The American Psychiatric Association is incorporating a statement into its practice guidelines advising psychiatrists to routinely inquire about pregnancy plans and discuss the risk of unplanned pregnancy and contraception.1 Although the majority of patients seen in general psychiatric practice are women, especially women of reproductive age, psychiatrists are often unlikely to inquire about and document discussions of contraception use and pregnancy planning.2
In the US, 51% of pregnancies are unintended, and 40% of unintended pregnancies end in abortion.3 Most of these unintended pregnancies occur in women who were not using any form of contraception. Unintended pregnancies have a higher risk of adverse maternal and child health outcomes. In addition, these pregnancies are costly: in 2010, the total public expenditure on perinatal care for unintended pregnancies was $21 billion. Psychiatrists who treat women and adolescent girls may find it necessary to discuss with their patients reproductive planning and the role of contraception in setting comprehensive treatment goals.
Psychiatric knowledge about these issues is important for all patients; however, it is particularly important in the case of women with chronic mental illness, many of whom lack general knowledge about contraception and are less likely to use birth control, despite wishing to prevent pregnancy.4
Various psychiatric disorders have their own specific risks. In bipolar disorder, unplanned pregnancy is common. In one observational study that compared women with bipolar disorder with healthy controls, the bipolar women reported more frequent unplanned pregnancies (32.8% of pregnancies were planned among the bipolar women compared with 78.1% of pregnancies among healthy controls without mental illness).5 Women with primary psychotic disorders, such as schizophrenia, are at greater risk for coerced sex, risky sexual behavior, and unplanned/unwanted pregnancy.4 Among women with borderline personality disorder, those with more severe symptoms are at greater risk for unplanned pregnancy and teen-age pregnancy than are women who have Axis 1 disorders.6
Women with substance use disorders are also at higher risk for unplanned pregnancy, which increases the risk of fetal exposure to illicit substances, alcohol, and tobacco, particularly during organogenesis in early pregnancy. In a survey of women attending outpatient drug treatment programs, high rates of pregnancy were reported, and 70.5% of pregnancies were unplanned.7 In addition, women with substance use disorders are at risk for risky sexual behaviors, including prostitution.8 In a growing number of states, instead of receiving treatment, women with substance use disorders and concomitant pregnancy are at risk for criminal prosecution.9
Because of these risks, good psychiatric practice should include questions about contraception, pregnancy planning, and counseling about reproductive safety of the patient’s specific drug regimen in order to prevent unintended pregnancy and plan for a healthy pregnancy when desired.
Polypharmacy should be kept to a minimum and known teratogens, such as valproic acid and carbamazepine, should be avoided if possible in women not using reliable contraception. The psychiatrist should understand the interactions between psychotropics and hormonal contraceptives. Drugs such as carbamazepine, oxcarbazepine, topiramate, and modafinil can decrease the effectiveness of hormonal contraceptives, while oral contraceptives can decrease serum levels of valproate and lamotrigine.10,11 The safety of psychotropic drugs during pregnancy and the risk of untreated illness should be discussed so that if a woman becomes pregnant, she will not immediately discontinue her medication.
Psychiatrists should be prepared to ask basic questions about contraceptive use and pregnancy wishes and, if necessary, refer to a reproductive psychiatric specialist or collaborate with the patient’s primary care physician or gynecologist to establish an appropriate treatment plan.
The authors are members of the Committee on Gender and Mental Health, the Group for Advancement of Psychiatry. The authors report no conflicts of interest concerning the subject matter of this article.
1. Robinson GE. Contraceptive care for women with chronic, serious mental illness. American Psychiatric Association Action Paper ADMNOV1212F; 2012. For a copy of this paper, please e-mail Dr Robinson at [email protected].
2. Blehar MC, Oren DA. Women’s increased vulnerability to mood disorders: integrating psychobiology and epidemiology. Depression. 1995;3:3-12.
3. Guttmacher Institute. Unintended Pregnancy in the United States. February 2015. http://www. guttmacher.org/pubs/FB-Unintended-Pregnancy-US.html. Accessed June 11, 2015.
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