Engaging in discussions of sexual/reproductive issues
To assist women with schizophrenia with pregnancy-related medical and psychiatric problems, the literature recommends that care providers initiate discussions of sexual issues with their patients. In their 2004 review of sexuality and schizophrenia, Kelly and Conley (2) noted that sexual functioning in individuals with severe mental disorders was receiving relatively little clinical attention. They noted that care team members were reluctant to discuss sexual concerns with patients for fear of triggering psychotic behavior. In contrast to attitudes expressed by care providers, those who were themselves affected by schizophrenia seemed prepared to discuss sexual matters and revealed to the researchers that counseling about intimate relationships was, for them, an important unmet need. A qualitative interview study exploring sexual matters with patients diagnosed with psychosis noted that respondents showed a willingness to discuss intimate feelings, that symptoms were not exacerbated, and that no interviews had to be prematurely terminated (3). A recent qualitative inquiry revealed that nurses were ambivalent about initiating such discussions (4) because, according to study results, of insufficient sexual knowledge, because they did not see it as part of the nursing role, because they considered their patients too ill to discuss sex, and because they were themselves uncomfortable with the topic. Waiting for patients to open the conversation resulted in the topic never emerging at all. One important observation that emerged from this study was that the nurses involved viewed mental health consumers as ‘desexualized.’ Psychiatrists have also been reported to view patients with schizophrenia as ‘asexual’ or as too socially isolated to be engaging in interpersonal sex (5).
This is unfortunate because sexual matters seem important to explore in women with schizophrenia, who have low rates (relative to their peers) of maintaining long-term sexual relationships but, as noted by Miller in 1997 (1), high rates of unsafe sexual behaviors and sexual exploitation. According to the literature, women suffering from schizophrenia use sex in exchange for cigarettes or other goods and often have histories punctuated by rape and sexual abuse (6, 7). They are exposed to sexually transmitted disease and to unwanted pregnancy more often than women without schizophrenia (6, 7). Reviewing 84 studies of reproductive health in women with serious mental illness, Matevosyan (8) concluded that the rate of lifetime sexual partners in this population was relatively high, that contraceptive usage was low, and that rates of unwanted pregnancy and sexually transmitted infection were higher than might be expected. The majority (54–74%) of adults with severe mental illness are reported to be sexually active (9) and the majority, for a variety of possible reasons (10), does not use contraception. In a study of 152 male and female adults with serious mental illness, sexual risk behavior was related to specific illness-associated issues such as lack of planning ability, inaccurate assessment of risk, poor communication skills, lack of information, lack of motivation, and lack of skills as well as to poverty and homelessness (11).
Quinn and Happell (12) have explored the use of guidelines to help mental health nurses raise the topic of sexuality with their patients. Physicians have found that taking a thorough sexual history serves as a good introduction to a discussion about sex (13) but that only 25% of charts on an internal medicine ward documented any aspect of having taken a sexual history. Recent practice recommendations advise that intimate relationship counseling form a part of all comprehensive programs for schizophrenia (14, 15).
Contraception and women with schizophrenia
Clinical studies reveal that one aspect of relationship counseling, contraceptive counseling, is critical in this population (16), although a number of barriers prevent clinicians from providing it (17). These barriers include a relative lack of knowledge about contraception, insufficient training in this area, personal discomfort with the topic of sex (18), and incorrect assumptions about pregnancy risk in schizophrenia, the mistaken belief, for instance, that antipsychotic medication, when it results in amenorrhea, necessarily protects patients against pregnancy (19).
To meet the needs of preventing unintended pregnancy, the practice recommendation is that healthcare providers be knowledgeable about contraception and prepared to discuss options with all female patients and their partners (20), not excluding women with serious mental health problems (21). As reviewed recently in Seeman and Ross (16), clinicians are advised to discuss the pros and cons of all contraceptive methods with their patients, from abstinence to rhythm methods, to withdrawal, to male and female barrier methods, to pills, progesterone injections, intrauterine devices (IUDs), sterilization, and emergency contraception. The hierarchy of contraceptive effectiveness in descending order is as follows: i) female sterilization and long-acting hormonal contraceptives (IUDs and implants), ii) larger copper IUDs, iii) smaller copper IUDs and short-acting hormonal contraceptives (injectables, oral contraceptives, patch, vaginal ring), and iv) barrier and natural methods (22). IUDs need to be inserted by a physician and can sometimes be accidentally expelled, but have been recommended as the most suitable contraceptive system for women with chronic illness because they are long lasting and require little attention (23). Depo-Provera, a once-every-12-week injection, has a failure rate of only 1% and may be a good choice for women with schizophrenia who come to clinic for depot antipsychotic medication (16).
Hormone pills (in various strengths and combinations) taken by mouth are 97–99.9% effective if used correctly and consistently but may interfere with the metabolism of therapeutic drugs like clozapine that are partially metabolized by liver enzymes CYP 34A (24), as are oral contraceptives. When combination oral contraceptives are taken together with clozapine, competitive substrate inhibition occurs, with consequent increase in clozapine blood levels that can result in side-effects (24). Discontinuing contraceptive pills during the course of treatment with clozapine, on the other hand, decreases clozapine blood levels, which may result in suboptimal dosing.
Comorbid conditions such as obesity and diabetes are relatively prevalent in women with schizophrenia and can augment cardiac and vascular risk induced by both contraceptives and antipsychotics. The use of hormonal contraceptives is, thus, contraindicated in women who are 35 years of age or older and those who smoke 15 or more cigarettes a day (25).
Hormones can also be delivered by skin patch, subdermal implant, vaginal ring, transdermal gel, or spray. Delivered by these routes, hormones bypass the liver and, therefore, are not subject to drug–drug interactions. Because sexual activity is often unplanned and unpredictable among women with schizophrenia, emergency contraception may be critical; several forms are now available and should be discussed with patients (26). Vaginal douching, widely practiced by women of many cultural backgrounds in the mistaken belief that it is an effective contraceptive measure (27), needs to be actively discouraged because, in addition to being ineffective, douching increases the risk of pelvic and vaginal infections.
Contraceptives can only be prescribed with a woman’s complete understanding of what they are for, how they are to be used, their contraindications, their cost, and their expected side-effects. Reviewing the literature, counseling about contraception has been found to be an important part of comprehensive care for serious and persistent mental illness (16).
Women with schizophrenia and preconception care
Preconception care has been defined as addressing issues preparatory to conception and childbearing, with emphasis on critical matters such as intimate partner violence, financial resources, adequate nutrition, safe housing, smoking cessation, substance use, and access to primary care (28). It is recommended that grieving and loss over past custody loss be openly addressed because it is not uncommon in this population (29). The woman’s current support system needs also to be evaluated as this largely determines her ability to care for children (29). Genetic and socioeconomic implications of childbearing are important, and referral for genetic counseling may be indicated (30). Patients need to be helped to understand the longitudinal literature on developmental and health outcomes of children born to mothers with schizophrenia (31–34).
If the woman appears to the clinical team to be so impaired that motherhood is inadvisable, either for her own sake or for the sake of her child-to-be, this opinion needs to be communicated to her, to her partner, and to her family. The views of all stakeholders will be important and may be at odds with medical opinion (35). Hans-Georg Gadamer has argued that every person brings his own prejudgments to every encounter, his own ‘horizon of understanding’ (36). Attempting to view conflictual situations from the perspective of others tends to deflect argument and increases a patient’s sense of her own autonomy (37). Educational interventions, including corrective feedback, multiple opportunities for learning, repetition of key elements of information, reorganization, or simplification of information, may be able, incrementally, to influence the patient’s and family’s understanding (38).
Should pregnancy be decided upon, conception may prove difficult because of the hyperprolactinemia resulting from antipsychotic medication (39). It can be facilitated by lowering the dose of the antipsychotic if it is unnecessarily high or by switching to a prolactin-sparing antipsychotic such as quetiapine, olanzapine, ziprasidone, or aripiprazole (40). In a placebo-controlled trial, Shim et al. (41) studied 56 treated patients with schizophrenia and hyperprolactinemia. They were randomized to treatment with aripiprazole (a high-affinity D2 receptor partial agonist) or placebo for 8 weeks. Adjunctive aripiprazole treatment reduced prolactin levels by over 80% compared with baseline levels, so that most patients had prolactin levels within normal range by week 8, while this was true for only 3.6% of patients in the adjunctive placebo group.
Guidelines indicate that folic acid supplementation should be started prior to conception in women intending to become pregnant. The goal is for women to begin pregnancy with a concentration of red blood cell folate of 906 nm (42).
Women with schizophrenia and middle pregnancy
Should danger to self or others in the context of psychosis appear over the course of pregnancy and should physical restraint become necessary, the woman should be restrained on her side to prevent compression of the aorta and impairment of placental perfusion (43). Treatment with ECT, although not a standard treatment for schizophrenia (84), can sometimes be considered as an alternative to drugs – it is generally considered safer in pregnancy than drugs (85, 86).
Normal physiologic changes of pregnancy trigger a series of metabolic alterations that may, in conjunction with antipsychotic treatment, increase the risk for gestational diabetes. A glucose tolerance test between weeks 24 and 28 and low-carbohydrate diets are indicated. As drops in blood pressure occur in mid-pregnancy, postural hypotension (which reduces placental perfusion) needs to be monitored in women on antipsychotic medication (87).
An important focus of investigation in the care of pregnant women with schizophrenia is the issue of domestic abuse. Altarac and Strobino (88) found that 14% of 808 women at an urban hospital reported physical abuse during pregnancy. That percentage is approximately twice as high in psychiatric patients (89) and is associated with adverse birth and delivery outcomes and with subsequent loss of custody (90).
Psychological stress in schizophrenia pregnancies is often grafted onto the background stress of poverty and unemployment, single status and the prospect of single parenthood and social exclusion. Stress via neuroendocrine and inflammatory mechanisms, especially when experienced in the 5th and 6th month of pregnancy, has been shown to contribute significantly to adverse outcomes for the child (91–93). Recent animal studies have uncovered mechanisms by which changes in the maternal milieu are transmitted to the developing embryo and translated into epigenetic alterations (91–93).
Antipsychotic effectiveness and side-effects have to be carefully monitored throughout pregnancy. Substantial changes in pharmacokinetics (absorption, distribution, metabolism, and excretion) occur throughout gestation, potentially requiring dosage adjustments of antipsychotics during each trimester of pregnancy (94, 95). In general, the doses of olanzapine and clozapine (mainly metabolized via CYP 1A2) will need to be decreased because CYP 1A2 enzymes are down regulated as pregnancy advances, while the doses of other antipsychotic medications may need to be increased because their main metabolizing enzymes are up regulated. There will be individual variation depending on slow or rapid metabolizer status, especially of drugs chiefly metabolized via CYP 2D6 (96, 97). Because of the extent of individual variation and the many factors that determine dose requirements, there are no guidelines for increasing or decreasing specific antipsychotic doses during pregnancy other than the general recommendation to keep doses as low as possible and to monitor the patient closely (68).
In addition to careful pharmacotherapy, many other issues arise in middle pregnancy: family connections need to be secured and maintained, birthing classes organized, adequate housing and income arranged, and, if necessary, child protection agencies alerted to the possibility that the patient may need assistance once the baby is born.
Women with schizophrenia and late pregnancy
In the month prior to expected delivery, it is recommended that antipsychotic doses be kept especially low to prevent both side-effects and withdrawal effects in the newborn (64, 98). Drugs administered near term may accumulate in the fetus and after delivery, when their clearance is dependent on an immature infant kidney, produce adverse effects. Toxic effects of antipsychotic drugs observed in newborns include motor restlessness, dystonia, hypertonia, and tremor (64, 98). In 2011, the U.S. Food and Drug Administration (FDA) updated the labels for the entire class of antipsychotic drugs. The new labels now contain more details on the potential risk for abnormal muscle movements and withdrawal symptoms in newborns exposed to these drugs during the third trimester of pregnancy (99).
It is suggested that patients be educated regarding the signs of labor and familiarized in advance with the setting in which the birth will take place. Denial of pregnancy in the face of imminent labor is a psychiatric emergency (100), which may require involuntary hospitalization on the grounds that unassisted delivery poses substantial risk to the patient. Obstetrical difficulties have been reported to be more frequent in mothers with schizophrenia than in mothers with other psychiatric illnesses (75).
Women with schizophrenia and the postpartum period
The results of postpartum studies (101) suggest that women with schizophrenia are best to stay in the hospital after delivery as long as is necessary to allow complete assessment of their health and the health of the newborn. During this period, the mother is educated regarding postpartum issues and infant care. After hospital discharge, when the mother is confined to the house, the mental health team can keep in contact through home visits.
New mothers with schizophrenia can become stressed and depressed like all other mothers, but the main concern in this population is postpartum psychosis. The relative risk of postpartum psychosis among first-time mothers with a previous hospitalization for any psychiatric disorder is more than 100-fold that of the general population (102). Twenty-five percent of women with schizophrenia develop postpartum psychosis (103). After one postpartum episode, the risk for recurrence is high (104). The onset occurs within the first 1–4 weeks after childbirth and develops rapidly. Psychotic symptoms are prominent and, characteristically, cognition becomes grossly impaired and insight into illness disappears. Behavior may become disorganized, potentially jeopardizing the safety of mother and child. Suicidal or homicidal ideation is a cause for concern. Hormonal shifts, obstetrical complications, dehydration, sleep deprivation, marital discord, and increased psychosocial stress all contribute to the risk (103).
Preparation beforehand is considered important – that is, education about the risk of postpartum psychosis following delivery (105) and about the need to restart medication at full dose immediately after the baby’s birth. With permission from the patient, husband and family members are encouraged to attend management discussions, which will include issues of security, possible hospital admission, antipsychotic medication, and psychotherapeutic intervention (106–108).
Breastfeeding affords many health benefits for mothers and babies, enhances bonding, and, for most mothers, is easier than bottle-feeding. The American Pregnancy Association recommends breastfeeding (109), but the FDA advises against it (until more clinical studies are available) when the mother is taking the newer second-generation antipsychotics (110). Relatively few adverse effects have been reported in case studies, but the data are sparse, as shown by recent reviews (111–113).
It has been hypothesized that exposure to drugs by fetuses and neonates can lead to late neurodevelopmental (114) or metabolic (115) effects. The concerns stem from results of preclinical animal studies. Close follow-up of exposed children is, therefore, recommended.
Women with schizophrenia and parenting
The question of safe or ‘good enough’ parenting is a primary concern for the woman with schizophrenia, her family, and her treatment providers. Formal assessment of parenting capacity may be indicated, but regular informal evaluation over time is always considered good clinical practice. Factors underscored in the literature are the mother’s symptoms, her ability to learn and practice safe infant care, as well as the availability of support (116).
A psychotic illness does not need to interfere with an individual’s ability to be a good parent as long as childcare needs are met, the home is safe, and there is financial security. Nevertheless, approximately 50% of mothers with schizophrenia temporarily or permanently lose custody of their children (117, 118). The mental health team can help mothers with schizophrenia to maintain custody by assisting them in looking after their own health, self-monitoring for signs of relapse, organizing a crisis plan in case their ability to care for their children is temporarily impaired, availing themselves of parenting resources, documenting care and attention to safety issues. Together, patient and care provider can profit by learning to navigate the family law system in their jurisdictions (29, 119).
The literature suggests that inquiries be made at all visits about children and child difficulties and the nature of disciplinary methods used by the parent, in order to prevent potential neglect and abuse of children. Unsupported mothers have difficulties with parenting skills such as responsiveness, that is, prompt attention to children appropriate to their developmental stage and contingent on their needs and their behavior (118). Parenting behavior such as open communication, high levels of warmth and praise, consistency, and the setting of reasonable limits is usually modeled by older family members, who may not be available to mothers with schizophrenia. Some studies find that the mere fact of reducing maternal symptoms helps mother–child relations (120), but a recent review emphasizes that this in itself is not enough (120).
A review of parenting intervention for mothers with schizophrenia has found the following to be effective: didactic parenting classes, direct parenting coaching of mothers, parent support groups in which parents help one another, and time-limited co-parenting support (121). Mother and baby in-patient units, where mother–child contact can be maintained during acute episodes of illness and where clinical staff can assess and assist mothers with parenting skills, have been popular in the UK and in Australia, but a Cochrane review finds no hard evidence for their superiority over standard in-patient treatment (122).
Useful services for parents with schizophrenia need to bridge the adult/child mental health divide and provide family-centered care with full interagency cooperation (123). The term ‘wraparound’ has been used to describe a strength-based approach that provides family-oriented care. An array of both formal services and natural supports is included, with attention to mother and child health, substance abuse counseling, case management, liaison with schools, the legal system, welfare, crisis management, housing, transportation, vocational help, spiritual, cultural, and recreational guidance, and respite care (124). In addition, clients on limited incomes may need help with financial planning, dealing with welfare-to-work expectations (125), and preparation for employment.