Decision-making about Psychopharmacology Use among Pregnant and Post-partum Women and their Physicians: A key informant study

Background and Purpose

Social work practitioners often engage in decision-oriented activities with a range of clients related to psychopharmacology (Bentley, Walsh & Farmer, 2005). For pregnant and postpartum women in particular, decisions to initiate or continue psychiatric medication are complicated by concerns regarding fetal/infant risk, uncertainty about symptoms that could negatively impact parenting, and worries about conflicting social messages about medication use while pregnant or breastfeeding. We argue the ostensible simplicity of published algorithms and consensus guidelines to assist physicians with prescribing (e.g. Jain & Lacey, 2005; Nonacs & Cohen, 2003, Altshuler et al., 2001) bely the complexities of real-world decision-making between women and their health providers. A social work research agenda aimed at developing more responsive, collaborative, and compassionate care should consider behavioral theory (including decision science and Anderson's model of health service use, 1995), previous clinical trials and social science research, as well as multiple stakeholder perspectives and interdisciplinary viewpoints. The objective of this research was to uncover central themes in decision-making around psychiatric medication among women and their physicians, and to detail the ways in which these themes would explicitly inform subsequent research.

Methods

Qualitative key informant interviews (N=12) were conducted using a semi-structured guide with a purposive sample of pregnant and postpartum women as well as community practice ob-gyn providers. Women narrated their life stories of psychopharmacology decision-making, while physicians provided detail on influential decision-making factors and described “successful” and “unsuccessful” experiences with prescribing. Coding of narrative data into themes was affirmed through progressive member checking among participants and an interdisciplinary advisory panel of academics and direct providers across obstetrics and gynecology, nursing, pharmacy, psychiatry, social work, and health administration. A questionnaire with items directly derived from the themes was subsequently field tested in a convenience sample of health care providers and women consumers.

Results

Themes that emerged in the interviews suggested that women's decision-making balances a desire for symptom management optimizing pregnancy and parenting experiences with determination to minimize fetal/infant risks; self-regulation of medications was a clear and cogent theme as well. The ob-gyn providers had sophisticated psychopharmacology knowledge, but perceived an intense responsibility to serve as “default mental health providers.” A theme emerged with both physicians and women that the dearth of information regarding long-term effects of medications on children perpetuates fears and fuels a strong desire for increased collaboration and more candid communication among women, ob-gyn providers, and mental health practitioners alike.

Conclusions and Implications

The results of this study informed the instrument development for a large scale survey (to be discussed and distributed) which examines the relative importance of costs and benefits weighed by consumers and providers during psychopharmacology decision-making, identifies facilitators and barriers to their responsive communication, and catalogs critical incidents and time points within ongoing processes of psychopharmacological assessment. The ultimate goal of our research is to inform practice models that can be integrated into both social work and health care practice settings to enhance compassionate care and candid communication about psychiatric medication.