Stll Rough, but Complete and Improving

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 medication treatment is at times withheld in favor of long term committment for this population due to a blend of limited choice as well as poor access to care and information.

Psychosis is the most severe form of mental illness, often robbing its suffererss 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 women treated with antipsychotic medication, women previously diagnosed with psychosis without medication had four times the risk of psychiatric relapse and hospitalization. Psychiatricallly hospitalized psychotic women experience notably 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.

Doctors often hesitate to prescribe medications for potentially deadly psychosis when they prescribe the exact same medication for inconvenient nausea during pregnancy. With the exception of mood stabilizers, all antipsychotics are safe throughout pregnancy. Even mood stabilizers are safe after the first trimester, and one mood stabilizer, Lamictal, is shown to be safe even in the first fourteen weeks. In uninsured/publicly insured inpatient and outpatient psychiatrists have been known to withhold pregnancy safe antipsychotic medications, instead leaving pregnant women committed, untreated and fully psychotic for many weeks. Try to imagine a middle class woman with private insurance treated this way, 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. Poor women usually have limited public and no home access to the internet. Privately insured women obviously have better access to health care and more choices. In addition, privately insured women tend to have more collaborative relationships with their doctors, more time in office visits, more liklihood of consults, and they are free to “doctor shop” if they are denied treatment with medication by one physician. Very few doctors accept medicaid,or take uninsured patients, and in any place but a large city there may be only one game in town. Certainly many poor women enjoy full and rich social networks and supportive partners, but overall these benefits are more availible to richer women. If a doctor does try to commit a privately ensured wealthy woman without offering treatment instead of containment, richer women are more likely to have people in their lives to authorize treatment when the actively psychotic woman cannot consent to treatment herself.

Several low cost 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 basic health care would resolve some of the disparity in care because all women would be publicly insured and many more doctors would accept a national insurance. Discrimination based on ability to pay would be greatly reduced. Finally, community efforts to establish medical guardians for psychotic women that do not depend on intact families or present fathers, perhaps through groups Le Leche League and local childbirth assistants would prevent women from being incarceated rathed than medically treated unless the lack of medication was the woman's choice before she became psychotic.