Laura J. Miller

Assessing parenting competency in individuals with severe mental illness: A comprehensive service

Determining the parenting capabilities of individuals with severe mental disorders who are alleged perpetrators of child abuse or neglect is a profoundly difficult task. This article discusses the methodological shortcomings of some widely used assessment strategies and outlines the components of a comprehensive parenting competency evaluation for individuals with severe mental illness. Procedures identifying both risk factors associated with abuse or neglect and protective influences against child maltreatment are summarized. These procedures are illustrated by describing a Chicago-based parenting assessment team for parents with severe mental disorders.

Beyond screening: assessment of perinatal depression in a perinatal care setting

Although screening for perinatal depression substantially improves detection, screening alone does not improve treatment entry or outcome. This paper summarizes a pilot evaluation of the feasibility and patient acceptance of on-site diagnostic assessment in perinatal care settings for women who screen positive for perinatal depressive symptoms. The model included screening, assessment by the perinatal care provider, an algorithm to guide decisions, guidelines for evidence-based antidepressant treatment, support through phone and webbased consultation, and quality monitoring to track and remedy “missed opportunities” for screening and assessment. A mean of 17.1% of women screened were identified as having depressive symptoms in need of further assessment. Of those identified, a mean of 72.0% received a diagnostic assessment on site. A mean of 1.4% of patients refused on-site diagnostic assessment. It is feasible to incorporate assessment for depression into perinatal care. This paves the way for better engagement in treatment, and better clinical outcomes.

Ethical Issues in Perinatal Mental Health

The principles of autonomy, beneficence, nonmaleficence, and justice can guide clinicians in finding ethical approaches to the treatment of women who have psychiatric disorders during preconception, pregnancy, and postpartum. Table 1 summarizes some clinical dilemmas in perinatal mental health care, the ethical conundrums posed by these situations, and guiding principles or tools that can help clinicians resolve ethical conflicts. The concept of relational ethics helps resolve apparent mother-offspring ethical conflicts, and the practice of preventive ethics helps anticipate and reduce the risk of ethical dilemmas and adverse clinical outcomes. These central principles suggest the following guidelines in caring for perinatal women: In situations that seem to pit the needs of a pregnant or postpartum woman against the needs of her fetus or baby, reframe the problem to find a solution that most benefits the mother-baby dyad while posing the least risk to the dyad. In evaluating a pregnant womans ability to make autonomous, informed decisions about medical care, assess her ability to decide on behalf of both herself and her fetus. When explaining the risks of treatments such as psychotropic medication during pregnancy, avoid errors of omission by also explaining the risks of withholding the treatments. Apply the principle of justice to ensure that women are not stigmatized by having psychiatric disorders or by being pregnant. When screening for maternal psychiatric symptoms, ensure that the benefits of screening outweigh the ethical costs by designing effective follow-up systems for helping women who have positive screens. When treating women of reproductive age for psychiatric disorders, proactively discuss family planning and, when appropriate, the anticipated risks of the illness and the treatment during future pregnancies. Offer preventive interventions to reduce these risks.

Comprehensive care of pregnant mentally ill women

Since the onset of deinstitutionalization, there has been an unanticipated and dramatic increase in pregnancies among women with chronic mental illness, with no specific planning for how to address the unique clinical needs of this high-risk population. Shortcomings in delivering care to mentally ill women within general health care systems are reviewed, including failure to assist with family planning, failure to observe worsening mental health during pregnancy, inadequate planning for child custody, lack of access to services, and omitted pelvic examinations. Necessary components of a system to provide comprehensive and coordinated care for pregnant mentally ill women are described. These include assessment of adaptation to pregnancy and competency to care for an infant, somatic and psychotherapeutic treatment, parenting skills training, family planning services, outreach, and close liaison with obstetric services. A Chicago-based collaborative program is described as an example of providing comprehensive, specialized care with limited financial resources.

Major mental illness during pregnancy

Abstract Pregnancy can be a particularly difficult time to develop symptoms of a major mental illness. Psychiatric symptoms can impair a woman’s ability to manage the profound changes accompanying the birth of a child. Mental illness can adversely affect nutrition, prenatal care, and obstetric outcome. If symptoms persist postpartum, they can interfere with mother-infant attachment and, ultimately, the cognitive and behavioral development of the child. 1 The seriousness of these consequences underscores the importance of early detection and treatment of antenatal mental illness. However, diagnosis of some psychiatric disorders during pregnancy is made more difficult by the overlap between symptoms of the disorders and symptoms of pregnancy. Treatment of severe disorders is more complex, due to potential adverse effects of psychotropic medications on the fetus, neonate or pregnant woman. This article reviews findings about the presentation and course of major mental illnesses during pregnancy. A detailed review of psychotropic medications during pregnancy is beyond the scope of this article, but is covered in recent reviews. 2 , 3

Psychopharmacology during pregnancy

Abstract When major psychiatric illness accompanies pregnancy, it is important to weight the risks of prescribing medication against the risks of withholding medication. This article summarizes available data about the risks of untreated psychiatric disorders and the risks of commonly used psychopharmacologic agents during pregnancy. Potential risks of the latter include morphologic teratogenicity, behavioral teratogenicity, fetal and neonatal toxicity, neonatal withdrawal, and effects on the pregnant woman. Certain prescribing practices can minimize the possible risks. These include using nonpharmacologic psychiatric interventions in cases in which they are effective, supplementing specific nutritional elements, finding the minimum effective dose, avoiding certain drug combinations when possible, tapering doses gradually for pregnant women and neonates, and using pharmacologic antagonists to reverse toxicity. Patient education about the additive risks of alcohol drinking, cigarette smoking, stress, poor nutrition, and lack of prenatal care can also improve outcome. Discussing treatment options in detail will help pregnant patients make informed choices about psychopharmacology during pregnancy.