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Diana Carter, MBBS, Xanthoula Kostaras, BSc

Psychiatric disorders in

Depression, panic disorder, bipolar illness, and other psychiatric conditions can occur during pregnancy and should be considered when assessing the health of a pregnant patient.

ABSTRACT: Pregnancy is generally Depression in pregnancy psychosis. (A full description of phar- thought to be a time of happiness During pregnancy, symptoms of de- macological and nonpharmacological and emotional well-being for a wo- pression such as changes in sleep, therapies for these disorders will ap- man. However, for many women, appetite, and energy are often difficult pear in Part 2 of this theme issue in pregnancy and motherhood increase to distinguish from the normal expe- April 2005.) their vulnerability to psychiatric con- riences of pregnancy. Although up Several risk factors and psychoso- ditions such as depression, anxiety to 70% of women report some nega- cial correlates have been identified as disorders, eating disorders, and psy- tive mood symptoms during preg- contributing to depression during choses. These conditions are often nancy, the prevalence of women pregnancy. The most clearly identi- underdiagnosed because they are who meet the diagnostic criteria for fied risk factors include a previous his- attributed to pregnancy-related depression has been shown to be tory of depression, discontinuation of changes in maternal temperament between 13.6% at 32 weeks gesta- medication(s) by a woman who has a or physiology. In addition, such tion and 17% at 35 to 36 weeks ges- history of depression, a previous his- conditions are often undertreated tation (see theTable ).1,2 The course tory of postpartum depression, and a because of concerns about poten- of depression varies throughout preg- family history of depression. Several tial harmful effects of medication. nancy: most studies report a symptom key psychosocial correlates may also Practitioners and allied health pro- peak during the first and third tri- contribute to depression during preg- fessionals caring for pregnant or mesters and improvement during the nancy: a negative attitude toward the postpartum patients affected by psy- second trimester.3 In a recent study, pregnancy, a lack of social support, chiatric conditions can access ser- more women became depressed be- maternal stress associated with nega- vices for these patients by contact- tween 18 and 32 weeks gestation tive life events, and a partner or fami- ing the Reproductive Mental Health than between 32 weeks gestation and ly member who is unhappy about the program at BC Women’s Hospital and 8 weeks postpartum.1 pregnancy.3-4 St. Paul’s Hospital. Depression is the most common Depression that is left untreated in psychiatric disorder associated with pregnancy, either because symptoms pregnancy. Pregnant women may also are not recognized or because of con- suffer from anxiety disorders, such as cerns regarding the effects of medica- panic disorder, obsessive-compulsive disorder, and eating disorders. While Dr Carter is co-director of the Reproductive it is rare for women to experience first- Mental Health program at BC Women’s onset psychoses during pregnancy, Hospital and St. Paul’s Hospital. Ms relapse rates are high for women pre- Kostaras is a research assistant in the viously diagnosed with some form of Reproductive Mental Health program.

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Psychiatric disorders in pregnancy

Table. Prevalence of depression in pregnancy. between plasma levels of cortisol in the mother and in the fetus may have Author N Patients experiencing depression (%) implications for the developing fetal brain.10 Treatments for panic disorder At At At At 8 weeks At birth in pregnancy may include pharmaco- 18 weeks 32 weeks 35 weeks postpartum logical therapies, particularly benzo- Evans et al.1 9028 11.8 13.6 — — 8.1 diazepines for nighttime sedation and symptomatic relief, and antidepres- Josefsson 1158 — — 17 18 13 sants, as well as nonpharmacological et al.2 therapies such as cognitive behavioral therapy, supportive psychotherapy, tions, can lead to a host of negative However, full disclosure of both the relaxation techniques, sleep hygiene, consequences, including lack of com- risk and benefits of various antide- and dietary counseling. pliance with prenatal care recommen- pressant medications should be made dations, poor nutrition and self-care, to the patient and, if possible, her part- self-medication, alcohol and drug use, ner prior to starting any pharmacolog- Treatment of suicidal thoughts and thoughts of ical treatment. harming the fetus, and the develop- depression in Anxiety disorders in ment of postpartum depression after pregnancy relies the baby is born. An additional and pregnancy important implication of untreated Data are available on some of the on the same maternal depression is the psycholog- disorders that affect pregnant wo- therapies used for ical effect that the depression may men (panic disorder and obsessive- have on the fetus. One study that compulsive disorder) but very little depression at any examined 1123 mother-infant pairs information exists regarding others time in life, with reported that infants of mothers de- (generalized and pressed in pregnancy showed less fre- social ). the added need to quent positive facial expressions and ensure the safety vocalizations, and that these infants Panic disorder were also harder to console.5 Thus, the The course of panic disorder during of the fetus. relationship between maternal depres- pregnancy is variable and remains sion and early childhood problems unclear. While case reports of preg- may be part of a sequence that starts nant women with pre-existing panic with depressive symptoms during disorder have suggested a decrease in Obsessive-compulsive disorder pregnancy. symptoms during pregnancy,7 large- Obsessive-compulsive disorder (OCD) Treatment of depression in preg- scale studies have reported that there is characterized by thoughts that can- nancy relies on the same therapies is no decrease in symptoms for women not be controlled (obsessions) and used for depression at any time in life, with pre-existing panic disorder.8 repetitive behaviors or rituals that can- with the added need to ensure the safe- In addition, a subgroup of women not be controlled (compulsions) in ty of the fetus. Psychotherapies that may experience first-onset panic dis- response to these thoughts. Several have been recognized as effective order during pregnancy. Women pre- reports suggest that women may be at treatment for depression include cog- senting with panic attacks for the first an increased risk for the onset of OCD nitive behavioral therapy and inter- time should be screened for thyroid during pregnancy and the postpartum personal psychotherapy.6 Education disorder. The possible effects of anxi- period.11,12 In one study of women with and support are also important, partic- ety and panic on the course of the preg- diagnosed OCD, 39% of the partici- ularly as pregnancy is a unique expe- nancy and the health of the fetus are pants reported that their OCD began rience for women, some of whom may not well understood. One study showed during a pregnancy.11 Treatments for not know what to expect. Pharmaco- a correlation between increased anxi- OCD in pregnancy are the same as logical therapies are also recognized ety and increased resistance in uterine those in nonpregnant adults and as effective treatment for depression. artery blood flow.9 The correlation include cognitive behavioral therapy

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and pharmacotherapy. Women with there are many negative consequences ued lithium prior to conception, with severe OCD can become quite inca- for both the mother and her infant. One the relapse rates for either depression pacitated and will require treatment. recent study reported that pregnant or mania in the pregnant women being women with active eating disorders the same as in nonpregnant matched Generalized anxiety disorder appear to be at greater risk for deliv- women.20 In another study, pregnancy There are no data on the prevalence or ery by cesarean section and for post- appeared to have a protective effect course of generalized anxiety disorder partum depression.16 In addition, against an increase in symptoms in (GAD) through pregnancy. Most wo- eating disorders during pregnancy women with lithium-responsive bipo- men, naturally enough, worry about have been linked with higher rates lar I disorder who had discontinued the health of the fetus and how they of miscarriage and lower infant birth their lithium during pregnancy; how- will cope with labor and bodily weights.17 ever, there was a 14% rate of relapse in the last 5 weeks of pregnancy.21 In both studies, the risk of relapse in the postpartum period was very high, ranging from 25% to 70%. In women It appears that some women with with a history of bipolar mood disor- der, the decision whether to use mood bipolar disorder may experience a stabilizers must be made following an relief from symptoms during assessment of risks and benefits. Fac- tors to consider include number and pregnancy, but that the risk for severity of previous episodes, level of relapse in the postpartum period insight, family supports, and the wish- es of the woman. Careful monitoring is high. of psychological symptoms through- out the pregnancy is of paramount importance.

Schizophrenia changes. Excessive worrying, howev- Psychoses in pregnancy The limited data on schizophrenia in er, may be a symptom of GAD or The occurence of new episodes of psy- pregnancy suggest that this disease depression. chosis during pregnancy is extremely has a variable course, with some wo- rare. However, for women with a his- men experiencing an improvement in Social phobia tory of psychosis, particularly psy- symptoms, while others experience a There are no data on either first-onset chosis in previous , the worsening of their illness.22 Regard- social phobia or pre-existing social relapse rates are high, with the most less of the course of the illness, women phobia in pregnancy. A very small common manifestations being bipolar with a history of psychosis require number of women experience toco- illness, followed by psychotic depres- close monitoring by health care pro- phobia, an unreasonable dread of sion and schizophrenia.18,19 fessionals during pregnancy. Psy- .13 These women are more chosis during pregnancy can have prone to postpartum depression if Bipolar mood disorder devastating consequences for both the denied the delivery method of their The information regarding the course mother and her fetus, including fail- choice (i.e., cesarean section). of bipolar disorder in pregnancy is ure to obtain proper prenatal care, limited. It appears that some women negative pregnancy outcomes such as Eating disorders in with bipolar disorder may experience low birth weight and prematurity, and pregnancy a relief from symptoms during preg- neonaticide or suicide. Treatment of The prevalence of eating disorders in nancy, but that the risk for relapse in acute psychosis in pregnancy is manda- pregnant women is approximately the postpartum period is high. One tory and includes mobilization of sup- 4.9%.14 While studies have suggested recent study reported that pregnancy ports, pharmacotherapy, and hospital- that the severity of symptoms may had no impact on the course of bipo- ization. Electroconvulsive therapy actually decrease during pregnancy,15 lar disorder in women who discontin- may be used for psychotic depression.

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Psychiatric disorders in pregnancy

Summary cy and the puerperium: A preliminary chiatric history characteristics. Acta Psy- Early identification and treatment of study. Biol Psychiatry 1996;39:950-954. chiatr Scand 1987;75:35-43. psychiatric disorders in pregnancy can 9. Teixeira JM, Fisk NM, Glover V. Associa- 20. Viguera AC, Nonacs R, Cohen LS, et al. prevent morbidity in pregnancy and tion between maternal anxiety in preg- Risk of recurrence of bipolar disorder in postpartum with the concomitant risks nancy and increased uterine artery resis- pregnant and nonpregnant women after to mother and baby. Both psychother- tance index: Cohort based study. BMJ discontinuing lithium maintenance. Am J apy and pharmacotherapy should be 1999;318:153-157. Psychiatry 2000;157:179-184. considered. In British Columbia, the 10. Glover V. Maternal stress or anxiety dur- 21. Grof P, Robbins W, Alda M, et al. Protec- Reproductive Mental Health program ing pregnancy and the development of tive effect of pregnancy in women with (www.bcrmh.com) offers consulta- the baby. Pract Midwife 1999;2:20-22. lithium-responsive bipolar disorder. J tion and education services to practi- 11. Neziroglu F, Anemone R, Yaryura-Tobias Affect Disord 2000;61:31-39. tioners and allied health professionals JA. Onset of obsessive-compulsive dis- 22. Patton SW, Misri S, Corral MR, et al. throughout the province. order in pregnancy. Am J Psychiatry Antipsychotic medication during preg- 1992;149:947-950. nancy and lactation in women with schiz- Competing interests 12. Buttolph ML, Holland AD. Obsessive- ophrenia: Evaluating the risk. Can J Psy- None declared. compulsive disorders in pregnancy and chiatry 2002;47:959-965. childbirth. In: Jenike M, Baer L, Minichiel- References lo WE (eds). Obsessive-Compulsive Dis- 1. Evans J, Heron J, Francomb H, et al. orders: Theory and Management. 2nd Cohort study of depressed mood during ed. Chicago: Year Book Medical Publish- pregnancy and after childbirth. BMJ ers; 1990:89-95. 2001;323:257-260. 13. Hofberg K, Brockington I. Tokophobia: 2. Josefsson A, Berg G, Nordin C, et al. An unreasoning dread of childbirth. A Prevalence of depressive symptoms in series of 26 cases. Br J Psychiatry late pregnancy and postpartum. Acta 2000;176:83-86. Obstet Gynecol Scand 2001;80:251- 14. Turton P, Hughes P, Bolton H, et al. Inci- 255. dence and demographic correlates of 3. Kumar R, Robson KM. A prospective eating disorder symptoms in a pregnant study of emotional disorders in child- population. Int J Eat Disord 1999;26:448- bearing women. Br J Psychiatry 1984; 452. 144:35-47. 15. Blais MA, Becker AE, Burwell RA, et al. 4. O’Hara MW. Social support, life events, Pregnancy: Outcome and impact on and depression during pregnancy and the symptomatology in a cohort of eating- puerperium. Arch Gen Psychiatry 1986; disordered women. Int J Eat Disord 43:569-573. 2000;27:140-149. 5. Zuckerman B, Bauchner H, Parker S, et 16. Franko DL, Blais MA, Becker AE, et al. al. Maternal depressive symptoms dur- Pregnancy complications and neonatal ing pregnancy, and newborn irritability. J outcomes in women with eating disor- Dev Behav Pediatr 1990;11:190-194. ders. Am J Psychiatry 2001;158:1461- 6. Karasu TB, Docherty JP, Gelenberg A, et 1466. al. Practice guideline for major depres- 17. Brinch M, Isager T, Tolstrup K. Anorexia sive disorder in adults. American Psychi- and motherhood: Reproduction pattern atric Association. Am J Psychiatry 1993; and mothering behaviour of 50 women. 150(suppl 4):1-26. Acta Psychiatr Scand 1988;77:611-617. 7. Hertzberg T, Wahlbeck K. The impact of 18. Kendell RE, Chalmers JC, Platz C. Epi- pregnancy and the puerperium on panic demiology of puerperal psychoses. Br J disorder: A review. J Psychosom Obstet Psychiatry 1987;150:662-673. Gynaecol 1999;20:59-64. 19. McNeil TF. A prospective study of post- 8. Cohen LS, Sichel DA, Faraone SV, et al. partum psychoses in a high-risk group. 2. Course of panic disorder during pregnan- Relationships to demographic and psy-

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