Family planning and parenthood needs of women with severe mental illness: clinicians' perspective

The conversation about family planning and desire for children in mental healthcare: Patients' perspective versus Professionals' perspective in a mixed methods study

BACKGROUND

Reproductive health and mental health are intertwined, but studies investigating family planning needs and desire for children in mental healthcare are scarce.

METHODS

We studied the experiences of (former) patients, those with close relationships with the (former) patients (close ones) and mental health professionals (MHP) on discussing family planning and desire for children in mental healthcare. We combined quantitative (two nationwide surveys) and qualitative data (four focus groups) in a mixed-methods approach with sequential analytical design.

RESULTS

Combined data from focus groups (n = 19 participants) and two surveys (n = 139 MHPs and n = 294 (former) patients and close ones) showed that a considerable group of MHPs (64.0%), patients (40.9%) and close ones (50.0%) found that family planning should be discussed by a psychiatrist. However, several obstacles impeded a conversation, such as fear of judgment, lack of time and knowledge and limited opportunity for in-depth exploration of life themes in therapeutic relationships.

CONCLUSIONS

To increase the autonomy of patients in discussing family planning, we suggest MHPs explore the desire to discuss family planning with all patients in the reproductive phase of life, prior to discussing contraceptive care. MHPs should receive education about psychiatric vulnerability in relation to family planning and desire for children, and patients and close ones should be empowered to initiate a conversation themselves.

Sexually transmitted infections, sexual life and risk behaviours of people living with schizophrenia: systematic review and meta-analysis

BACKGROUND

Sexually transmitted infections (STIs), along with sexual health and behaviour, have received little attention in schizophrenia patients.

AIMS

To systematically review and meta-analytically characterise the prevalence of STIs and sexual risk behaviours among schizophrenia patients.

METHOD

Web of Science, PubMed, BIOSIS, KCI-Korean Journal Database, MEDLINE, Russian Science Citation Index, SciELO and Cochrane Central Register were systematically searched from inception to 6 July 2023. Studies reporting on the prevalence or odds ratio of any STI or any outcome related to sexual risk behaviours among schizophrenia samples were included. PRISMA/MOOSE-compliant (CRD42023443602) random-effects meta-analyses were used for the selected outcomes. Q-statistics, I2 index, sensitivity analyses and meta-regressions were used. Study quality and publication bias were assessed.

RESULTS

Forty-eight studies (N = 2 459 456) reporting on STI prevalence (including 15 allowing for calculation of an odds ratio) and 33 studies (N = 4255) reporting on sexual risk behaviours were included. Schizophrenia samples showed a high prevalence of STIs and higher risks of HIV (odds ratio = 2.11; 95% CI 1.23-3.63), hepatitis C virus (HCV, odds ratio = 4.54; 95% CI 2.15-961) and hepatitis B virus (HBV; odds ratio = 2.42; 95% CI 1.95-3.01) infections than healthy controls. HIV prevalence was higher in Africa compared with other continents and in in-patient (rather than out-patient) settings. Finally, 37.7% (95% CI 31.5-44.4%) of patients were sexually active; 35.0% (95% CI 6.6-59.3%) reported consistent condom use, and 55.3% (95% CI 25.0-82.4%) maintained unprotected sexual relationships.

CONCLUSIONS

Schizophrenia patients have high prevalence of STIs, with several-fold increased risks of HIV, HBV and HCV infection compared with the general population. Sexual health must be considered as an integral component of care.

Bipolar Disorder, Genetic Risk, and Reproductive Decision-Making: A Qualitative Study of Social Media Discussion Boards

In this study, we present views on bipolar disorder and reproductive decision-making through an analysis of posts on Reddit™, a major Internet discussion forum. Prior research has shown that the Internet is a useful source of data on sensitive topics. This study used qualitative textual analysis to analyze posts on Reddit™ bipolar discussion boards that dealt with genetics and related topics. All thread titles over 4 years were reviewed (N = 1,800). Genetic risk was often raised in the context of Redditors' discussions about whether or not to have children. Reproductive decision-making for Redditors with bipolar was complex and influenced by factors from their past, present, and imagined future. These factors coalesced under a summative theme: for adults with bipolar disorder, what was the manageability of parenting a child? Reproductive decisions for individuals with bipolar disorder are complex, and Reddit™ is a novel source of information on their perspectives.

An Examination of Turkish Nurses' Attitudes, Awareness and Practices Regarding Reproductive Health Needs of Individuals With Schizophrenia

Aim: This study was conducted to evaluate Turkish nurses' attitudes, awareness and practices regarding reproductive health needs of individuals with schizophrenia. Method: The sample of this descriptive study consisted of 96 psychiatric nurses and 90 nurses and midwives working in family health centers who agreed to participate. The data were presented as numbers and percentages, and chi-square analyses were used to compare the groups. Findings: Although the majority of nurses stated that family planning education should be given to individuals with schizophrenia, to both genders and to both single and married patients, the proportion of those who give family planning education is only 23.5%. Of the nurses, 58.8% recommend tubal ligation as a method of family planning for individuals with schizophrenia, 39.6% of nurses think that involuntary abortion or sterilization for individuals with schizophrenia is necessary even if they do not support it culturally, and 20.3% of nurses provide sexual health counseling to individuals with schizophrenia. It appears that nurses, as members of society, do not approve of marriage or parenting by individuals with schizophrenia. Result: This study found that both nurses working in primary care and psychiatric clinics had negative attitudes towards the reproductive health of individuals with schizophrenia.

Addressing the sexual and reproductive health needs of women who use mental health services

Pregnancies in women with serious mental illness are high risk and such women are also less likely to engage in the recommended health screening for women of reproductive age. Hence, reproductive health issues are important aspects of physical healthcare that should be assessed in women accessing mental health services. Pregnancy planning and management are crucial in reducing risk of relapse in women with affective disorders, and psychiatrists should acquaint themselves with the screening programmes and reproductive and sexual health services in their area and encourage their patients' uptake of these. Clinicians should be aware of the reproductive impact of medications and the needs of specific groups of women.

The attitudes of mental health professionals towards patients' desire for children

Background

When a patient with a serious mental illness expresses a desire for children, mental health professionals are faced with an ethical dilemma. To date, little research has been conducted into their strategies for dealing with these issues.

Methods

Seven focus groups with a total of 49 participants from all professional groups active in mental health (nurses, psychologists, social workers and psychiatrists) were conducted in a 330-bed psychiatric hospital. Group discussions were transcribed verbatim and analysed by the documentary method described by Bohnsack.

Results

Mental health professionals did not feel that their patients’ desire for children was as important in daily practice as were parenting issues. When discussing the desire for children on the part of patients, the following themes emerged: “the patient’s own decision”, “neutrality”, “the patient’s well-being”, “issues affecting the children of mentally ill parents” and “appropriate parenthood”. In order to cope with what they perceived as conflicting norms, mental health professionals developed the following (discursive) strategies: "subordination of child welfare", "de-professionalisation", "giving rational advice" and "resignation".

Conclusions

The theme of “reproductive autonomy” dominated mental health professionals’ discourse on the desire for children among psychiatric patients. “Reproductive autonomy” stood in conflict with another important theme (patient’s children). Treating reproductive issues as taboo is the result of the gap between MHPs’ perceptions of (conflicting) norms when dealing with a patient’s desire for children and the limited opportunities to cope with them appropriately.

In order to support both patients with a desire for children and mental health professionals who are charged with providing counselling for such patients, there is a need to encourage ethical reflection and to focus on clinical recommendations in this important area.

Pregnancy in the severely mentally ill patient as an opportunity for global coordination of care

Although obstetricians commonly care for pregnant patients with psychiatric disorders, little has been written about the implications of managing a pregnancy during a prolonged psychiatric hospitalization for severe mental illness. Multidisciplinary care may optimize obstetric and psychiatric outcomes. We describe a severely mentally ill patient at 27 weeks' gestation (G1P0) who was admitted after a suicide attempt. She exhibited intermittently worsening depression and anxiety throughout a 2-month inpatient psychiatric hospitalization, during which her psychiatric and obstetric providers collaborated regarding her care. We review recommendations for antepartum and intrapartum treatment of the acutely suicidal and severely mentally ill patient and, in particular, the evidence that a multidisciplinary coordinated approach to planning can maximize patient physical and mental health and facilitate preparedness for delivery.

What can we learn? Adult outcomes in children of seriously mentally ill mothers

PROBLEM

Information is lacking about the experiences, needs of, and interventions for children of seriously mentally ill mothers.

METHODS

Quantitative and qualitative methods of inquiry were used to retrospectively explore the characteristics and needs of adult children of seriously mentally ill mothers. The sample (N = 40) was recruited by referral and media advertisements. Childhood variables related to attachment, family environment, and parenting were compared to adult well-being outcomes of depression, quality of life, sense of coherence, and self-esteem. Participants also responded to the question "What other question should have been included in this study about your experience as the child of a seriously mentally ill mother?" and, additionally, spontaneously added their own clarifications of their answers to the survey questions.

FINDINGS

It was apparent that the childhoods of participants were disruptive and often painful. Over half of the sample reported having their own diagnosis of depression in adulthood. Despite these factors, most members of the study sample were functioning well in adulthood, most often as a result of their own initiative.

CONCLUSIONS

A high rate of depression in adulthood and participants' own descriptions of their painful memories and experiences of childhood identifies that more can and should be done to assist children of mentally ill mothers to cope with their environments. Interventions at various times in childhood are described.

Mothers with a serious mental illness: a critical review of the literature

The desire to mother in women with a serious mental illness (SMI) is increasingly recognized by health care professionals. Defining women with an SMI strictly in terms of cause, course, and treatment overshadows the diversity of their role as a mother. A review of the literature reveals that limited published research exists on the subjective experiences of mothers with an SMI. Often, the reviewed studies reinforce mothers as pathological. Viewed as lacking mothering abilities, they are not recognized as mothers. This article critically examines how the literature about mothers with an SMI has contributed to their marginalized position. To this end, a literature review was undertaken and examined from Oliver's theoretical notion of subjectivity from the marginalized or "othered" position. Subjectivity based on witnessing a mother's self-identity creates possibilities that are not exclusionary because of her difference secondary to illness.

Attitudes towards patient gender among psychiatric hospital staff: results of a case study with focus groups

There is an increasing awareness of gender-related issues in psychiatry. However, empirical findings on attitudes of psychiatric staff towards patient gender are limited. Gender-related issues are particularly relevant in the debate about mixed versus segregated sex wards, yet while the appropriateness of mixed-sex wards is questioned in Great Britain this is not the case in Germany. To investigate attitudes of psychiatric staff towards both patient gender and mixed versus segregated sex wards, we conducted a case study using focus groups with members of professional teams. We evaluated the transition process from two single-sex wards to two mixed-sex wards in a 330-bed psychiatric hospital in a rural area in south Germany. Staff described female patients as more externally oriented, motivating of others, demanding, and even sexually aggressive. Male patients, on the other hand, were described as more quiet, modest, or lazy. Furthermore, participants described the mixing process as a positive development whereas they did not see a need for gender-separated wards in order to protect vulnerable female patients. Some gender descriptions by professionals are "reversed" in comparison with gender stereotypes supposed to be present in wider society. The perception of crossed gender norms may affect staff attitudes towards the vulnerability of female patients in psychiatric settings and the provision of single-sex wards in in-patient psychiatric care. Practical implications are discussed against the background of a high rate of female patients with sexual abuse histories.

Health problems of women with severe mental illness

PURPOSE

To provide a review of the health problems of women with severe mental illness (SMI) that are related to their psychiatric disorders and disabilities, prolonged use of psychotropic medications, and high-risk lifestyle practices.

DATA SOURCES

Review of current literature uncovered through MEDLINE, Cumulated Index to Nursing and Allied Health, and Psychological Abstracts as well as the authors' clinical experiences.

CONCLUSIONS

Women with SMI are at increased risk for obesity as well as cardiovascular, endocrine, and infectious disorders. They also experience psychotropic medication-related disorders such as amenorrhea, galactorrhea, sexual dysfunction, breast cancer, and osteoporosis. High-risk lifestyle practices, excessive weight gain, low physical activity, substance abuse and unprotected sexual activity increase risk for health problems. The mental illness, residual disabilities, sequelae of childhood abuse, poverty, limited social support and health knowledge deficits affect their ability to maintain optimum health.

IMPLICATIONS FOR PRACTICE

Knowledge about women with SMI and their health problems will enable nurse practitioners to better meet the needs of this vulnerable population.

Ethical challenges of decision making with pregnant patients who have schizophrenia

OBJECTIVE

Because there is a dearth of literature, we developed an ethical framework to guide decision making about the management of pregnancy of patients with schizophrenia.

STUDY DESIGN

We review pertinent literature on schizophrenia and pregnancy, including information on maternal and fetal risks and outcomes, and relate this information to ethical concepts.

RESULTS

The ethical framework has five components: the concept of chronically and variably impaired autonomy, assisted decision making, surrogate decision making, strategies for dealing with the physician's feelings in response to these patients, and the concept of the fetus as a patient. We apply this ethical framework to clinical challenges of decision making during pregnancy with this patient population.

CONCLUSIONS

The preventive ethics strategies of assisted and surrogate decision making can be used to prevent ethical conflicts in decision making about the management of pregnancy of patients with schizophrenia. These preventive ethics strategies should contribute significantly to reducing the vulnerability of these patients and therefore to enhancing their autonomy in the physician-patient relationship.