Download CHAPTER 16: Psychiatric Symptoms and Pregnancy

CHAPTER 16:
Psychiatric Symptoms and
Pregnancy
Introduction
• Many women experience a spectrum of
psychiatric symptoms around the time of
childbearing.
– Antenatal = during pregnancy
– Postnatal = following pregnancy
• Some women will experience psychiatric
disorders, which are burdensome, costly, and
require safe, efficacious treatment.
The Burden of Antenatal and Postnatal
Psychiatric Symptoms
• Reproductive events are not protective against
psychiatric symptoms.
• True prevalence is unclear due to
methodological limitations.
– E.g., timing and method of assessment
• In DSM-IV-TR, there is no distinct prenatal or
postpartum psychiatric disorder classification.
Mood Symptoms
• Antenatal Depressive Symptoms
– Prevalence: 8.5% to 11%
– Pregnancy is a time of increased risk for women
with a history of depression.
– There is a potential for adverse consequences to
pregnancy health, fetal development, birth
outcomes, and postnatal health.
Mood Symptoms
• Antenatal Hypomanic and Manic Symptoms
– Antenatal manic symptoms seem to be the least
common affective experience.
– Bipolarity is the most robust predictor of severe
postnatal mental health complications, including
psychosis .
Mood Symptoms
• Postnatal Depressive Symptoms
– “Baby blues”
• Mood lability, depressed or irritable mood,
interpersonal hypersensitivity, tearfulness, and
preoccupation with infant well-being
Mood Symptoms
• Major Depressive Episodes (MDEs) With
Postpartum Onset
– Similar to MDE that occurs at nonreproductive
times
– More anxiety, somatic complaints, sleep
disturbances
– Distressing, intrusive thoughts about infant safety
or parenting competency and guilt
Mood Symptoms
• Postnatal Hypomanic Symptoms
– Similar to hypomania that occurs at
nonreproductive times
– May be more difficult to detect
– An incorrect diagnosis may lead to:
• Subsequent use of antidepressant pharmacotherapy for
later postnatal depressive symptoms
• An underestimation of risk for postpartum psychosis
• Both of which are associated with increased risk for
suicide and infanticide.
Intervention Recommendations
• Evaluate pregnant women for risk factors at
least once every trimester.
• Provide early and frequent psychoeducation,
assessment, and treatment.
• Screen for personal or family history of
bipolarity, especially before initiating
pharmacotherapy.
• Discourage abrupt changes in treatment
regimen.
Psychotic Symptoms
• In postpartum psychosis, symptom onset is often
rapid, and there is a dramatic change in the
woman’s functioning.
• Symptoms may consist of:
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Severe mood lability
Marked cognitive disturbance and impairment
Delusional beliefs about her infant
Bizarre behavior
Hallucinations
Unusual psychotic symptoms, such as tactile or olfactory
hallucinations, and command hallucinations to kill her
infant
Anxiety Symptoms
• Obsessive-Compulsive Disorder
– Intrusive thoughts often center on causing harm
to fetus or infant.
– Differs from postpartum psychosis in that the
woman recognizes that the thoughts are
unreasonable and avoids action.
– Inhibits bonding or attachment.
– Associated with depressive symptoms.
Sociodemographic and Environmental
Risk Factors
• Factors that contribute to risk during and following
pregnancy:
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Poverty
Unintended pregnancy
Single relationship status
Good to poor overall health
Marital or partner-related conflict
Limited social support
Childhood adversity
Negative life events
Intimate partner violence before or during pregnancy
Childcare stress
Effects on Women and Their Families
• Consequences of Antenatal Mood and Anxiety
Symptoms
– Adverse pregnancy, childbirth, and neonatal
outcomes
• Consequences of Postnatal Mood and Anxiety
Symptoms
– Impairments in mothering, poor mother–infant
interactions, disrupted infant behavior and
development, and inadequate infant health
management
Engaging Women in Treatment
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Identification Women in Need
Motivation and Practical Barriers to Care
Stigma
Treatment Acceptability
Conclusion
• Puerperal psychiatric disorders are of great
clinical and public health importance
• Further study should address:
– Strategies for understanding for whom to
intervene, how to intervene, and how to engage
– Whether there is a risk threshold for illness
duration and severity, and whether there are
sensitive periods when susceptibility and impact
peak