Current Women's Health Reviews - Volume 6, Issue 1, 2010

Schizophrenia presents differently in women than in men, somewhat later in life on average and, initially, in a more benign way. Women who later experience psychotic symptoms often report childhoods and teenage years relatively free of problems. They do well in school, have friends, and keep jobs. By the time illness comes, they may be mothers. Even after the beginning of symptoms, they do well relative to men. They generally respond positively to treatment, continue to maintain a network of friends, and may be able work at jobs outside the home or in the home, looking after their families. Schizophrenia wreaks a lesser toll on thought processes in women than it does in men and they usually retain a wide range of emotions and an ability to take pleasure in life. They are less withdrawn and isolated than men with this illness. On testing, their brains appear comparatively immune to the ravages inflicted by the schizophrenia process on the brains of men. Of course, this is all relative. In many ways, the lot of women with schizophrenia is very difficult. Compared to the general population, proportionally more women than men with schizophrenia take their own lives. They have more unmet service needs than men in three important areas: physical health, safety, and child care [1-3]. The series that follows, focused on the reproductive needs of women with schizophrenia, addresses aspects of medical health, treatment, law, ethics and safety, and parenting. The first paper, by Sarah Romans, discusses sexuality in the context of women with schizophrenia, an important topic not often addressed in the psychiatric literature. A key conclusion is made: the quality of sexual experience for women with schizophrenia is poor. When women with schizophrenia take control of their lives, they will want answers to the questions that most directly affect their pleasure and well-being. How should clinicians advise women with schizophrenia who come for preconception counseling? This question is addressed by Ariela Frieder. She concludes that it important to provide services for such women because they are at a high risk of psychotic symptoms during pregnancy, which, if untreated, can lead to fetal distress. They are at increased risk of fetal malformations, obstetrical and neonatal complications, and postpartum exacerbation of psychosis. Attention needs to be paid to their living accommodations, disposable income, social support and parenting skills in order to make childbearing safe. Simone Vigod and Lori Ross continue this theme. They address the epidemiology of psychotic symptoms during pregnancy and postpartum in women with schizophrenia. They conclude that, although risk factors for psychosis in the perinatal period are poorly characterized, the level of pre-existing illness, medication non-adherence and poor social support are all likely to be relevant. If not in place, they advocate preventive and intervention services in the perinatal period.

This article reviews the published English literature to learn what is empirically known about the sexuality of women with schizophrenia. Although this aspect of patients' lives is an important determinant of their quality of life, too little is known. It is clear that women with schizophrenia have high rates of sexual dysfunction which may or may not be side effects of medications used to treat their disorder. They also show higher rates of high risk sexual behaviors, those likely to result in HIV/AIDS, and unwanted pregnancies which may be related to the higher rates of sexual and physical abuse than that seen in non-affected women. Qualitative studies which are few in number and literary accounts by women with the illness hint that women with schizophrenia wish for rewarding sexually intimate relationships but infrequently attain them. Clinicians who are handicapped by great gaps in available research do a poor job at discussing and advising women about their options and rights. The author identifies a number of key clinical questions requiring answers.

This article outlines guidelines for preconception counseling of women with schizophrenia. Preconception care creates the opportunity to address risky behaviors, change unhealthy lifestyles, enhance the patient's knowledge about the genetics of her disease and the risk for her offspring, improve parenting skills, mobilize resources and the necessary support system in a timely manner and ultimately improve the health and quality of life of both the woman and her offspring. Women with schizophrenia are in particular need of preconception interventions. They are at a high risk of relapse during pregnancy unless their illness is treated. Psychosis during pregnancy can lead to fetal distress, denial of pregnancy, failure to participate in prenatal care and to recognize the signs of labor. Women with schizophrenia are at high risk of fetal malformations, obstetrical and neonatal complications and postpartum psychosis. In addition, schizophrenia is associated with homelessness and low socioeconomic status. Moreover, women with schizophrenia have poor social support and often lose the custody of their children. Identification and treatment of women with severe mental illness prior to conception is essential to reducing negative outcomes.

This article reviews the literature on the epidemiology of schizophrenia in pregnancy and the postpartum period. The prevalence of psychotic symptoms is reviewed, along with course and risk factors. Psychotic symptoms occur in women with schizophrenia during pregnancy, and are associated with increased risk of poor obstetrical and postpartum mental health outcomes. In the postpartum period, there is converging evidence that although the highest risk of relapse is in the early postpartum period, women continue to relapse and require admission to hospital throughout the first postpartum year. Risk factors for psychosis in the perinatal period are poorly characterized, but likely include the level of pre-existing illness, medication non-adherence and poor social support. Taken together, the findings of this review support the need for prevention and intervention services in the perinatal period for women with schizophrenia.

Denial is a defense that can help reduce anxiety when coping with a stressful event, but can be detrimental to an individual if it prevents adaptation. Three types of denial of pregnancy have been described: affective, pervasive and psychotic denial. The pregnancies of women with schizophrenia can be complicated by psychotic denial of pregnancy. Misinterpretations of the symptoms of pregnancy, grief from prior loss of custody of a child, and active psychiatric symptoms may increase the risk for denial of pregnancy. The consequences of failing to accept a pregnancy can be severe, including lack of prenatal care, limited time to prepare for parenting (with subsequent risk of custody loss), and neonaticide. These risks can be alleviated by early identification of women with psychotic denial of pregnancy and implementation of medication, psychotherapy and social support. At the individual level, education about family planning may be helpful in preventing further episodes. At the public policy level, Safe Haven laws may prove to be beneficial in preventing neonaticide.

The goal of prenatal care is a healthy pregnancy and prevention of adverse maternal and fetal outcomes. Women with schizophrenia who become pregnant pose unique challenges to the delivery of prenatal care and are at high risk for adverse perinatal outcomes. Pregnancy in these women should be considered high risk. Offspring of women with schizophrenia are genetically predisposed to developing schizophrenia. Obstetric complications such as diabetes, prematurity, and fetal growth retardation also place the offspring at greater risk for development of schizophrenia, regardless of the genetic vulnerability. Pregnant women with schizophrenia are at greater risk for inadequate prenatal care and known obstetric complications, which are further risk factors for schizophrenia in the offspring. Thus, the genetic and obstetric environment of the fetus predisposes to the development of schizophrenia. This risk may be mitigated by increased vigilance in providing prenatal care to these women and preventing or minimizing illness and treatment emergent complications during pregnancy. In this article we review: 1) the barriers to adequate prenatal care in women with schizophrenia, 2) factors associated with the illness and its treatment requiring attention and monitoring during prenatal visits, and 3) the multi-disciplinary, collaborative approach to the delivery of prenatal care for these women.

It is important to evaluate the safety of antipsychotic drugs in pregnancy and the postpartum, especially as most women with schizophrenia need to continue their treatment during pregnancy and breastfeeding. With the increasing use of second generation antipsychotics, which cause less hyperprolactinemia-induced infertility than was the case with older drugs, the number of women with schizophrenia becoming pregnant will likely increase. In this review, I discuss the current available, evidenced-based information regarding the safety of antipsychotic drugs used in pregnancy. These include the first generation (chlorpromazine, fluphenazine, haloperidol, loxapine, perphenazine, prochlorperazine, promethazine, thioridazine, trifluoperazine) and second generation (aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone). To date, there has been no definitive association between use of these agents and an increased risk of birth defects or other adverse outcomes. Women who are pregnant or breastfeeding and require treatment should always discuss the risks/benefits of pharmacotherapy with their own physician. The evidenced-based information contained in this paper will be of use in their joint decision.

For some women with schizophrenia, adapting emotionally to pregnancy and motherhood is a struggle. Women with schizophrenia may have difficulty acknowledging and accepting the pregnant state, accurately interpreting the physical changes brought on by pregnancy, accepting prenatal care, managing pregnancy-linked anxieties, forming a reality-based attachment to the fetus, and grieving prior custody loss. Flexible psychotherapy, in which the therapist alters pacing, role and modality based on evolving developmental needs as pregnancy progresses, can be a useful adjunct to pharmacotherapy and psychosocial rehabilitation. This article uses composite case examples to illustrate the use of short-term psychotherapeutic strategies for women with schizophrenia during pregnancy, incorporating elements of cognitive-behavioral therapy, motivational interviewing, social skills training and family systems intervention. The article additionally describes assessment for psychotherapy, and the unique challenges of forming a therapeutic alliance when a therapist feels responsible for the patient's fetus as well as for the patient.

The purpose of this article is to describe the challenges and opportunities for acute psychiatric inpatient staff to engage the psychotic pregnant woman in optimal psychiatric and obstetric care, in order to facilitate a positive outcome for mother and baby. We will describe the role of comprehensive, integrated services for mentally ill pregnant women, initiated on a specialized Inpatient Women's Issues Consultation Team and delivered in a culturally competent fashion. Illustrations will be taken from a composite case representing several common key clinical situations in our population. The myth that a medication-free pregnancy is always safest for the pregnant woman is dispelled, and thoughtful, individualized, and informed risk-benefit analysis is recommended instead. Risks for psychotic relapse are identified, appreciating that multiple stressors combine to create the need for comprehensive assessment and treatment in inpatient psychiatric units. Close collaboration among psychiatric, obstetric and pediatric inpatient-outpatient services promotes optimal execution of joint treatment planning. Rapidly restoring the woman to competency and engaging her in psychiatric and obstetric decision-making is the goal. In sum, specialized comprehensive services for psychotic pregnant women provide the opportunity for individualized, therapeutic, evidence-based care, addressing the complex mixture of socio-cultural, medical, obstetric and psychiatric issues each woman bears.

Background: Schizophrenia has been seen as a severe and persistent illness that disqualifies mothers from adequately parenting their children. Aim: To understand the scope of the issue, to learn about the subjective experiences of mothers and children, to appreciate the impact of psychotic illness on children at various ages, and to review the necessary components of intervention programs. Results: Approximately half of all women with a diagnosis of schizophrenia are mothers. The rate of custody loss in this group is high. Most women with schizophrenia value their roles as mothers, and their adult children remain attached to them. There can be serious harms, however, associated with being the child of a mother with psychotic illness. Most of these appear to be mediated not by the illness itself but by associated risks: poverty, substance abuse, domestic violence, social isolation, and/or substandard housing. Intervention programs have begun to cut across agency divisions to provide wraparound care in multiple domains for families in distress. Conclusion: Schizophrenia in mothers poses problems for offspring but does not preclude effective parenting.

This article examines the contexts associated with the rare but serious issue of women with schizophrenia who kill their children (filicide). It reviews some of the legal issues that arise in the aftermath of these filicides and discusses therapeutic interventions.

Objective: This paper identifies factors that contribute to the vulnerability of pregnant patients with schizophrenia and discusses the ethical issues in preventing and terminating pregnancies, managing labor and delivery, and treating psychosis during pregnancy. Method: PubMed and PsychINFO databases were searched using combinations of search terms including ethics, pregnancy, perinatal period and schizophrenia for relevant articles. In addition, an ethical framework was developed that was based on professional virtues, ethical principles of respect for autonomy and beneficence, the ethical concept of fetus as patient, and assisted and surrogate decision-making. Results: The processes of assisted decision-making constitute key components of the ethical framework and of professional responses to impairment in autonomy. These processes, which include education, skill training in problemsolving strategies, and treatment of psychosis and related conditions help women to regain capacity and to make prudent decisions based on their own long-standing values and beliefs. Psychiatry, family planning and sexual health services are integrated and coordinated to provide the requisite assessment, monitoring and protection of patients. Conclusions: Implementation of these recommendations should reduce the vulnerability of pregnant patients with schizophrenia and protect them from unwanted pregnancies and adverse pregnancy outcomes.