Saturday, February 24, 2007

Home Work


This is for our obstetrician blogger friend who wanted some help with her homework: preparing a lecture for OB/GYN residents on psychiatric issues in pregnant women.
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I'm going to ramble (I'm good at that), no references, no specifics.
What do we do about psychiatric disorders in pregnant women? This is a tough question, mainly because we know so very little, it's not unlike the issues that get put forth regarding the efficacy and safety of treatments in children: both are populations that don't get experimented on. To figure out the teratogenic effects of medications (one option in treatment) on the unborn fetus, studies are done on pregnant laboratory animals, which often tell us little about the effects on unborn people. We simply can't design studies that purposefully expose pregnant women to medications and ask Hey What Happens to those kids. What we know is incidental: someone taking the medication gets pregnant, it's reported, outcomes are followed up on. Little is known about exposure at varioius times during fetal development, and outcome is generally limited to structural birth defects and behavior in the immediate post-natal period. So there's nothing that says that a 6 week old fetus exposed to psychotropic drug X is more likely to have reading delays at age 7 or coordination problems or is less likely to fill-in-the-blank. And just to make the story more complicated, we also don't know what effects untreated maternal mental illness have on the fetus, so even if there is some risk from medications, it's looking like very sick mothers aren't good for babies, and maybe the risk of treatment with medication may be better than the risk of not medicating, but this remains speculation as these issues are only just beginning to get the attention they deserve.
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Any way you dice it, I think an obstetrician needs to refer a mentally ill pregnant patient.
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From my shrinky perspective, I believe the fetus should be exposed to a minimum number of Unnecessary medications, I think they are all Potential toxins. I tell pregnant patients that the threshold for medication is raised: I ask them to tolerate some distress for the sake of the baby, we do this anyway. We ask pregnant women to give up all the essentials: cigarettes, alcohol, otc medications, Diet Coke, street drugs, Diet Coke, coffee, hair chemicals. Perhaps we ask pregnant patients to tolerate symptoms of mild depression or anxiety or sleeplessness that we might otherwise offer medication for. The threshold for psychotherapy should also be lowered: talking is unlikely to harm the fetus, frequent sessions provide an outlet for the patient and a means to increase coping mechanisms, and systems are set in place for the therapist to do on-going evaluation and monitoring. Other support systems need to be shored up: family members often must be called upon and all available resources may be needed. A therapist may need to work with the patient on the importance of taking care of herself and accepting help from others: often a difficult thing for moms to do.
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Sometimes, issues related to coping and expected discomfort can be confused with symptoms of mental illness. A woman is sad, tired, nauseated (for Fat Doctor), not eating well, crying. Does she tell her obstetrician that she and her husband are fighting non-stop, that her co-workers are angry about her pregnancy, that the other 5 kids are overwhelming, or does she simply say "I'm depressed," a self-made diagnosis that may or may not be right and may or may not need medications?
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Sometimes, there is no escaping medication: a pregnant woman is so symptomatic that medication must be given. We don't leave patients psychotic (hallucinating or delusional) or manic, or terribly depressed; in these instances we offer medication and do our best to work with what we hope will be safe and we avoid those meds we know are not. I'll leave the lists to you, but the patient gets the best care when the psychiatrist and the obstetrician work together.
So why do I think you should refer? I'll give it to you as bullet points:
  • OBs don't spend the time with patients needed to make an accurate psychiatric diagnosis and this is essential.
  • OBs don't generally have a good enough handle on diagnosis and treatment of psychiatric disorders to be doing it. (And I don't catch babies).
  • If the baby has a bad outcome for any reason, a defense attorney will have no problem targeting an OB who treated a psychiatric illness in an expecting mother.
  • If the mother does something horrible because of untreated or wrongly-treated mental illness, this can be catastrophic.
  • OB's typically stop seeing the patient 6 weeks after delivery and the patient will need on-going psychiatric care.
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When do you refer?
  • If the patient appears to be having psychiatric symptoms that are endangering herself or the baby: a sad mom who isn't gaining the necessary weight due to poor appetite, one example.
  • If the patient mentions suicide or harming the baby or any pre-existing children.
  • If the patient says she thinks she has a psychiatric disorder or names an illness.
  • If you even wonder if you should refer. Phrase it as an evaluation: I'd like you to see a psychiatrist one time just to get a handle on whether there is even a problem.
To our OB friend, I hope this helps.