A woman with major depression with psychotic features requesting a termination of pregnancy
Depressive Disorder, Major
Case Presentation Ms. A, a married, pregnant 31-year-old woman with a history of major depressive disorder, was admitted to an inpatient psychiatric unit with dysphoria, ruminative worries about her work performance, difficulty sleeping, doubts about her potential to be a goodmother, and suicidal impulses to jump out of her apartment window. On the day before admission, she impulsively punched herself in the abdomen with the hope of inducing a miscarriage. Acting on the advice of her outpatient psychiatrist, Ms. A's husband brought her to the hospital. Ms. A had no previous history of psychiatric hospitalization, suicide attempts, self-injurious behavior, drug or alcohol use, or manic symptoms. She had no unique access to lethal means other than residing on a high floor of an apartment tower. She did not have any medical problems. Her mother had major depressive disorder that was controlled with paroxetine, and therewas no family history of suicide. Ms. A, a resident foreign national who spoke English fluently, was employed as an intellectual property attorney and was married to a compatriot who was a graduate student. (Some details have been changed to protect the patient's privacy.) Ms. A's pregnancy was planned. Under the supervision of her outpatient psychiatrist, she had discontinued venlafaxine (225 mg/day) prior to conception because of concerns about teratogenicity. Threemonths later, Ms. A was promoted to a more senior role at her law firm and was assigned more complex cases. She began experiencing anxiety and worries that she would be unable to perform effectively. She also had difficulty concentrating on her work, insomnia, and ruminative worries that she would be fired, lose her visa, and ultimately be unable to support her husband and child financially. She developed delusions that her colleagues were recording her conversations and collecting evidence to justify her termination. For these symptoms, her outpatient psychiatrist restarted venlafaxine at 75 mg/day and initiated olanzapine at 5mg/day 1month before admission. At the time of admission, Ms. A was grossly dysphoric and preoccupied with ruminative worries about the cost of hospitalization. She reported ongoing suicidal ideation and was initially placed on a one-to-one observational status. She requested a consultation with an obstetrician to facilitate a termination of pregnancy. When her desire for an abortion was explored further, she responded with questions about the relative cost of an abortion compared with ongoing psychiatric hospitalization. She also had a delusional certainty that her fetus was irrevocably harmed by the psychotropic medications she had taken. Two psychiatrists felt that Ms. A lacked capacity to consent to a termination of pregnancy on the day of admission. Shewas at 22weeks and 6 days of gestation, and abortion is legal in New York State until 24 weeks. The patient's husband was her next of kin. He expressed ambivalence about the patient's desire for an abortion but stated thathewould supporther wishes. The patient declined ECT but accepted pharmacotherapy, and the treating psychiatrist felt that she had capacity to make this decision. Given its prior efficacy, venlafaxine was titrated to 300 mg/day; olanzapine was titrated to 15 mg/day. The hospital's obstetrics servicewasconsulted to counsel the patient; they gave the inpatient psychiatry team a 5-day window to treat the patient and make a final capacity determination regarding the patient's request for an abortion. The hospital's ethics committee was consulted to provide additional guidance to the inpatient psychiatric service. The hospital's legal affairs department was consulted to help determine whether Ms. A's husband, the surrogate of highest priority, could give surrogate consent if the patient still desired a termination but continued to lack capacity to give informed consent to the procedure at the end of the 5-day window. On the fifth day of hospitalization, the same two attending psychiatrists re-evaluated Ms. A. Over the preceding 5 days, she had engaged with the inpatient milieu and had begun to integrate the viewpoints of other patients who she felt encouraged her to continue the pregnancy. She expressed ambivalence about her prior request for a termination. Afetal ultrasound examination demonstrated a male fetus with no evidence of congenitalmalformation, and Ms. Abecameless fixatedon the potentially teratogenic effects of venlafaxine and olanzapine. She was also able to understand the risks and benefits of the proposed abortion procedure, which involved a fetal intracardiac potassium chloride injection followed by an evacuation and curettage. Both psychiatrists nowfelt that Ms. A's capacity to consent to anabortion had been restored. However, after additional discussions with her husband, her family, and the obstetrics service, Ms. A elected to carry the fetus to term. After additional inpatient treatment, Ms. A was discharged from the psychiatric unit and returned to work. She was admitted to the obstetrics service 3 months later at full term, and she delivered a healthy male infant. The psychiatry service evaluated Ms. A in the postpartum period and noted that she was euthymic. She had continued her venlafaxine and olanzapine, with sustained remission of her depressive symptoms. She reported looking forward to spending time with her son during her maternity leave.