Commentary on RANZCP clinical practice guidelines for the management of schizophrenia and related disorders – Section on pregnancy and schizophrenia

The recently published clinical practice guideline (Galletly et al., 2016) appropriately highlights pregnancy as an important area for attention in the management of women with schizophrenia. The guideline focuses on the use of, and safety of, antipsychotics and other psychotropic medications in the treatment of women who are pregnant. Despite the importance of broader aspects of care during pregnancy, they are given little attention, and of note no mention is made of the implications for parenting and infant development. This is a serious omission.

As stated in the Royal Australian and New Zealand College of Psychiatrists (RANZCP) guideline, it is important to ensure that the mother remains well during the pregnancy. This requires much more than the use of antipsychotics. Mental health clinicians/case managers providing care and support to pregnant women with schizophrenia can and should have an important role in improving obstetric and neonatal outcomes for these women and their children. This should include discussing with all patients what plans they have regarding pregnancy, assisting women to understand the potential risks they and their infant may face, assisting with access to adequate contraception if the woman’s decision is not to become pregnant. When a woman chooses to have a baby, assistance should include initiating referrals to appropriate antenatal services and providing linkage to early and ongoing antenatal care, as well as other essential services such as housing support to enable the best possible outcomes for the woman and her baby.

Women with schizophrenia have much higher rates of smoking, alcohol use and illicit drug use compared with pregnant women without these disorders. Smoking in pregnancy increases the risk of low birth weight, preterm birth, small for gestational age babies and perinatal death. Alcohol consumption during pregnancy increases the risk of miscarriage, stillbirth and premature delivery and may be associated with a range of alcohol-related birth defects and alcohol-related neurodevelopmental disorders. Illicit drug use during pregnancy may cause serious pregnancy complications such as placental abruption, as well as a range of cognitive problems and neurodevelopmental effects in the infant. Some illicit drugs used during pregnancy, particularly opiates and amphetamines, produce a withdrawal syndrome following delivery in the neonate. Addressing these and other lifestyle factors, such as exposure to domestic violence, unstable housing, poor nutrition and obesity, is key to reducing the risks to both the pregnant woman and her infant.

For many women with schizophrenia, the illness has an adverse impact on the transition to motherhood, parenting ability and development of the mother–infant relationship. Human development occurs in the context of early relationships and is directly impacted by the quality of emotional interaction and regulation between the primary carer and infant. The infant brain is sensitive to the timing and quality of emotional and social responses, and the experience of mistimed or misattuned responses is stressful and aversive. Mothers with schizophrenia can find recognition and response to infant communication difficult and are less sensitive in their responses. Negative symptoms and emotional blunting are major contributing factors but medication, co-morbid alcohol and drug use may also be influential (Davidsen et al., 2015; Wan et al., 2007). Social factors such as isolation, poverty and family violence also directly impact parenting capacity.

Children of parents with mental illness are significantly more likely to have attachment insecurity and patterns of disordered attachment behaviour including inappropriate care giving and anxiety. Specifically, these children are at risk of both internalizing and externalizing disorders and attentional and learning difficulties. They are also at increased risk of developing schizophrenia.

The high risk of impaired parenting together with the importance of the early infant–caregiver relationship for later child development means that assessment of parenting capacity must be a key part of antenatal and early postnatal care, and the possible need for involvement of child protection services should be actively considered. This assessment should take into account whether the woman’s partner or another support such as her mother may be able to provide assistance and support with parenting. Clinicians should ensure that these issues have been carefully considered, and when there are doubts about parenting capacity, they should facilitate a comprehensive review of mother–infant interaction and infant development. Australian and international data suggest that around 50% of women with schizophrenia will have involvement with child protection services in the perinatal period (Nguyen et al., 2012), and around 40% of children of women with schizophrenia will be placed in out of home care at some time during their childhood (Ranning et al., 2015).

The management of women with schizophrenia who are planning to become pregnant, who are pregnant or who are new mothers are clinically complex tasks. In order to provide comprehensive guidance, we suggest that the college now develop a detailed clinical practice guideline for the management of schizophrenia and related disorders in women during the perinatal period.

See Guideline by Galletly et al., 50: 410–472.