Evidence-Based Reviews

Psychiatric illness during pregnancy

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Early detection, individualized care can promote health for mother and infant


 

References

Perinatal psychopathology is a common and undertreated problem with wide-ranging consequences for both mother and child.1-4 Women at risk for psychopathology are more likely to engage in unhealthy behaviors such as smoking and substance abuse and have difficulty engaging in treatment and attending psychiatric and obstetrics appointments.5 In addition, many of these women have trouble attaching to and caring for their infants and struggle with everyday stressors during pregnancy and postpartum.6

Routine prenatal screening for mental illness coupled with non-judgmental, collaborative, and individualized care delivered by a multidisciplinary team is critical for treatment engagement and adherence. Providers should be aware of risk factors for perinatal psychiatric illness—including a history of mental illness, stressful life events, and interpersonal conflict—and should be versed in current treatment guidelines.

CASE REPORT: Difficulty coping

Ms. A, age 28, is referred to our High Risk Perinatal Team by her obstetrician when she is approximately 6 weeks pregnant. She is single, has 3 other children (age 10, 4, and 2), a history of depression, and chronic pain related to an auto accident 3 years ago. She reports that this pregnancy likely is the result of a sexual assault, but she has decided to keep the baby. Ms. A describes severe depressive symptoms, including insomnia, low appetite, feelings of worthlessness, and thoughts of harming herself. In addition, she has incapacitating panic attacks and constantly worries about her children’s safety when she is not with them. She schedules an appointment with the perinatal team, but does not show up twice.

When our team finally sees Ms. A, she is well into her second trimester and brings her 2 youngest children with her. She says she recently was fired from her job as a cashier because she missed too many days of work, and is applying for Medicaid. Recently, her back and shoulder pain have worsened, and she is running out of her prescription for acetaminophen/hydrocodone. Ms. A’s affect is flat, her mood depressed, and she has difficulty explaining her history because her 2-year-old son interrupts the interview. She has never been in psychotherapy, and is reluctant to take antidepressants. Despite a difficult first visit, she engages with the clinician and agrees to schedule a second appointment.

What complicates pregnancy?

Women are at higher risk for developing depression during puberty, the perinatal period (ie, pregnancy and first year postpartum), and perimenopause.7 These times often are fraught with unfamiliar hormonal fluctuations, role transitions, emotional upheaval, and physical changes. However, because these times are expected to be stressful, serious mood changes often go unnoticed by patients and untreated by clinicians.8 Women are expected to celebrate, thrive, and “glow” during pregnancy, and those who suffer from depression and anxiety frequently do so in silence. Social stigma surrounding perinatal depression or anxiety leads many women to believe they are alone in their struggle and hesitant to seek help.9

Most pregnant women who develop psychiatric illness do not present for treatment.10 One study found that 86% of pregnant women who screened positive for depression in an obstetrics (OB) setting did not receive treatment.11 Some women are reluctant to take antidepressants out of concern for their infant’s safety,8 and psychotherapy or alternative approaches are not available in all areas.12 Transportation, childcare issues, or ongoing life stressors may prevent women from seeking help (Box 1).9

Diagnostic uncertainty among professionals may aggravate undertreatment. Clinicians who are unfamiliar with the presentation of perinatal mental illness may mislabel depressive features—such as irritability, loss of interest in activities, low energy, increased anxiety, difficulty sleeping, or appetite dysregulation—as normative experiences during pregnancy or adjustment after childbirth. Concerned about fetal exposure to potentially teratogenic compounds, clinicians may under-dose otherwise effective medications, which can lead to treatment resistance. Even if treated aggressively, depression in pregnancy may persist because of other factors, such as comorbid anxiety, somatization, pain, substance use/dependence, undiagnosed bipolar illness, or the presence of severe psychosocial stress or trauma.

Maternal suicide and/or harm to the infant—the most severe result of untreated perinatal psychopathology—is rare.13 Common negative outcomes of untreated depression or anxiety in pregnant women include inadequate weight gain, preeclampsia, difficulty bonding with their unborn baby, premature labor, and lack of follow through with prenatal care.14,15 Symptoms become harder to treat when aggravated by psychosocial stressors such as poor social support, ambivalence about the pregnancy, and/or substance abuse.

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