collect an exhaustive history and review of systems in order to separate the normal somatic symptoms of pregnancy from a major mood episode. The Edinburgh Postnatal Depression Rating Scale and the Beck Depression Inventory  can be useful tools for
clinicians as they have been validated for use in the obstetric population. Special attention should be paid to family history of mood disorders as well as previous history of harm to self or others, history of psychosis, and history of symptoms linked to prior reproductive events. Further, personal or family histories should be fully explored as they may point to bipolar spectrum illness and guide treatment choices.
When discussing possible interventions, discussions should be approached from an approximation of a risk–risk ratio, the risk of exposure of the fetus or newborn to maternal illness versus the risk of exposure to the treatment that is being proposed.Discussion of medication treatment of mental illness in
pregnancy and during lactation typically includes a consideration of data on risks of exposure at distinct phases in the peripartum period: teratogenic risk, neonatal risks, neurodevelopmental risk, and effects on lactation. A presentation of known data should underscore the paucity of randomized controlled trials and limitations of the available data while acknowledging that substantial data and clinical experience
support the safety and efficacy of many treatments. With that in mind,
non-medication interventions have shown promise in helping improve health and mitigate symptoms and should be considered as clinically appropriate.