Practice Resource for Reproductive Psychiatry/Women’s Mental Health in Forensic Psychiatry Practice

Phenomenology of Psychiatric Illness Among Females with Juvenile Justice Involvement

Existing literature has established that psychiatric disorders are more prevalent among justice-involved adults, with over-representation among females.^37,–,39 Among justice-involved female children and adolescents, the prevalence of psychiatric problems is also elevated, with high rates of trauma and abuse, substance use, disruptive behavior, mood, and learning disorders, which are all thought to play a critical role in precipitating or perpetuating delinquent behaviors.⁴⁰ Forensic psychiatrists evaluating and treating justice-involved women should be aware of these gender differences to provide evidence-informed and unbiased evaluations.

Young women who are justice-involved present with a unique constellation of risk factors, psychiatric vulnerabilities, and needs. They are more likely to have experienced sexual victimization, a depressive disorder, or high levels of parental conflict; come from dysfunctional homes; and be involved with an older male partner or friends.^41,42 They most commonly will present in a noninstitutional setting, as courts tend to divert justice-involved females to the community.⁴³ Children in postadjudication settings, such as residential placements, show higher rates of psychiatric problems than children in other settings,⁴⁴ highlighting the complex interplay between serious delinquent behaviors and psychiatric illness.

Juvenile justice-involved females experience psychiatric disorders more than their male counterparts. McCabe and colleagues⁴⁵ found that nearly two-thirds of adjudicated females experienced at least one Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) disorder compared with one-half of adjudicated males and one-third of a community sample. Other studies have found similar or even higher rates of psychiatric disorders.⁴⁶ Studies examining the burden of psychiatric disorders in juvenile correctional facilities are not generalizable because of the limitations of small or male-only samples or examining a single psychiatric disorder. In contrast, the largest and only statewide census sample of committed youth found sex, race, or ethnic differences in the prevalence of psychiatric disorders, which was consistent with previous studies of both population types.⁴⁷ Depressive disorders, bipolar disorder, and anxiety disorders, including posttraumatic stress disorder (PTSD), had a higher prevalence in females.⁴⁷

Comorbidity is particularly important. Over half of the justice-involved female youths met the criteria for two or more disorders; thus, comorbidity is the norm.⁴⁸ Abram⁴⁸ also found that juvenile females had a greater chance of developing a substance use disorder than males if they had at least one other psychiatric diagnosis. Substance use prevalence tends to be similar between males and females, but girls generally show an earlier age of initiation and may show a more versatile pattern of use.⁴⁹ Alcohol use is commonly reported, and this may be associated with the high rates of trauma and PTSD among girls.^50,51 Mood disorders are also highly prevalent among justice-involved girls, occurring at higher rates than justice-involved males and at four or five times the rate of girls in the general population.⁵²

Regarding suicide attempts and self-injurious behaviors, adolescent females engaging in delinquent acts also attempt suicide at higher rates than depressed female adolescents residing in the community (27-58% versus 20%).^53,–,55 Nonsuicidal self-injury (NSSI) also occurs frequently. Up to 79 percent of self-injurers report a history of abuse or neglect.^56,–,58 There is a limited literature base specifically examining rates and impact of NSSI within juvenile justice-involved populations in general. A small study by Chaplo et al.⁵⁹ found that sexual abuse was a significant predictor of NSSI beyond other types of trauma. Justice-involved young females were much more likely to experience sexual abuse than males. NSSI functions as a self-regulatory mechanism in the context of stress and, often, posttraumatic symptoms.⁶⁰

Experiences of neglect, violence, maltreatment, and abuse are the norm for justice-involved youth, with over 90 percent of youth reporting an experience of at least one trauma and a high proportion experiencing multiple traumas.⁶¹ Compared with males, females reported higher rates of sexual and physical abuse as well as polyvictimization.^62,–,65 Because of the high number of justice-involved female youth who report sexual abuse, some researchers have hypothesized that childhood sexual abuse is a unique risk factor for future female delinquency.⁶⁶

PTSD is nearly three times more prevalent among justice-involved girls than boys, similar to community samples, with girls experiencing a more severe symptom course than boys.^45,64,67 A history of sexual abuse was more often found in girls with more extreme delinquency outcomes than those without.^68,69 Early puberty is a risk factor for psychopathology, including delinquency, in females.⁷⁰ It may be that early puberty leads to premature sexual experimentation and affiliation with older male peers and uncovering of mood or other psychiatric disorders.⁴¹ But early puberty could also be a marker for other risk factors for delinquency, such as sexual abuse. A few studies have established that women with sexual abuse histories tend to experience earlier menarche because of dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis.^71,–,73 There is also an association between early menarche and physical abuse, although far less robust.^72,74

Literature documenting reproductive health in detained youth is limited. Some studies estimate that between 20 to 40 percent of girls coming into the juvenile system have a documented sexually transmitted infection (STI), and they report higher numbers of sexual partners than girls in community samples.^75,–,77 These risky sexual behaviors may be multifactorial, including poor access to health care and education, poverty, reactions to complex trauma, and, for some, prostitution. Substance use and depressed mood also increase the probability of high-risk behaviors.⁷⁸ These girls’ sexual contact may be with older individuals; Lederman and colleagues documented that more than one-third of girls at a juvenile detention facility were sexually involved with someone at least five years their senior.⁷⁹ For many detained girls, their incarcerated time represents their only contact with medical providers and potential reproductive counseling.⁸⁰ Many detained girls also have health problems, including obesity, high rates of physical injuries, and other chronic medical conditions, which likely have been untreated or underdiagnosed because of poverty, parental neglect, abusive environments, or other factors.⁷⁹ Some detained girls enter the juvenile system pregnant or may become pregnant while under community supervision, but the exact prevalence is unknown. Nearly one-quarter of detained girls reported a lifetime history of pregnancy.⁸¹ These health-related concerns are important considerations for forensic psychiatrists working with this population.

Other factors unique to female delinquents include higher rates of familial mental illness⁴⁵ and a tendency to come from dysfunctional homes. Although limited by small sample sizes, Leve and Chamberlain reported that 70 percent of delinquent girls had at least one parent who had been convicted of a crime compared with 41 percent of males, but others have found family histories of antisocial personality to be similar between males and females.⁸² Girls may be more sensitive to relational elements and susceptible to harsh parenting, low warmth, maltreatment, and other factors. No distinct gender-specific pathway to delinquency has been uncovered.⁸¹ Additionally, disruptive females may be perceived as more deviant because of expected gender norms,⁸³ thus evoking a harsher response from the primary caregiver. Even emotionally dysregulated infants may precipitate a harsher parental response, which may be relevant to the development of conduct disorder.⁸⁴ Most girls, however, tend to follow an adolescent-onset and limited delinquent course, with a small proportion becoming persistent adult offenders.⁸⁵

Long-term follow-up of justice-involved girls paints a bleak portrait. Well over half of these girls reported ongoing victimization into adulthood, especially at the hands of romantic partners.⁷⁷ Many continued to engage in high-risk behaviors, such as drunk driving or carrying a gun, and had an increased risk of premature death. They were five times more likely to die violently compared with women in the general population.⁸⁶

Legal Disposition of Justice-Involved Female Youths

The Office of Juvenile Justice and Delinquency Prevention (OJJDP) published a national report in 2019 relying upon data from the Federal Bureau of Investigation’s (FBI’s) Uniform Crime Reporting Program, OJJDP’s juvenile court data archive, and census of youth in residential placement. By 2015, arrests, petitioned delinquency cases, and status offenses or violations because of being a minor were at their lowest point in decades, following a peak in arrests and delinquency in the late 1990s to the early 2000s. Notably, however, the female proportion of arrests from 2006 to 2015 continued to rise to nearly one-third of total arrests.⁸⁷ Overall, males accounted for a greater proportion of the arrests within each delinquent offense category, with one notable exception: prostitution, where young women accounted for 76 percent of arrests.

The typical female delinquency case involves a girl aged 15 or older who is of minority ethnicity and charged with a property offense; larceny or theft offenses are the most common.⁸⁷ In girls younger than 15, offenses against people (rather than property) were most common. Girls accounted for a small proportion, less than one-fifth, of violent crime index offenses, which included rape, armed robbery, and aggravated assault. On the other hand, females accounted for 43 percent of status offenses (actions considered delinquent because of the juvenile’s age, which includes truancy, curfew violations, and running away), a much larger percentage than the delinquency caseload (28%). The typical female status offense involved a girl 15 years or older. The most common status offense for both males and females was truancy. Females accounted for more truancy and running away cases than did their male counterparts.

Across all offense categories, females were less likely to be detained and, even if referred to juvenile court, more likely to receive informal sanctions. When adjudicated, females usually received probation and were less likely to be placed in out-of-home placements. Public order violations, such as obstruction of justice, which included probation violations and escape from custody, were more likely to result in placement.⁸⁷

Specialized Assessment and Treatment Approaches for Justice-Involved Female Youths

In response to the harmful effects of trauma on youth offenders and frontline staff, the U.S. Department of Justice has called for creating trauma-informed juvenile justice systems. A relative consensus regarding the core domains of a trauma-informed juvenile justice system exists in the literature, but there is much less agreement on the specific implementation and policies.⁸⁸ When possible, health care and facility leadership staff should attempt to incorporate a coordinated multidisciplinary trauma-informed perspective in their diagnostic and treatment practices to enhance the quality of care for these youths. This perspective should include routine screening of youths for trauma exposure; evidence-based practice adopted by service providers; accessible resources on trauma to adolescent health care providers, youths, and their families; and consistency that there is a continuity of care across service systems.⁸⁹

Important concerns that are particularly relevant with detained or adjudicated female youths include weighing the risks and benefits of the proposed psychotropic medication: the medication’s risk of overdose; pregnancy; and short- and long-term side effects, such as sedation and weight gain; anticipated youth compliance; the facility custody (if no health care staff are on site to administer); “cheeking” and trading medication for various reasons; and the parent or legal guardian’s reliability to supervise the youth’s medication and ensure follow-up psychiatric treatment. Other important variables to consider include prescription coverage, health plan benefits, and the potential for medication abuse and diversion (e.g., psychostimulants). The youth’s treating psychiatrist should consult with the youth’s treatment team and reassess the need for continuation or adjustments to various psychotropic medications based on compliance, side effects, current symptoms, level of functioning, and treatment needs. The clinical team, other relevant staff, and family members when appropriate should explore the circumstances and rationale for a youth’s pattern of medication refusal.⁹⁰

Baby Snatchers and Kidnapping by Cesarean

Regarding infant abductions, D’Orban¹¹¹ described impulsive psychotic offenses, “comforting offenses,” and “manipulative offenses.” The impulsive psychotic offenses often included midlife women who had been unable to care for their children and believed that the infant was their own. The “comforting offenses” were noted to be “committed by young girls from deprived backgrounds with immature, hysterical personality traits, sometimes associated with mild mental handicap” (Ref. 112, p 196). Finally, the “manipulative offenses” were “committed with the intention to consolidate an insecure relationship with a man and influence his feelings, by pretending to him that he is the stolen child’s father” (Ref. 112, p 196). D’Orban¹¹² noted “the motives underlying pseudocyesis include the need to secure a husband’s wavering affections and bolster a faltering marriage and to obtain a child as a plaything and companion. The motives are clearly similar to the motives found in the manipulative and the comforting types of child theft” (Ref. 112, p 197).

An investigation of hospital abductions of infants studied 77 American cases over the decade from 1983 to 1992. Seventy-three of those were returned safely within a fortnight. Rabun¹¹³ noted that almost all abductors were women who tended to be overweight and impersonating a nurse. Male partners were noted to be naive about infants and childbirth. The women often simulated pregnancies and nesting prior to the abductions and had histories of feigned pregnancies, miscarriages, and stillbirths. Almost half of the nonfamily infant abductions from 1983 to 2006 were taken from health care settings (47% were taken from the hospital, birth center, or pediatric clinic).¹¹⁴ Two-fifths (40%) were taken from homes. Almost all abductors were women, and almost half impersonated a health care worker. Almost one-fifth (18%) used violence, and 13 percent had made a previous attempt at abduction. Hospital staff thus play a key role in the prevention of hospital infant abduction.

Fetal abduction (also known as cesarean kidnapping) accounts for three percent of all infant abductions. The pregnant woman is usually killed prior to the removal of the fetus. The perpetrator uses a confidence-style approach. The abductor has usually faked a pregnancy and plans to dispose of the mother's body.¹¹⁵ Frierson¹¹⁵ noted that steps involved in fetal abduction include faking a pregnancy, identifying and contacting pregnant women, obtaining weapons for the murder and cesarean section, choosing a location, subduing and killing the mother, the cesarean section itself, disposing of the mother’s body, and finally, convincing others that the baby is hers.¹¹⁵ The abductor may trick others into believing she is pregnant by wearing padding, which simulates pregnancy, and researching how to feign positive pregnancy tests.

Fetal abductors will rarely meet legal criteria for insanity.¹¹⁵ The overwhelming majority of women who feign pregnancy do not become baby snatchers. There may be an elevated risk of suicide after a foiled attempt.¹¹⁵

Neonaticide and Safe Haven Laws

Neonaticide refers to child homicide on the first day of life.¹¹⁶ In neonaticide cases, the mother almost always acts alone, as the father is often no longer part of her life. Mothers who commit neonaticide are often in their teens or twenties, have limited resources, are unmarried, and with an unwanted pregnancy.¹¹⁷ They have rarely been diagnosed with a mental illness prior to the homicide, and suicide is rare in the western world among women who commit neonaticide.¹¹⁷ Neonaticides often occur after denial or concealment of pregnancy.¹¹⁷ Evolutionary psychiatry has been used as an explanatory model to help explain some child homicides as rational acts.¹¹⁷

Regarding neonaticide, it is important to consider where the study originated and the sample population. In general population studies, maternal perpetrators of neonaticide have been generally found to be single and young of lower socioeconomic status, living with their parents, experiencing denial or concealment of pregnancy and thus a lack of prenatal care, and fearful of repercussions.¹¹⁷ They tend to lack any serious mental illness prior to the offending,¹¹⁸ although they may develop PTSD, anxiety, or depression subsequently. A study of American neonaticide pretrial detainees primarily referred by defense attorneys for psychiatric evaluation found both denial of pregnancy and dissociative symptoms were often self-reported.¹¹⁹ No measure for malingering was able to be used, and the study relied on self-report measures.

Most neonaticides occur at home. Fathers rarely participate in neonaticides.^120,121 Multiple women have committed serial neonaticides. DNA evidence has recently been used to identify women who years later were identified as neonaticide perpetrators.¹²²

In America, Safe Haven Laws have existed since 1998 with the goal of decreasing rates of newborn abandonment and neonaticide. These now exist in all 50 states.¹¹⁸ Safe Havens vary in different states but may include hospitals, police stations, and fire stations as safe places for women to drop off their unwanted infants. Mothers will often remain anonymous and will not be prosecuted. Age ranges vary for Safe Havens, including infants under 72 hours old to up to a year old, depending on state and location. Data are not systematically available, but some studies suggest Safe Haven Laws may decrease the number of neonaticides. Neonaticides do still occur. It has been noted: “Women make quite different choices when they choose abandonment in a Safe Haven (hospital), abandonment in a place where the infant is not likely to be found (trash receptacle), and neonaticide. It may be different groups of women who act in these different ways” (Ref. 118, p 45).

Opposition to Safe Haven laws includes that it may potentially encourage women to conceal their pregnancies and to birth infants outside hospitals unsafely, thereby encouraging abandonment. Another concern is that these laws are not well publicized and thus are not well known by the population in need of them. Outside of the United States, other prevention methods are used, such as anonymous free delivery of unwanted babies in France. Also, baby hatches exist at similar locations (hospitals) outside of the United States, where mothers can safely relinquish their unwanted infant unharmed.¹¹⁸

Infanticide, Infanticide Acts, and Filicide

Infanticide and filicide both involve the murder of one’s child. Infanticide is a less precise term, which overlaps a legal definition that only includes certain mothers who kill their infant up to one year of age. Filicide includes child murder by the parent, usually up to age 18, while the child is still living in a dependent relationship with the parent.¹²⁰

Although the United States does not have an Infanticide Act, approximately two dozen countries other than the United States, including Canada, have an Infanticide Act. These laws decrease penalties for mothers who kill their child within the first year of life in general, although in parts of Australia and New Zealand, the law includes older children.¹¹⁷ The 24 nations that have Infanticide Acts, tend to follow the original British Infanticide Act of 1922 (amended in 1938). This act has allowed mothers to be charged with what is akin to manslaughter rather than murder if they were experiencing a mental disturbance at the time that they killed their infant under age one. Initially, this law was based on the concept of “lactational insanity.” Historically, women servants killed their infants, whom they could not look after and still work. The public has often given leniency to women who are convicted of infanticide; women will often receive sentences of probation and referral to mental health treatment rather than incarceration.¹²³ Those criticizing infanticide laws often point out the following: fathers are not eligible, the life of the child may be devalued, and a woman in the same mental state may kill a young child under age one and an older child and would only be eligible for infanticide for one of the children killed.^117,123

Identification and treatment of parental mental illness, personality disorders, and substance use disorders is part of prevention of infanticide. Infanticide is related to mental illness in some cases. When postpartum psychosis is not treated, the risk of both suicide and infanticide rises, as well as the risk of child maltreatment. This risk of child maltreatment may be because of the mother’s confused or delusional thinking.¹²⁴ It is critical to understand whether the mother’s hallucinations and delusions involve the infant; infanticidal ideas and behaviors have both been associated with a mother having psychotic thoughts about her infant.¹²⁵

In addition to parental risk factors, risk factors in the infant or child that may increase the risk of maltreatment and death include colic, autism, and developmental disability.¹²⁶

In evaluating filicide research, it is vital to consider that common factors among mothers or fathers who kill vary depending on the type of population studied. For example, jail and correctional studies will have different expected results than studies of mothers in the forensic hospital and coroner studies or general population studies.¹²⁰ What is commonly found among mothers who kill is “a pattern of powerlessness, poverty, and alienation” (Ref. 120, p 1582).

When evaluating international studies about filicide, caution must be used because rates across countries may significantly differ related to societal and cultural differences.¹²⁸ In the United States, infant homicide rates are higher than in most countries. A recent study¹²⁹ found that those children at the highest risk of being killed in Denmark included young children whose mothers had been hospitalized because of mood disorders or schizophrenia. To decrease the risk of filicide, as one does with other types of violence, one should consider the various static and dynamic risk factors.¹²⁸

General population studies of women who killed their children often demonstrate that these mothers are socially isolated, have poor socioeconomic status, and are full-time caregivers who may have been violently victimized themselves.¹²³ Persistent crying or other child factors were sometimes the described precipitant to the filicide. Substance misuse often occurred in this group as well. Mental illness may or may not have occurred in this group.¹²³ In the corrections population, mothers who killed tended to be similarly unemployed victims of abuse themselves who had limited social support and education. Mental health concerns and substance use concerns were also noted, as were multiple stressors. Finally, and alternatively, in psychiatric samples of women who had killed their children, studies found frequent psychosis, suicidality, depression, and a history of mental healthcare. Some personality disorders and some intellectual disorders were noted. Significant life stressors were common.¹²³

In a study regarding psychiatrists’ knowledge about maternal thoughts of child harm, most psychiatrists underestimated how often depressed mothers experienced thoughts of harming their child. Approximately one-half of the psychiatrists indicated that they did not ask specifically about filicidal thoughts but rather asked about general homicidal thoughts.¹³⁰ Asking mothers about filicidal thoughts is critical in performing risk assessments.

When filicide is committed jointly with suicide, mental illness may often have been involved. Although many mothers attempt suicide with filicide, just as in suicide cases, women may be less likely to die by suicide than men based on the attempted method. Fathers and mothers commit filicide at similar rates,¹¹⁷ yet fathers are approximately twice as likely to commit filicide-suicide.^120,131,132

Regarding infanticide and filicide motives, not all are related to serious mental illness. Resnick¹¹⁶ described the five motives for filicide in a categorization that remains commonly used today. The five motives currently include fatal maltreatment, unwanted child, partner revenge, altruistic, and acutely psychotic.¹²³ Fatal maltreatment is the most common cause of child murder and occurs as the result of abuse or neglect, which is often chronic.^117,124 In an unwanted child case, they are unwanted, such as because of inconvenience or other plans for a new partner or new life. Partner revenge is meant to cause psychological pain and suffering in the other surviving parent, such as during custody battles. In distinction, in altruistic filicide, parents, often with a psychotic or depressive disorder, kill their children out of their perception of what love is, believing that they’re preventing suffering on Earth, or kill a child when they are themselves suicidal to prevent that child from being parentless. Finally, in acutely psychotic filicide cases, parents kill their child for no comprehensible motive. This may occur in response to command hallucinations or in confusion or delirium. The final two motives: altruistic and acutely psychotic, are most likely related to a serious mental illness whereas the others may or may not involve serious mental health problems.¹²³

When completing a not guilty by reason of insanity (NGRI) evaluation for filicide, the definition of the cognitive prong in the case or statutory law of the jurisdiction should be considered. In addition to the routine assessment of collateral records, additional records that may be useful include prenatal care records, pediatrics records, and Child Protective Services records.¹¹⁷ Recommendations for questions in a comprehensive interview after filicide are outlined in the Friedman et al.¹³³ chapter on writing a maternal filicide report.

In cases of fatal maltreatment, there may be mental illness, but there may also be evidence of personality disorder, anger problems, intellectual disability, or substance use.¹¹⁷ Similarly, in unwanted child cases, there is often an absence of severe mental illness. Parents who engage in partner revenge filicide may have a personality disorder. Regarding altruistic filicide cases, these parents often experience a psychotic disorder or depressive disorder, and similarly, parents with acutely psychotic filicide often have a psychotic disorder.

Among mothers found NGRI in two American states, almost three-quarters had previous treatment by mental health care providers.¹³⁴ Over two-thirds were experiencing auditory hallucinations, frequently command hallucinations. Approximately half were depressed at the time of the filicide. Almost three-quarters experienced considerable developmental stressors, including incest or the death of their mother, for example. The motives among the mothers found Not Guilty by Reason of Insanity were predominately considered altruistic motives or acutely psychotic motives.¹³⁴

Rates and Pregnancy Testing

A significant number of women in the United States are confined to either correctional institutions or psychiatric hospitals. In recent decades, the number of women incarcerated in the United States has risen dramatically from 26,378 in 1980 to 222,455 in 2019, with most of these women being within their reproductive years.^135,136 Even higher numbers of women enter mental health facilities each year, with approximately 400,000 women of childbearing age being psychiatrically hospitalized in 2016.¹³⁷ Data on pregnancy among incarcerated or psychiatrically hospitalized women are sparse because of inconsistent screening and reporting practices in these settings.^137,138 It is estimated that anywhere from three to ten percent of female inmates are pregnant at the time of admission to a correctional institution,^136,138 and no statistics regarding pregnancy rates among psychiatric inpatients are available in the current literature.

Pregnancy testing is needed when a woman is admitted to a correctional or psychiatric facility because reports of sexual, contraceptive, and menstrual histories are often unreliable.¹³⁹ Up to 80 percent of female inmates endorse heterosexual activity in the weeks leading up to incarceration, with less than 30 percent using a reliable form of contraception.¹⁴⁰ Knowledge of pregnancy status upon admission to either a correctional or a mental health facility is crucial to providing timely initiation of prenatal care, counseling regarding abortion or adoption, identifying women at risk of pregnancy-related complications, ensuring appropriate activity restrictions (e.g., work and bunk assignments), analyzing risks and benefits of treatment decisions, and minimizing risks of adverse pregnancy outcomes related to medication use and other interventions.^136,141

Despite being an important aspect of medical evaluation, pregnancy testing is not uniform across correctional or inpatient psychiatric facilities, with a recent report showing less than 40 percent of jails routinely obtaining pregnancy tests at intake¹⁴² and pregnancy testing rates ranging from 59 percent to 94 percent upon admission to psychiatric hospitals.¹³⁷ Screening for pregnancy has been identified as a high-priority measure to improve the quality of inpatient psychiatric care,¹³⁷ and several organizations, including the American College of Obstetricians and Gynecologists (ACOG) and the National Commission on Correctional Health Care (NCCHC), have recommended that all women of reproductive age be offered pregnancy testing upon reception to correctional institutions.^141,143 Even when pregnancy testing is negative, screening upon incarceration or psychiatric hospitalization allows providers to discuss family planning strategies with a group of women at increased risk for unintended pregnancies.^137,144

Abortion Access

Women with psychiatric illnesses and women in the criminal justice system have elevated rates of unplanned pregnancies.^144,145 Being incarcerated or psychiatrically hospitalized does not preclude a woman’s legal right to abortion, although the state in which she is hospitalized may restrict abortion access. Timely access to abortion for these populations is often inconsistent and unreliable because of variations in policies, ill-defined counseling practices, concerns about potential coercion, and logistical challenges involving appointment scheduling, transportation, and payment.^146,–,148 In some instances, abortion is viewed as an elective procedure and therefore denied until a woman’s release, resulting in delays in care.¹⁴⁷ Given the time restrictions on pregnancy termination, abortion should be considered a medically necessary procedure and arranged as expeditiously as possible.¹⁴⁷

Informed consent is especially important when abortion is being considered, given that the procedure is time-sensitive and irreversible and that the decision-making process may be complicated by conflicting opinions among stakeholders, sociopolitical controversies, and strong emotional reactions from patients or clinicians.¹⁴⁹ Consenting to abortion should be assessed similarly to the capacity to consent to any significant, permanent medical procedure.¹⁵⁰ Preabortion counseling should be comprehensive and nondirective.¹⁴⁹

Contraception

Psychiatric hospitalization and incarceration both offer an opportunity to provide family planning services to women whose reproductive health care needs often go unmet.^145,147,151 Taking a sexual history upon admission may allow for the use of emergency contraception. A study of newly arrested women found that nearly 30 percent were eligible for emergency contraception, and of those, almost half indicated a willingness to take emergency contraception if available.¹⁵² In surveys of female inmates in Rhode Island, half of the respondents indicated they did not wish to become pregnant. Less than 30 percent reported consistent preincarceration birth control use, over 80 percent had prior unintended pregnancies, 35 to 40 percent had previous abortions, and over 80 percent anticipated resuming sexual activity after release.^145,147 Studies have found that female inmates are amenable to starting contraception during incarceration and are much more likely to initiate birth control when provided free of charge by the correctional institution rather than postrelease.^145,147 ACOG recommends that all incarcerated women be offered services for contraceptive methods, including emergency contraception, based on the medical need to minimize the risk of unintended pregnancy.¹⁴¹

Like incarcerated women, women with serious mental illness have relatively low rates of contraceptive use compared with the general population and high rates of unintended pregnancies.¹⁵¹ Women with psychiatric illness may have limited access to obstetrical or gynecological services, and contact with mental health care providers may serve as their only opportunity to address reproductive needs.¹⁵¹ Many mental healthcare clinicians do not routinely discuss birth control with their patients.¹⁵³

Female permanent contraception, or tubal ligation, is one of the most common methods of birth control used by women in the United States.¹⁵⁴ Permanent sterilization among incarcerated women and women with psychiatric illnesses has a dubious history and raises several ethics concerns relating to informed consent and coercion. Long-acting reversible contraceptives (LARCs) are extremely effective in preventing pregnancy, have high continuation rates, and may be a more suitable alternative in these populations.¹⁵¹ Admission to a correctional facility or psychiatric hospital is an opportune time to address family planning in a population at risk for unintended pregnancy and other adverse reproductive health outcomes.

Pregnancy Management

Providing prenatal care to women in correctional and psychiatric settings poses several challenges because of complex logistics and conflicts between institutional priorities and health care needs. Treatment is often shared between facility medical staff and community obstetrical providers, and problems may arise involving transportation, coordination of care, and delays in obtaining emergency services. Security presence during appointments may give rise to confidentiality concerns. Furthermore, women housed in correctional or psychiatric institutions lack control over their surroundings, including noise levels, clothing, food choices, sleep schedules, and the timing of meals and snacks, which may exacerbate pregnancy-related discomfort.

Community standards for prenatal care apply to women who are incarcerated or psychiatrically hospitalized^141,155 and include pregnancy testing; pregnancy counseling; access to abortion; evaluation and treatment of substance misuse, HIV, and depression; provision of appropriate vitamins and nutrition; and delivery in a hospital with facilities for high-risk pregnancies.¹⁴¹ The National Commission on Correctional Health Care (NCCHC) and the Federal Bureau of Prisons have set similar standards. Yet compliance with such guidelines is variable across institutions, with shortcomings identified in a wide range of areas, including pregnancy testing at intake; access to abortion; provision of prenatal, labor and delivery, and postpartum care; HIV treatment; mental health services; nutrition and vitamin supplementation; special accommodations; substance misuse treatment; and pregnancy outcomes reporting.^143,156,157

Perinatal Medication Treatment in Prison and Forensic Hospitals

For further details about prescribing for women in corrections, please refer to Friedman et al.² When treating mental illness during pregnancy, the psychiatrist should consider the risks and benefits of the medication to the mother and the dyad.¹⁵⁸ Potential medication risks during pregnancy include elevated rates of miscarriage, congenital malformation, premature delivery, perinatal syndromes (withdrawal or toxicity), and behavioral teratogenesis. Risks and benefits to both the mother and the infant should also be considered in lactation, as the vast majority of medications will pass into breastmilk.¹⁵⁸ The psychiatrist must weigh the risks of the specific medication with the risks of not treating mental illness, which may include violence, suicide, and not taking care of oneself or obtaining proper prenatal care.

In a correctional or forensic hospital environment, the psychiatrist should coordinate with other medical professionals, such as obstetricians and pediatricians. For those women with new onset of depressive symptoms in the mild range during pregnancy, psychotherapy alone, with close follow-up and a proactive approach and planning to start medication if symptoms worsen, may be appropriate. Although a full discussion of medication use during pregnancy and postpartum is outside of the scope of this document, the psychiatrist should be aware that, for depression during pregnancy and the postpartum, SSRIs are the first-line agents, in particular sertraline and citalopram, which have relatively good safety profiles during pregnancy. Paroxetine is not a preferred treatment in pregnancy for major depressive illness because of its potential for increased rates of infant cardiac malformation.¹⁵⁸ Readers are also referred to the “Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum Clinical Practice Guidelines” published by the American Colleague of Obstetricians and Gynecologists.¹⁵⁹

Among women with bipolar disorder or schizophrenia, olanzapine and quetiapine are commonly used in pregnancy.^160,–,162 Where possible, the use of multiple agents should be avoided because of a paucity of research on polypharmacy and the potential for increased risk of adverse effects.

Pregnancy Outcomes

Data regarding births and pregnancy outcomes in U.S. correctional and psychiatric settings are minimal. No pregnancy-related reporting requirements have been standardized or mandated across American systems.¹⁴⁰ A study from 1998 found 1,400 births across 43 state prisons.¹⁴⁰ More recently, a survey of 12 months of pregnancy statistics from 22 state prisons and the Federal Bureau of Prisons reported 1,396 pregnancies with 753 live births (92% of outcomes), 46 miscarriages (6%), 11 abortions (1%), four stillbirths (.5%), two ectopic pregnancies (.25%), three newborn deaths, and no maternal deaths.¹⁴⁰

Compared with the general U.S. population, incarcerated women and women with mental illness have higher rates of adverse pregnancy outcomes, including prematurity and low birthweight.^13,163 When compared with similarly disadvantaged groups, depending on the timing of incarceration, imprisoned women may have improved outcomes with less prematurity, fewer stillbirths, and higher birth weights, suggesting some aspects of confinement, such as adequate housing, regular nutrition, and forced sobriety, may be health promoting among this vulnerable population.^{140,163,–,165} Relatively positive birth outcomes in correctional populations should be interpreted within the context of broader social determinants of health.¹⁴⁰ To date, there is no systematic published data regarding pregnancy outcomes among forensically psychiatrically hospitalized women.

Use of Restraints

Using restraints among pregnant inmates and psychiatric inpatients is controversial.¹⁶⁶ A restraint is defined as any manual method that immobilizes or limits the movement of a person’s arms, legs, body, or head.¹⁶⁷ The main reason for restraint use is to prevent escape (correctional) or harm to self or others (psychiatric).¹³⁶ In correctional settings, shackling or restraints are routinely used during transport and may include ankle cuffs, handcuffs, or belly chains.¹³³ In psychiatric hospitals, soft restraints, restraint masks, or fabric body holders are used during behavioral crises.¹⁶⁷ Many organizations, including the American Civil Liberties Union, the American Psychological Association, and ACOG, have opposed the routine use of restraints among pregnant women in corrections.¹³⁶ Restraints in pregnancy may have potential adverse health effects, including impaired mobility, discomfort, increased risk of falls, delays in care during obstetrical emergencies, increased risk of blood clots, decreased placental blood flow, and interference with labor and delivery.^141,168 Restraints should be used only when there is an imminent risk of harm to the pregnant woman, her fetus or newborn, or others and only when less-restrictive alternatives, such as verbal de-escalation or increased staffing, are unsuccessful.^169,170

Postpartum Epidemiology and Presentation of Postpartum Depression and Postpartum Psychosis

Postpartum depression is common, with rates as high as one in five mothers.¹⁷¹ Although the DSM-5 requires the symptoms to begin within a month postpartum for diagnosis, the window of vulnerability is often the entire first year postpartum, which has the highest risk of suicide for women.¹⁷² Like in pregnancy, symptoms are often missed or overlooked, yet the impact is on the woman, the infant, and the entire family unit. Recognizing the difference between postpartum depression and the “baby blues” is important. The latter is very common, upward of three-quarters of postpartum women experience a several-day period of irritability and heightened emotions related to the hormonal changes and sleep deprivation of the postpartum period.¹⁷³ This typically resolves by the end of the second week postpartum and is not associated with more concerning symptoms, such as thoughts of death or difficulty with baby bonding.

Several risk factors can predispose someone to postpartum depression. These include biological and genetic vulnerabilities, such as a history of depression, family history of postpartum mood conditions, or experience with other hormonally mediated conditions, such as premenstrual dysphoria.¹⁷⁴ These also include social and psychological risk factors, such as ambivalence about the pregnancy and relationship and family conflict or interpersonal violence. A difficult or traumatic delivery, poor pain management, and challenges with breastfeeding may also contribute to the risk of postpartum depression.¹⁷⁵

There is also a substantial percentage of women who are labeled as treatment-resistant depression who have a bipolar spectrum condition. In a multicenter study of first-episode depression (n = 885), 15 percent of those with first-onset postpartum episodes met DSM-IV criteria for bipolar disorder. In comparison, only five percent of those with first-onset nonpostpartum episodes did.¹⁷⁶

Bipolar disorder is the most common underlying diagnosis for a presentation of postpartum psychosis, a condition affecting about one to two per 1,000 women, with a high risk of recurrence and often onsetting shortly after delivery.¹⁷⁷ Untreated postpartum psychosis carries with it risks of suicide and infanticide.¹²⁴ It can often manifest with a delirium-like presentation, with confusion, disorientation, and depersonalization, making recognizing the diagnosis more challenging.¹⁷⁸

It is also important not to confuse postpartum psychosis, because of its inherent risks, and postpartum obsessive-compulsive disorder (OCD), with intrusive, distressing thoughts.¹²⁴ With the latter, the intrusive thoughts, often of harm befalling the baby or other family, possibly at the hands of the mother, are ego-dystonic and distressing to the woman. In contrast, with postpartum psychosis or certain personality conditions, the thoughts of self or other harm can be ego-syntonic and are cause for clinical concern.

Forced Separation and Custody Loss

Approximately three-quarters of the women incarcerated in the United States are mothers. In contrast to fathers in custody, who often rely on their children’s mothers for childcare, many incarcerated women are single parents lacking paternal support.^136,179 Few U.S. correctional facilities (and no forensic psychiatric hospitals) allow children to coreside with their mothers, meaning that most children of incarcerated or hospitalized mothers will be placed with a family member, a friend, a foster home, or given up for adoption.¹³⁶ While in custody, mothers may maintain contact with their children through letters, telephone calls, video conferences, and face-to-face visits. Fewer than half of incarcerated women have in-person visits with their children for various reasons, including transportation problems, prohibitive geographic distances, facility environment not being child friendly, security procedures, and short visitation times.¹³⁶

Under the Adoption and Safe Families Act of 1997, mothers with no family to care for their children and who are incarcerated for more than 15 months may have parental rights permanently terminated, regardless of parenting abilities.^136,180 Separation can be detrimental to mothers and their children, leading to psychological harm and possibly increasing recidivism rates for female offenders.¹⁸⁰ NCCHC recommends facilities support efforts for women to maintain contact with their children and recognize the distress that separation may cause incarcerated women and their children.¹⁴³ Forensic psychiatrists may be asked to opine about the appropriateness of such contact.

Breastfeeding

The benefits of breastfeeding have been well documented, and many organizations, including the American Academy of Pediatrics and ACOG, recommend exclusive breastfeeding for the first six months of life.^181,182 Incarcerated or psychiatrically hospitalized women face barriers to breastfeeding, including physical separation from the infant, lack of access to breast pump and storage equipment, lack of privacy, and lack of lactation support and education.^136,183 Additionally, female inmates and women with serious mental illness often have demographic characteristics (such as low income, unstable housing, or substance misuse) that decrease the likelihood of breastfeeding.¹⁸³ Furthermore, potential effects of psychiatric medications on the newborn may cause concern among postpartum women and caregivers, and deter breastfeeding initiation in these populations.¹⁸⁴ Information regarding prescribing for incarcerated women in the postpartum period has been previously published in JAAPL,² and the reader is referred there. Studies of incarcerated mothers have shown that they often view breastfeeding as important and may derive psychological benefits from it.^183,185 NCCHC has recommended that correctional facilities, wherever possible and not precluded by security concerns, devise systems to enable postpartum women to express breastmilk and directly breastfeed.¹⁸⁶ Doula support programs have been shown to promote breastfeeding among incarcerated women.¹⁸³

Medication Treatment in the Postpartum

During breastfeeding in the postpartum, polypharmacy should similarly be avoided where possible. The preferred antidepressant in lactation is sertraline. Olanzapine or quetiapine are common prescribed antipsychotics in mothers with bipolar disorder or psychotic symptoms.¹¹⁸ Careful documentation of the mother’s thinking and the informed consent process should be completed. Finally, sedation as a side effect should be considered among mothers who need to care for their infant at night, for example, in mother-baby units of correctional facilities or under community control.

Mother-Baby Units and Visitation

The United Nations Children’s Fund (UNICEF) noted that mothers and infants should not be separated because of incarceration, related to the child’s best interest and the right to family life. Many nations outside the United States offer mother-baby units (MBUs). MBUs are currently offered in 10 states.¹³⁶ In Canada, depending on the jurisdiction and other factors, children may remain with their mothers until age four, seven, or 12.¹³⁶ The cost of housing a child in a prison nursery is similar to that of foster care.¹⁸⁷

MBUs allow children to live with their mothers in correctional facilities until 12 or 18 months of age. Specific criteria must be met in order for a mother to participate, such as not having a history of child maltreatment or being incarcerated for a non-violent offense. MBUs should include a child-friendly environment and focus on the relationship between the mother and the baby. “In theory, goals for MBUs should include providing a supportive environment and training for improved parenting, improved attachment, and decreased recidivism related to the importance of the mothering role” (Ref. 136, p 369).

It is recommended that postpartum mothers be screened for (and treated for) maternal mental illness. As well, Child Protective Services can assist in determining whether MBU placement is appropriate for the mother and infant.¹³⁶ Current studies indicate that mothers separated from their infants are more likely to be reincarcerated and to recidivate.¹³⁶ An American study of infants at prison nursery programs demonstrated that most developed secure attachment, which increased if they were in the MBU longer. This occurred even despite a mother’s attachment style being insecure.¹⁸⁸ There are arguments against MBUs, including the concern about the child’s rights, the suggested risk of incentivizing pregnancy, and an unnatural custodial environment for the child.¹³⁶

Because many incarcerated women have been living as the head of a single-parent household the month before their arrest, there may often be a lack of paternal support upon the mother’s incarceration. This is a gender difference because most incarcerated fathers identify the child’s mother as the primary caretaker.^133,189 Children are then often placed in grandparental care, foster care, and adoption.

Despite efforts, there may be limited contact with children when women are incarcerated, and children of incarcerated mothers are known to subsequently experience increased rates of depression, anxiety, and criminality.¹⁹⁰ Parenting classes are offered in many prisons. There are fewer women’s prisons than men’s, and they may be located in isolated areas far from population centers. This may make it difficult for the children of prisoners to visit their mothers in prison. This creates a problem, as contact while the mother is incarcerated predicts successful reunification once the mother is released from prison.¹⁹¹

Effects of Menopause

Menopause is a transitional period when decreased estrogen levels can be associated with both increased physical symptoms as well as mood and psychotic symptoms.¹⁹⁵ The menopause transition generally starts around the age of 47 and lasts four to seven years.¹⁹⁵ Physical symptoms may include irregular menstrual periods, hot flashes, night sweats, sleep disturbance, sexual dysfunction, and elevated risk of osteoporosis and cardiovascular disease.¹⁹⁵ Psychiatric symptoms may worsen during menopause, including more frequent symptoms of depression and a worsening of schizophrenia.¹⁹⁵

Health problems related to menopause are the third most common reported health concern in older women in prison.¹⁹⁶ Women are at increased risk of developing mood symptoms during perimenopause, especially women with an earlier history of depressive disorders.¹⁹⁷ For women, absent a prior history of depression, symptoms of depression were more than twice as likely to occur during the menopausal transition than premenopause.¹⁹⁸ Risk factors for developing depressive symptoms in menopause include a history of depression, vasomotor symptoms, sleep disturbances, surgical menopause, early age at menopause, negative attitudes about aging and menopause, and concurrent life stressors.¹⁹⁵

Women with severe mental illness, such as schizoaffective disorder, schizophrenia, bipolar disorder, or major depressive disorder, reported significant vasomotor, physical, sexual, and psychosocial symptoms related to menopause.^195,199 As well, women have a second peak of onset of schizophrenia after age 45, corresponding to the onset of menopause.^195,200

Medication dosage may need to be adjusted in menopause to maintain efficacy. The decreasing hormonal levels associated with menopause may affect drug metabolism. Some metabolizing enzymes are estrogen dependent. Other factors affecting drug metabolism and efficacy in older women include polypharmacy, alcohol, illicit drugs, liver mass, smoking, caffeine, and nutritional intake.¹⁹⁵

Pudas et al.²⁰¹ noted that, by midlife, changes in biological sex and sex-hormone-mediated memory circuitry become apparent. These changes during menopause may explain cognitive decline during aging.²⁰² Compared with premenopausal women, postmenopausal women show different hippocampal responses during verbal memory tasks.^203,204

Diagnostic accuracy is important when treating or performing evaluations of older women. Depression and other reversible conditions can be mistaken for neurocognitive disorder (NCD) in older women. A careful differential diagnosis should be considered when evaluating patients with suspected NCD.

In elderly women, the first symptoms of physical illness often are psychological or behavioral in nature. The onset of delirium can signify the presence of infection or other somatic conditions.²⁰⁵ Treatable medical conditions can be misdiagnosed as functional NCDs in older women.²⁰⁶

Aging Women in Corrections

Both the male and female prison population declined from 2018 to 2019. The number of males declined by two percent from year-end 2018 to year-end 2019. The number of women declined by almost three percent over the same period. Males accounted for 92 percent of the total prison population and females eight percent.²⁰⁷ Despite the overall decrease in the number of inmates, certain subgroups of the prison population are increasing. Persons older than 50 are the fastest growing segment of the prison population.²⁰⁸ Between 1990 and 2014, the number of prisoners over 50 had grown by more than 50 percent.²⁰⁹ Several factors have contributed to this increase: mandatory prison sentences, three-strikes legislation resulting in a sentence of life in prison after the third felony, and longer sentences.^210,211

Over the last 40 years, female incarceration rates in state prisons have risen substantially for all ages.²¹² A contributing factor is the increased involvement in the criminal justice system of white women charged with violent, property, and drug-related offenses.²¹³

The increase in the aging population, coupled with the increase in the female population, has combined to produce a substantial increase in the subgroup of older female inmates.²¹² In California alone, the number of geriatric female prisoners increased by 350 percent between 1996 and 2006.²¹⁴ In 2019, 3.2 percent of male prisoners and 1.6 percent of female prisoners sentenced to more than a year were 65 or older. Approximately 15.4 percent of women sentenced to more than a year were age 50 and older.²¹⁵

Because of the accelerated aging of the prison population associated with earlier development of disability, most correctional systems and facilities use the age of 50 or 55 to assign inmates to the geriatric population.^216,–,218 Those over 50 require enhanced medical services and support resources.²¹¹

Older female inmates have more chronic illnesses than nonincarcerated women and have higher rates of psychosocial stressors.^2,214 Inmates 55 and older have higher rates of hypertension, respiratory disease, and arthritis compared with women in the general population who are 65 and older.¹⁹⁶ Compared with their age-matched male inmates, older female inmates have worse physical health, more frequently disclose mental health problems,²¹⁹ and have higher rates of comorbidities than men.²¹⁴

Neurocognitive Disorders among Aging Female Prisoners

Women have increased risks of developing Alzheimer’s disease (AD) compared with men.^220,221 Several risk factors for neurocognitive disorder occur more frequently in the female incarcerated populations than in the general population. These include head injury, depression, obesity, and substance misuse.² Several studies strongly indicate that females with AD are more affected by disease processes than their male counterparts.^222,223 Compared with men, women with AD demonstrated a greater decline in essentially all cognitive domains than AD men.²²⁴

Twenty-eight percent of geriatric female prisoners studied in California reported memory loss, and 69 percent reported at least one impairment of Prison Activities of Daily Living (PADLs).²¹⁴

Because of the incidence of cognitive deficits in the aging populations, it is recommended that the standard patient screening and assessment process be expanded to include a standardized, objective screening measure of cognitive ability, such as the Mini-Mental State Examination and the Montreal Cognitive Assessments.²¹¹ The “start low, go slow” strategy when prescribing cholinesterase inhibitors can help decrease the frequency of adverse events in the geriatric population, especially in women.²²⁵ Serious events occurring immediately after initiating cholinesterase inhibitor therapy were associated with the higher starting dose. This association was stronger in women.²²⁵ Estrogen is not considered a prophylactic treatment for dementia.²

Prescribing in Geriatric Female Inmates

The same concerns about prescribing for the general geriatric population apply to the correctional population. Prescribing for geriatric patients requires attention to risks because of the prevalence of underlying medical conditions; heightened sensitivity to medication side effects, particularly in women; and the potential for drug-drug interactions.²²⁶ Risks are further increased by medical multimorbidity and polypharmacy, which are more frequent in aging women.²²⁷ Polypharmacy increases the risk of adverse events and iatrogenic harm.²²⁸ Side effects can affect cognition.²¹¹

Housing Older Females

Older women present unique physical and mental health problems that institutions must address to meet their health care needs. In addition to access to care problems, female inmates with a neurocognitive disorder or physical limitations may be subject to disciplinary actions when cognitive and physical impairment goes unrecognized.²¹⁸

Handtke et al.²²⁹ recommended tailored social and health interventions that address the specific needs of elderly women. Data were collected from two prisons in Switzerland housing women prisoners. Three main areas of particular vulnerability were identified: the status of “double minority” (being a woman and being elderly), health and health care access, and social relations.²²⁹ Aging women can be vulnerable to victimization by other younger inmates. There are separate housing units for older men; many advocate for these specialized units for women.²¹²

A national pilot study of federal and state prisons for women looked at services available to older women. The authors found that prisons reported supplying basic physical and mental healthcare services and most reported providing hospice services. Prisons housing larger percentages (or expecting to house larger percentages) of older female prisoners did not significantly differ in their approaches to assessing and providing healthcare compared with their counterparts. Enhanced services were recommended.²³⁰

Barry et al.²¹² conducted focus groups with health care workers in the Connecticut State Department of Corrections for Women to better understand the unique health care needs of older women prisoners. They identified challenges in caring for older women. These women had multiple comorbidities and exhibited cognitive or communication deficits, and they needed more intensive levels of care and higher staffing levels. The healthcare workers reported difficulty finding a balance in providing the appropriate level of empathy, given this restriction within the prison system. The healthcare workers recommended that more resources needed to be allotted for mental health needs for this age group.²¹²

There are also challenges in ensuring compliance with out-of-facility medical referrals. Barry²¹² noted that elderly female prisoners were reluctant to travel offsite for medical care and refused treatment. The same van used for medical appointments first dropped off defendants for court appearances. Being in the van with young and disruptive defendants was very distressing to the older women, who preferred to forgo care rather than ride in the van.

Correctional facilities have to deal with the challenge of caring for persons requiring nursing home levels of care and training staff to treat older populations. Alternatives such as specialized nursing units for women are being considered. Early release programs may be appropriate for severely physically and mentally compromised inmates.²¹¹

Malpractice Evaluations in Pregnancy

When treating pregnant women with mental health problems, psychiatrists need to be aware of both the risks of failure to treat as well as the potential risks from treatment with medication. Should a forensic psychiatrist be involved in a malpractice lawsuit in this area, both of these concerns should be considered in addition to routine items considered in a malpractice case.^149,158,234 Risks of untreated mental illness in pregnancy include suicide, infanticide, preeclampsia, poor prenatal care, increased risk of fetal exposure to drugs or alcohol, fetal exposure to maternal cortisol levels, preterm delivery, low birth weight, and failure to thrive. Just as there are reasons that serious mental illness is treated at any point in life, there are compelling reasons to treat mental illness during pregnancy, whether with medication, psychotherapy, or both. The psychiatrist should be aware that, in any evaluation of treatment during pregnancy and the postpartum period, no medication is without potential risk. All pregnancies have risks, even when the mother has done everything right. For example, approximately three percent of pregnancies in America yield infants with malformations.¹⁵⁸ When the psychiatrist is treating a pregnant woman with medications, considerations include the potential risk of miscarriage, risk of malformation, preterm delivery, perinatal toxicity, and behavioral teratogenesis.¹⁵⁸

Approximately 13 percent of pregnant women are prescribed antidepressant medications. Those with severe or moderate depression are more likely to require treatment with antidepressants than those with mild symptoms.¹⁵⁸ Rational medication decisions, informed consent, and good documentation are most important when treating pregnant women. The involvement of the patient’s partner and family in the discussion helps improve compliance and potentially reduce misunderstandings and disagreements about treatment. Medication management in pregnancy is largely outside of the scope of this document, but the reader is referred to Friedman et al.² In general, older medications for which there are more data available are more appropriate to utilize in pregnancy than brand new medications.¹⁵⁸ Exposure to agents of concern is often most critical in the first trimester of pregnancy during organogenesis. Other medications that cause the potential for withdrawal in the newly delivered infant may be considered problematic in the third trimester. Polypharmacy should be minimized in pregnancy where possible because of the potential multiplicative rather than the additive effect of two agents. Monotherapy should be considered where possible, as well as using a medication the patient has previously done well on. The lowest effective dose should be used.¹⁵⁸ Further, half of all pregnancies are unplanned; thus, many patients become pregnant under the care of a psychiatrist.¹⁵⁸ This should be considered when treating all women of reproductive age, and when possible, medications should be chosen that are safe in case she becomes pregnant.

Women may consider discontinuation of psychotropic medications upon learning they are pregnant. Women who stop their antidepressants during pregnancy are more likely to experience a relapse than those who continue their medication. Cohen et al.²³⁵ found that 26 percent of those continuing their antidepressants during pregnancy relapsed, compared with over two-thirds (68%) who had stopped the medication. Viguera and colleagues²³⁶ considered recurrence rates after discontinuation of mood-stabilizing medications, finding 52 percent recurrence within 40 weeks after lithium discontinuation during pregnancy (58% for nonpregnant). Postpartum recurrences were more frequent than those among nonpregnant women after the length of pregnancy. Recurrence risk was higher among those with rapid (rather than gradual) discontinuation. The effects of depression on infant development, as well as the mother-infant attachment, both need to be considered.

A major ethical and malpractice concern occurring during pregnancy and the postpartum includes the psychiatrist’s failure to treat the pregnant woman because of concerns about bad outcomes. Specifically, doctors may believe that, when a negative outcome occurs related to an intervention, it is different than when a negative outcome occurs because of an illness.^237,238 “Omission bias occurs because doctors are more concerned about acts of commission (if treatment were to lead to a negative outcome) than acts of omission (not treating a patient’s illness). When one is cognizant of this potential bias, one may address it— such that one ensures equal discussion of risks of treating and the risks of leaving maternal depression untreated” (Ref. 286, p 82).

Negative outcomes during pregnancy leading to malpractice cases may include a suicide or a homicide, an infant malformation, or another negative outcome. Suicide and homicide cases may allege the failure of the psychiatrist to treat. Evaluating forensic psychiatrists must consider, as the treating psychiatrist should have, the risks and benefits of various courses of action regarding treatment and whether the treating physician informed the mother of those risks. It is important that forensic psychiatrists be aware of the research, including recent research regarding valproic acid and lithium, which are never completely contraindicated in pregnancy or lactation.^240,241 Working knowledge of the state of the literature is important. A reproductive psychiatry consult should be obtained when necessary and feasible.²²⁸

Forced Medications in Pregnancy

Women with mental illness have increased risks of negative outcomes from pregnancy.⁸ Schizophrenia has been associated with having infants who are premature, small, or large for gestational age, as well as maternal preeclampsia.¹³ Additional risk factors found more commonly among women with serious mental illness include illicit substance use, use of alcohol, or smoking while pregnant. Women with serious mental illness also have elevated victimization rates and poor prenatal care.²⁴² Each of these is a risk factor for negative outcomes of pregnancy.

In completing evaluations for involuntary treatment in pregnancy, the following have been recommended⁸: the evaluating psychiatrist must be aware of the model used for involuntary treatment consideration in the state where the treating psychiatrist practices. The woman’s diagnosis, the rationale regarding the need for treatments with consideration of current knowledge about the use of antipsychotic and mood-stabilizing medication and pregnancy (including the risk in a specific trimester of pregnancy), the concerns about why capacity is lacking, and the least restrictive alternatives as far as treatment are important. The forensic psychiatrist should also understand potential pregnancy complications stemming from both untreated illness and treatment. In forensic reports, the harms of no treatment for mental illness should be described, as well as the risk of medications. Further, communication with staff in obstetrics and pediatrics is important. Friedman and colleagues (Ref. 8, p 222) also note, “if feasible, for involuntary medication orders in pregnancy, oral medications or possibly short-acting injectable antipsychotics are preferred over long-acting injections”. Forensic psychiatrists must “consider their own biases and potential biases or fears of others involved in the process” (Ref. 8, p 222). This includes treatment team members, the woman’s family, and the legal system.

Substance Use During Pregnancy

The use of substances during pregnancy has been shown to result in adverse infant health outcomes, including drug dependence, miscarriage, premature birth, low birth rate, and behavioral and cognitive problems.²⁴³ Treatment options for mothers who misuse substances during pregnancy include voluntary and involuntary treatment. Depending on the jurisdiction, pregnant mothers may be involuntarily civilly committed or placed in the protective custody of the state for treatment based on the risk of danger to the unborn infant. States also vary in mandated reporting requirements in cases of mothers misusing substances during pregnancy. At the time of authoring this document, 20 states have laws requiring health care providers to report perinatal substance use to child protective services and four states mandate health care providers to report only when the provider believes the substance misuse resulted in child maltreatment.²⁴⁴

Diagnosis of Eating Disorders and Pregnancy

Eating disorders are more common in women, with a lifetime prevalence of 8.4 percent compared with 2.2 percent in men.²⁴⁵ Eating disorders are serious psychiatric illnesses associated with high rates of medical morbidity and mortality. Apart from deaths from opioid abuse, eating disorders have the highest mortality rates of any psychiatric illness,²⁴⁶ both because of the medical complications of eating disorders as well as from suicide.²⁴⁷ Patients with severe and enduring eating disorders are a subgroup with longstanding and life-threatening disorders. These patients have a low likelihood of recovery, poor adaptive function, high levels of symptoms, and comorbid physical and psychological illnesses, and require the regular attention of a multidisciplinary team.^248,–,250 Treatment providers must therefore be realistic about the prognosis given the low odds of a cure and adjust treatment expectations accordingly.²⁵¹ Thus, managing this subgroup of patients may require trying a novel treatment modality and a shift in the goal of treatment from cure to harm reduction or ultimately to palliative or hospice care.

The bulk, 90 percent, of eating disorders develop before age 25.²⁵² Individuals with anorexia nervosa are also more likely to become pregnant at a young age compared with individuals who do not have an eating disorder.^253,254 Indicators of a suspected eating disorder include failure to achieve or maintain an appropriate weight for age and height; intense fear of gaining weight; preoccupation with feeling fat; abnormal electrolytes, such as a low serum potassium level;²⁵² oligomenorrhea; amenorrhea; and inadequate weight gain in pregnancy.²⁵⁵

Although the absence of menstruation is no longer required for the diagnosis of anorexia nervosa, the resumption of menses is still seen as a hallmark of recovery. Despite weight gain, amenorrhea persists in 15-35 percent of women with anorexia, possibly because of either a high level of exercise or anxiety.^256,257

The prevalence of eating disorders in pregnant or breastfeeding women is about five percent.²⁵⁸ Despite the absence of menses in many patients, women with anorexia nervosa are twice as likely to have an unplanned pregnancy, whereas women with bulimia have a 30-fold increased risk of unplanned pregnancies compared with the general population.²⁵⁹

Pregnant women with eating disorders are at high risk for poor nutrition during pregnancy and negative birth outcomes, including spontaneous abortion, preterm labor, and obstetrical complications.^260,–,262 They have a greater risk of having infants with low birth weight, smaller head circumference, microcephaly, intrauterine growth restriction, and perinatal mortality.²⁶³ Pregnant women with eating disorders are often younger than those without eating disorders, and they are more likely to experience higher pregnancy-related maternal and perinatal morbidity and mortality than older adult women.²⁶⁴

For those who refuse treatment for their eating disorders during pregnancy, involuntary psychiatric care may be considered, especially if the patient presents an imminent danger to herself or her unborn child or meets the statutory definition for grave disability in that particular state (e.g., if a woman is not able to provide adequate nutrition for herself).²⁶⁵ If the woman is too ill to take care of her infant after birth, consideration should be made for contacting Child Protective Services.

Capacity and Decision-Making in Eating Disorders

Guardianship and involuntary psychiatric commitment are legal measures utilized to compel treatment. Both measures require the individual to lack capacity. In most jurisdictions, guardianship does not grant a guardian the power to admit the ward to a mental health facility without the ward’s consent. Furthermore, the courts can only authorize ongoing psychiatric care and nutritional rehabilitation under commitment laws once the respondent is no longer medically compromised.²⁶⁵

Because therapeutic alliance is an important predictor of achieving a target weight and remaining in treatment, treatment providers often hesitate to initiate involuntary treatment.^266,267 These concerns must be weighed against concerns regarding future morbidity and mortality if a patient with severe anorexia nervosa continues to refuse life-saving care.²⁶⁸

A harm-reduction approach must consider several ethics matters to ensure clinicians understand the needs of a pregnant patient at a given time and make clinical decisions based on the jurisdictional standard of treatment decision-making. Principles such as “first do no harm” and respecting patients’ right to self-determination (taking capacity for decision-making into account) should be used as guides.