The “What I Wish I Knew” series of articles is a service of CPNP’s Resident and New Practitioner Committee. Articles are intended to provide advice from experts for students, residents, and new practitioners. Articles are not intended to provide in-depth disease state or pharmacotherapy information nor replace any peer-reviewed educational materials. We hope you benefit from this “field guide” discussing approaches to unique problems and situations.

Dr. Sophie Robert earned her Bachelors in Pharmacy from Laval University in Quebec City, and her PharmD from the University of British Columbia in Vancouver. She completed an ASHP-accredited psychiatric pharmacy practice residency at the Medical University of South Carolina in 2000. Dr. Robert is a Clinical Pharmacy Specialist in psychiatry in the Department of Pharmacy Practice at the Medical University of South Carolina (MUSC), a Clinical Assistant Professor at the South Carolina College of Pharmacy, and an Assistant Professor in the Department of Psychiatry and Behavioral Sciences at MUSC.

Before starting in her current position in 2012, Dr. Robert was a clinical pharmacy consultant for SCORxE Academic Detailing service at the South Carolina College of Pharmacy, where she served the roles of topic content developer, field educator and manager of other academic detailers. Previous to that, Dr. Robert worked in mental health research at the Ralph H. Johnson VA Medical Center from 2000 to 2007, focusing on schizophrenia and posttraumatic stress disorder psychopharmacology.

In her current role, Dr. Robert works closely with inpatient psychiatry teams and the psychiatry consult liaison team to optimize medication regimens, provide education to patients, and assist in transitions of care. She is actively involved in student and resident education, both through clinical teaching and lecturing in psychopharmacology lectures. Dr. Robert is also a consultant in the MUSC Psychopharmacology Clinic, where she assists in the management patients with treatment-resistant psychiatric disorders.

What are provider concerns and assumptions about patient’s using psychotropics during pregnancy?

A common assumption by providers is that the treatment of psychiatric conditions is more important than plans or desires for pregnancy on the part of the patient, or that the benefits of medication treatment clearly outweigh the risks in the setting of a current pregnancy. Providers’ own beliefs about the benefits of medication treatment may be ‘imposed’ on patients without an adequate two-way conversation. While providers may be well intentioned, this approach does not foster trust and openness in expressing concerns, validating them, or developing ‘buy-in’ on the part of patients.

I make it a point to take stock of my own personal beliefs, acknowledge them, and then set them aside to be able to help patients make the best informed decision in the most objective, non-biased, non-coercive, and non-judgmental manner. In order to make an informed decision about their own care, patients have to be provided with clear, factual information, at their health literacy level, that covers the various risks of medications, untreated psychiatric conditions and background malformation rates. This information should be provided in writing and is best delivered as part of a coordinated care plan across relevant providers such as psychiatric pharmacist, psychiatrist, and obstetricians.

A common concern that pharmacists face is feeling inadequately informed about the most recent literature on teratogenicity and other pregnancy or breastfeeding concerns and inadequately trained or skilled at interpreting, weighing, and summarizing the existing literature. Some agents have very limited data in human pregnancy or breastfeeding, thus decisions may need to be made based on information extrapolated from animal studies. Other agents have conflicting evidence of safety, partly due to various study design limitations such as lack of power from small sample sizes, lack of a comparison group (e.g., women with similar diagnosis and risk factors as those receiving the study medication), or data collection methods.

For example, in the 1970s, results from the International Register of Lithium Babies reported a much higher rate of Ebstein’s anomaly from lithium exposure during the first trimester compared to baseline population rate. However, the study suffered from several limitations, including lack of a control group and importantly, retrospective enrollment (i.e., after delivery), which biases toward reporting of negative outcomes. More recent, better designed studies have reported a much smaller risk of Ebstein’s anomaly from lithium exposure in the first trimester than originally reported. Additionally, understanding how the clinical data is recorded, being aware of potential misclassifications (e.g., right ventricular outflow defects may be more likely labeled as Ebstein’s in infants with known exposures to lithium given the drug’s well-known association with that defect), and being able to appreciate the clinical relevance of reported defects can be challenging for pharmacists unless they are very well versed in this area.

Lastly, pharmacists may not feel informed enough about the risks of untreated psychiatric conditions on mother and baby and comparative risks and benefits of non-medication treatment alternatives to be able to put in proper context the risks as well as the benefits of medication treatment on mother and baby. The most efficient way of addressing these knowledge gaps is to make use of resources that are specialized in the area of women’s health, pregnancy and breast-feeding, such as those listed in the following section below.

Another concern that pharmacists may have is that they might overwhelm and potentially scare a patient away from treatment while discussing medication risks. Who wouldn’t relate to this if one thinks of medication ads on television that provide a long list of scary side effects? This may lead to under-emphasis of some of the risks and over-playing of the benefits of medication treatments. Using a multidisciplinary approach to utilize different professionals’ knowledge can facilitate provision of balanced, comprehensive information.

Where can I find helpful resources to ensure most current evidence is discussed with patients?

I do my share of primary literature search on Medline or Pubmed to keep abreast of newest data in this area, but also use other resources that have evaluated and synthesized the literature for health care professionals. Such resources are maintained by expert in the fields so they definitely enhance my knowledge and facilitate quick access to a wealth of information! Below are three different types of resources I find very helpful.

  1. Teratology databases such as TERIS, Shepard’s, and Reprotox provide comprehensive, up-to-date, and concise summaries of the scientific literature on medication exposures during pregnancy and breastfeeding. Textbooks such as Briggs’ Drugs in Pregnancy and Lactation (also available online) provide similarly helpful information.
  2. Teratology Information Services such as
  • MotherToBaby by the Organization of Teratology Information Specialists (OTIS) is a great resource for patients and health care providers to access current and accurate information about exposures during pregnancy and breastfeeding. Experts can be accessed through a national call center, and various resources including patient education hand-outs are available on the website (https://mothertobaby.org/)
  • Motherisk, also affiliated with OTIS, is designed for mothers and healthcare professionals. It provides expert opinions, journal articles, helplines for mothers and more (www.motherisk.org)
  • Infant Risk Center from Texas Tech University Health Sciences Center is another helpful resource for mothers and health care professionals. It provides summaries on various topics related to pregnancy and breastfeeding, a hotline for mothers and providers, and discussion forums for mothers (https://www.infantrisk.com/)
  1. Guidelines from organizations such as the National Institute of Health and Clinical Excellence (NICE), the American Congress of Obstetricians and Gynecologist (ACOG), and joint reports from ACOG and the American Psychiatric Association (e.g., on the treatment of depression during pregnancy) are a great source of information on the risks of untreated psychiatric conditions in addition to risks and benefits of medication treatments, alternative treatments, and specific treatment recommendations.

What are strategies for tackling tough or uncomfortable topics?

First and foremost, I want to know what information, concerns, and potential preconceived notions or biases patients may have about the topic at hand. Finding out where patients are starting from helps me identify misinformation and gaps in knowledge to target. Learning their goals of therapy, personal preferences, and values helps me frame the discussion in a way that hopefully makes sense to them. We can then identify common grounds and move toward a shared plan through a fully informed decision process. And particularly when it comes to pregnancy, I tell patients that it’s ok to be uncertain, it’s ok to express concerns or fears, and it’s ok to need some time to make a decision. Of course, there are situations with a higher sense of urgency (e.g., acute mania) when decisions need to be made more quickly and with perhaps less patient involvement, but once the urgency passes and the patient is able to go through a more fully informed decision process, then they should be brought into a full discussion from that point on.

I supplement my verbal discussion with educational hand-outs, allow patients time to read over, and follow-up on any questions, and ensure that information has been well understood. Additionally, written care plans with the patients’ goals and preferences and summary of risks and benefits discussed can be valuable tools for patients and providers as a mean of more comprehensive documentation and communication. Lastly, a multidisciplinary approach involving the OB/GYN should be favored, particularly for high risk pregnancies and high risk medications, to ensure continuity of care.