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