Review of the Assessment and Management of Perinatal Mood and Anxiety Disorders
Abstract
Perinatal mood and anxiety disorders (PMADs) are the most common complication of childbirth. When poorly controlled, they are associated with worse obstetric outcomes, such as higher rates of preterm birth and unplanned cesarean delivery. They are also associated with suicide, a leading cause of perinatal maternal death. This article provides an overview of evidence-based recommendations for screening, assessment, and management of PMADs, including suicide risk assessment and management and pharmacological and nonpharmacological treatment options compatible with pregnancy and lactation. Although specialized reproductive psychiatrists can provide expert guidance for the management of PMADs, their scarcity means that most patients will not have access to this expert care and instead will seek guidance from general psychiatrists. This article provides a clinical guide for generalists that is based on the best current evidence, including recently released treatment guidelines.
Perinatal mood and anxiety disorders (PMADs), those present during pregnancy and up to 12 months postpartum, are the most common complication of childbirth, affecting one in every five to seven birthing individuals (1–3). Untreated PMADs can lead to significant maternal morbidity, including decreased adherence to medical care, poor nutrition, and loss of interpersonal and financial resources (4, 5). These conditions are also associated with increased risk for preeclampsia, gestational diabetes, preterm birth, and intrauterine growth restriction (6–8). PMADs can also contribute to substance use disorders, including smoking, which are a risk factor for maternal mortality (9, 10). PMADs, when untreated in pregnancy, put women at substantial risk for postpartum depression (11, 12).
PMADs can also lead to suicide, which is a leading cause of maternal mortality (13). The Centers for Disease Control and Prevention (14) recently released data from the 2017–2019 Maternal Mortality Review Committees, revealing that 80% of pregnancy-related deaths were preventable. They also noted that the most common causes of death, 23%, were due to mental health conditions, including suicide, overdose, and poisoning related to substance use disorders. Soon after, the Journal of the American Medical Association published a response article (15) bringing attention to the significance of these findings. Because of the prevalence of PMADs and the large population of reproductive-age women, most psychiatrists will encounter these disorders many times during their careers. Thus, having the capability to address and manage these conditions, in collaboration with obstetricians, is important for all psychiatrists. In this review, we summarize recent updates and suggested guidelines for screening, diagnosing, and managing PMADs.
We refer herein to pregnant and postpartum individuals as women or mothers. We do this for the sake of fluency but recognize that not everyone seeking care for PMADs identifies as a woman or mother. Research on people who can become pregnant and do not identify as women is scarce. We acknowledge that future research may allow us to offer evidence-based recommendations that may differ between cisgender women and other pregnant individuals.
Definitions
PMADs are mental health conditions occurring during pregnancy and up to 1 year postpartum, including conditions diagnosed prior to the pregnancy. Common conditions that we discuss include depressive disorders, anxiety disorders, bipolar disorder, and postpartum psychosis. (Postpartum blues, a period of mood lability that affects most women in the days following childbirth, is not considered a psychiatric disorder.) The term “PMADs” encompasses these individual disorders and is useful because of the extensive co-occurrence of anxiety and depression (up to 70%) and because of the lack of clarity in the literature concerning the definition of perinatal depression (16). According to the DSM-5 (17), a “major depressive episode with peripartum onset” is defined as an episode arising during pregnancy or within the first 4 weeks postpartum. This definition lumps together two entities that may be biologically distinct (antenatal and postpartum depression) and does not account for a diversity of clinical presentations—namely, the large number of women who have preexisting depression that continues through pregnancy or those who become depressed later during the first postpartum year. Finally, postpartum psychosis (a name that is under debate for the next edition of the DSM) is also a mood disorder (not a primary psychotic disorder). This condition is a psychiatric emergency, involving mood symptoms (usually manic or mixed), that is characterized by disorganization, confusion, psychotic symptoms, and agitation and is associated with high rates of suicide and infanticide (18).
Screening
Multiple professional societies, including the American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics, and the U.S. Preventive Services Task Force (USPSTF), recommend screening for PMADs during pregnancy and again postpartum (19–22). Studies (23–26) suggest that screening can be useful in reducing psychiatric symptoms, increasing remission rates, and increasing the rate at which obstetricians offer or provide treatment. ACOG recently released a clinical practice guideline (27) on screening and diagnosis of mental health conditions during pregnancy and postpartum. The guideline recommends that all women receiving preconception, antenatal, or postpartum care undergo screening for depression and anxiety with an accepted tool. This includes screening at the initial prenatal visit, later in pregnancy (usually around 28 weeks), and postpartum. Screening for bipolar disorder is also recommended before initiating therapy for anxiety or depression. The USPSTF (28) has endorsed depression screening for all adults, including pregnant and postpartum individuals (in 2016), and anxiety screening (in 2022).
Although screening will often occur in primary care or in obstetric practices (i.e., before the patient is referred for psychiatric treatment), general psychiatrists need to understand the screening tools used and know how to interpret them. Multiple screening tools have been validated for perinatal depression and anxiety; the most commonly used are the Edinburgh Postnatal Depression Scale (EPDS) and the nine-item Patient Health Questionnaire (PHQ-9) (27). The EPDS screens for anxiety and depression and includes a self-harm question, whereas the PHQ-9 screens for depressive symptoms and includes a self-harm question (29–31). Both tools are easy to administer and are short for the patient to complete. The EPDS is often preferred because it was designed specifically for the perinatal population. It includes questions about symptoms that are especially common during the perinatal period (such as anxiety) and excludes questions about somatic symptoms, which are easily confused with physical symptoms associated with pregnancy. The EPDS has been validated across cultures and is available in over 70 languages.
Screening alone does not diagnose a psychiatric disorder, rather it identifies patients who need further evaluation of their symptoms. A score of 10–13 on the EPDS suggests mild symptoms, ≥14 indicates likely depression, with a possible high score of 30. On the PHQ-9, a score of 5–9 indicates mild depression; 10–14 moderate depression; 15–19 moderately severe depression; and >20 severe depression. Questions 3–5 of the EPDS are often correlated with anxiety and can be used alone, as the EPDS-A, for anxiety only. A score of at least six on these three questions indicates elevated anxiety symptoms (32). Anxiety can also be evaluated with a separate tool, such as the Generalized Anxiety Disorder-7 (33).
Psychiatric screening in primary care and obstetric practices for perinatal patients, if done at all, is usually limited to anxiety and depression. However, individuals diagnosed as having bipolar disorder are at high risk for recurrence of illness during the postpartum period, with the most likely mood episode being a major depressive episode. Because many women who experience a depressive episode during the perinatal period are later diagnosed as having bipolar disorder—up to 7% with antenatal symptoms and close to 23% of those with postpartum symptoms (2, 34)—it is wise (and recently recommended by ACOG) to screen all pregnant patients for bipolar disorder. Importantly, bipolar disorder is one of the strongest risk factors for postpartum psychosis (35). Two recommended screening tools are the Mood Disorder Questionnaire and the Composite International Diagnostic Interview (36, 37). Although there is no screening tool for postpartum psychosis itself, which often arises suddenly and constitutes an emergency, prior identification of bipolar disorder can alert providers to patients who are at high risk.
Assessment of PMADs
Although screening can help to identify patients who are already struggling or who are at high risk, many frontline clinicians are reluctant to screen because of fear of uncovering illnesses they are not equipped to treat and for which there are inadequate referral sources (38). For this reason, ACOG’s new guidelines (27) stress the role of frontline clinicians (regardless of specialty) in initial assessment and diagnosis, as well as screening. Although obstetricians and primary care providers are thus increasingly able to take initial steps in assessment and management, many patients who screen positive will continue to receive immediate referral for a psychiatric diagnostic evaluation. That evaluation should include a few additional elements specific to the perinatal period. As for any patient, the clinician should obtain a thorough general medical, psychiatric, family, and social history that includes prior treatments, hospitalizations, and suicidality (39). Screening for substance use disorders and testing for general medical conditions, such as thyroid disease, anemia, and vitamin deficiencies—which can mimic or contribute to psychiatric symptoms—is also important. For perinatal patients, the psychiatrist should also obtain a thorough gynecologic history, including any history of mood symptoms tied to the menstrual cycle and those related to the use or cessation of hormonal contraception. It is especially important to note whether the patient has a personal or family history of a reproductive depressive disorder (perinatal depression, premenstrual dysphoric disorder, or perimenopausal depression) and a personal or a family history of bipolar disorder, because both increase the risk for postpartum depression, and the latter increases risk for postpartum psychosis. The primary goal of the initial assessment is to address immediate safety concerns (see section on assessing risk for self-harm below); determine the appropriate initial treatment; and determine whether referral to, or consultation with, a reproductive psychiatrist is needed.
Whereas depressive and anxiety disorders are the most common PMADs, psychiatrists who treat perinatal patients need to remain alert to the possibility of obsessive-compulsive disorder (OCD) (which is closely related to but no longer considered an anxiety disorder by the DSM) (17). Obsessive-compulsive symptoms are common during the perinatal period and often go unrecognized (40). Many patients with these symptoms will also manifest mood or anxiety symptoms, and if the clinician does not specifically inquire about OCD symptoms, the patient will often not volunteer them. Obsessions in the perinatal period are intrusive thoughts, often concerning infant harm or contamination. Compulsions can include frequently checking on the infant, seeking reassurance from medical professionals, or mental compulsions, such as lengthy Internet searches. These symptoms may not show up on typical OCD screening tools (such as the Obsessive-Compulsive Inventory–Revised) (41). Although there is some evidence that the Dimensional Obsessive-Compulsive Scale (42) and the Perinatal Obsessive-Compulsive Scale (43) may be more effective, they are not widely used, and most patients will arrive at psychiatric evaluation without having been screened for OCD. Whereas the exact prevalence of perinatal OCD is unclear, studies indicate increased prevalence during the postpartum period, with one study showing a prevalence rate as high as 16% (44).
One condition that requires special attention, and immediate action if suspected, is postpartum psychosis. Postpartum psychosis is considered a psychiatric emergency, because of its association with high rates of suicide and infanticide (18). It usually occurs 3–10 days after childbirth but may manifest any time within the first 4 weeks after delivery. These patients often present with an episode of mania, depression, or mixed features, along with confusion, disorientation, and psychotic symptoms. Symptoms fluctuate, and patients may have only limited insight into their new symptoms and low levels of functioning. Postpartum psychosis occurs in conjunction with only about one to two in 1,000 births, and thus universal screening is not recommended, but women with bipolar disorder and prior postpartum psychosis have much higher rates and should receive close monitoring (27). Other conditions, such as substance use disorders and general medical conditions, should be ruled out, but patients should be quickly evaluated by a psychiatric provider and admitted to a hospital for evaluation and treatment.
Distinguishing between the ego-dystonic intrusive thoughts of OCD and the ego-syntonic delusions of postpartum psychosis can be tricky and is vital in determining immediate risk. See Table 1 for guidance.
| Intrusive thoughts in obsessive-compulsive disorder | Delusions in postpartum psychosis |
|---|---|
| Content often concerns infant harm or contamination; may be violent or sexual | Content unusual, frequently bizarre; may also be violent or sexual |
| Thoughts disgust the patient, are unwanted | Thoughts are fixed false beliefs |
| Thoughts cause substantial distress and may engender compensatory behavior | Thoughts do not cause substantial distress |
| Example: Mother has violent image of dropping her baby on the stairs. She insists on bumping down the stairs sitting down. | Example: Mother believes baby has been brain-damaged by a bump on the head and that the baby would be better off dead; mother jumps out of window with baby. |
Treatment of PMADs
In an ideal world, patients and health care providers would prepare in advance for pregnancy, ensuring a pregnancy-compatible wellness regimen prior to conception. Because half of U.S. pregnancies are unplanned, psychiatric treatment providers should remain aware of the possibility of conception, even among women not actively planning to become pregnant (45). It is therefore crucial to consider the risk profiles of all psychiatric medications when treating any patient who could potentially become pregnant. Most psychiatric medications are compatible with pregnancy, but some are not. Valproic acid, for example, should never be a first-line medication for women of reproductive potential, because of its association with congenital malformations and intellectual disabilities among children (46, 47). Similarly, for patients with complicated illness and medication regimens, it is wise to think about maximizing dosage and minimizing the number of medications among those who could become pregnant (e.g., higher dosages of three medications would result in fewer exposures for the fetus than lower dosages of five medications). It is also vital—and within the scope of practice for psychiatrists—to counsel patients on using birth control when prescribing known teratogens, and to discuss interactions between hormonal contraception and psychiatric medications. Carbamazepine, for example, can reduce the efficacy of oral contraceptives, and estrogen-containing contraceptives can lower serum levels of lamotrigine (48). When pregnancy plans and medication choices are discussed in advance, the health care provider and patient can maximize pregnancy outcomes for the patient and fetus.
Once a patient conceives, shared decision making should be used to find the ideal treatment strategy for PMADs. The treatment of uncomplicated mild or moderate depression and anxiety in pregnancy and postpartum is not difficult and does not require referral to a specialized reproductive psychiatrist (a scarce resource that should be reserved for patients with more complex illness). The provider and patient together will have to carry out a “risk-risk” analysis, weighing the risks of untreated PMADs against the risks of medications to the fetus. PMADS themselves pose risks in pregnancy. Risks associated with untreated PMADs include higher rates of preeclampsia, gestational diabetes, preterm birth, intrauterine growth restriction, cesarean section, substance use, and suicide, and lack of adherence to prenatal care (6–12). In addition, babies born to women with untreated PMADs have elevated cortisol at birth (and thus greater reactivity), adverse effects on cognitive and emotional development, and higher rates of subsequent psychiatric disorders (49–51).
These risks must be weighed against the risks of medication, which are minimal for most drugs (See “Pharmacologic Options” section for a more detailed discussion of these risks.) Early studies (52) of selective serotonin reuptake inhibitors (SSRIs) found risks associated with medication use, but these studies compared women taking SSRIs with healthy women, which was an inappropriate comparison. Recent studies (53) that have used appropriate control groups (e.g., comparing women with depression taking SSRIs with women with depression not taking SSRIs, or comparing women taking an SSRI in one pregnancy but not in another) have found that psychiatric medications are largely a marker for the differences between women who are depressed and those who are not. Box 1 outlines general treatment strategies for patients with PMADs.
BOX 1. Key treatment points for perinatal mood and anxiety disorders
1.
Some women display vulnerability to reproductive hormonal transitions; for that reason, mood and anxiety symptoms commonly arise as such transition points.
2.
When treating women of reproductive age, bear in mind the patient’s potential for pregnancy (whether planned or unplanned)—so choose medication regimens with that in mind, even for patients who do not intend to become pregnant.
3.
Don’t undertreat the patient. Remember that pregnancy changes the body and metabolism; the same dosage used in pregnancy as in the nonpregnant state will yield a lower serum concentration.
4.
Remember to consider patient history—there is little to choose from in terms of risk profiles among SSRIs, so it’s important to choose a medication that works well for that patient.
5.
Remember that illness itself has detrimental effects for the mother and child; you are weighing the risks of treatment against the risks of illness, not against the benefits of not ingesting the medication.
6.
Sleep, social support, and a healthy lifestyle are crucial; remember to work with your patient on these issues too.
Nonpharmacologic Options
Depending on the severity of illness, nonpharmacologic options can be used as a sole treatment or as an adjunct. ACOG (54) recently recommended psychotherapy as a first-line treatment for mild to moderate perinatal depressive disorders. Cognitive-behavioral therapy, interpersonal psychotherapy, and dialectical behavior therapy are all evidence-based treatments for use in the perinatal period (55). Bright light therapy is another safe and effective treatment for depression; there are limited data on effectiveness in pregnancy, but the existing data (56) are promising and the treatment is benign. Other nonpharmacologic treatment options can be considered, with some evidence supporting exercise, yoga, and massage (as long as the patient has no medical indications contraindicating exercise in pregnancy, as determined by the obstetrician) (57). Patients can also be counseled on lifestyle modifications, such as smoking cessation and healthful sleep habits. Disrupted sleep and insomnia during the perinatal period have been linked to increased depressive symptoms, both concurrent and subsequent (58–60). Suggested interventions to improve postpartum sleep for women with mood disorders, and thus to improve mental health, include a mindset focused on self-care as opposed to self-sacrifice, avoiding frequent waking at night, recruiting help for overnight newborn feeding sessions, and pumping breast milk or substituting formula to decrease overnight breastfeeding (61). Cognitive-behavioral therapy for insomnia is another effective option when insomnia, rather than overall sleep deprivation, is the issue (62, 63).
Pharmacologic Options
When weighing pharmacologic treatment options for perinatal patients, some general principles highlighted by reproductive psychiatrists are important to consider. These principles include using the lowest effective dosage of medication, using medication that works for the patient, avoiding polypharmacy when possible, minimizing medication switches, and considering an untreated PMAD as a pregnancy exposure (54). Although considerable data support the use of individual psychiatric medications in pregnancy, the data are less clear on combinations of medications. Therefore, it is recommended to use the lowest effective dosages and the smallest number of exposures. Each individual medication is an exposure, but the illness itself is also an exposure. It is therefore illogical to use a low dosage that is ineffective for the patient, because the fetus is then exposed to the medication and the illness.
SSRIs are generally accepted as first-line medications for PMADs (54). If a patient has used one successfully in the past, the physician should restart the same medication. Risk profiles are similar for all SSRIs, but because not all patients respond to all medications, taking patient history into account is important. There have been conflicting data on the use of paroxetine in pregnancy and its association with fetal cardiac malformations. This association has not been upheld in repeated larger studies and in studies that have controlled for confounding factors. Currently, it is reasonable to continue or to restart paroxetine if it has worked for a patient in the past (64, 65). For patients who have not previously used such medications, any SSRI is acceptable; clinicians often choose to start with sertraline, which has the best evidence for low passage into breast milk (66). (Prior to starting an SSRI, remember to screen for bipolar disorder.) Continuing to administer validated tools to assess patient response during treatment is important. Apart from SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs) and tricyclic antidepressants are also commonly prescribed and acceptable for the treatment of PMADs. SSRIs, SNRIs, and tricyclic antidepressants used in pregnancy are all associated with a risk for poor neonatal adaptation syndrome after birth. This is a behavioral syndrome lasting less than 2 weeks; it may include increased fussing and crying, as well as difficulty feeding, and occurs in up to 30% of babies exposed to these medications in utero (67–69). Stopping medications to avoid this syndrome is not recommended; there is no clear evidence that stopping these medications during pregnancy decreases risk for the syndrome.
A promising treatment arena for postpartum depression is the newer drugs based on neuroactive steroids. These drugs work rapidly and through a unique mechanism of action. They are positive allosteric modulators of the GABA-A receptor, and considerable evidence has implicated GABA-ergic dysfunction in postpartum depression (70, 71). The U.S. Food and Drug Administration’s approval of two drugs specifically for postpartum depression—brexanolone in 2019 and zuranolone in 2023—is acknowledgment that the biological etiology of postpartum depression may differ from that of major depressive disorder. Brexanolone, an intravenous formulation, remains an option for patients who are hospitalized or are willing to be hospitalized—but its high cost, continuous monitoring through a Risk Evaluation and Mitigation Strategy, and need for hospitalization have limited its uptake (72). Zuranolone, which is taken in pill form for 2 weeks, shows a similar rapid onset of action and holds promise for treatment (to our knowledge, there are no data to date on sustained response past 45 days and limited data on breastfeeding safety) (73).
For women with bipolar disorder, continuing with pharmacological treatment if indicated is important, because of the high risk for relapse into a mood episode and of postpartum psychosis. Although valproic acid should be avoided whenever possible because of its effects on infant development, other mood stabilizers can be used in pregnancy. Women who discontinue mood stabilizers for pregnancy have an 85% chance of relapse into a mood episode, and this risk must be weighed against the risks of the medication (74). The choice of mood stabilization will depend on prior history; use whatever has worked for the patient in the past (excluding valproic acid). Lamotrigine and antipsychotic medications have reasonable safety profiles. Carbamazepine and oxcarbazepine are associated with neural tube defects (although at lower rates than valproic acid). High-dosage folic acid supplementation is often recommended with these medications and can prevent spontaneous spina bifida, but evidence is lacking that it can prevent neural tube defects associated with these medications (75). Lithium has an association with fetal cardiac anomalies, but the rate of this is much lower than previously thought, and this risk must be weighed against the risk for relapse (76). If a patient stays on this medication, a detailed anatomy ultrasound and fetal echocardiogram should be considered to assess cardiac development. Lithium levels require close monitoring throughout pregnancy and the postpartum period if continued, because changes in metabolism and glomerular filtration rate in pregnancy, and fluid shifts at delivery, can alter concentrations substantially (with significant decreases in concentration as pregnancy progresses and significant increases following delivery). The point of close monitoring is to adjust dosages to keep the patient close to the serum concentration that kept her stable prior to pregnancy. Because most patients will require increases in lithium dosages across pregnancy, it is important to remember to resume the pre-pregnancy dosage immediately after delivery. Some evidence also supports a change to twice-daily dosing during pregnancy (77). There are no universally accepted clinical guidelines for monitoring, but one evidence-based approach (78) involves monitoring lithium levels every 3 weeks until 34 weeks of gestation, then weekly until delivery, and twice weekly during the first 2 weeks postpartum. Monitoring high-risk scenarios for lithium toxicity, such as sepsis in pregnancy or hyperemesis gravidarum, remains important (77).
When used to treat perinatal anxiety, benzodiazepines should be prescribed only for a short period of time, while waiting for SSRIs and SNRIs to take effect, or as rescue medications for panic attacks. They have been associated with a small increased risk for neonatal intensive care unit admission and neonatal sedation (79).
Postpartum psychosis requires emergency treatment and should be managed with inpatient care and the advice of a reproductive psychiatrist. Patients with suspected postpartum psychosis should not be left in sole care of their children. Benzodiazepines and sedative antipsychotics can be used for immediate symptom management, but the most important management step is to start lithium as soon as possible. There is strong evidence that as many as 98% of patients with postpartum psychosis will respond to lithium, and valuable time is often wasted with antipsychotics before lithium is started (47, 80). Additionally, patients treated with lithium have significantly lower rates of relapse compared with those treated with antipsychotic monotherapy (80). Patients with postpartum psychosis who do not respond to lithium—or, for that matter, severely depressed or manic patients who do not respond to pharmacologic management—can be treated with electroconvulsive therapy.
For pharmacological management during pregnancy and postpartum, it is important to keep in mind changes to metabolism, volume of distribution, and glomerular filtration rate during pregnancy. For most medications, these changes will result in a serum level in late pregnancy that is 40%–50% lower than that of the pre-pregnancy level. For medications, such as lithium and tricyclic antidepressants, that are monitored by serum level, dosages can be adjusted accordingly. There is no accepted guideline for prophylactic dosage changes for other medications, but a careful clinician will keep a close eye on symptoms and will often find a need to increase the dosage as the pregnancy progresses.
Assessing Risk: Suicide and Infanticide
Suicidality and suicide are dangerous and unfortunately common in the perinatal period. Suicide is less common during pregnancy than at other times in a woman’s life but is more common within the first year postpartum (81). However, reports of suicidal ideation during pregnancy have increased during the past 10 years, with a more drastic increase among Black women (82). Some risk factors for perinatal self-harm and suicide include substance misuse, previous trauma, low socioeconomic status, known psychiatric disorders, prior self-harm, being unmarried, obstetrical complications, intimate partner violence, fetal loss, serious newborn illness, being a veteran, insomnia, and sudden discontinuation of psychotropic medications in pregnancy (83–86). Suicide attempts and suicidality can have dramatic effects on pregnancy and newborns. One study (87) showed that pregnant women with suicidal ideation were at fourfold risk for having an infant of low birth weight. Maternal suicidality has also been associated with poor mother-infant bonding and with poor cognitive development among children (88, 89). Another study (90) noted higher rates of offspring suicidality when exposed to parental suicidal behavior at a younger age.
Together, suicide and substance or drug overdose are currently the leading causes of maternal mortality, accounting for 22.7% of U.S. pregnancy-related deaths (91). Maternal Mortality Review Committees (92) have deemed all deaths by suicide, overdose, or both as preventable. As such, all providers should screen for and address suicidal ideation or behaviors and substance use disorders in pregnancy. As mentioned previously, both the EPDS and PHQ-9 screening tools have questions about suicidality. It is therefore vital when using these tools to assess both the overall score and the answer to the suicidality question; a positive response requires immediate assessment. This assessment includes asking whether the patient has a specific plan, the means to execute the plan, and intent. The Columbia–Suicide Severity Rating Scale can be used to determine level of risk (93). When suicidal ideation is fleeting and infrequent, when there is no immediate intent or plan, and when the patient can identify significant protective factors (for example, faith, existing children, other family members), outpatient treatment is appropriate (27). Pregnancy alone is not a significant protective factor. In this scenario of suicidal ideation without immediate intent or plan, it remains important to establish a safety plan and close follow-up.
Maternal infanticide is a tragic and horrifying occurrence, no less horrifying for its infrequency. The legal codes of some countries consider the likelihood of maternal mental illness in neonaticide (infanticide occurring prior to 12 months postpartum), but the United States makes no such distinction. Although no screening tool or set of diagnostic questions can prevent this outcome among seriously ill women, there are opportunities for recognizing and addressing severe postpartum mental illness before this point is reached. The thorough medical, psychiatric, and family histories called for in the previous assessment section; the appropriate use of pharmacologic and nonpharmacologic treatment; and appropriate involvement of family and other supports can improve maternal health before it reaches this critical point (94).
Conclusions
Almost all psychiatrists will encounter women with PMADs at some time, and it is important to be able to address and manage these conditions. These disorders can have serious implications, affecting the patient, fetus, and entire family unit. Important take-home points for this overview include the following. First, it is crucial for psychiatrists and obstetricians to collaborate during pregnancies affected by PMADs to create a plan that is safe and effective for the mother and fetus. Second, treatment of uncomplicated depression and anxiety in pregnancy is within the scope of general psychiatrists and obstetricians; both sets of providers must be knowledgeable about these conditions. Third, when considering treatment plans for women of reproductive age, the psychiatrist should be mindful of the patient’s potential for conception. Fourth, uncontrolled PMADs are associated with worse obstetric outcomes, and medication use during pregnancy is often associated with less risk than the untreated disorders. Fifth, personal or family history of bipolar disorder is the biggest risk factor for postpartum psychosis; perinatal patients with psychiatric symptoms should receive screening for bipolar disorder. Last, suicidality and postpartum psychosis are obstetric emergencies.
Future Directions
As highlighted in this review, obstetricians are not always comfortable managing PMADs, and thus it is important for psychiatrists to be able to collaborate with them and provide guidance. Collaborative care treatment models, integrating mental health providers into the prenatal clinic setting to comanage these conditions, are an excellent way to extend the scarce resource of reproductive psychiatrists to more patients. Preliminary data on these models have demonstrated mental health treatment rates significantly greater than those achieved with standard care models (25, 95). Until such models are widespread, general psychiatrists will continue to receive referrals and to manage PMADs on their own and thus must be well-versed in the complicated needs of this population. Many states now have access programs (modeled on the original Massachusetts Child Psychiatry Access Program for Moms: https://www.mcpapformoms.org), which allow for in-the-moment consultation with perinatal psychiatrists.
One reason that frontline providers—whether general psychiatrists or obstetricians—are uncomfortable treating PMADs is the lack of education provided about these conditions. Residents in obstetrics and gynecology have a vague requirement to learn about depression and anxiety but with no specific criteria; psychiatry residents are not obligated to learn anything about reproductive transitions. This gap in education has resulted in two kinds of specialists who should have knowledge of these disorders but do not (96, 97). Until graduate medical education takes PMADs seriously, we will continue to train generations of physicians who are uncomfortable treating these disorders.
Several solutions have arisen to make up for this lack of formal education in reproductive psychiatry. The National Curriculum in Reproductive Psychiatry (https://ncrptraining.org) is a free web-based curriculum for psychiatry residency programs. The curriculum provides over 75 hours of teaching on important topics and can be used in a modular fashion, with adaptations for obstetric learners to be published soon and a once-yearly CME event. Massachusetts General Hospital offers online courses, and multiple organizations that focus on and promote research on perinatal mental health treatment research (e.g., Marcé of North America, the North American Society for Psychosocial Obstetrics and Gynecology, Postpartum Support International, the National Network of Depression Centers Women & Mood Disorders Task Force) hold conferences and other educational events. Finally, a few residency programs have elective tracks in reproductive psychiatry (and even fewer, two to our knowledge, have required experiences in reproductive psychiatry). In addition, there are 18 post-residency fellowship programs open to psychiatrists (with some open to obstetricians) who desire formal training in the field.
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Published in print: Winter 2024
Published online: 16 January 2024
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Dr. Osborne reports receiving royalties from UpToDate and the American Psychiatric Association, editorial fees from Elsevier, and research support from NIH. Dr. Weingarten reports no financial relationships with commercial interests.
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