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Patient is (PIC)turing Pregnancy - Mental Health

Background

  • Scope: Women in reproductive age are more likely to have mental health issues such as depression and anxiety (26 percent) and other mental health issues (35 percent). Other conditions may include: Anxiety disorders, attention deficit hyperactivity disorder (ADHD), bipolar disorder. Borderline personality disorder, eating disorder and schizophrenia.

  • Preconception Significance: Psychiatric disorder in pregnancy can lead to poor obstetric outcomes, postpartum psychiatric disease, increased substance abuse, low prenatal care, and adverse infant outcomes that may cause more trauma to mother and infant.

Reproductive life plans are essential for women with comorbidities between drug addiction and mental illnesses. These plans should focus on contraception while conditions stabilize.

Medication regimens for mental illness can pose threats to maternal and fetal well-being.   Medications must discussed with the physician and patient before stopping contraception and beginning conception.

Decisions about treatments during pregnancy should be made as risk to the mother and baby from the disorder outweighs risk of treatment.

  • Risk Identification:

Screening:

  • Family history of mental illness

  • Personal history of mood disorders, depression

  • History of postpartum depression, psychosis

  • History of military service (for military sexual trauma or exposure to combat, both associated with mental health illness)

Clinician Guide

  • Mental health screenings should be a part of routine primary care, screening for:

    • Alcohol/substance abuse

    • Psychosocial stress (abuse/intimate partner violence, financial issues, lack of social support)

    • History of personal or familial mental illness

    • Other current illnesses

    • Current medications

    • History of mental illness during previous pregnancies

    • Illness instability

    • Served in the military, ask:

      • Did you experience unwanted sexual attention (touching, pressure, harassment)?

      • Were you ever forced or threatened with force to have sexual contact against your will?

      • If the patient asks “yes” to these questions requires a psychiatric evaluation.

  • Educate woman on the impact of pregnancy on mental health and subsequent birth outcomes.

  • Discuss the importance of the reproductive life plan and pregnancy with women with mental illnesses. However, encourage women that they can still have healthy pregnancies and babies but they must manage disease carefully with safe medications.

  • Woman should NOT discontinue medications without medical guidance first.

Depression

Prevalence: 26 percent of women have depression or anxiety. More than 60 percent of women experience depression during pregnancy

  • Providers must routinely screen for depression and anxiety for all women of childbearing age.

  • Note for depression in previous pregnancy as an indication for postpartum depression as depression could lead to preterm birth, low birth weight and other adverse effects.

  • Note for anxiety disorders during pregnancy can also lead to poor birth outcomes, complications during pregnancy, child behavioral issues socially and with mother.

Medication:

  • 68 percent of women who stop using antidepressants will relapse into depression.

  • Coordination between maternity provider, mental health provider, and primary care provider in woman with mental health and preconception care plans is essential.

  • A single medication with higher does is preferred to multiple medications

  • When selecting medicine to minimize the risk of illness:


    • Efficacy

    • Woman’ personal response

    • Available and reliable pregnancy safety information

  • If patient decides to continue antidepressants after discussing with provider, always choose the most effective in treating patient in the past.

  • SSRIs are the usual treatments for depression in most patients, pregnant or not. However, note, paroxetine in first trimester is associated with increased cardiac malformations.

  • Consider suggesting therapies such as psychotherapy, cognitive behavioral therapy, interpersonal therapy to women who want to avoid antidepressant medication.

  • Woman should NOT discontinue medications without medical guidance first.

Family Planning and Contraception:

  • If there is a deviation in the plan of treatment, help the woman to understand these changes and encourage her to find a method of contraception until depression can be controlled with new treatment.

Bipolar Disorder

Prevalence: About 2.6 percent of the U.S. population, older than 18 years old (median age: 25).

  • Bipolar is a mood disorder with episodes of mania, hypomania and depression.

  • Onset usually begins during reproductive years.

  • Screen for familial patterns as 10 percent of first degree relatives are usually affected:

    • Ask of familial history of mood disorders and personal history of depression or mania.

    • If screens positive, refer for a psychiatric assessment.

  • During pregnancy and postpartum, a woman is at high risk for relapsing into bipolar disorder (10-20 percent prevalence of postpartum psychosis). NOTE: this puts women at high risk for suicide and infanticide.

Medication:

  • There can be a high relapse risk if medications are discontinued.

  • Choose drug therapies during preconception/prenatal period by:

    • Response to previous medications

    • Severity of illness

    • Euthymia during medication use

    • Relapse time after discontinuation of medication

    • Recovery time after reintroduction of medication

    • Fetal safety of drug

  • First trimester exposure to lithium increases risk of cardiac malformation by 10-20 times more than the general population (Absolute risk 0.05-0.1%). Must weigh risks and benefits before conceiving.

  • Anticonvulsants for bipolar disorder increases risk of neural tube disorder (1-7%). For those on these medications, high dosage of folic acid is recommended starting one month before attempt at conception and throughout the first trimester.

  • Also, discuss medication choices with the woman’s psychiatric provider.

Family Planning and Contraception:

  • Encourage woman to think about the risks of untreated disease versus treatment and pregnancy. Until a decision is made, stress continued contraception.

  • Contraception is recommended until woman’s mental illness is well controlled.

  • Encourage woman to contact your office if reproductive life plans on pregnancy changes.

Schizophrenia

Prevalence: With 1 percent of the U.S. population, the average onset for women is 25 years old.

  • Screen for family history of psychotic disorders and personal history of psychosis.

  • Women with schizophrenia have a higher prevalence of cigarette smoking, alcohol use, illicit drug use, low socioeconomic status and all are associated with poor birth outcomes.

  • Some of the antipsychotic medications for treatment have an increased risk for causing Type 2 diabetes mellitus and thus women on this drug should be monitored accordingly.

Medication:

  • There is a high risk for relapse if medications are discontinued.

  • Teratogenicity from antipsychotics use on schizophrenia have not been confirmed.

  • Deviations from medication regimens should be coordinated with woman’s mental health provider.

  • If benefits of medication treatment during preconception/prenatal period are better than risk of relapse, then continue treatment.

Family Planning and Contraception:

  • Encourage woman to think about the risks of untreated disease versus treatment and pregnancy. Until a decision is made, stress continued contraception.
       

  • Encourage contraception while woman is treated for substance abuse/chronic illnesses.

  • During preconception, connect woman to resources for psychiatric stability, prenatal care, and parenting support.

 

Page Updated: 5/21/2018