Old Challenges Meet New Ones When Treating Women With Psychiatric Illness Before or During Pregnancy

Everyone who treats a woman of reproductive age, pregnant or not, for psychiatric illness should be on the same page, according to Marlene Freeman, MD, an associate professor of psychiatry at Harvard Medical School, who spoke at a recent meeting of mental health professionals. That means that psychiatrists, obstetrician-gynecologists, nurses, and pharmacists should ideally understand the risks and benefits of antidepressant and antipsychotic medication for women who, even if they are not planning pregnancy, may face it in their future, she said.

Why? Freeman stressed that given the high rate of unplanned pregnancies in the United States—49%—and the early onset of mental illness in teens and young women, clinicians should keep these facts front of mind when planning treatment.

Besides half of overall pregnancies being unplanned, 80% of teen pregnancies are unintended; by the age of 40, most women in the United States—82%—will have had a child. Combine that with the knowledge that mental illness strikes early, with 50% of all diagnoses presenting by age 14 and 75% of showing up by age 24, clinicians should keep reproductive potential in mind, Freeman said.

When women hear different bits of medical advice from all quarters, whether solicited or not, it causes anxiety, and that is particularly acute for women with mental illness, she noted.

“It is absolutely terrifying to get one thing from a psychiatrist and then hear something from a nurse in the OB office and then another thing from a pharmacist,” Freeman said. She later pointed out that every package insert for antidepressants recommend that women stop taking them in the third trimester, which is not advised and was included without any study whatsoever, she said.

“We want women to approach delivery rock steady,” she said, noting that women with a history of any mental illness are already at a higher risk of postnatal depression. “Can you imagine a worse time to go off an antidepressant for people at risk of postnatal depression?”

Freeman said when assessing women, this year she has added a new question, asking them if they vape. In addition, she recommends that clinicians ask very specifically about marijuana use, pointing out that “patients will agonize over taking a relatively safe medication” but think nothing about using marijuana.

The younger the woman, the more likely they are to use marijuana during pregnancy, with Freeman saying about a third of women in their 20s use it. Some are stopping their psychotropic medications for it and some are using it for morning sickness.

If women need to be on psychiatric medications while trying to get pregnant or during pregnancy, it helps doctors to know which drugs have worked well in the past, instead of attempting something new during the pregnancy, Freeman said.

“If we really want to help women, we can help them lead the lives they want to be leading,” Freeman said. “For many, that means maintenance treatment.”

If a patient is not actively trying or interested in becoming pregnant, “ask about contraception” she said, because when it comes right down to it, not using birth control “is trying to become pregnant. Intent doesn’t matter much,” she said to rippled laughter.