Microsoft word - mood and anxiety disorders during pregnancy and the postpartum period _2_.doc
Mood and anxiety disorders during pregnancy and the
Miriam B. Rosenthal, MD, Associate Professor of Psychiatry and Reproductive Biology, Case Western Reserve University Chief of Behavior Medicine, University MacDonald Women's Hospital
symptons and syndromes of mood and anxiety disorders that may occur during
effects of these disorders on mothers, infants and family screening process treatment options, resources and access to care.
While men and women have similar rates of mental illness, patterns differ with women having about twice the prevalence of depressive and anxiety disorders from adolescence through menopause. These rates are observed worldwide and in varying cultures. The childbearing years are times of special vulnerability for women and for the impact that untreated depressive disorders may have on their children and families, an area still not well researched. This is especially troubling at a time when treatments have become available! The largest community surveys of mental disorders in the United States come from the work done by the National Institutes of Mental Health's Epidemiologic Catchment Area Program (ECA) and the National Comorbidity Survey (NCS) done in the early 1990s. The prevalence rates showed about 30% for mental and addictive disorders and lifetime rates of about 50%. Yet services provided would suggest that less than one-third of those with active disorders were receiving any treatment in a one-year period (Narrow 2002). This percentage is probably even lower in pregnant and postpartum women, especially ethnic minorities and women with less resources and no insurance.
Women are more likely to experience mood and anxiety disorders during and after a pregnancy than at any other time of their lives. These conditions are considered to be among the least recognized at the same time that they are the more treatable. Pregnancy and postpartum mental disorders affect about 10-20% of women having a healthy baby, with figures being much higher in women who have experienced pregnancy losses or babies with illness or abnormalities. At a forum last year held by the Congressional Black Caucus Legislative Conference in Washington, D.C., there was discussion of passing legislation introduced by Rep. Bobby L. Rush (D-IL) that should to expand research on postpartum depression. The Perinatal Depression Project in Cleveland was especially timely.
Pregnancy is a major developmental life transition involving biological, psychological and social changes. Most of these are quite normal, and pregnancy and the postpartum period are supposed to be times of happiness. Often these are periods of mood lability,
anxiety about the health of the fetus and partner compatibility, and family well-being. There are temporary periods of feeling blue, yet more serious and debilitating emotional illnesses may occur. The blues are not considered a mental illness. Postpartum blues occur within the first 2-3 weeks after birth, occur in up to 70% of women worldwide and cross-culturally. There are symptoms of mood lability, anxiety, tearfulness, irritability, insomnia (even when the baby is asleep) and fatigue. The causes are thought due to the marked fall in estrogen and progesterone, in addition to any illnesses or personal crises that may be occurring then. No treatment is indicated.
Postpartum depression is Major Depression defined in the Diagnostic and Statistical Manual of the American Psychiatric Association and has symptoms similar to depressions occurring at other times of life. There is a disturbance of mood lasting more than 2 weeks, a lack of pleasure in anything (anhedonia) accompanied by changes in sleep, appetite, thinking, libido, possibly obsessive-compulsive ideas (of harming self or baby) and sometimes suicidal ideas. There may be feelings of guilt. It usually occurs during the pregnancy but more likely in the first three months after delivery. It affects about 10-20% of women giving birth. In nursing mothers, there may be onset about the time of weaning. The best predictors of this condition are a past history of depression or anxiety disorders, a family history of such conditions, premenstrual syndrome, lack of social supports, adverse life events occurring during the pregnancy such as death of a close person. Milder symptoms may not reach diagnostic levels but need evaluation, which also must include a very thorough physical exam, appropriate laboratory tests and thyroid function levels. A great help in diagnosis has been the use of psychological tests such as the Edinburgh Postnatal Depression Scale or other similar scales for depression and anxiety. Treatment includes use of medications, psychotherapy, group treatments, support groups, and involvement of family for emotional supports. The antidepressant medications have been an invaluable addition. Among these, the first line treatments have been the selective serotonin reuptake inhibitors, which include fluoxetine, sertraline, paroxetine, citalopram, and fluvoxamine. These have been studied more in pregnancy and postpartum period including nursing mothers. Estrogen has also been used with some success in the treatment. Interpersonal psychotherapy has been useful. Having mental health professionals available in the offices and clinics which offer obstetrical and pediatrics services to pregnant women and new mothers has been a way of identifying and treating women who may be reluctant to go to mental health settings. It is also quite interesting that postpartum depression may affect fathers, grandparents and adoptive parents, which may give some increasing support for non-hormonal factors causing these conditions. The effects of depression on pregnancy include women taking more risk-taking behaviors like smoking and use of drugs and alcohol. Prematurity may be more common in depressed mothers, but more data is needed.
Psychosis in pregnancy or the postpartum period is the most serious and severe form of mental illness and occurs in about 1% of women. It is characterized by a loss of reality testing, the presence of hallucinations and delusions, possible agitation or severe withdrawal. The recent very tragic case of Andrea Yates, a 36-year old mother and nurse who drowned her five children, delusionally believing that they would be better off
in another world, is an example of the extreme danger that this severe illness can bring. The psychoses are usually bipolar disease, psychotic depression, schizophrenia, or organic disorders, which can be induced by metabolic disruption or drugs. These women require immediate hospitalization after evaluation by a mental health professional, treatment with medications and psychotherapy, and are never to be left alone until they are definitely better. Medications include antipsychotic drugs, mood-stabilizing drugs, and possibly for treatment refractory conditions, electroconvulsive therapy. Infanticide is rare, but may occur with psychosis.
Anxiety disorders may occur with depression or independently. Obsessive-compulsive disorders, panic, posttraumatic stress disorders may start during or after pregnancy. All are treatable. Perinatal losses or the occurrence of fetal anomalies or severe illnesses in baby or mother may be precipitating causes. Domestic violence increases in pregnancy and often with a new baby in the household. This needs further research.
The Edinburgh Postpartum Depression Scale is a very useful tool used to measure depression in pregnancy and postpartum. It was chosen after a careful reading of the instruments used in recent studies and discussion with some of the researchers in this field (Wisner, Appleby, Murray, Schaper, Yonkers, Glaze, and Zelkowitz). Other instruments include Prime-MD, Beck Depression Inventory, Center for Epidemiologic Studies Depression Scale (CES-D) and Psychiatric Sympton Index.
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