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Mental Health Conditions

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  • Normal physiological hormonal transitions that occur during a woman's life cycle can increase her vulnerabilities to mental health disorders or exacerbate existing mental health disorders.
  • Reproductive events including the menstrual cycle, pregnancy, lactation, and the postpartum period may affect management decisions.
  • Screen for mental health conditions in all women of childbearing age by asking about family history of mental health conditions (i.e. psychosis, depression, psychotic or affective disorders). Ask about mood disorders, personal history of depression, other psychiatric conditions and interpersonal violence.
  • VA requires that providers screen all Veterans for military sexual trauma (MST) as part of the mental health assessment. [View screening questions (+)]
  • While you were in the military, did you receive uninvited and unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or verbal remarks?
  • While you were in the military, did someone ever use force or threat of force to have sexual contact with you against your will?
    • Women at risk should receive a formal psychiatric assessment.
    • Appropriate contraception should be offered to women who do not desire pregnancy.

    Counsel on Increased Risk With Pregnancy

  • For patients with a mental health diagnosis, consider a referral to a mental health specialist if they are not already connected to a mental health provider.
  • There are several very effective methods for the treatment of a wide range of mental health disorders, and many of these treatments do not require the use of medication.
  • Preconception care should be provided collaboratively by the primary care and mental health providers with an ob/gyn involved as needed.
  • Treatment is provided during pregnancy when the risk to the mother and fetus from the disorder outweighs the risk of the intervention.
  • Patients with similar illness histories make different decisions regarding treatment during pregnancy when presented with the risks and benefits of medication treatment and other available therapies. No decision is risk-free. Risks of untreated psychiatric illness during pregnancy:
    • Relapse or exacerbation of symptoms.
    • Higher rates of C-section, preterm birth, low birth weight, being smaller for gestational age.
  • Additional risks with pregnancy may occur with relationship difficulties, financial strain, and interpersonal violence.
  • Screening for past and current interpersonal violence, including Military Sexual Trauma (MST), is indicated for all patients. Support for these issues should be made available (see resources).
  • Management

  • Medication Management
    • Anxiety Disorders (not including PTSD)
      • Normal physiological hormonal transitions that occur during a woman’s life cycle may increase her vulnerability to mental health disorders or exacerbate existing mental health disorders.
      • Reproductive events including the menstrual cycle, pregnancy, lactation, and the postpartum period may affect management decisions.
      • Screen for mental health conditions in all women of childbearing age by asking about family history of mental health conditions (i.e. psychosis, depression, psychotic or affective disorders). Ask about mood disorders, personal history of depression, other psychiatric conditions and interpersonal violence.
      • VA requires that providers screen all Veterans for military sexual trauma (MST) as part of the mental health assessment. [View screening questions (+)]
      • While you were in the military, did you receive uninvited and unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or verbal remarks?
      • While you were in the military, did someone ever use force or threat of force to have sexual contact with you against your will?
        • Women at risk should receive a formal psychiatric assessment.
        • Appropriate contraception should be offered to women who do not desire pregnancy.
        • Counsel on risks that may increase with pregnancy
          • For patients with a mental health diagnosis, consider a referral to a mental health specialist.
          • There are several very effective methods for the treatment of a wide range of mental health disorders.
          • Preconception care should be provided collaboratively with the mental health provider and primary care provider and ob/gyn involved when needed.
          • Treatment is provided during pregnancy when the risk to the mother and fetus from the disorder outweighs the risk of the intervention.
          • Patients with similar illness histories may make different decisions regarding treatment during pregnancy when presented with the risks and benefits of medication treatment and other available therapies.
          • No decision is risk-free.
          • Risks of untreated psychiatric illness during pregnancy include:
            • Relapse or exacerbation of symptoms.
            • Higher rates of C-section, preterm birth, low birth weight, being small for gestational age
          • Additional risks with pregnancy may occur with co-existing relationship difficulties, financial strain, and interpersonal violence.
      • Women have higher rates of panic disorder and general anxiety disorder than men.
      • Risk of untreated anxiety during pregnancy include increase of fetal exposure to cortisol (stress hormone) which may cause vasoconstriction and affect maternal blood flow of oxygen and nutrients to fetus; increased risks of postpartum depression and increased risk of neonatal irritability and decreased activity.
      • Benzodiazepines are labeled by the US FDA as increasing risk for congenital malformations. Inconsistent findings of congenital malformations with first trimester exposure. During late pregnancy, benzodiazepine use can increase neonatal sedation, lone tone, and cyanosis. When possible, avoid during first trimester and avoid polypharmacy.
      • Selective serotonin reuptake inhibitors (SSRIs) have more reproductive safety data than most other medecines used during pregnancy. Absolute risk of malformations with SSRI exposure in pregnancy is small. Neonatal withdrawal syngdrome can occur - ususally mild and easy to manage.
      • Inform patients starting treatment with a selective serotonin reuptake inhibitor (SSRI) that anxiety symptoms may initially increase.
    • Bipolar Affective Disorder
      • Onset of bipolar disorder typically occurs during the childbearing years
      • Unintended pregnancy can precipitate mood episodes
      • During pregnancy, increased risks of untreated illness include relapse, cesarean delivery, low birth weight, and postpartum illness.
      • Clinical management depends on severity of illness, risk of recurrent episodes and history of the illness.
      • Valproate use during early pregnancy is associated with about 10% risk of neural tube defects or other congenital malformations, and data from lithium registries suggest an increase in cardiac and other anomalies, especially Ebstein's anomaly. There are limited reproductive safety data on atypical antipsychotic drugs. Risk is highest with anticonvulsant polytherapy. Carbamazepine and lamotrigine are associated with less reproductive risk than valproic acid.
      • The benefits of medication treatment may outweigh the risks by reducing the morbidity and mortality associated with untreated bipolar disorder. Discuss risks and benefits with patient, including the implications of postpartum relapse for mother and baby.
      • Polytherapy is often needed to manage mood during pregnancy.
      • Patients need to be closely monitored and cared for by a multidisciplinary provider team
    • Depression
      • In all age groups, depression is more common among women than men.
      • Depression during pregnancy is the strongest predictor of postpartum depression.
      • Some data support increased rates of obstetrical complications and poor neonatal outcome in depressed pregnant women including an increased risk of preterm birth and low birth weight.
      • Research supports adverse effects of depression in pregnancy on patient, infant and families.
      • Antidepressants are not major teratogens. Selective serotonin reuptake inhibitors (SSRIs) have more reproductive safety data than most other medicines. The absolute risk of congenital malformations with SSRI exposure during pregnancy is small. Reproductive safety data more limited for Selective Norepinephrine Reuptake Inhibitors (SNRI).
      • Tricyclic antidepressants (TCA) are not associated with an increased risk for congenital anomalies but may have some undesirable side effects.
      • Safest medication to use across pregnancy is the one that is able to achieve euthymia.
      • Avoid monoamine oxydase inhibitors in women trying to conceive.
    • PTSD
      • Benzodiazepines are contraindicated for PTSD.
    • Schizophrenia
      • Higher rates of substance abuse, nicotine dependence, engaging in higher sexual behavior, increased risk of sexual assault among schizophrenics,
      • Pregnancy complications include unplanned pregnancy and decreased prenatal care,
      • Collaborative clinical management with Mental Health team and Gynecology.
      • Treatment options may include various types of therapy and depend on the patient's needs and condition.
      • The majority of antipsychotic medications used to treat schizophrenia appear to be relatively safe for use during pregnancy and breastfeeding. There are limited reproductive safety data on atypical antipsychotic drugs.
      • Valproate use during early pregnancy is associated with about 10% risk of neural tube defects or other congenital malformations.
  • Non-Pharmacologic Treatment
    • Refer patient to Mental Health team
    • Treatment options may include various types of therapy depending on the patient needs and condition.
  • Contraception Counseling

  • Work with the patient to identify the method that best meets her contraceptive and reproductive health plan needs.
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