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Legal News
Good Communication Crucial in Prescribing for Pregnant Women
Psychiatric News
Volume 42 Number 12 page 12-24
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Psychiatrists should help pregnant patients sort through scientific data and other information when helping them decide whether to take a psychotropic medication. 

©Brooke Fasani/Corbis

Prescribing medications to pregnant patients with psychiatric problems can be risky business, so to speak. Psychiatrists should avail themselves of the most up-to-date findings on the use of medications during pregnancy to help patients make informed treatment decisions, according to risk-management experts.

"Weighing the risks and benefits of prescribing medications during pregnancy is complicated" by research findings that sometimes contradict one another and mixed messages from popular media that can confuse patients and their families, said Jacqueline Melonas, R.N., M.S., J.D., vice president of risk management at Professional Risk Management Services Inc., the administrator of the APA-endorsed Psychiatrists' Liability Insurance Program.

Several studies have reported that some infants exposed to selective serotonin reuptake inhibitors (SSRIs) in utero may experience neonatal abstinence syndrome, for instance, which includes agitation, feeding, and sleep disturbances.

In addition, the Food and Drug Administration (FDA) issued a public-health advisory in December 2005 about the risk that paroxetine could increase cardiac malformations of the fetus during the first trimester. In July 2006, the FDA alerted the public about an increased risk of neonatal persistent pulmonary hypertension with SSRI use.

Some studies have shown that discontinuing antidepressants while pregnant can raise the risk of depression relapse, which can also pose a risk to unborn children (Psychiatric News, April 7, 2006), and has been associated with low-weight babies or premature births.

According to Melonas, between 7 percent and 13 percent of women who are pregnant may experience depression, and many physicians share concern not just about how to ensure health for expectant mothers and their unborn babies, but also about malpractice claims if there is an adverse outcome in relation to the pregnancy.

She noted that some psychiatrists feel uncomfortable treating pregnant patients even if they do have good information about the risks and benefits of various treatments. "In such cases, it is best to transfer the patient to another psychiatrist's care" during pregnancy, she said.

Psychiatrists who do decide to care for the patient, however, must stay abreast of the latest scientific information and policy issues related to treatment of pregnant women with psychotropic medications, Melonas noted.

If there is legal action, "psychiatrists are expected to be responsible for knowing about the scientific information available to them at the time" of treatment, she said.

Good sources of information include peer-reviewed journal articles, practice guidelines, professional literature, and information from professional organizations and government agencies, according to Melonas.

Communication is another essential part of managing treatment in pregnant patients—not just between the treating psychiatrist and the patient's obstetrician, but between all clinicians on the treatment team, and of course between the psychiatrist and patient.

To help patients make an informed decision about whether to take a psychotropic medication during pregnancy, the psychiatrist should discuss the risks and benefits of the proposed treatment, alternatives to the proposed treatment, the risks and benefits of those alternatives, and the risks and benefits of doing nothing.

While helping patients make a decision about treatment, Melonas pointed out that psychiatrists should consider a number of variables that may impact the decision. For instance, how do patients' significant others view the treatment dilemma, and how do they communicate this to the patient? How are patients affected by media attention on the topic? Are patients competent to make a decision about treatment?

What psychiatrists want to avoid, Melonas said, is leaving patients with a great deal of scientific information about the risks and benefits of taking medication during pregnancy without helping them sort through the information and their feelings about treatment options.

Finally, psychiatrists must document in patients' charts the clinical basis for the agreed-upon treatment as well as all baseline laboratory testing results, a comprehensive medical history, and the results of physical exams required before medications were prescribed. Communications with patients, family members, and other physicians should also be documented.

More information about various risk management strategies is posted online at<www.prms.com>.

Anchor for JumpAnchor for Jump

Psychiatrists should help pregnant patients sort through scientific data and other information when helping them decide whether to take a psychotropic medication. 

©Brooke Fasani/Corbis

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