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Psychiatric Disorders in Pregnancy BCMJ /#47Vol2.wrap3 2/18/05 3:52 PM Page 96 Diana Carter, MBBS, Xanthoula Kostaras, BSc Psychiatric disorders in pregnancy 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. 96 BC MEDICAL JOURNAL VOL. 47 NO. 2, MARCH 2005 BCMJ /#47Vol2.wrap3 2/18/05 3:52 PM Page 97 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 anxiety disorder and pressed in pregnancy showed less fre- social phobia). 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 VOL. 47 NO. 2, MARCH 2005 BC MEDICAL JOURNAL 97 BCMJ /#47Vol2.wrap3 2/18/05 3:52 PM Page 98 Psychiatric disorders in pregnancy 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
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