A 33 y.o. woman with a history of recurrent major depression, after discussion during pre-pregnancy

planning, decides to continue her medication when she becomes pregnant. She wants to have another child, and had taken the medication for postpartum depression prior to seeing you. Since seeing you, she had a recurrence of her depression with significant symptoms and restarted her SSRI. Her symptoms are under good control. She becomes pregnant several months later, and a few weeks after finding out she is pregnant, decides she wants to stop her medication due to the risk of neurodevelopmental disorders, particularly autism. This is something that you had discussed with her previously in regards to continuing the medication and she had seemed clear in her decision, but has suddenly become anxious and doubtful. Of note, her sister’s child has been diagnosed with autism. How do you handle this?

Another woman who presented with a significant depression, including suicidal thoughts in her first trimester agreed to increase the dose of her SNRI and meet for psychotherapy. Her depression lifted eventually. However, in her third trimester, she decreased her dose as she had been told by her obstetrician that might be advisable given the risks of side effects in the newborn. You had discussed this risk and she had been advised to continue at the most effective dose. Nevertheless, she decided to decrease her dose even though you express concern about postpartum recurrence. What is the best approach?

In working with perinatal patients with psychiatric disorders, we can face dilemmas regarding medications that bring up questions about weighing risks, advising patients, and how strongly to weigh in on the patient’s decision. We want to respect a patient’s autonomy, but are aware of the potential difficulties that can arise if a patient decides not to take medications or wants to change to a “safer” medication. Some women are clear about continuing the medications that are working for them and do not waver. Many women have some initial discomfort and can feel the seriousness of the decision to continue medication and possible risks and need to work through these feelings and anxieties to accept taking medication while pregnant. Some women are clear about the symptoms they will experience and the how detrimental these will be, particularly if they have another child at home to care for.

Nevertheless, as in the cases above, patients can and do change their minds, in surprising ways and make decisions that we wouldn’t necessarily agree with or recommend.

In approaching this situation, we certainly can try to understand their reasons including those that are unique to their situation as well as the more common misconceptions about the risks of taking medication in pregnancy. Even if we know the risks to be low, that is not how our patients may feel.

Many women feel anxious about exposing their baby to any kind of risk of an adverse outcome, and that may be based in their own psychology, family history, cultural beliefs or prior experiences. They may feel like they are a bad or negligent mother for exposing their child to a medication. Whose needs come first, theirs or the baby’s? Some women feel some shame and stigma as someone who needs medications during pregnancy. They may have thought they were clear about their decision, but when they are actually pregnant, they feel differently as the reality of the baby now plays more of a role in their decision making.

As a clinician, it is helpful if we can be clear about our position in regards to these issues and the risks involved. It can feel difficult to ask a woman to take a risk that she perceives to be unacceptable, perhaps bringing up our anxieties about whether the medication we are prescribing puts the fetus at risk. As a perinatal psychiatrist, we are sometimes practicing in a way that our colleagues are not as comfortable with. The patient’s anxieties can be influential. We tend to be more accepting of and tolerant of uncertainties given our experience over time. We are also able to be clear if the data is clear and has led to a consensus in the field in regards to taking a particular medication in pregnancy.

In talking to our patients who have considerable anxiety or may change their minds, we can certainly review again the data that we have about the medication, the consensus as to the level of risk if any that a particular medication poses and the risks of untreated illness. We are also aware of the severity of her symptoms in her recent depression and can raise this. We can explore her reasoning. We have a strong basis for our recommendation to continue medication and want to make this recommendation clearly but with tact. We may have to accept that we cannot convince the patient otherwise. We also may be able to work with the patient to agree to a plan restart their medication or increase their dose again if they have a significant recurrence. We can also remind someone that meeting their needs is meeting the baby’s needs.

It is also important that we consider our relationship with the patient. Even if they go against our advice, it is much better if the patient feels they can still rely on us and is open to our involvement even if they are not taking medications. It can be helpful to see the patient more often to be able to pick up on symptom recurrence sooner rather than later. Many patients will agree to this. Sometimes, if patients become symptomatic, we may also have to bear a period of depression and anxiety with them as they come to terms with their need for medications which may include a sense of failure. We want to preserve our working relationship with our patient, and ultimately need to respect their wishes.

Sometimes, it might indeed work out in their favor, but we want to be there if they need us.

Catherine Mallouh M.D., Associate Clinical Professor, volunteer faculty, University of California, San Francisco. Private practice in San Francisco, specializing in perinatal psychiatry.

This is a first article in a series that will highlight the clinical dilemmas faced in clinical practice. We hope to invite other members to contribute and would welcome responses to this piece. You can send me an email: cmalmd@yahoo.com