Schizophrenia Hospitalization Drops in Pregnancy, Post Partum

Nancy A. Melville

March 21, 2016

For women with schizophrenia, use of acute care psychiatric services declines substantially during pregnancy and, with the exception of the first days after delivery, during the first year post partum, new research shows.

"Except for the first 9 days after delivery, women with schizophrenia had lower use of acute care psychiatric services during pregnancy and postpartum, compared with the 1-year period before pregnancy," the authors, led by Simone N. Vigod, MD, of the Women's Mental Health Program at Women's College Hospital, in Toronto, Canada, write.

"This finding is encouraging for women with schizophrenia, their families, and their care providers when making decisions about reproduction."

The study was published online March 15 in the Journal of Clinical Psychiatry.

50% Reduction

The study involved analysis of data on 1433 women in Ontario with schizophrenia who experienced live birth between 2003 and 2011 and for whom records were available on the use of acute care psychiatric services during pregnancy and the first year post partum.

The rate of having at least one hospitalization for acute care psychiatric care was 12% during pregnancy, compared with 25% in the year prior to conception, for an incidence rate ratio (IRR) of 0.50 (95% confidence interval [CI], 0.43 - 0.60).

Hospitalizations dropped by about a third, to 19%, during the 1-year period post partum (IRR, 0.66; 95% CI, 0.57 - 0.76).

The exception was the rate of psychiatric hospitalizations during the first 9 days after birth, which was more than three times the rates before pregnancy (IRR, 3.59; 95% CI, 2.74 - 4.69). The rate significantly decreased, however, by 10 to 29 days post partum (IRR, 0.87; 95% CI, 0.56 - 1.24).

During the year before conception, 20% of women had at least one psychiatric emergency department visit without hospitalization; the percentage dropped to 10% during pregnancy and to 15% in the year after birth.

A leading hypothesis for the reductions of psychosis in pregnancy is that the higher levels of estrogen during pregnancy can have neuroprotective benefits.

Conversely, the sudden dip of estrogen following childbirth could increase vulnerability to psychiatric symptoms, particularly when accompanied by sleep deprivation and the stresses of caring for a newborn, the authors speculate.

Other factors that could play a role in the reduced need for acute psychiatric services include potentially increased exposure to outpatient mental health services or stepped up adherence to treatment, motivated by concerns for a healthy pregnancy and post-childbirth experience.

Encouraging Finding

Although the study did not include data on the use of antipsychotics among the women, recent research conducted by the same investigators, which was published in the BMJ in 2015, showed that about 50% of women with schizophrenia remain on their medication throughout pregnancy, owing to concerns about the effects of discontinuation, said Dr Vigod.

"The larger issue, which is also under investigation, is, what is the impact of discontinuation on mental health stability for pregnant women with schizophrenia, and that this must be weighed against possible negative impact of staying on antipsychotic medication," she told Medscape Medical News.

"At this point, I am most often recommending that pregnant women with schizophrenia remain on medication throughout pregnancy. With the high risk of hospitalization in the first 9 days post partum, we should certainly be closely monitoring women who went off medications in pregnancy for a need to restart medication, and perhaps having them restart medication right away after the baby is born to prevent destabilization," she said.

The investigators are preparing to publish a follow-up study evaluating the risk factors associated with postpartum episodes. Although the findings are not yet public, Dr Vigod said some characteristics clearly point to potential risks.

"In general, one would suspect that the most prominent risk factors would be a previous history of psychiatric instability, medication discontinuation, and/or social risk factors that might compromise any woman's ability to cope post partum, including poor social support, financial issues, and/or interpersonal problems with partners," she said.

"It is important to remember, though, that women may have this rapid destabilization even in the absence of any of these risk factors."

With approximately half of women with schizophrenia expected to become pregnant, the findings provide important insights ― and some reassurance, Dr Vigod added.

"[The findings] demonstrate that women with schizophrenia can, and do, achieve enhanced stability during and after pregnancy, so this is an important, encouraging finding for women and providers in discussions about pregnancy planning," she said.

"There are some particularly high-risk times, such as the period shortly after childbirth, when women may be at risk for rapid onset of symptoms that unavoidably require urgent management, so this should be planned for in advance by ensuring adequate monitoring and treatment of maternal mental health."

The study was funded by a research operating grant from the Canadian Institutes of Health Research and by the Institute for Clinical Evaluative Sciences. Coauthor Sophie Grigoriadis, PhD, received compensation as a speaker and advisory board member for Eli Lilly, and coauthor Mary V. Seeman, DSc, received compensation as a consultant for Clera Inc.

J Clin Psychiatry. Published online March 15, 2016. Full text

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