Pregnancy and Clozapine

Developments in psychopharmacology may soon place schizophrenia on the growing list of chronic diseases that were once uniformly catastrophic, but are now truly manageable. More people with schizophrenia may lead healthy and productive lives, unhindered either by the disease or by the consequences of its treatment.

Traditional antipsychotic medications were instrumental in the deinstitutionalization movement, and for some patients these agents successfully attenuated the positive symptoms of psychosis and permitted supported community living. However, the extensive side effects associated with the dopaminergic agents had a significant negative impact on most patients' functioning. Much attention has been focused on movement disorders as a major adverse outcome. However, the most common physiological aberrations associated with traditional antipsychotic medications may be their neuroendocrine properties, including hyperprolactinemia, amenorrhea, and infertility among female recipients. As we discussed in a recent psychopharmacology column in this journal (February 1998), endocrine effects of antipsychotics have only recently received significant attention.

In this issue, Drs. Dickson and Hogg present a case report describing the pregnancy of a patient treated with clozapine. This case is noteworthy for several reasons. The authors note the limited published information available to help guide clinicians and patients through essentially uncharted territory. They correctly point out that risks of fetal exposure to clozapine must be balanced against the mother's likelihood of psychotic relapse off the medication. Further, enormous medical resources are needed to obtain a successful birth outcome.

The implications of a potential "baby boom" among schizophrenic parents are manifold. Medical care, including obstetric care, of women with severe mental illness is often suboptimal. Many psychiatrists are assuming more responsibility for the primary health care of these women. Psychiatrists will need to remain well versed in the endocrine effects of successive generations of psychotropic medications. They also will likely be expected to assist their patients through the decision-making process of all aspects of pregnancy, from conception to delivery and beyond.

The heritability of schizophrenia from parent to child is significant. Whether increased fertility among patients with schizophrenia will lead to increased family clustering of the disorder remains speculative. What does seem clear is that children born into families affected by schizophrenia are at elevated risk for compromised outcome, by dint either of genetic loading or of chaotic upbringing. We need to educate our patients about these risks, and to develop public policy in conjunction with our other medical colleagues to limit the risks where possible.