This article is a brief overview of an important topic in psychiatry. Residents and fellows receive very little, if any, exposure to peripartum psychiatric disorders in training.
- 20% of pregnant women experience postpartum mood and anxiety symptoms. This is more common than gestational diabetes (10%) but does not get the same attention or routine screening.
- "Baby blues" are mood changes that occur within days of delivery; "baby blues" often subsides in 2-3 weeks; 50-80% of women experience this and it is not considered a disorder.
Postpartum psychosis is a psychiatric emergency; may signify preexisting bipolar disorder (4% have involved infanticide).
Peripartum OCD, occurs in 3-5% of mothers and is ego-dystonic; mothers often have intrusive fears of harming the baby.
Edinburgh Postnatal Depression Scale - quick self report.
Rationale for pharmacological treatment
While medications have potential and varying effects on the fetus, the harm to the fetus/newborn in foregoing treatment is substantial. The effects of untreated depression on neonatal outcomes were systematically reviewed by A. Jarde et. al. (JAMA Psychiatry, 2016; 73(8))
- Untreated depression was associated with pre-term birth (OR=1.56) and low birth weight (OR 1.96).
- Post-natal morbidity includes failure to thrive, attachment disorder, and developmental delay at one year of age (Langan R. Am. Fam. Physician, 2016).
- Most medications should be used at lowest effective dose;
- Most medications may need to be increased during 3rd trimester, and adjusted carefully after delivery due to significant shifts in body fluid distribution.
- Current FDA labeling of medications' pregnancy risk is misleading. Labeling of pregnancy risk has been changed for new medications coming to market.
- The new rule replaces the product letter categories – A, B, C, D and X – with three detailed subsections that describe risks within the real-world context of caring for pregnant women.
- Most medications should be continued during breastfeeding.
SSRIs and SNRIs are not causally associated with birth defects; Paxil is somewhat more suspect, not first choice, but should be continued. There is risk of pre-term birth (4-9% vs >20%); there is a small increase in risk of a miscarriage, particularly in first term. The largest study of association of SSRIs with autism, found an increase in risk; however it had a number of important shortcomings: it did not capture parental age, smoking, or controlled for siblings with autism.
- Medications for controlled depression should generally be continued since the risk of relapse is very high.
- Depakote causes severe birth defects. It is crucial to council all women of child-bearing age about this risk and check if the woman is pregnant before starting. Since a substantial number of pregnancies are unexpected, many psychiatrists do not use Depakote as the first-line treatment for bipolar disorder in women of child-bearing age.
- Lamotrigine is an option; possible un-established risk of cleft palate.
- Lithium - increases risk of Epstein Anomaly in first trimester, from 1/20000 to 1/1000, still a low absolute risk; it can be used with caution risk assessment and education. Potentially can cause "floppy baby syndrome." Due to rapidly shifting body fluid levels it is important to check Lithium levels, particularly before and after the delivery.