Treatment of the psychotic pregnant patient

Childbirth and mental disorders

This review approaches the topic of childbirth and mental illness using a model of perinatal health which takes into consideration the multiple determinants of health, approached from a lifespan perspective. The paper seeks to answer four broad questions using this model and available literature: (1) What is the relationship between childbirth and mental disorders? (2) How common are mental disorders during childbearing, and what is the perinatal course of illness? (3) What are the effects of mental illness during childbearing on foetal and infant developmental outcomes? (4) How do you approach the detection and treatment of mental disorders during the perinatal period?

Protective effect of pregnancy in women with lithium-responsive bipolar disorder

BACKGROUND

Recent psychiatric literature, while indicating a high incidence of postpartum depression, contains a few clinical reports which support our observations that women with episodic bipolar disorder often remain well without treatment during pregnancy. Our retrospective study statistically examines the clinical course of 28 women with RDC typical bipolar disorder, type I, who became pregnant prior to receiving successful lithium prophylaxis.

METHODS

We derived all data from the International Group for the Study of Lithium-treated Patients (IGSLI) database of excellent lithium responders. Data were compared both intraindividually, using data from three 9-month periods - immediately prior to pregnancy, pregnancy and postpartum - and interindividually, using never-pregnant women as controls.

RESULTS

Intraindividual data show that women with typical bipolar disorder, type I, experience significantly fewer and shorter recurrences during pregnancy than either before or after. Interindividual comparisons indicate that the recurrence risk during pregnancy is markedly lower than the clinical course would predict. Moreover, the few recurrences observed during pregnancy all took place in the last 5 weeks.

LIMITATIONS

Limiting cases to lithium responsive patients could have reduced heterogeneity and perhaps generalizability.

CONCLUSIONS

The findings, nonetheless, indicate a marked improvement of the clinical course of typical bipolar disorder, type I, lithium-responsive, during pregnancy. Exploring the underlying protective mechanisms may lead to new understanding of the pathophysiology of mood disorders and to new approaches to treatment and prevention.

Comprehensive care of pregnant mentally ill women

Since the onset of deinstitutionalization, there has been an unanticipated and dramatic increase in pregnancies among women with chronic mental illness, with no specific planning for how to address the unique clinical needs of this high-risk population. Shortcomings in delivering care to mentally ill women within general health care systems are reviewed, including failure to assist with family planning, failure to observe worsening mental health during pregnancy, inadequate planning for child custody, lack of access to services, and omitted pelvic examinations. Necessary components of a system to provide comprehensive and coordinated care for pregnant mentally ill women are described. These include assessment of adaptation to pregnancy and competency to care for an infant, somatic and psychotherapeutic treatment, parenting skills training, family planning services, outreach, and close liaison with obstetric services. A Chicago-based collaborative program is described as an example of providing comprehensive, specialized care with limited financial resources.

Great expectations: challenges for women as mental health administrators

Although women have made many strides in the area of leadership, stereotypes still exist that limit their power. Traditional concepts of femininity have not typically been associated with strength and competence. This article describes an inpatient unit at San Francisco General Hospital, University of California, San Francisco, which is led by a group of women. The unit houses a women-focused treatment team specializing in treating women who have serious mental illness with histories of severe trauma, including poverty and violence. The article describes the challenges and rewards available to women leaders in this type of setting. Four areas of women's leadership are explored: the stereotypes women have about each other as leaders, the expectations and biases of staff and trainees, the projections of patients onto women leaders, and women's leadership in relation to department administration. Strategies for addressing biases in these areas and developing women's leadership conclude the article.

The effects of dual diagnosis on pregnancy and parenting

The desire to give birth and nurture can be significant for women with mental illness and substance-abuse disorders, despite the many internal and external barriers to the effective achievement of these desires. This article provides information on the effect of coexisting mental illness and alcohol or other drug dependency on pregnancy from a medical, obstetric, psychiatric, and psychologic perspective. The article also explores the effect on parenting and highlights the need to assess for parental competency in this population. Treatment planning, including the use of psychotropic medication and the need for collaboration between providers is discussed.

A Psychiatric Residency Curriculum About Gender and Women's Issues

Over the last 30 years, major advances have been made in our understanding of how bio-logical factors and sociocultural influences contribute to gender differences, gender identity formation, and gendered role behavior. Sensitivity to the psychological effects of changing family structure and workforce composition, the contribution of reproductive events, and the high rates of exposure to trauma in women is essential for optimal psychiatric assessment and treatment planning. This knowledge has not been systematically integrated into residency training. The authors present an outline for a curriculum in gender and women's issues, including educational objectives, learning experiences through which residents could meet these objectives, and recommended readings. The authors also discuss potential obstacles and suggest helpful strategies for implementing the proposed curriculum.

Denial of pregnancy: a review and case reports

This paper describes the characteristics of women who deny awareness of their pregnancies, the underlying causes and conflicts, and specific interventions required to address these issues. Case reports illustrate this complication of pregnancy. The absence of many physical symptoms of pregnancy, inexperience, general inattentiveness to bodily cues, intense psychological conflicts about the pregnancy, and external stresses can contribute to the denial in otherwise well-adjusted women. Assessment should include the possible contribution of painful reactivation of memories concerning childhood or adult trauma and the effect of dissociative states on the development of denial of pregnancy. Psychotherapy is recommended to resolve these conflicts, and to prevent future pregnancy denials and child abuse or neglect. Denial of pregnancy is easier to understand in women with psychosis or serious cognitive impairment than in those without such disorders. The underlying illness requires treatment by a psychiatrist. Psychological conflicts also exist in psychotic women, such as the intense wish to have a baby while fearing loss of the infant to child-protection services. Acknowledging the conflict and supporting the mother despite her puzzling behavior is an important task for health caregivers.

Medical disorders in the schizophrenic patient

OBJECTIVE

The primary purpose of this review of medical disorders in the schizophrenic patient is to provide the clinician interested in Consultation/Liaison psychiatry and psychosomatic issues a comprehensive and current review of the subject.

METHOD

The authors used the Index Medicus and Medline to find recent review articles and research articles related to medical disorders in the schizophrenic patient. Also, the authors described their clinical experience in Consultation/Liaison psychiatry working with schizophrenic patients in a large, tertiary-care academic medical center.

RESULTS

The authors divided their review into: 1) mortality and morbidity in schizophrenia, 2) differential diagnosis, 3) specific comorbidity management problems, 4) caring for schizophrenics on medical/surgical wards, and 5) antipsychotic drugs in the medical setting. Schizophrenia remains an important subject for Consultation/Liaison psychiatrists.

CONCLUSIONS

Schizophrenia and its protean manifestations confound the care of the medical patient. The psychosis of schizophrenia may impair the patient's capacity to recognize or articulate emerging medical illness, or to respond to therapeutic interventions. The psychiatrist caring for and consulting on patients with medical illnesses bears major responsibility for understanding the complex interface of schizophrenia and medical illnesses. Psychiatrists need to educate our medical and surgical colleagues how schizophrenia alters the usual presentation, clinical course, and response to treatment of common medical and surgical illnesses.

Psychotropic drugs in pregnancy and lactation

OBJECTIVE

This article reviews the literature on the use of psychotropic drugs in pregnancy and lactation.

METHOD

Medline search yielded more than five hundred titles. Articles were reviewed and ninety-one were selected for reference.

RESULTS

Fetal physiology and teratogenicity are discussed and the effects of specific drugs on the fetus and newborn are presented. When possible, recommendations for use or non-use are presented.

CONCLUSIONS

Though no controlled studies have ever been done in pregnant women to truly prove their safety, it appears that most, but not all, current psychotropic drugs appear fairly safe for use in pregnancy.

Research in pregnancy and mental illness: testing old wives' hypotheses

Methodological challenges encountered in evaluating the relationships between life stress, mental illness and pregnancy outcome are identified and several studies on the relationships between pregnancy and childbirth and psychosocial factors, including life stresses, major psychiatric disorders, and puerperal depression, are reviewed. Certain methodological pitfalls are illustrated by showing how relationships between psychiatric diagnosis, severity of psychiatric symptomatology, life stresses, strains specific to the pregnancy, amount of intervention received and outcome of keeping or losing the infant have been explored. Five stages of research are identified and particular difficulties encountered at each stage are described with application to the authors' longitudinal study.

Treatment and outcomes of psychotic patients during pregnancy and childbirth

This study examined whether particular groups of psychotic women are likely to present management problems during pregnancy and childbirth. The pregnancy courses and outcomes of 22 psychiatric inpatients were reviewed. Schizophrenic women with delusions or psychotic denial about the pregnancy were significantly less likely to detect labor than were nondelusional women. Ability to detect signs of labor and cooperate with labor instructions was significantly more likely in women with bipolar affective disorders than in those with schizophrenic disorders, and was also more likely in those women with severe personality disorders and substance abuse histories. The total patient cohort underwent significantly more cesarean sections than their nonpsychiatric counterparts who delivered at the same hospital. These findings suggest that psychotic women are at high risk for the development of pregnancy and birth complications.

Chronic mental illness and perinatal outcome

A retrospective review of pregnant women admitted to a state psychiatric facility and to an acute university psychiatric unit compares various characteristics of the two populations. No major significant differences were noted in demographic, psychiatric, or obstetric characteristics. It was hypothesized that the patients from the state facility would have a better perinatal outcome secondary to an opportunity for closer prenatal follow-up. No differences were noted in perinatal outcomes between the two facilities. Significantly poorer perinatal outcomes were noted in the combined group of psychiatric patients when compared were noted in the combined group of psychiatric patients when compared with the state of Oregon's birth-outcome statistics. The importance of prenatal care in this high-risk population is discussed, and specific recommendations are offered.

The pregnant psychiatric inpatient: a missed opportunity

The authors describe a group of pregnant psychiatric patients admitted to a psychiatric service in an urban hospital. A high rate of involuntary admission (44%), homelessness (36%), and substance abuse (64%) was noted. In this group of high-risk obstetric patients, we identified risk factors associated with noncompliance with ongoing prenatal care. Brief psychiatric hospitalization can be an important aspect in improving obstetric outcome by providing an opportunity to collect obstetric information and promote ongoing prenatal care.

An overview of somatic treatment of psychosis during pregnancy and postpartum

Treatment and management of the psychotic pregnant patient is insufficiently covered by most standard texts and the current literature. To date, there are no controlled studies on the efficacy of different therapeutic modalities during pregnancy. Medications that have proved effective in the treatment of the various psychoses are not without added risk for the pregnant patient. However, there is no effective medical treatment without attendant risk. Although the psychotic pregnant patient presents a therapeutic dilemma, these patients can be effectively treated by a program that allows for flexibility and innovation within the framework of sound conservative medical practice. Professional territorial difficulties can be avoided by a unified effort.

Effect of pregnancy on psychosis: life circumstances and psychiatric symptoms

As part of an ongoing prospective study to correlate mother and infant outcome with social isolation during pregnancy, the Schedule for Affective Disorders, SADS-C, was administered to twenty-seven psychotic patients late in pregnancy. Extensive standardized evaluation of life stresses and social supports included a Prenatal Interview with sixty items relating to demographics, drug use, health and obstetrical history, family involvement and development expectations of the infant, and a thirty-item Difficult Life Circumstances questionnaire. In this sample the patients' previous life adjustments were stabilized by their pregnancy unless the pregnancy itself created personal stress for the patient. Higher scores on Difficult Life Circumstances were found to be associated with more psychiatric symptomatology. Symptoms of pregnancy confounded SADS-C items measuring vegetative signs of depression. One group of items on the SADS-C appeared to selectively identify a subset of women whose underlying affective symptomatology was potentiated by pregnancy. A second group of items identified women whose symptoms appeared to be reactive to current situational strains.

Nursing management of the pregnant psychotic patient during labor and delivery

Pregnant psychotic women are high-risk patients who require both psychiatric and obstetric nursing expertise. Symptoms of psychosis are described, including disorganized thinking, impaired judgment, and distorted interpretations of reality. Various ways these symptoms can interfere with the labor and delivery process are discussed. Specific principles for assessment and intervention in the care of these patients are explained including the use of psychiatric consultation, medication, and psychotherapeutic interventions.