During my post-graduate year two (PGY2) psychiatry specialty residency, I developed an interest in women's mental health. For a number of reasons, I identified this patient population as an area that I wanted to focus my efforts in researching, understanding and treating. Specifically, mental illness during pregnancy surfaced as a special population that needed the care of a pharmacist. Our detail-oriented approach and evidence-based rationale is of utmost importance to these women and their children. I arrived at my PGY2 residency eager to focus on women and children after completing my PGY1 residency at a Veterans Affairs Medical Center. Though female veteran medical care was a priority, the majority of my specific experiences had been in a male population. For that reason I jumped at the opportunities to learn more about women's mental health issues.
Shortly after I started at the University of North Carolina Hospitals in Chapel Hill, NC, our psychiatry department opened the first perinatal psychiatry inpatient unit in the United States. We began admitting women in September of 2011 and offered an interdisciplinary approach to patient care. The five bed unit has private rooms and was redesigned with new or expecting mothers in mind. It is modeled after similar units that exist in several European countries and includes gliders for breastfeeding and a variety of other amenities. The unit offers extended visiting hours to encourage family involvement and mother-child interaction. Interpersonal psychotherapy, partner-assisted therapy, mindfulness-based cognitive behavioral therapy and mother-infant attachment therapy are provided during hospitalization. Other specialized services include yoga for pregnant or postpartum women, spiritual support, and lactation and nutrition consultation1.
As a member of the multidisciplinary team, pharmacists or pharmacy residents attend rounds daily. The primary goal is to provide comprehensive, evidence-based care to our patients. Primary literature in this special population is lacking, which is very unfortunate given the fragile condition of these patients and the impact mental illness has on a woman during pregnancy. The role of the pharmacist is vital in managing pregnant patients appropriately. Pregnant women may experience new psychiatric symptoms or an exacerbation of an existing condition. Also, many women are advised to discontinue their medication upon becoming pregnant without consideration of the potential risks of untreated mental illness. This knee jerk reaction leads to unnecessary relapses and admissions. Patient specific scenarios should be considered when deciding to continue a medication during pregnancy. The American Psychiatric Association and the American College of Obstetricians and Gynecologist guidelines provide guidance for when to consider discontinuation of a medication during this sensitive time period2.
Depression is the most common complication of childbearing and may affect between 14 to 23% of women2,3. The Diagnostic and Statistical Manual for Mental Disorders (DSM-V) does not distinguish between a major depressive episode and perinatal depression, but it does provide a subset for postpartum depression which is defined as onset within 4 weeks of delivery4. Despite this recommended criteria, most clinicians consider a depressive episode within 12 months of delivery to be postpartum depression, as defined by the Agency for Healthcare Research and Quality (AHRQ)5. Separate criteria would be ideal as many of the symptoms of depression are difficult to distinguish from situational alterations in a new mother's life. For example, insomnia is common, if not anticipated, with the arrival of a newborn. Additionally, weight/appetite fluctuations and fatigue are ordinary in pregnant women and new mothers. The Edinburgh Postnatal Depression Scale (EPDS) is a ten item questionnaire completed by the patient to assess if her specific symptoms may be attributed to a depressive episode or are simply related to a change in her environment6. In my experience, women with postpartum depression are less likely to report feeling sad, but often endorse feelings of detachment or anxiety. These feelings of detachment and anxiety lead to excessive guilt. When considering pharmacotherapy during pregnancy or breastfeeding, the interdisciplinary team discusses the risks and benefits of pharmacotherapy versus untreated depression with the patient. An informed decision and conversation about potential therapeutic options is essential.
While working with the inpatient unit, I learned more about the transition of care to our outpatient Women's Mood Disorder clinic, the site for my ambulatory rotation during residency. My residency program director coordinated with the attending physician who oversaw the clinic, and I was immediately acknowledged as a member of the team. I was the first pharmacist to practice in this setting, which was a valuable experience in and of itself. I spent six months in the once-a-week clinic and grew to love my time there. To date, this was the most informative and rewarding patient care experience of my career.
As the pharmacist on the inpatient unit and in the outpatient clinic, I participated in patient interviews and discussed medication selection with the physicians. Our decision accounted for patient specific factors (i.e. use a sedating agent if mother complains of insomnia, avoiding medications that may adversely affect milk supply), previous medication trials, adverse events, drug interactions and cost. Additionally, we took into consideration stage in childbearing (prior to conception, pregnant, or postpartum), specific trimester if pregnant and whether the mother intended to breastfeed. And last, but certainly not least, available safety data weighed heavily in which agent we ultimately recommended to the patient. As part of my role in the outpatient clinic, I was present for all informed consent discussions along with the resident and attending physician treating the patient. I was available to the patient and her family/spouse for medication-related questions or concerns. I frequently counseled patients and their families during our sessions or once they had returned home
My time in these two unique settings provided experiences that vastly expanded my clinical knowledge and molded an empathic and professional patient rapport. Not only did these rotations shape me as a clinician, but deeply impacted me personally. The courageous women who overcame fear and stigma to seek help will forever inspire me. Their stories motivate me to be an advocate for this special patient population and drive me to provide unsurpassed patient care.