Psyched Out

Psychotic Disparity: Low Income Women and Mental Health Treatment in Pregnancy
by Mary H

An often overlooked issue of social justice is the disparity in treatment given to impoverished uninsured/publicly insured and wealthier privately insured women who experience psychosis during pregnancy. An impoverished, pregnant and actively psychotic woman is among society's most vulnerable citizens. Yet doctors sometimes hesitate to prescribe the exact same medication for potentially deadly psychosis that they give for inconvenient nausea during pregnancy, leaving pregnant women committed in locked facilities, untreated and fully psychotic for many weeks.

Psychosis is the most severe form of mental illness, often robbing its sufferers of even the ability to perceive it as a disease with treatment available. Suicide is a serious risk among psychotic patients, with research showing a 4-10% death rate. Compared to pregnant women treated with antipsychotic medication, women diagnosed with psychosis without medication had four times the risk of psychiatric relapse and hospitalization. Psychiatrically hospitalized psychotic women experience markedly worse pregnancy outcomes. They have twice the rate of stillbirth, infant death, premature birth, low birth weight and small for gestational age babies compared to psychotic women treated outpatient. All antipsychotics are proven safe throughout pregnancy, several are used to treat nausea. Mood stabilizers for manic psychosis are safe after the first trimester, and one mood stabilizer, Lamictal, is shown to be safe even then. Try to imagine a middle class woman with private insurance committed and left untreated, and the primary cause of this social injustice is clear: social class.

Wealthier, privately insured women enjoy several key benefits from their social status and personal power. They often have better access to information about their illness and medications before pregnancy and more access to other pregnant women with psychosis through the internet. Privately insured women obviously have better access to health care and more choices. Privately insured women tend to have more collaborative relationships with their doctors, more time in office visits and they are free to “doctor shop” if they are denied treatment with medication by one physician. Certainly many poor women enjoy rich social networks and supportive partners, but overall these benefits are more available to richer women. If a doctor does try to commit a privately insured wealthy woman, she is likely to have a medical guardian to approve medications when she cannot consent to treatment herself due to the psychosis.

Several solutions could improve care for impoverished uninsured/publicly insured women. Improved education for both doctors and women of childbearing age could be provided along with the popular campaign giving information about postpartum mental health. Universal health care would resolve some disparity in care because many more doctors would accept a national insurance and discrimination based on ability to pay would be greatly reduced. Finally, community efforts to establish volunteer medical guardians for psychotic women that do not depend on intact families, perhaps through Le Leche League and local childbirth assistants, would prevent a woman from being incarcerated rather than medically treated unless she chooses that path before she becomes ill.