How clinicians can support women in making decisions about psychopharmacological treatments in pregnancy
Authors: Megan Galbally, Nicole Woods, Martien Snellen
Journal: World Psychiatry (2022)

Ensuring that women can make fully informed decisions about all aspects of their care in pregnancy is not only required by law in many jurisdictions, but is integral to the provision of respectful and contemporary person-centred health care. Many health systems acknowledge now the importance of mental health in pregnancy through the common practice of universal screening for depression, as well as the increased awareness and health promotion campaigns around maternal mental health. However, when it comes to delivering a clear message that supports women to prioritize their mental health, ambivalence emerges, particularly if staying well involves psychopharmacological treatments. A common misperception is that not treating a mental health disorder with medication is a risk free option. Also, undertreating with medication is common and perceived as a lower risk option, although it may result in exposure both to the agent and to the illness. For women with moderate to severe mental disorders, such as major depression, schizophrenia and bipolar disorder, it is not a risk free pathway to undertreat or not treat, as both these options may have significant implications and impacts for maternal health, for pregnancy outcomes, as well as for the longer-term outcomes in the child. The overarching principles of informed consent for psychopharmacological treatment in pregnancy involve understanding and communicating risks associated with treatment. These include the nature, magnitude and probability of risks associated with a treatment and any alternative options, including no treatment1. Adapting information, checking on shared understandings, and providing information in a number of formats and, where appropriate, involving partners, family or carers, can be important tools. Moreover, many women are motivated by wanting the best outcomes for their unborn child. Going through the risks of a specific treatment on the one hand, but, on the other, the risk of significant relapse in the early postpartum, potentially impacting the woman's ability to care for her newborn, is recommended practice. It is important to deliver a clear message that caring for one's own mental health is also the start to parenting and caring for the unborn child. An essential principle, when supporting informed decision making for mental health treatments in pregnancy, is indeed to not only focus on the risks/benefits for a woman's health, but also understand the implications for her fetus/infant and for the evolving relationship between the two. These three elements of focus – maternal mental health, fetal/infant well-being, and the quality of the mother-infant relationship – should be core to all perinatal mental health care2. To do this requires a clinician to support decision making that encompasses information across all these three aspects of risk/benefit from treatment options. First of all, clinicians should be skilled in understanding and interpreting the latest research findings and also be able to place them in the complex interplay of multiple factors that occur in pregnancy3. Unfortunately, our research base for psychopharmacological treatments in pregnancy requires navigating a web of conflicting and often confusing findings, including associations without adjustment for relevant confounders or with other obvious methodological flaws. Clinical guidelines can provide some direction, but evidence-based practice also requires consideration of broader expertise, individual patient characteristics and, importantly, patient preference. Secondly, clinicians must distil research findings for key outcomes into information that can be adapted during a clinical discussion. It is not comparing outcomes to the general population, but comparing outcomes for those treated compared to untreated. Equally important is communicating if a risk is unlikely to be clinically significant4. The overall aim is to provide clear and respectful communication that fosters a women's sense of empowerment, choice and control. Getting this right not only improves informed decision making, but also leads to a positive therapeutic relationship. What each woman wants may vary from copies of scientific papers to a brief summary of risks and benefits. Ensuring that clinicians adapt information appropriately is part of woman-centred care. Thirdly, the discussion of viable alternative treatments is critical to ensuring that informed decisions can be authentically made. However, viable means available, acceptable and appropriate to the clinical presentation. Evidence base for psychosocial interventions usually relies on training and fidelity to a specific intervention, not a grab bag of techniques5. Ensuring that an evidence-based alternative is offered is essential. However, informed decision making is not served by a discussion of options that are not truly viable or clinically appropriate. Finally, the clinician needs to be clear about his/her own recommendation while respecting the women's right to choose the best option for her, whether this aligns or not with the clinician's own choice. Putting all this into practice is challenging. For women with long-standing mental disorders, such as schizophrenia or bipolar disorder, the ideal time to discuss options is pre-conception. For women in the childbearing years, caution should be exercised with some agents, such as valproate. In many jurisdictions, there are now limitations on prescription of valproate to women, due to the risks to fetal well-being and the high rate of unplanned pregnancies. Changing a woman from medications contraindicated in pregnancy should be well in advance of trying to conceive. For those women on medications such as lithium, lamotrigine or antipsychotics, ensuring effective treatment leading into a pregnancy is recommended, as well as consideration of areas such as folate supplementation, assessing vitamin D levels and a focus on overall general health. While it may not be advisable to change a medication, it is possible to minimize harmful impacts through careful monitoring and dose adjustment, since both hepatic metabolism and renal clearance accelerate in later pregnancy. There are clinical aids that can be adapted to support this within services6. An example of monitoring and dose adjustment is with lithium: this includes ensuring early screening for risk of a cardiac malformation, then careful and close blood monitoring of levels throughout third trimester, prior to delivery and into the postpartum7. For antipsychotics, especially those with metabolic risks, another example is early screening for gestational diabetes at 16-18 weeks, rather than waiting until the usual routine screening at 28 weeks, to detect and manage any emerging diabetes early and prevent harm from prolonged hyperglycaemia to the woman and the baby8. For some women taking antidepressants, there is a concern that their baby may be born addicted and this comes from the misunderstanding of poor neonatal adaptation symptoms associated with antidepressants in pregnancy. Explaining that this may be neither a withdrawal or toxicity response, is likely self-limiting and mostly mild is important to place this in context of managing mental health9. The choice between uncertain options is not easy for women or for treating clinicians. Any change in the foreseeable future will require a concerted effort by clinicians, researchers, funders and women, to shift the current research agenda and ensure there is investment in studies able to provide clarity for risks and benefits from psychopharmacological treatments during pregnancy. Ultimately, it will be this investment, together with delivery of person-centred care, that will support the evolution of truly informed decision making for mental health treatments, including pharmacological ones, in pregnant women.