Special Populations, Reproductive Psychiatry, and Psychosocial/Adjustment Issues
Oncology and the medically complex
Depression in cancer is underrecognized; somatic criteria overlap with illness, so emphasize anhedonia, hopelessness, guilt and worthlessness. Corticosteroids cause mood lability, insomnia and psychosis; treat with dose reduction and antipsychotics rather than antidepressants alone. Delirium at the end of life is common and often reversible. Watch interactions: fluoxetine or paroxetine with tamoxifen, and opioids combined with serotonergic agents.
Reproductive psychiatry
Screen perinatally with the EPDS; item 10 addresses self-harm. Postpartum psychosis is a psychiatric emergency requiring hospitalization, with high recurrence risk. Untreated perinatal depression and anxiety carry their own risks; sertraline is a common first-line choice in pregnancy and lactation because of its data. Do not stop maintenance medication abruptly on discovery of pregnancy; consult and document a risk-benefit discussion. Valproate is teratogenic and avoided in people who may become pregnant; lithium and Ebstein anomaly require individualized discussion. ECT is used in pregnancy for severe illness with obstetric coordination.
Pediatrics, geriatrics, trauma and adherence
Children need developmental framing, assent, and collateral from school and caregivers; atypical antipsychotics require metabolic monitoring. Older adults need the Beers list, anticholinergic burden review, and vigilance for falls and delirium. After trauma, expect acute stress symptoms and avoid forcing exposure. Adherence improves with health literacy assessment, motivational interviewing, simplified regimens and attention to cost.
Trap
Stopping an effective antidepressant at conception, or dismissing postpartum psychosis as hormonal.
Rule of thumb
Treat the illness: an untreated perinatal disorder is a risk to both mother and child.