Management of Psychiatric Disorders during the Perinatal Period.

Abstract

INTRODUCTION The psychiatrist working in a general hospital psychiatric unit has several opportunities for consultation-liaison work with the obstetrician. There is a bidirectional relationship between psychiatry and obstetrics. While on one hand, the improved management of psychiatric illness is helping many more women with mental illness embrace motherhood; on the other hand, psychiatrists often receive referrals for the evaluation of women undergoing treatment for infertility or Assisted Reproductive Techniques (ART) or antenatal and postnatal care. From the obstetrician’s point of view, the major contributors to maternal mortality in the past were obstetric complications such as hemorrhage and medical disorders complicating pregnancy such as diabetes mellitus and hypertension. However, with improved obstetric care protocols and a significant reduction of maternal mortality rates due to obstetric and medical diseases, maternal mental health has come to the fore as one of the major contributors to morbidity and mortality. A psychiatrist may receive a referral for consultation in three broad situations: Either as an out-patient referral from the antenatal or postnatal clinic of obstetrics; In the obstetric in-patient or labor room; or From the obstetric emergency services. This article is organized as follows: First, we would like to give a broad overview of the various conditions that may be seen in the context of the perinatal period, including the medical disorders that can lead to these presentations and the suggested investigations. Second, we present a format for clinical assessment. Third is a note on the general principles of management in the perinatal setting, including a note on the risk-benefit analysis of medications and management planning. Fourth is a section on the management of individual disorders in the perinatal period. Finally, we cover other conditions such as management of suicidal risk, agitation, the use of electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (RTMS), and the future role of mother–baby units (MBUs) in general hospital psychiatry. OVERVIEW OF PSYCHOLOGICAL CONDITIONS IN THE PERINATAL PERIOD Preconception In the preconception stage, there are broadly three groups of patients who may be referred for evaluation: (i) Patients undergoing treatment for infertility or ART who may be referred for psychological issues such as stress, anxiety, and depression; (ii) Patients with previous traumatic experiences during pregnancy and childbirth; (iii) those with preexisting psychiatric illness. Patients who are undergoing treatment for infertility and those with previous traumatic experiences during childbirth, such as injuries during labor, disrespectful care during labor, stillbirth, or requirement for emergency interventions including Caesarean section may be at risk for psychological morbidity such as depression and anxiety. Patients with preexisting psychiatric illnesses may need a review of their clinical condition and decision on continuation, modification, or discontinuation of medication will have to be taken. During pregnancy referrals may be received for women with new onset of a psychiatric condition, preexisting mental illness, or for psychological distress caused by psychosocial factors such as marital discord, domestic violence, or substance use in spouse. Events around childbirth, such as stillbirth can lead to grief. There may be psychological distress related to gender of the infant. Medical illness in the infant and separation of mother and infant due to NICU admission may also lead to psychological distress including anxiety, anticipatory grief. In the postpartum period, disorders of mother–infant bonding may be there. Mood-related changes may present as postpartum blues or postpartum depression (PPD). Postpartum psychosis (PPP) is a particularly severe form of behavioral disturbance that may be seen in the postpartum period. Tables 1 and 2 present an overview of the various conditions seen in the perinatal period.Table 1: Overview of perinatal psychiatric conditions for which consultation may be soughtTable 2: Overview of postpartum psychiatric conditionsOUTLINE OF CLINICAL ASSESSMENT OF PERINATAL PSYCHIATRIC CONDITIONS When the psychiatrist is called for the evaluation of the obstetric patient, the psychiatric evaluation may proceed along the following lines [outlined in Box 1].Box 1: Clinical assessment in perinatal psychiatry historyHistory includes a routine psychiatric history and in addition, specific history pertaining to the perinatal context is elicited. This includes a history of past pregnancies and their outcomes, including traumatic pregnancies, obstetric complications, and perinatal loss. Current pregnancy details including psychosocial context of pregnancy, support from spouse and family as well as a history of substance use and domestic violence is collected. Care is taken to ensure privacy to the woman and family members as they may not be forthcoming with a history of psychological symptoms in a crowded emergency room or in the obstetric ward. Physical examination should be conducted to rule out organic etiology of the psychiatric presentation. Some of the common etiological possibilities such as hypertension, anemia, jaundice, thyroid disorders, connective tissue disorders, movement disorders, cerebral and cerebrovascular disorders must be ruled out. In addition to clinical examination, certain investigations [Table 3] and referrals to other specialists may be advised to the obstetrician.Table 3: Suggested laboratory investigations for diagnosis of common medical conditions occurring in the perinatal periodMental status examination can be done using the routine format used for general psychiatric evaluation. Particular note must be made if the patient has confusion, perplexity, or even frank disorientation as these may alert us to a medical/neurological etiology. Attention is given to the presence of delusions related to the infant or the presence of hallucinations that refer to the infant. These may have a bearing on the risk assessment that is done. Cognitive functions can be assessed as part of the routine mental status examination and followed up with further structured cognitive assessments which can help us assess the possibility of an organic etiology. Risk assessment should include an assessment of risk of suicide, infanticidal risk, and risk of harm to others. In every case, a specific enquiry must be made about suicidal ideas, plans, or any recent attempts of suicide. We may also use structured tools for the assessment of suicide risk. This may include the IS PATH WARM? Signs[15] or any other structured tool for assessment of suicidal risk. Mothers with severe mental illness (SMI) in the postpartum period may have infanticidal ideas and risk for infant harm. The presence of a depressive disorder and suicidality as well as psychotic symptoms related to the infant can lead to risk of harm to the infant.[16] Mothers with postpartum mania may handle the infant in a rough manner leading to potential injuries to the infant. They may also be verbally or physically aggressive to the infant during the irritable phase. Table 4 lists some psychopathology specific to the perinatal period and its clinical implications.Table 4: Psychopathology related to the infant and its implicationsPsychometric tools [Table 5] are helpful in the objective assessment of the patient’s clinical condition and can help monitor the treatment outcomes. While some scales are useful for screening in the antenatal setting, others are useful in rating the severity of psychopathology. Finally, some scales are particularly designed for research purposes use in specialized in-patient peripartum psychiatry settings; they assess constructs such as maternal behavior and mother–infant bonding or have been adapted for the peripartum setting.Table 5: Psychometric tools that may be useful in perinatal psychiatryROUTINE SCREENING FOR DEPRESSION AND ANXIETY IN THE ANTENATAL AND POSTNATAL PERIOD While universal screening may tend to overestimate the prevalence of psychosocial disorders or even unduly raise the alarm in the case of false-positive screen (~35%–40%), the Marce International Society position paper recommends that a basic inquiry into current symptoms using the Whooley’s questions, Patient Health Questionnaire-9[4] or Edinburgh Postnatal Depression Scale[5] along with inquiry about past and family history of psychiatric disorders may be useful.[17] The Whooley’s questions[3] are the first two questions of PRIME-MD, namely: (1) In the past 1 month, have you felt down, depressed or hopeless? (2) In the past 1 month, have you been bothered by little interest or pleasure in things? The offer for screening must be backed up with adequate resources to provide timely and appropriate services required for the woman (including appropriate referrals to secondary or tertiary care centers). In larger centers with multi-disciplinary teams, this may be possible within the hospital, however, obstetricians working in smaller centers without in-house counselors or mental health professionals may refer the women appropriately. Psychometric tools specific for the peripartum setting such as specialized MBUs or research purposes include the NIMHANS Maternal Behaviour Scale for rating maternal behavior and the Postpartum Bonding Questionnaire which is helpful in screening for disorders of mother–infant bonding. The Stafford Interview is a detailed interview schedule useful in MBUs and for research purposes. Table 5 lists some psychometric tools that may be used in perinatal psychiatry. We also suggest the settings in which the scales may be used. GENERAL APPROACH TO THE PATIENT IN PERINATAL PSYCHIATRY If the woman consults during the preconception period, and the woman is still symptomatic, we may advise the couple to delay pregnancy. They can plan for pregnancy once the clinical condition stabilizes. In case the woman is on medications and is asymptomatic, a trial of discontinuation may be attempted for women who have a history of mild illness such as a mild depressive episode in the past. The risk of relapse and the need for early review in case of relapse has to be emphasized in such cases. It is beneficial if there is a supportive caregiver at home who can detect early signs of relapse and bring the patient for management in the event of relapse. In case of SMI, prophylactic medications are preferable even if the patient is presently asymptomatic. A medication which is relatively safe in pregnancy and lactation may be chosen. We may need to taper and discontinue medications that are adjunctive in nature and no longer required. This may include benzodiazepines, beta-blockers, and anticholinergic agents. The decision to change the medication to another one with greater safety data may not be required in every case unless the risks of continuing the current medication are high for the given patient. However, abrupt discontinuation of medications must be avoided. Folic acid 5 mg/day is prescribed in all women who are planning for pregnancy. When a woman presents for consultation during pregnancy, we must emphasize that early and regular antenatal check-up and planning childbirth at a hospital with adequate facilities for maternal and neonatal care, including neonatal intensive care is preferable especially if the mother is taking psychotropic medications. All mothers on psychotropic medications are advised to undergo anomaly scans in early trimester (10–12 weeks) as well as at 16–18 weeks when fetal echocardiography can also be done especially for mothers who are on medications that may be associated with a risk of congenital cardiac defects (e.g., selective serotonin reuptake inhibitor [SSRI], lithium). If it is not a planned pregnancy and there were no prior opportunities to modify the medications in the preconception period, medications may be modified as outlined above. For new onset of psychiatric disorder during pregnancy, psychotherapy is preferred for mild illness in the first trimester. However, in case of persistent or worsening symptoms and in women with severe course of illness, medication may be initiated. Since pregnancy can alter the pharmacokinetics of medications, there may be a need for dose adjustments. A slow rate of gastric emptying and increased intestinal transit time can delay the absorption of orally administered medications. Increased plasma volume, lower lean muscle to adipose tissue, and changes in plasma protein binding leads to greater volume of distribution for lipophilic medications. Medications that undergo hepatic metabolism are cleared faster due to increase in CYP450 enzyme activity and Phase 2 enzyme activity (Uridine diphosphate Glucoronoyl Transferase) and increased steroid hormone levels. Medications that undergo renal clearance undergo greater clearance due to a higher glomerular filtration rate. These pharmacokinetic changes may require the following precautions [Table 6].Table 6: Pharmacokinetic considerations in pregnancyLACTATION ADVICE Prefer a minimum number of medications, preferably monotherapy in lactation. The medications which have low relative infant dose (RID) (preferably <10%) are compatible with breastfeeding. Since the medications achieve a steady state level after a few days of treatment, there is no need for withholding breastfeeding for a few hours after each dose of medications. On-demand breastfeeding is recommended. The infant should be monitored for signs of medication-related toxicity such as excessive sedation, floppiness, respiratory depression, cyanosis (with sedatives), or excessive crying, irritability, diarrhea, jitteriness, seizures (with antidepressants), and for rigidity, poor suck reflex, poor feeding, irritability (with antipsychotics). Breastfeeding may have to be withheld in case of any signs of toxicity and a review of medication done. In case of preterm or low birth-weight neonates or neonates with medical or surgical disorders, the advice of the pediatrician or neonatologist may be sought regarding the safety of breastfeeding. This is important because the metabolism of medications may be affected in neonates with these conditions and they may be at greater risk of adverse effects as compared to healthy neonates who are born at term and have normal weight. One of the concerns with the use of psychotropic medications has been a possible delay in infant development.[19] However, the developmental delay is usually mild and is reversible with the infant catching up with the peers once the exposure to psychotropic medication stops after weaning. Moreover, such delays were more common in low-birth-weight or premature infants or those born to elderly mothers.[20] In view of this, general advice must be given regarding adequate stimulation of infants. This would include ensuring that the mother or another caregiver is able to provide adequate sensorimotor stimulation to the infant in the form of massage and oil bath, singing lullabies, cooing and talking the infant, providing a variety of colors and sounds through toys, providing an emotional attachment figure to the infant in cases where the mother has severe negative symptoms or sedation due to medications. The possible risks of this mild and reversible delay outweigh the benefits of effective ongoing medications for SMI in the mother. Figure 1 outlines the general approach to the woman depending on the context of referral. The general advice for the stage at which the woman is seen and general considerations in medical management are listed next.Figure 1: General approach to management in perinatal psychiatryRISK BENEFIT ASSESSMENT AND MANAGEMENT PLANNING One of the concerns of medication use in perinatal psychiatry is regarding the potential harms of psychotropic medications on the pregnancy and fetal and neonatal outcomes. There is often hesitation among patients, caregivers, and other physicians to continue psychotropic medications during pregnancy. Some patients stop medications abruptly once they conceive and risk a relapse of psychiatric illness putting themselves and the fetus at risk. A risk-benefit assessment with regard to the use of medications in the perinatal period becomes important along with planning of pregnancy to mitigate these risks. The four major considerations of risks and benefits to the mother and fetus/infant that need to be considered are:-(i) risks of untreated maternal psychiatric illness; (ii) benefits of avoiding medication exposure; (iii) benefits of adequate control of maternal illness; and (iv) risks of medications. The risks of untreated maternal depression or SMI include the risk of poor adherence to antenatal care, self-neglect and neglect of infant, suicidal risk and/or infanticidal risk, poor nutrition, and physical disorders. Risk of domestic violence, substance use, and poor obstetric outcomes such as preterm labor, low birth weight, and stillbirth increase in patients who are symptomatic. The risks of untreated maternal illness are weighed against the medication-related risks. Medication-related risks include the teratogenic potential of medications, potential for maternal morbidity, adverse fetal, neonatal, and childhood outcomes. In this section, we discuss some of these risks which can aid in decision-making regarding psychotropic medications. The teratogenic risk categories for medications were formerly reported as Food and Drug Administration (FDA) categories from 1979 to 2015. Some representative medications and their FDA category are listed in Table 7.Table 7: FDA categories of medications, safety indication, and medication listsThese FDA categories were critiqued for being overly simplistic and misleading. They were replaced by the new Pregnancy and Lactation Labelling Rule[21] from June 30, 2015. The new rules categorize the risks into three headings: Pregnancy-related risks are mentioned. This includes any information on disease-related risks to mother and fetus or embryo, any dose adjustments required during pregnancy, maternal adverse reactions, fetal/neonatal adverse reactions, and finally effects on labor and delivery Lactation-related labeling includes details of the presence of drug and active metabolites in human milk, effects of drug on the infant, and effects of drug on breastfeeding itself. Information on minimizing exposure and monitoring for adverse effects is also listed Females and males of reproductive potential. This section covers the advice regarding requirements for pregnancy testing, contraceptive use before or during drug therapy. It also includes information on the effect of the drug on reproductive potential. These considerations help us to decide on medication management for psychiatric illnesses in pregnancy and postpartum. Some key medication-related risks are conveyed to the woman and caregivers in terms of risk/potential for major congenital malformations, any increased risk of specific congenital malformations, or adverse maternal and fetal outcomes while comparing these risks with the risk of similar adverse outcomes in women who decide to discontinue medications during pregnancy. Dara from large registry-based studies has suggested that the risks of a particular adverse outcome may not be attributable to the medication itself and may be due to the underlying condition for which the medication is being prescribed. This is called as “confounding by indication.” Table 8 lists the risks associated with some of the psychotropic medications with relative risks which can aid in patient education. However, it is pertinent to note that the evidence in this field is still emerging and it is important to review the latest evidence periodically and adapt the patient counseling accordingly.Table 8: Summary of risks associated with psychotropic medications[19, 22]PROCESS OF DISCUSSION OF RISKS AND BENEFITS OF MEDICATIONS WITH MOTHERS AND THEIR FAMILIES Once the clinical assessment is completed and a decision is made that the woman will have more benefits than risks of taking medications, the following discussion is suggested with the woman and family regarding the medication options [Box 2 and Figure 2].Box 2: Discussion of medication risks and benefitsFigure 2: Sample risk graphics to show risks during pregnancyMANAGEMENT OF PSYCHIATRIC DISORDERS IN THE PERINATAL PERIOD Common mental disorders include anxiety, depression and related disorders such as adjustment disorders are usually amenable to psychotherapy in the initial stages and when they are mild in severity. Therefore, the principle is to treat mild episodes of these disorders with psychotherapy alone. Cognitive behavior therapy (CBT) may help in anxiety as well as depression. Interpersonal psychotherapy may help in depression and exposure and response prevention (ERP) may be provided for treatment of obsessive–compulsive disorder. If the anxiety or depressive symptoms are persistent, recurrent or are worsening in severity; or if there is poor response to psychotherapy alone-medication may be prescribed for the management of the illness. Anxiety disorders Some women experience anxiety or stress related to infertility and treatment for infertility, previous pregnancy loss, fear of pain during labor (tokophobia), and concerns about traumatic experiences during pregnancy. In such cases, management involves psychoeducation, supportive counseling, and reassurance by obstetrician after due antenatal check-up. In case these measures do not help, more structured psychotherapy or medications may be considered as in the case of anxiety or depression. SSRIs (except paroxetine) are the medication of choice for the management of anxiety disorders in pregnancy. Buspirone (FDA category B) does not have many human studies to support the use. Depressive disorders In the case of depressive disorders, the risk-benefit assessment for considering medication prophylaxis has the following considerations. Women who have had a single mild episode of depression in the past may be given a trial of discontinuation of antidepressant medications if they are asymptomatic for 6–12 months. However, those who have had a more severe illness such as recurrent (four or more lifetime episodes) of depression, or have had severe depression with psychotic symptoms, or had suicide attempts during the depressive episode or have required hospitalization or ECT for control of depressive symptoms in the past will benefit from continuing the antidepressant prophylaxis.[23] The presence of domestic violence and previous traumatic experiences increase the risk and the presence of adequate social support is a protective factor against depression. Obsessive compulsive disorder For mild severity of symptoms, previous response to ERP/CBT with prolonged remission and absence of significant comorbidity like depression may allow a trial of discontinuation of SSRI treatment. However, in more severely ill women with comorbid depression or suicidal risk, the risks of discontinuation of medication may exceed the benefits. MANAGEMENT OF SEVERE MENTAL ILLNESS IN PERINATAL PERIOD SMI refers to Bipolar affective disorder and schizophrenia. In the context of perinatal psychiatry, severe behavioral disturbances can also occur in PPP as well as PPD which is often of abrupt onset, with severe symptoms, psychotic symptoms, and suicidal risk. The risk of relapse of bipolar disorder is as high as 66% in women who discontinue prophylaxis as opposed to about 25% among those who continue prophylaxis.[24] Women with schizophrenia are also advised to continue prophylaxis in the perinatal period. Second-generation antipsychotics (SGA) are preferred for prophylaxis. There is a risk of increased weight gain as well as gestational diabetes with SGA and women should be monitored for excessive weight gain and asked to undergo a glucose tolerance test during pregnancy.[19] Bipolar disorder Monotherapy with SGA is preferred as outlined above. In bipolar depression, there may be a need to add antidepressants for a short period in some women. Some women may require the addition of a mood stabilizer. Valproate and carbamazepine are avoided during pregnancy due to the risks of congenital malformations and neurodevelopmental disorders.[25] However, low-dose lamotrigine (<325 mg/day) may not be associated with risk of major congenital malformations and may be continued in women with bipolar depression after discussing the risks and benefits.[26] Similarly, in women who have required lithium prophylaxis to remain well, it may be considered after discussion with the woman and caregivers. Therefore, when SGA alone is not effective as prophylaxis and a mood stabilizer is required, lithium or lamotrigine may be considered as per the woman’s clinical profile. Relapse prevention strategies for bipolar disorder include: Avoiding sleep deprivation, stress management, ensuring medication adherence, avoiding substance use, and knowledge of early warning signs of a recurrence with self-monitoring of symptoms. Schizophrenia Monotherapy with antipsychotic medication is preferred for the management of schizophrenia. SGAs are usually preferred when treatment has to be initiated. While first-generation antipsychotics (FGAs) or long-acting injectable antipsychotics (LAI) are not initiated for treatment of schizophrenia during pregnancy. This is because there is less safety data regarding these medications. In case a woman is maintaining well on FGAs and a change of medications carries the risk of relapse, we may decide to continue the medications after discussion with the woman and family. In case a woman conceives while of effective treatment with LAI antipsychotics, the discontinuation may not immediately reverse the possibility of adverse effects as the clearance of these LAI drugs may take weeks after stopping treatment.[27] While most antipsychotics are compatible with breastfeeding and have RID <10%, clozapine is contraindicated in breastfeeding. For the management of severe postpartum psychiatric conditions, medications compatible with lactation are preferred. PPD typically begins within the first 4 weeks following delivery, but the risk period can be up to 2 years’ postdelivery. In mild cases, it may be managed with antidepressants alone. In cases of psychotic depression, an antipsychotic is also prescribed. However, the bipolar disorder must be ruled out in women before prescribing antidepressants for long periods. Severe illness, where suicidal risk is high, may warrant in-patient care to ensure safety of the patient, infant and others family members. Women with a previous episode of PPD may be given prophylactic antidepressants in the postpartum period. Brexanolone (allopregnanolone) is an endogenous progesterone metabolite which acts as an allosteric modulator of the GABA-A receptor. Brexanolone is recommended for moderate to severe PPD in a stepped dosing pattern as follows: 30 mg/kg/hour in first 4 h, followed by 60 mg/kg/h for next 20 h, then at a maximal dose of 90 mg/kg/h for next 28 h and then stepped down to 60 mg/kg/h for 4 h and 30 mg/kg/hour in the last 4 h. The administration of the requires close monitoring in an in-patient setting. Headache, dizziness, fainting, or syncope are the major adverse effects reported. The drug though approved by FDA is yet to be launched in India. PPP is a SMI which has abrupt onset in the postpartum period (usually within 4–6 weeks of childbirth). It may present as any one of the following clinical syndromes – acute mania, acute and transient psychotic disorder, catatonia, or psychotic depression. The specific underlying disorder must be treated after ruling out medical conditions that can mimic PPP. In addition, PPP is also often severe in presentation with suicidal risk or risk of harm to the infant or others. This may often require in-patient care for adequate management of symptoms. The mainstay of management of PPP is usually an SGA which is compatible with breastfeeding. While SGA alone may suffice in case of acute psychotic presentations, psychotic depression may require the addition of an antidepressant. In case of mania, a mood stabilizer may be initiated. Catatonia is common in pregnancy and postpartum period. About 20% of women admitted in the perinatal period had catatonia as opposed to about 8% of admissions to acute in-patient psychiatric units.[28] The management of catatonia in pregnancy often presents with a particular difficulty in management because it necessitates the use of a benzodiazepine – lorazepam for its management. However, the symptoms of withdrawal and refusal to eat can cause dehydration, hypoglycemia, and electrolyte imbalance. The presence of stupor or immobility increases the risk of venous stasis and deep vein thrombosis during pregnancy. Therefore, the benefits of treatment with lorazepam often exceed the risks associated with its use for patients having reduced oral intake, rigidity and immobility. Typically, management can be initiated with low-dose of lorazepam 3–8 mg/day (given in divided doses of 1–2 mg three or four times a day). In case of inadequate response over the first 24–48 h, the dose may be increased to 8–16 mg/day while monitoring for maternal pulse and blood pressure, and fetal heart rate. Further doses may be withheld if the maternal pulse is below 60 bpm or blood pressure is below 90/60 mmHg or fetal heart rate is below 100 bpm. When lorazepam is used, attempt must be made to reduce the dose and discontinue the medication while monitoring for symptoms of relapse. Another psychotropic medication must be initiated according to the underlying diagnosis. ECT is the other option for the management of catatonia that does not respond to lorazepam alone. Table 9 summarizes the management strategies for various psychiatric disorders depending on the clinical aspects of the disorder in a given patient.Table 9: Overview of preferred line of management for psychiatric disorders in the perinatal periodMANAGEMENT OF ALCOHOL USE DISORDER DURING PREGNANCY Fetal exposure to alcohol is associated with growth restriction, facial anomalies, and central nervous system dysfunction such as low intelligence and inattention-hyperactivity in the child. No level of alcohol use can be considered safe in pregnancy. Women must be educated about the risks of alcohol use and advised against drinking. Low levels of alcohol consumption may require brief intervention or motivational interviewing, however, those with moderate or high-risk use may require specialist deaddiction intervention. Mothers with alcohol dependence who experience significant withdrawal symptoms can be treated with a short course of benzodiazepine medications. Lorazepam or diazepam may be considered for detoxification in case of severe withdrawal symptoms. Long-term prophylaxis for relapse prevention relies on motivational interviewing and relapse prevention strategies. There is not much safety data to support the routine use of medications such as naltrexone or acamprosate. They may be prescribed in women who have a high risk of relapse. Disulfiram is avoided in pregnancy. MANAGEMENT OF OTHER SUBSTANCE USE DISORDERS IN PREGNANCY AND POSTPARTUM Cannabis use is associated with an increased risk of mood disorders, autism spectrum disorders, and inattention-hyperactivity in the offspring. Tobacco use is associated with risk of preterm birth, low birth weight, and malformations of lips and mouth as well as risk of increased maternal bleeding during labour. Psychotherapeutic methods are preferred for low levels of use. There is not much evidence for the safety of nicotine replacement therapy including patches and bupropion (FDA Category B) for the treatment of tobacco use disorders. Limited evidence suggests that they may not increase the risk of adverse neonatal outcomes.[29] The evidence for the safety of these medications is not extensive and hence treatment decisions must be taken on an individual basis. SUICIDE IN PREGNANCY AND POSTPARTUM The risk of suicide among women is higher in the 1st year after childbirth than any other time in their lives. Younger age, belonging to a middle socioeconomic status, poor perceived support, domestic violence, depressive symptoms, and having a past history of suicidality predict suicidal risk. Women are also more likely to use more lethal methods in the perinatal period. Suicidal risk and infanticidal risk may occur together and require attention. In-patient care may be considered along with ensuring the presence of family members and adequate social support to ensure a careful watch over the mother during the period of suicidal risk is essential. Box 3 summarizes interventions specific and appropriate for women with suicidal risk in the perinatal period.Box 3: Summarises interventions specific and appropriate for women with suicidal risk in the perinatal periodMANAGEMENT OF AGITATION IN THE PERINATAL PSYCHIATRY SETTING Agitation in the peripartum setting can put the mother and fetus/infant to risk of harm. Verbal de-escalation must be done first followed by oral medication such as lorazepam 1–2 mg or promethazine 25–50 mg or olanzapine 5–10 mg or chlorpromazine 50–100 mg. In case oral medications are not effective, intramuscular injection of lorazepam 2 mg or promethazine 25–50 mg or haloperidol 2.5–5 mg (in combination with promethazine to prevent dystonia) or olanzapine 10 mg may be considered. Regular monitoring of temperature, pulse rate, respiratory rate, blood pressure, and fetal well-being measures may be essential. Care should be taken to ensure that patient is lying supine with right hip elevation to avoid compromise of blood supply to fetus. ELECTROCONVULSIVE THERAPY The use of ECT during pregnancy may be life-saving in certain cases. Patients with catatonia or severe suicidal risk secondary to depression who do not respond to medical management alone may be considered for ECT. Some additional precautions taken during ECT in pregnancy are outlined in Box 4.Box 4: Use of electroconvulsive therapy in pregnancyREPETITIVE TRANSCRANIAL MAGNETIC STIMULATION The safety of RTMS during pregnancy has not been widely studied, however, the few studies that have been done in pregnancy have not reported any adverse maternal or infant-related outcomes due to RTMS.[30] MOTHER–INFANT BONDING INTERVENTIONS IN WOMEN WITH PSYCHIATRIC PROBLEMS Many mother–infant dyads will have been separated from each other or may have difficulties in forming attachment because of a mental health problem in the mother. Early attachment problems are a risk for later externalizing and internalizing problems in the child and other emotional difficulties in adolescence and adulthood. Adequate attention should be paid to the assessment of bonding using the instruments mentioned above and a good clinical interview. If a bonding problem is found interventions include education about the same training in infant care, modeling, video-enabled feedback training, and in case of a severe problem, mother–infant psychotherapy. Having an additional caregiver such as a grandmother or father is often beneficial. IN-PATIENT CARE OF PERINATAL MOTHERS AND THE MENTAL HEALTHCARE ACT 2017 The Mental Healthcare Act, 2017 recommends the least restrictive option for patient care. Therefore, outpatient care is preferred in mild psychiatric illnesses or exacerbations. However, in moderately severe illness episodes or exacerbations, inpatient care may be required to ensure safety of mother and infant. When inpatient care is provided to a mother with low risk of suicidal or infanticidal risk, rooming-in of mother and child (under 3 years of age) is recommended as per Section 21[2] of the Mental Healthcare Act, 2017. In case a decision to separate the mother and baby is made by the treating psychiatrist based on information available regarding the patient’s illness and an assessment of the patient’s clinical condition; the decision must be reviewed every 15 days. In case the separation must continue beyond a period of 30 days, the Mental Health Review Board must be informed and permission sought for the same. MBUs are in-patient units with at least four in-patient beds which allow the rooming-in of mothers and their infants or children under the age of 3 years and are run by a multi-disciplinary team of psychiatrists and allied health professionals. The requirements of setting up an MBU in India have been outlined by Chandra et al., 2015.[31] There may be a need to set-up MBUs in the future. CONCLUSION The role of a psychiatrist in the care of mothers with mental illness broadly includes evaluation and management of mothers with (i) psychological issues related to all aspects of pregnancy and childbirth such as infertility and its treatment, traumatic experiences related to pregnancy and childbirth; (ii) management of new-onset psychiatric conditions in the perinatal period; and (iii) management of preexisting psychiatric illnesses in mothers planning pregnancy. The major decisions regarding choice of treatment is taken based on risk-benefit analysis of the treatment of the psychiatric condition against the risks of untreated psychiatric illness in the mother. In general, the benefits of prophylaxis for mothers with SMI exceed the risks. Individualized decision may need to be taken in each case. The new legislation, Mental Healthcare Act 2017, encourages the setting up of specialized MBUs for the joint admission of mothers with their infant or children under the age of 3 years. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.