Use of Clozapine in Women of Childbearing Age: A Literature Review and Recommendations

Concerns about medications in women of childbearing age include impact on fertility, pregnancy, neonatal outcome, breastfeeding, and behavioral teratogenesis. The objectives were to examine possible risks of clozapine on these parameters. PsycINFO and MEDLINE searches were performed and Novartis was contacted regarding their clozapine pregnancy registry. Since prolactin levels are not elevated with clozapine as they are with typical antipsychotics, there is not interference with fertility. Adverse pregnancy outcomes included gestational diabetes, should dystocia, seizure, and mild floppy infant syndrome. Higher concentrations of clozapine were present in breast milk than in maternal blood. Despite a lack of case-control prospective data, available information raises some questions regarding the safety of clozapine in pregnancy. Suggestions for treatment are made. Reproductive counseling should be given to women starting on clozapine. Individual risk-benefit assessments must be performed. In pregnant women taking clozapine, the clinician should screen for gestational diabetes and advise against breastfeeding

Guns, Schools, and Mental Illness: Potential Concerns for Physicians and Mental Health Professionals

Abstract Since the recent shootings in Tucson, Arizona; Aurora, Colorado; and Newtown, Connecticut, there has been an ever-increasing state and national debate regarding gun control. All 3 shootings involved an alleged shooter who attended college, and in hindsight, evidence of a mental illness was potentially present in these individuals while in school. What appears to be different about the current round of debate is that both proegun control and antiegun control advocates are focusing on mentally ill individuals, early detection of mental illness during school years, and the interactions of such individuals with physicians and the mental health system as a way to solve gun violence. This raises multiple questions for our profession about the apparent increase in these types of events, dangerousness in mentally ill individuals, when to intervene (voluntary vs involuntary), and what role physicians should play in the debate and ongoing prevention. As is evident from the historic Tarasoff court case, physicians and mental health professionals often have new regulations/duties, changes in the physician-patient relationship, and increased liability resulting from high-profile events such as these. Given that in many ways the prediction of who will actually commit a violent act is difficult to determine with accuracy, physicians need to be cautious with how the current gun debate evolves not only for ourselves (eg, increased liability, becoming de facto agents of the state) but for our patients as well (eg, increased stigma, erosion of civil liberties, and changes in the physician-patient relationship). We provide examples of potential troublesome legislation and suggestions on what can be done to improve safety for our patients and for the public

Unsolicited E-mails to Forensic Psychiatrists

communication is pervasive. Since many forensic psychiatrists have their e-mail addresses available online (either on personal websites, university websites, or articles they have authored), they are likely to receive unsolicited e-mails. Although there is an emerging body of literature about exchanging e-mail with patients, there is little guidance about how to respond to e-mails from nonpatients. Therefore, we used a Delphi technique to develop a consensus about salient points for the forensic psychiatrist to consider regarding responding to e-mails from nonpatients and the risks entailed. Four scenarios are described, including e-mails from nonpatients and unknown others requesting advice or help. The potential ethics-related, legal, moral, and practical concerns for forensic psychiatrists are discussed. Finally, potential pitfalls for forensic psychiatrists are described