CLINICAL HANDBOOK OF SCHIZOPHRENIA

474 VI. SPECIAL POPULATIONS AND PROBLEMSThe major reason for loss of the parenting role among adults with schizophrenia appearsto be loss of custody of children. Although there are no nationally representative dataon the prevalence of parents’ ultimate loss of custody or contact with children, researchersconducting smaller, treatment-setting-based studies find rates of custody loss from 30 to70% or higher for women with SMI. Whereas maintaining custody or relationships withchildren can motivate some mothers to participate in treatment, other mothers may avoidtreatment, or avoid disclosing parenting difficulties, if they fear this may result in custodyloss. Parents may also have difficulty visiting children who live with others, because they anticipatethe painful feelings of loss that recur each time a visit ends.PREGNANCY AND PARENTHOODIN THE TREATMENT OF SCHIZOPHRENIATreatment interventions can directly support parental functioning, via psychosocial rehabilitationand support strategies, or indirectly, via incorporating consideration of the effectson parenting into all aspects of treatment. Because antipsychotic medication is thecornerstone of treatment for schizophrenia, it is important to consider the effects of thesemedications on parental functioning.Pharmacotherapy for Parents with SchizophreniaOptimal pharmacotherapy can support effective parenting for women with schizophrenia,beginning even before pregnancy. Effective antipsychotic medications, especiallythose that alleviate both positive and negative symptoms, can improve overall functioning,strengthen social networks, and promote capacity for committed, intimate relationships,paving the way for better parenting support. By contrast, antipsychotic medicationsthat elevate prolactin, most notably risperidone and haloperidol, can impair fertilityand cause menstrual unpredictability, making it more difficult to plan a pregnancy.During pregnancy, withholding or underdosing antipsychotic medication may reduceprenatal care and increase the risk of obstetric complications. The postpartum period, a highrisktime for developing an exacerbation of schizophrenia, may contribute to parenting difficulties.Additionally, discontinuing and then resuming antipsychotics can increase the risk oftardive dyskinesia and adversely affect long-term morbidity from schizophrenia.While no antipsychotic medications to date are approved by the U.S. Food and DrugAdministration (FDA) for use during pregnancy, understanding pregnancy-related advantagesand disadvantages of commonly used antipsychotic medications allows for optimalprescribing. Relevant data are summarized below and may also be found in Table 45.1.First-generation antipsychotic agents (FGAs) have been relatively well studied duringpregnancy due to decades of use. Haloperidol used to be a common treatment for excessivenausea and vomiting during pregnancy in nonpsychotic women. Studies have shownno increased risk of congenital anomalies in offspring after in utero haloperidol exposure.Other high-potency FGAs, such as trifluoperazine and fluphenazine, have been less systematicallystudied, but available data do not show increased risk of physical anomaliesin exposed offspring. By contrast, low-potency FGAs such as chlorpromazine have beenfound to increase the risk of physical anomalies nonspecifically after in utero exposure.This may result from decreased placental perfusion due to the orthostatic hypotensionthat is a relatively common side effect of these agents.Haloperidol does not appear to increase the risk of cognitive or neurodevelopmentalproblems in children exposed in utero. However, some data show that children exposed