Table of contents (9 chapters) Front Matter Pages ixii General Considerations in Treating Psychiatric Disorders During Pregnancy and Following Delivery Victoria Hendrick Pages 112 Prevalence, Clinical Course, and Management of Depression During Pregnancy Sanjog Kalra, Adrienne Einarson Pages 1340 Postpartum Depression C. Neill Epperson, Jennifer Ballew Pages 4181 Treatment of Anxiety Disorders in Pregnancy and the Postpartum Jonathan S. Abramowitz, Karin Larsen, Katherine M. Moore Pages 83108 Bipolar Disorder Lori L. Altshuler, Carol Kiriakos Pages 109138 Schizophrenia During Pregnancy and the Postpartum Period Pages 139152 Pregnancy and Substance Abuse Karen A. Miotto, Elizabeth Suti, Monique M. Hernandez, Phivan L. Pham Pages 153178 Eating Disorders in Pregnancy and the Postpartum Debra L. Franko Pages 179196 Children of Parents With Mental Illness Mary F. Brunette, Teresa Jacobsen Pages 197227 Back Matter Pages 229241
General Considerations in Treating Psychiatric Disorders
Disorders During Pregnancy and Following Delivery
Many pregnant women and new mothers experience psychiatric illnesses, with depressive and anxiety disorders being the most prevalent among those of reproductive age Severe conditions like bipolar disorder and schizophrenia often first appear during these years Effective psychiatric treatment frequently involves medication, and this chapter discusses crucial factors for ensuring the safety and well-being of both mother and child during pregnancy and the postpartum period.
Key Words: Psychiatric disorder; pregnancy; postpartum; breast-feeding; women.
Women aged 18 to 45 are at the highest risk for developing psychiatric disorders, with depressive and anxiety disorders being the most prevalent Many may face these challenges during pregnancy or breastfeeding, especially those with a history of relapses, as they are at increased risk for recurrence during this time It is essential for women with recurrent psychiatric disorders to seek a prepregnancy consultation to discuss the safest treatment options.
Table 1 Lifetime and 12-Mo Prevalence Rates of Psychiatric Disorders in Women and Men
Lifetime 12 mo Lifetime 12 mo Lifetime 12 mo
Any NCS disorder 48.7 27.7 47.3 31.2 48.0 29.5 a Nonaffective psychosis includes schizophrenia, schizophreniform disorder, delusional disorder, and atypical psychosis.
The National Comorbidity Survey (NCS) emphasizes the importance of consulting with healthcare professionals for women on psychiatric medications who are trying to conceive or are pregnant This consultation should review any past attempts to discontinue medication, ensuring a safe and informed approach to managing mental health during this critical period.
When considering pregnancy, a woman who experienced a quick relapse after stopping medication may need to continue her treatment during pregnancy Conversely, if she has successfully maintained her well-being for several months without the medication, she might be able to gradually reduce and eventually stop the medication before trying to conceive.
Women in their mid- to late-30s or those with a history of infertility should consider continuing their medication while trying to conceive, as it can be safely discontinued once a pregnancy test is positive, approximately two weeks post-conception This strategy minimizes embryological exposure to the medication since placental circulation is not established until 2-3 weeks after conception It's important to taper certain medications, such as mood stabilizers and antidepressants like paroxetine and venlafaxine, to reduce the risk of psychiatric relapse and withdrawal symptoms Additionally, medications with antifolate properties, including valproate and carbamazepine, should be avoided for six weeks after conception due to their association with an increased risk of neural tube defects.
Whether the discussion with the patient takes place prior to or follow- ing conception, it should review the following:
1 The available information on the risks of medication exposure during pregnancy and nursing.
The study faces limitations due to small sample sizes and insufficient information regarding the neurobehavioral effects of prenatal medication exposure Additionally, naturalistic designs may overlook confounding variables, including maternal nicotine use and health habits, which could influence outcomes.
4 The patient’s likelihood of a psychiatric relapse during pregnancy and the postpartum period.
5 Measures that may reduce likelihood of relapse (e.g., psychotherapy; couples counseling, attention to psychosocial stressors).
6 The general incidence of birth defects (approx 2–4%) regardless of prenatal medication exposure.
Clinicians must ensure that patients fully comprehend the information provided regarding their care Ongoing discussions about the risks and benefits should take place throughout the pregnancy and be meticulously documented Involving the father in these conversations is highly beneficial for comprehensive decision-making.
During pregnancy, nonpharmacological interventions, such as psychotherapy, counseling, relaxation techniques, and addressing psychosocial stressors, should be prioritized over medications However, if these methods prove inadequate or have failed previously, medication may be necessary It's essential for patients to seek support from family and friends in caring for the infant, prioritize rest and sleep, and reduce other responsibilities Hiring a child-care assistant, even for part of the day, can significantly alleviate stress and enhance well-being.
Psychiatric medication doses should be kept to the minimum necessary, with monotherapy preferred over polytherapy During the first trimester, the use of medications should be minimized or avoided, especially when safety data is limited Clinicians should prioritize the latest research findings over FDA Use-in-Pregnancy ratings when selecting medications It's important to note that the FDA Pregnancy Category B rating can be misleading, as it does not guarantee safety in pregnancy compared to Category C medications In some cases, Category C medications with low human risk data may be safer than Category B medications lacking human data.
When prescribing psychiatric medications to pregnant women, it is crucial to consider that many drugs can worsen typical pregnancy-related physiological changes For instance, medications with anticholinergic properties, such as tricyclic antidepressants and certain antipsychotic agents, may increase the risk of constipation Therefore, careful evaluation of medication effects is essential to ensure the well-being of both the mother and the developing fetus.
Table 2 FDA Use-in-Pregnancy Ratings
A Controlled studies in women show no risk.
B Animal studies show no risk, but there are no controlled studies in humans; or animal studies show adverse effect that has not been confirmed in human studies.
C Animal studies show risk but there are no controlled studies in humans; or studies in animals and humans are not available.
D There is evidence of risk in humans, but the drug may have benefits that outweigh the risk.
General Considerations 5 ric medications worsen the orthostatic hypotension and/or fatigue com- mon in pregnancy (Table 3).
Clinicians must prioritize the risks associated with medication use during pregnancy while also highlighting the critical need to avoid nicotine, alcohol, and illicit drugs Emphasizing proper nutrition and dietary habits is essential, particularly for women with chronic mental illnesses who may struggle with poor eating patterns Additionally, women with schizophrenia face a heightened risk of obesity, which is a significant risk factor for neural tube defects.
More than 50% of pregnancies in the United States are unplanned
Many women with chronic mental illnesses may experience unprotected sex and inconsistent contraceptive use, leading to unintended pregnancies Clinicians should prioritize education on contraceptive methods for those not wishing to conceive and routinely check for missed menstrual periods The importance of effective contraception has increased, especially with the rise in medication use among this population.
“atypical” antipsychotic medications (e.g., olanzapine, quetiapine) that, unlike the older antipsychotic agents, do not raise prolactin levels and therefore do not interfere with women’s ability to conceive.
3 EFFECT OF PREGNANCY ON DRUG METABOLISM
Physiological changes during pregnancy can significantly impact the serum concentrations of psychiatric medications, necessitating adjustments in dosages For instance, the blood levels of nortriptyline, a tricyclic antidepressant, tend to fall below the therapeutic range by the fifth month of pregnancy Elevated levels of estradiol and progesterone induce certain hepatic enzymes in the cytochrome P450 system, such as 3A4 and 2D6, which are responsible for metabolizing medications like quetiapine, clozapine, and risperidone Conversely, cytochrome 1A2, the primary enzyme for olanzapine metabolism, becomes less active during pregnancy, potentially leading to increased blood levels of olanzapine.
Pregnancy can lead to significant variations in how medications are cleared from the body For drugs that require careful management within a specific therapeutic range, such as lithium, tricyclic antidepressants, and antiepileptic medications, it is essential to increase the frequency of blood level monitoring to ensure safety and efficacy.
Table 3 FDA Use-in-Pregnancy Ratings for Specific Medications
Medication FDA Use-in-Pregnancy Rating
During pregnancy, the FDA has not established a specific monitoring rating for medications, so it is advisable to check medication blood levels at least once a month during the second and third trimesters If the dosage of a medication is increased while pregnant, it is recommended to reduce it after delivery to prevent potential toxicity in the mother postpartum.
4 PSYCHIATRIC MEDICATION USE NEAR TERM
Neill Epperson and Jennifer Ballew 4 Treatment of Anxiety Disorders in Pregnancy
Postpartum depression (PPD), commonly referred to as postpartum, is a significant mental health issue affecting mothers after childbirth, characterized as major depressive disorder It can arise as a new condition, a recurrence of previous depression, or stem from issues during pregnancy PPD is linked to serious health risks for both mothers and infants, with prevalence rates ranging from 10% to 13%, making it one of the most frequent complications associated with childbirth Despite its commonality, the understanding of PPD's causes, progression, and treatment remains unclear, largely due to societal perceptions that idealize motherhood This idealization has inadvertently hindered the identification and research of PPD, limiting effective clinical intervention and scientific exploration.
Postpartum depression (PPD) remains a significant public health issue, affecting over 400,000 women annually in the United States This chapter aims to synthesize the latest research on the detection, causes, and treatment of postpartum depression By doing so, it seeks to empower primary care providers to better assess and treat postpartum women, ensuring that many who might otherwise lack care receive the support they need.
Key Words: Postpartum; depression; children; treatment, breast-feeding.
THE FIRST STEP TO SYMPTOM RESOLUTION
1.1 The “Mental Health-Friendly” Environment
Creating a supportive clinical environment that integrates mental health into overall wellness is essential for encouraging women to share their emotional concerns during pregnancy and the postnatal period By prominently displaying educational resources on anxiety and depression, as well as other common pregnancy-related issues, healthcare providers can help destigmatize mental health disorders Additionally, consistently asking about symptoms of depression and anxiety during pre- and postnatal visits demonstrates that clinicians recognize and prioritize the unique needs of each patient.
Hiring a local wellness expert for in-office workshops focused on mental well-being during and after pregnancy demonstrates a primary care practice's dedication to its patients' mental health This initiative requires minimal financial and time investment from busy providers As more mental health professionals shift to fee-for-service models, it's essential for primary care practices to prioritize prevention services and offer in-house counseling for immediate psychiatric assessments Failing to do so can lead to wasted nursing and staff time in finding external mental health care providers during postpartum crises.
1.2 Routine Screening for Mental Illness in Pregnant and Postpartum Women
For clinicians aiming to implement routine screening for postnatal depression, two effective patient-rated tools are available to identify depression in postpartum women The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item questionnaire that asks women to self-assess on a scale from 0 (not at all) to 3 (all of the time) regarding statements such as “I have been able to laugh and see the funny side of things” and “I have felt sad or miserable.” This instrument is straightforward to score, with a threshold of 12.5 or higher indicating potential depression.
Postpartum depression (PPD) is prevalent among women visiting primary care clinics, with studies indicating a significant number of probable cases The Postpartum Depression Screening Scale (PDSS) is a recently developed tool designed to evaluate symptoms unique to new mothers, boasting high sensitivity and specificity for detecting PPD Unlike the Edinburgh Postnatal Depression Scale (EPDS), which consists of 10 questions, the PDSS includes 35 items but is accessible, written at a third-grade reading level, and can be completed in just 5 to 10 minutes.
A PDSS score ranging from 35 to 59 signifies normal post-delivery adjustment, while a score between 60 and 79 suggests minor postpartum depression (PPD), indicating the need for formal psychiatric evaluation Scores from 80 to 175 indicate a positive screening for major PPD, necessitating an immediate referral for mental health evaluation.
To identify additional psychiatric disorders alongside depression, clinicians can utilize the Primary Care Evaluation of Mental Disorders patient health questionnaire (PRIME-MD) A study involving 2,747 women in various obstetrics/gynecological practices revealed a 19% prevalence of psychiatric diagnoses among pregnant or postpartum women This rate mirrors that of the overall group, indicating the necessity for routine mental health screenings in all OB/GYN patients.
Identifying the specific nature, onset timing, duration, and severity of mood disturbances in postpartum women is crucial for accurate diagnosis The differential diagnosis can include normal adjustment reactions, baby blues, anxiety disorders, postpartum depression (PPD), postpartum psychosis, and bipolar disorder.
It is essential to rule out organic causes such as thyroid dysfunction in postpartum women, as approximately 5% experience this issue Among those with thyroid peroxidase antibodies during early pregnancy, about 50% may develop thyroid dysfunction within the first nine months after delivery Notably, one-third of these women could face permanent hypothyroidism Research indicates that women with thyroid peroxidase antibodies during early gestation are at a heightened risk for postpartum depression (PPD), irrespective of their thyroid function after childbirth.
The baby blues affect 26–85% of postpartum women, making them a common and normal reaction to childbirth Characterized by symptoms such as dysphoric mood, tearfulness, irritability, emotional lability, anxiety, and sleep disturbances, this syndrome typically peaks around 3–4 days after delivery and usually resolves within hours to a few days However, more severe symptoms during this period may increase the likelihood of developing major depressive disorder (MDD).
Table 1 Characteristics of the Baby Blues, Postpartum Depression (PPD), and Postpartum Psychosis: Sorting Through the Differential Diagnosis
Characteristics Baby blues PPD psychosis
Duration hours to a few days √
Confusion/disorientation √ a Symptom included in the DSM-IV criteria for major depressive disorders.
At six weeks postpartum, it is crucial for all new mothers to be aware of the possibility of experiencing mood symptoms, commonly referred to as the baby blues Healthcare providers should inform pregnant women about these symptoms during the first week after delivery If mood symptoms persist beyond a few days or become severe enough to hinder daily functioning, it is essential for mothers to reach out to their healthcare provider for support.
Postpartum Depression (PPD) affects 10–15% of postpartum women and can lead to significant distress and functional impairment lasting into the first year if untreated Diagnosis follows the DSM-IV criteria for Major Depressive Disorder (MDD), with the addition of “with postpartum onset” if symptoms arise within the first four weeks post-delivery While PPD shares symptoms with baby blues and postpartum psychosis, the latter is characterized by decreased sleep, agitation, rapid speech, and unusual behavior, resembling mania in bipolar disorder The relationship between postpartum psychosis and ongoing bipolar affective disorder remains unclear, though women without a prior psychiatric history may experience a temporary condition known as “pure puerperal psychosis.” It is crucial to assess for subtle signs of psychosis, even when a patient appears to behave normally during consultations.
Postpartum psychosis (PPD) presents distinct clinical features compared to psychosis occurring at other times, often characterized by confusion, disorganization, and fluctuating symptoms Common manifestations include thought disorganization, bizarre behavior, delusions, and self-neglect While obsessions and compulsions in PPD do not differ significantly from nonpuerperal depression, aggressive thoughts regarding the infant are more prevalent If these violent thoughts, such as harming the baby, occur without signs of psychosis and are distressing to the mother, emergency care may not be necessary However, in cases of psychosis or suicidal ideation, the lack of distress associated with these thoughts may indicate a higher risk for infanticidal behavior, necessitating inpatient hospitalization and pharmacotherapy as standard treatment.
Table 2 Examples of Questions to Use in the Primary Care Setting to Probe for Psychiatric Disorders in Postpartum Women
General well-being “Motherhood can be quite an adjustment How has it been going for you?”
Depressed mood “Have you been feeling down or more sad recently?”
Anxious mood “Do you find that you are feeling more tense and on edge than usual?” “Are you worrying about even small things?”
Many mothers often experience persistent worries regarding their baby's health and overall well-being These concerns can be difficult to shake off, leading to intrusive thoughts that linger despite efforts to focus on more positive aspects of parenting.
Psychosis “Have you or your family members noticed that you don’t seem to be your usual self lately?” “Have you been experiencing any unusual thoughts or feelings?”
Infanticidal or “It can be hard to be a new mother, and suicidal thoughts sometimes infants can be very frustrating.
Have you been so frustrated with [infant’s name] that you have had thoughts or feelings of hurting him/her?”
“Sometimes people feel so bad or upset that they don’t feel like living anymore Have you had these kinds of feelings recently?”
Seeman 7 Pregnancy and Substance Abuse
This chapter focuses on the reproductive care needs of women with schizophrenia, beginning with an overview of the illness and its treatment medications It highlights the antenatal requirements, the progression of the illness during pregnancy, and the potential risks to both mother and fetus if left untreated The chapter also examines pregnancy outcomes for women with schizophrenia, the postpartum experience, and the long-term effects on their children Additionally, it discusses the advantages and disadvantages of antipsychotic medications during pregnancy and breastfeeding, as well as the essential services these women need Effective intervention during pregnancy and the postpartum period is crucial for preventing psychiatric disabilities in future generations.
Key Words: Schizophrenia; women; pregnancy; breast-feeding; postpartum.
Schizophrenia is a complex brain disorder affecting approximately 1% of the global population, with similar prevalence across different races, cultures, and social strata It has a high heritability factor, with symptoms typically emerging in men during late adolescence and somewhat later in women The disorder is characterized by debilitating symptoms, including profound social withdrawal, mental disorganization, and distorted perceptions of reality, such as experiencing hallucinations.
Schizophrenia is characterized by a range of symptoms, including "positive" symptoms such as hallucinations and delusions, and "negative" symptoms like apathy and loss of motivation Cognitive symptoms include difficulties in focusing attention, abstract thinking, memory issues, and maintaining meaningful conversations Additionally, individuals may experience affective and behavioral symptoms, as well as interpersonal challenges If left untreated, schizophrenia significantly disrupts daily life activities.
On neuropsychological testing, patients with schizophrenia show a pattern of widespread dysfunction Imaging studies reveal reductions in the size of many brain structures when compared with age and sex controls
Schizophrenia is a neurodevelopmental disorder largely influenced by genetics, with environmental factors like prenatal infections, birth complications, and brain injuries exacerbating its severity It is probable that schizophrenia, as we understand it today, represents a group of distinct illnesses that share similar symptoms.
Individuals with schizophrenia often face interpersonal challenges and may struggle to form long-term romantic relationships, although women in this demographic tend to have better social functioning than men and are more likely to have partners and children Currently, around 60% of women with schizophrenia in Europe and North America are mothers While pharmacotherapy is a crucial component of a comprehensive biopsychosocial treatment plan, it is important to note that first-generation antipsychotics can lead to significant side effects, including extrapyramidal symptoms, sedation, cognitive impairment, and metabolic issues In contrast, second-generation antipsychotics, or atypical drugs, are now recommended as first-line treatments due to their broader symptom control capabilities.
• Social withdrawal, loss of interest and energy
• Impaired attention (inability to focus/sustain attention)
• Impaired executive function (poor problem solving, reduced ability to learn from mistakes or feedback, reduced capacity to form new concepts)
• Impaired memory (encoding, consolidation, retrieval, and recognition)
Schizophrenia is characterized by 141 symptoms, including negative, cognitive, and affective symptoms While newer antipsychotic medications offer fewer side effects, such as extrapyramidal symptoms (EPS) and tardive dyskinesia, they can lead to unwanted effects like insulin and leptin imbalances, resulting in obesity and a heightened risk of diabetes.
Women with schizophrenia experience lower fertility rates compared to the general population, a trend that may improve with the adoption of newer antipsychotic medications that do not elevate prolactin levels and thus do not hinder conception A Finnish study analyzing fertility rates of 870,093 individuals born in the 1950s found that 1.3% were diagnosed with schizophrenia, predominantly treated with first-generation antipsychotics The average number of children for women with schizophrenia was 0.83, while men had 0.44, in contrast to 1.83 for women and 1.65 for men in the general population.
Table 3 Atypical Antipsychotic Drugs Used in Schizophrenia
Table 2 Advantages of Second-Generation Over First-Generation Antipsychotic Drugs
• Improved therapeutic effect in some treatment-resistant patients
• Improved therapeutic effect on negative symptoms and neurocognitive deficits
• Reduced potential to cause acute EPS (akathisia, dystonia, parkinsonism)
• Reduced potential to cause longer-term EPS (e.g., tardive dystonia, tardive dyskinesia, tardive akathisia)
• For some of the newer drugs, reduced potential to elevate prolactin levelsEPS, extrapyramidal symptoms.
Women of childbearing age with severe, ongoing illnesses like schizophrenia need specialized support beyond standard psychiatric care to ensure a healthy pregnancy and effective mothering This includes comprehensive training in critical areas often overlooked in rehabilitation programs, such as health promotion, family planning, relationship dynamics, safety considerations, and pregnancy preparation.
Health promotion includes teaching nutrition and fitness, as well as provision of smoking- and substance-cessation programs Self-care can be poor in schizophrenia A pregnant mother needs to consume 2000–
To support a healthy pregnancy, women should aim for a daily intake of 2800 calories through a well-balanced diet rich in vitamins and minerals, including folic acid supplements prior to conception Women with schizophrenia often face higher rates of smoking and alcohol use, which can negatively impact neonatal health Additionally, obesity is prevalent in this population due to medication side effects, a sedentary lifestyle, and reliance on fast food, often stemming from poverty and limited cooking skills These factors contribute to increased risks during pregnancy, such as eclampsia and gestational diabetes.
Effective family planning for women with schizophrenia must address cognitive impairments and their heightened vulnerability to uninvited sexual contact and assertiveness challenges Safety counseling is crucial, as these women may reside in precarious situations such as shelters or unsafe neighborhoods, making them more susceptible to sexual assault, injury, disease transmission, and unwanted pregnancies Additionally, relationship counseling plays a vital role, as many women express a lack of agency in their relationships and often struggle with maintaining or ending unsatisfactory partnerships.
Preparation for pregnancy classes and support groups for women with schizophrenia of childbearing age is essential, emphasizing the significance of prenatal care in case of pregnancy These programs should cover options for unwanted pregnancies, educate participants about child development, and highlight the importance of pre-pregnancy folate supplementation Additionally, they must explain the roles of child welfare agencies, provide information on securing suitable family housing, and offer budgeting assistance to prepare for the financial responsibilities of single parenting.
Approximately 50% of pregnancies in women diagnosed with schizophrenia are unplanned, which raises concerns about potential exposure of the developing fetus to nicotine, substance abuse, and high medication doses during the crucial first trimester of pregnancy.
3 COURSE OF ILLNESS IN PREGNANCY
Many pregnant women with schizophrenia face challenges such as being single, living in poverty, and often being estranged from family The severity of their illness can fluctuate throughout pregnancy, and it remains unclear how pregnancy and lactation impact schizophrenia symptoms Interestingly, there is a slight reduction in psychiatric service contact and admissions during pregnancy compared to other times While some women may experience symptom relief, others may become more delusional, deny their pregnancy, or pose risks to their fetus Approximately 25% of pregnancies in this demographic are electively terminated.
Becoming a mother is important to most women with schizophrenia
The desire to avoid harming the fetus may lead to a sudden stop in medication, which can paradoxically worsen the patient's condition This deterioration often results in inadequate self-care and disengagement from healthcare providers and family support.
Women with schizophrenia often encounter stigma surrounding their diagnosis, leading to disapproval from families, caregivers, and communities regarding their decision to have children This societal pressure may result in some women denying their pregnancy, a self-defeating strategy that ultimately hinders access to essential prenatal care.