Counselling psychotropics in an unplanned pregnancy (CASC)

Station instructions (candidate)

You have 7 minutes. Explore understanding and fear without dismissing it. Explain why stopping everything today is not automatic. Name that valproate is the agent of greatest concern for major malformations and learning/developmental outcomes and outline a switch plan. Frame lithium with modern small absolute cardiac risk language if relevant to her history. Include postpartum risk, obstetric liaison, and a clear safety-net. Do not guarantee zero risk from any option.[1][2][4]

Marking domains

Agenda and empathy; accurate untreated bipolar/postpartum risk framing; correct valproate hierarchy (MCM + neurodevelopment); modern lithium absolute-risk counselling if discussed; shared decision without coercion; obstetric/perinatal psychiatry plan; crisis and early follow-up safety-net; invitation for partner questions. These domains match CASC priorities for perinatal medication stations.[1][2][3][5]

Model communication map

1. Open: congratulate carefully; check dates, supports, and what they read online; name the shared goal — keep mother well and protect baby as much as evidence allows.[6]
2. Illness first: bipolar can return if medicines stop suddenly; pregnancy does not protect; the weeks after birth are especially high risk for severe episodes.[1][5]
3. Baseline risk: any pregnancy has roughly a 2–3% chance of a major birth difference without medicines — context for numbers.[4]
4. Valproate truth: among mood medicines, valproate has the highest known risk of major birth defects and of effects on learning/development in children exposed in the womb — we plan to change off valproate urgently with specialist support, not continue it casually.[2][3]
5. Lithium if offered: modern large studies show a small increase in heart differences, not the nightmare percentages of old stories; if lithium fits her history we use scans, blood levels, and a birth plan — a joint decision.[4]
6. Today’s actions: obstetric confirmation, stop-switch plan written, who to call if mood rises or sleep collapses, early review, written information.[6]
7. Close: partner questions; no guarantee of zero risk; no abandonment — we walk the pregnancy with them.[6]

Common fails

• Agreeing to stop all medicines the same day without relapse framing.[1]
• Minimising valproate risk or treating it as interchangeable with lithium.[2][3]
• Calling lithium “poison” or “completely safe.”[4]
• Ignoring postpartum peak risk.[5]
• No obstetric liaison or follow-up plan.[6]