Caring for Pregnant Women: A Psychiatrist’s Guide
Every psychiatrist will see a pregnant woman or other patient who is pregnant someday. When that person presents to your office, will you be ready? Many of us received little if any training on the subject, so the American Psychiatric Association’s Committee on Women’s Mental Health would like to help. Read on for five things every psychiatrist needs to know before a pregnant patient walks in your door.
Rachel Zhuk, M.D., is a reproductive psychiatrist and clinical instructor at the Icahn School of Medicine at Mount Sinai. She practices in New York City and is a member of APA’s Committee on Women’s Mental Health.
- Your patient is counting on you. Access to psychiatric care is often limited in many areas. In New York City where I practice, wait lists are often months long. Reproductive psychiatrists are not numerous, so your patient probably won’t see one quickly if they leave your care. Pregnant patients seen in reproductive psychiatry practices have often decompensated or worsened clinically during a lapse in care. They often require multiple medications to stabilize their condition when they were previously maintained on one. They describe feeling abandoned by their doctor. Your patient is lucky to have a thoughtful psychiatrist who is willing to continue to treat them during and after pregnancy. Just remember…
- There is no risk-free option. Many patients and physicians have concerns about psychiatric medications, but the risk of stopping or delaying pharmacologic treatment during pregnancy is often more severe. Untreated psychiatric illness in pregnancy also carries risk to both mother and fetus. Untreated illness is associated with risk of substance use, poor engagement with prenatal care, preterm birth and low birth weight babies, to name a few. It may sound complicated, but…
- You have time to research best practices. Your patient’s pregnancy has already been exposed to their current medication, so you have a few days to do your research. You prescribe the current regimen for good reason and it may be acceptably safe. A new medication carries its own risks and uncertainties, as well as the risk of under-treatment and decompensation. Remember, the best medication in pregnancy is often the one that works best for the individual patient. Of course, when feasible it’s always good to…
- Consider reproductive safety before a pregnancy begins. 50 percent of pregnancies in the U.S. are unplanned, and 80 percent of women will be pregnant at some point in their lives, so assume your patient could eventually become pregnant on the medicine you’re starting. A few examples: Depakote is associated with neural tube defects and autism, and should not be first line for anyone who could carry a pregnancy. All things being equal, an SSRI is a safer choice than a newer atypical antidepressant, and olanzapine has a longer safety record than brexpiprazole. Older medications often have had more reassuring safety data collected, due to the length of time they have been available. Lorazepam has been used for longer than the z-hypnotics, and recent studies have been reassuring. Benzodiazepines were believed to cause cleft palate, but additional data has either found the risk to be very low, or not confirmed the risk at all. And always know…
- You are not alone. Whether you prefer a website, a book, or an expert consultation, help is available.
Free online resources for quick in-office lookups:
- Womensmentalhealth.org - a broad, high-quality resource on perinatal mental health including topic summaries and roundups of recent research. Recommended for patients as well.
- Mothertobaby.org - factsheets for patients and providers on medication in pregnancy and lactation
- Lactmed - summaries of literature on medication in lactation
- Textbooks: Two excellent textbooks in perinatal psychiatry have recently been published. Consider an addition to your reference stash:
- Women's Mood Disorders: A Clinician’s Guide to Perinatal Psychiatry 1st ed. 2021 Edition. Ed. Cox, Elizabeth.
- Textbook of Women's Reproductive Mental Health 1st ed. Hutner, Lucy A., M.D., Ph.D Lisa A. Catapano, M.D., et. al.
- Ask a friend! Live expert consultation services are available to discuss your individual case.
- Perinatal Psychiatry Access Programs in the United States
- Also note two additional lines: New York (1-855-227-7272) and South Carolina (843-792-MOMS)
- Lifeline for Moms – 508-856-8455
- Many areas have local consultation programs too, see if you have one nearby: