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PerinatalMoodandAnxietyDisordersCortA.Pedersen,M.D.UNCDepartmentofPsychiatryPrevalenceofPerinatalDepressiveandAnxietyDisordersDepression:approximately14%withinthefirst2-3monthspostpartum(similarrateduringpregnancy).HalfmeetDSM-IVcriteria,halfRDCcriteria.Anxiety:Atleast14%inpostpartumperiodcombiningpanicdisorder,OCDandgeneralizedanxietydisorder.Byfar,themostcommonseriousmedicalcomplicationsoftheperinatalperiod.ObstaclestoRecognitionandTreatmentofPerinatalMood/AnxietyDisordersHighexpectationsofjoy&happinesswithnewbaby:cognitivedissonanceifdysphoricsymptomsarise.Attributionofdysphoriatostress,notassessinghallmarksymptoms.Selfblame.Lackofknowledgeaboutmoodandanxietydisorders.Criticalroleofantenataleducation.CommonDysphoricEmotionalExperiencesinNewMothersMoodlability-bluesandeuphoria.Oftenunanticipatedandsometimesoverwhelmingstressofnewborncare:lossofcontrolofone’stime,feelingtrapped,“WhydidIdothis?”Heightenedanxietyduetohyper-vigilanceaboutthebaby’swelfare.Delayedfeelingsofloveforthebaby.DiagnosingPerinatalDepression:

HallmarkPsychologicalSymptomsDepressivemood,sadness,tearfulness.Diminishedinterestorpleasureinmostactivities(especiallyintakingcareofthebaby).Feelingsofworthlessnessorinappropriateguilt(especiallyaboutbeinganinadequatemother).Recurrentthoughtsofdeathorsuicide.

EdinburghPostnatalDepressionScale:Coxetal.,1987,BrJPsychiatry150:782-6.

AmbiguousSymptoms

(oftenduetoperinatalphysiologicalchanges,

demandsofnewborn,notdepression)ChangesinappetiteorweightSleepdisruption(however,persistentinabilitytosleepwhenthebabyisasleepisacommonsymptominpostpartumdepression).Persistentfatigue.Psychomotorretardationoragitation.Diminishedsubjectiveperceptionofabilitytothinkorconcentrate.BiologicalRiskFactorsfor

PostpartumDepressionHistoryofpostpartumdepression(upto50%risk).Historyofdepressionnotassociatedwithpregnancy(upto25%risk).Depressivesymptomsduringpregnancy.Familyhistoryofdepression.Historyofpremenstrualdysphoricdisorder.Postpartumblues.

Dohormonesplayarole?Progesteroneandestrogenlevelsdropprecipitouslypostpartum.Cortisol,thyroidandotherlargehormonalshiftsalsooccur.However,hormonelevelsandchangesinlevelsdonotcorrelatewithmoodsymptoms.Butrecentresearchindicatesthatwomenwhogetperipartumdepressionaremoresensitivetohormonefluctuations(Blochetal.,2000AmJPsychiatry157:924-930).PsychosocialRiskFactorsforPerinatalDepressionLackofsocialsupport.Poorrelationshipwiththefatherofthebaby.Stressfullifeevents.Primiparity.Adolescence.

PostpartumDepressionPredictorsInventory-Beck,1998,JOGNN27:39-46.PostpartumAnxietyDisorders:

ClinicalCharacteristics

Panicdisorder:Intensefearofharm/harmingbaby.Palpitations,hyperventilation,sweating,etc Difficultycaringfor,leavingbaby.OCD:Intrusivethoughts/imagesofgrievousharmtobaby.Mothersometimesimaginesherselfinflictingharm.EffectsofPregnancyontheNaturalCourseofAnxietyDisordersPanicdisorder:Increasedriskofrecurrenceorintensificationpostpartum.Obsessivecompulsivedisorder:ManywomenwithOCD(perhapsaround40%)haveinitialonsetofsymptomsduringpregnancyorthepostpartumperiod.PerinatalDepressionandAnxiety:TreatmentandProphylaxisStressreduction.Supportgroups.Psychotherapy:interpersonal,cognitive-behavioral,supportive.O’Haraetal.,2000,ArchGenPsychiatry57:1039-1045.Medication:usualtxsaregenerallyveryeffective.SSRIsbestforprophylaxis.Estrogen?LighttherapyPre&PostpartumPrevalenceofPsychiatricAdmissionsamongWomenPostpartumPsychosis:

ClinicalCharacteristicsIncidence:1-2/1000,firstfewpostnatalweeks.90%+arepsychoticmooddisorders.Moodsymptoms:depression,mania,mixed,cycling.Suicidalimpulses.Psychoticsymptoms:hallucinations,delusions,thoughtdisorder.Delusion-basedhomicidal/infanticidalimpulses.Symptomsofdeliriumoftenpresent:disturbancesofconsciousness,attention,cognition,perception,fluctuationofsymptoms.RiskFactorsforPostpartumPsychosisHistoryofbipolarorschizoaffectivedisorder:riskincreaseswithnumberofpriorepisodesandprominenceofpsychoticsymptoms(perhapsuptoa50%risk).Historyofpostpartumpsychosis(50-75%risk).ManagementandTreatmentofPostpartumPsychosisManagement:Hospitalizeimmediately(psychiatricemergency!)Constant,closeobservationSupervisevisitswithbabyTreatment:Moodstabilizers(lithium,valproicacid)AntipsychoticsAntidepressants(ifprimarilydepressed)Benzodiazepines(agitation)ECTPostpartumPsychosisProphylaxisMedication:Startmoodstabilizersimmediatelypostpartumorevenlateinpregnancy.Estrogen?General:Socialsupport/helpnetworkinplace.Patient/familyeducationaboutsymptoms.Planofactionifsymptomsdevelop.AssessingtheSafetyofPsychotropicMedicationsinPregnancy/LactationProspective,doubleblindstudiesdrugtrialsareunethical.Therefore,wearedependentoninformationfromcasereports,retrospectivechartreviews,animaltoxicologystudies.Bestsummariestodateofthisbodyofevidence:Wisneretal.,(2002)NEJM347:194-199;Newportetal.(2004)TheAPATextbookofPsychopharmacology,3rdEditionAssessingtheSafetyofPsychotropicMedicationsinPregnancy/Lactation-contAconsiderablebodyofevidenceaccumulatedoverthelast2decadesindicatesthatfetal/newbornexposuretomostclassesofpsychotropicmedicationisrelativelysafeevenduringthefirsttrimester.Mountingevidencethatstressduringpregnancy,includingthestressofuntreatedseverepsychiatricillness,hasadverseeffectsonfetaldevelopment.PotentialRisksofTreatmentwithPsychiatricMedicationsMalformations.Behavioralteratogenicity.Drugeffectsonthenewborn-toxicity,withdrawal.Bloodvolumechanges:Druglevelsshiftintothesub-therapeuticrangeduringpregnancyortoxicrangepostpartum.PotentialRisksofNotTreatingWithPsychiatricMedicationsDepression,otheruntreatedpsychiatricdisordersduringpregnancyareassociatedwithpoorobstetricoutcomes.Inuterostressretardsfetalgrowth,maydisruptnormalbehavioraldevelopment.Childrenofmentallyillmothershavemoremedical,psychological,andcognitiveproblems.Increasedriskofrecurrenceandtreatmentresistanceofillness.AntidepressantsinPregnancyandLactationSSRIsrelativelysafeevenduring1sttrimesterexceptparoxetine(increasesbirthdefectrates).Worrisomerecentreportsthatexposureduringlatepregnancymorethandoublesprevalenceofpulmonaryhypertensioninnewborns.SSRIs(especiallysertraline,citalopram,paroxetine)andTCAs(especiallynortriptyline)relativelysafeinbreast-feeding.Fluoxetineaccumulation,TCA-inducedseizures.Venlafaxineaccumulatesinmilk.Insufficientinformationaboutnewerantidepressants,trazodone.Bupropion:FDAriskcategoryB.MAOIsassociatedwithgrowthretardation,congenitalmalformations.MoodStabilizersinPregnancyandLactationLithium:Firsttrimesterexposure-0.1%riskofEbstein’sanomaly(10-20xRR).Safer2ndand3rdtrimesters.Increasesbirthweight.Newbornhypotonicity,arrhythmias,hypothyroidism,DI.Contraindicatedduringnursing.Anticonvulsants:Firsttrimesterexposure-higherratesofmiscarriage,birthdefects(NTD,orofacialclefts),IUGR,neonatetoxicity,cognitiveimpairmentwithVLP&CBZ(VLP>CBZ)butnotwithLTG(smallerdatabase).SomeevidenceoxcarbazepinesaferthanVLP.Nursing-verylowVLP,CBZbreastmilkconcentrations.LTG?AnxiolyticsDuringPregnancy/LactationDiazepam,otherbenzos:initialreportsthat1sttrimesterexposuretodiazepam,otherbenzosincreaseriskoforalcleftsnotsubstantiated.Clonazepam:lowestteratogenicityofallbenzosinanimalstudies.Noclearteratogenicitywhenusedinpregnantepileptics.Lorazepam:safetrackrecord.Limitedmilkpenetration.Low-mediumdosesconsideredreasonablysafe.Risks:infantsedation,hypotonicity,postnatalwithdrawal.Alprazolam:someevidencethatexposuremayincreaseoralcleftrisk12times(0.06%to0.7%).Buspirone:?AntipsychoticsinPregnancy/LactationPhenothiazines1sttrimesterexposuremayincreasemalformationratefrom2.0%to2.4%.Aliphatic>piperazine,piperidine.Haloperidolrelativelysafe.Infanttoxicity:EPS,bowelobstruction(rare).Atypicals:malformation,IUGRratesappearWNLs.Metabolic,neurodevelopmentaleffects,neonatetoxicity,breastmilkconcentrationsunknown.EPStreatments:Diphenhydramineisprobablysafestalthoughbirthdefectsratesomewhathigherwith1sttrimesterexposure;increasedmalformationratewithbenztropine,trihexyphenidyl,andespeciallyamantadine.Propranololisreasonablysafe.PsychotropicsinPregnancy/Lactation:GeneralConsiderationsExplainrisksandbenefitsofmedicationandnon-medicationtreatmentapproaches,respectthemother’’swishes,documentdecision-making.Don’’tusemedicationunlesstrulynecessary,especiallyduringthefirsttrimester.Dosemedicationstoadequatelytreatdisorders(i.e.,don’tunder-medicatetodecreasedrugexposure).PsychotropicsinPregnancy/Lactation:GeneralConsiderations-cont.Adjustdosesofsomemedications(moodstabilizers,antidepressants)tocompensateforchangesinbloodvolumeaspregnancyadvancesandpostpartum.Considertaperingdoseorstoppingsomemedicationspre-partumtodiminishdrugeffectsonthenewborn,especiallyifthereareobstetriccomplications.GuidelinesforTreatmentofMajorDepressionDuringPregnancy/LactationSSRIs(fluoxetine,sertraline)orsecondaryaminetricyclicantidepressants(desipramine,nortriptyline)duringpregnancyorlactation.Buproprionisprobablyreasonablysafe.MonitorTCAbloodlevels;increasedoseasnecessaryaspregnancyadvances,cutbackdoseatparturition.GuidelinesforTreatmentofManiaDuringPregnancy/LactationFirsttrimester:Haloperidolforpsychosis,clonazepamforagitation;ifmoodstabilizerisnecessary,lithiummaybefirstchoice.ECT.Second/Thirdtrimester/Postpartum:Lithiumoranticonvulsants,haloperidoland/orclonazepamiftrulyneeded.Continuetreatmentpostpartumifnoobstetriccomplications.Followbreast-fedinfantsclosely.GuidelinesforTreatmentofManiaDuringPregnancy/Lactation-contMonitorbloodlevelsofmoodstabilizersaspregnancyadvancesandincreasedosestomaintaineffectiveconcentrations.Atparturition,decreasedosesofmoodstabilizersbyapproximatelyonethirdtopreventlevelsfromrisingintothetoxicrange.GuidelinesforTreatmentofAnxietyDisordersDuringPregnancy/LactationPanicDisorder:SSRIsorsecondaryamineTCAs.Clonazepamifabenzodiazepineisnecessary.Obsessive-CompulsiveDisorder:SSRIsorclomipramineifSSRIsareineffective(riskofhypotensionduringpregnancy,infantseizures).GuidelinesforTreatmentofPsychosisDuringPregnancy/LactationHaloperidolwouldgenerallybethefirstchoicealthoughphenothiazinesprobablyincreaseriskminimally.FirstchoiceforcontrollingEPSisdiphenhydramine.Trytoavoidduringfirsttrimester.ManagingPregnancyinWomenWhoRequireChronicPsychotropicMedicationEmphasizethei