Perinatal Depressive and Anxiety Disorders

How to Cite This Chapter: Dama M, Van Lieshout R. Perinatal Depressive and Anxiety Disorders. McMaster Textbook of Internal Medicine. Kraków: Medycyna Praktyczna. https://empendium.com/mcmtextbook/chapter/B31.II.21.22. Accessed October 04, 2022.
Last Updated: July 15, 2022
Last Reviewed: July 15, 2022
Chapter Information

IntroductionTop

Pregnancy and the first year post partum, commonly referred to as the perinatal period, are widely believed to be a time of bliss and joy. However, for many mothers and birthing parents the risk of depressive and/or anxiety disorders is elevated. When untreated, these mental health problems can negatively impact the mother, their family, and their newborn.

In this chapter we discuss the etiology of perinatal depressive and anxiety disorders as well as methods of their detection, outline recommended treatments, and discuss the consequences of untreated illness during this important period in life. 

Epidemiology, Clinical Features, EtiologyTop

Epidemiology

The estimated prevalence of a major or minor depressive episode in high-income countries during pregnancy ranges from 8% to 13%, and similar estimates exist for the rates of major or minor depressive episodes during the first 12 months of the postpartum period. An antenatal depressive episode most commonly occurs during the first trimester of pregnancy, while postnatal depressive episodes, during the first 3 months post partum, followed by a steady decline in the prevalence rate during the rest of the first year of the postnatal period.

Anxiety disorders are also very common during the perinatal period, when the prevalence rate ranges from ~8% to 15% during pregnancy and 8% to 16% post partum. Of particular interest to mothers and clinicians is the fact that rates of generalized anxiety disorder (GAD) and obsessive-compulsive disorder (OCD) are higher among pregnant and postpartum individuals compared with the general population. Among specific anxiety disorders, GAD appears to be the most common anxiety disorder to develop during gestation, and symptoms of GAD comprise what is most commonly referred to as antenatal anxiety. The other common anxiety problems occurring in pregnancy include specific phobias (eg, fear of childbirth), social phobias, agoraphobia, post-traumatic stress disorder (PTSD), OCD, and panic disorder. As for the postpartum period, GAD appears again to be the most prevalent postnatal anxiety disorder, with its symptoms being most commonly referred to as postpartum anxiety (PPA). Other common postnatal anxiety disorders include specific phobia, social phobias, PTSD, OCD, panic disorder, and agoraphobia.

Clinical Features and Screening

Identifying a major depressive episode (symptoms: see Depressive Disorders) throughout pregnancy and the postpartum period can be complicated given the dimensional nature of symptoms in major depressive episodes. Physiologic changes that commonly occur throughout the perinatal period can produce physical complaints that resemble somatic symptoms of a major depressive episode (eg, changes in appetite, weight, sleep, and energy). As a result, it is important to complement the use of screening instruments with a clinical interview and careful clinical judgement.

Of these instruments, the Edinburgh Postnatal Depression Scale (EPDS), which focuses more on the neurocognitive symptoms of depression (eg, low mood and anhedonia), has the most evidence to support its ability to identify probable cases of perinatal depression reliably and accurately. In general, an EPDS score ≥11 either during pregnancy or post partum is suggestive of at least a minor depressive episode, while an EPDS score ≥14 during the perinatal period suggests that the mother is likely experiencing a major depressive episode. The following range of EPDS scores may be considered when assessing the severity of perinatal depression over time: no to minimal depression (0-9); mild depression (10-13); moderate depression (14-19); and severe depression (20-30).

When investigating for the presence of perinatal anxiety disorders, there are a couple of caveats to consider. Similar to perinatal depression, some of the physical complaints that normally occur throughout the perinatal period can resemble somatic symptoms of an anxiety disorder (eg, palpitations, headaches, and sleep changes). Therefore, clinicians need to be cognizant of these physical complaints when assessing for the presence of an anxiety disorder among perinatal individuals. In addition, mothers may present with pregnancy-specific anxiety, which is a syndrome that appears to be distinct from anxiety disorders defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM). Pregnancy-specific anxiety can center on the mother fearing and worrying about the fetus’ health, the process of delivery, and/or their ability to care for the infant following childbirth. Furthermore, they can also be concerned about their own health or have concerns about their own physical appearance.

Unlike perinatal depression, significantly less evidence exists to support the widespread use of any specific screening instrument for perinatal anxiety. Some have suggested that a score ≥5 (or >5) on the anxiety subscale of the EPDS (EPDS-A; summed score of items 3, 4, and 5; range of total score: 0-9) can identify probable cases of an anxiety disorder among perinatal mothers. A score ≥40 on the state subscale of the State-Trait Anxiety Inventory (STAI-S) has also been used to screen for probable cases of perinatal anxiety disorders. For the screening of specific anxiety disorders, the Generalized Anxiety Disorder-7 (GAD-7) (available at mdcalc.com) has been recommended as well, with a cutoff score ≥13 to identify probable cases of GAD among perinatal mothers. The Perinatal Obsessive-Compulsive Scale (POCS) may be a useful screening tool for perinatal OCD as it contains items that are specific to addressing obsessions and compulsions relating to the fetus/newborn baby. This is important given that perinatal OCD often presents with a distinctive clinical picture and course where obsessions and compulsions are focused on the fetus and/or newborn baby.

The severity of depressive and anxiety disorders is defined according to the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Etiology and Risk Factors

A complex interactive etiologic pathway involving psychosocial, clinical, and biologic factors contributes to the development of perinatal depressive and anxiety disorders.

Psychosocial risk factors for perinatal depression and anxiety include a lack of partner or social support, history of abuse (especially a history of childhood sexual abuse), domestic violence, unplanned or unwanted pregnancy, and experiencing adverse life events and/or high levels of perceived stress during pregnancy.

Clinical risk factors include a past history of mental illness (particularly a mood or anxiety disorder), history of premenstrual syndrome, past or present pregnancy complications, hyperemesis gravidarum, gestational diabetes, multiparity, history of miscarriage, having an emergency caesarean section, preterm delivery, chronic medical conditions (eg, hypertension/heart disease), sleep disorders (eg, insomnia), smoking and alcohol intake, and adolescent age.

In terms of biologic risk factors, genetics appears to play a role in the etiology of postpartum depression (PPD). A family history of PPD is higher among mothers who develop perinatal depression and mothers with PPD also report to have more than expected first-degree relatives with a major depressive disorder (MDD).

Major changes occur in the hypothalamic gonadal, adrenal, and thyroid axes as well as in the systems regulating prolactin and oxytocin levels throughout the perinatal period. However, for most of these hormones, it is not their absolute levels that are related to the development of perinatal anxiety or depression but rather the abrupt change seen in the hormonal milieu. Levels of estrogen and progesterone increase gradually during pregnancy with a rapid and abrupt drop to prepregnancy levels immediately in the postpartum period. It has been suggested that this rapid drop in these reproductive hormones contributes to the development of PPD. This notion is supported by the known interplay between reproductive hormones and neurotransmitters involved in mental health disorders (eg, serotonin and dopamine). Estrogen modulates changes in neurotransmitter systems, which in turn may influence maternal sensitivity, behavior, and attitude post partum. In terms of metabolic disorders, hypothyroidism can directly contribute to the development and presentation of a depressive disorder perinatally. Hypothyroidism often occurs in the setting of postpartum thyroiditis, a common complication affecting close to 5% of mothers in the postpartum period. As for other endocrine and metabolic disorders, some research has suggested that perinatal anemia (eg, iron deficiency in particular) and vitamin D deficiency may contribute to the development of PPD as well.

Sleep is frequently disrupted during pregnancy as well as post partum. If mothers experience dramatic changes in sleep patterns and quality throughout the perinatal period, they may be at an increased risk of depression. Such changes would involve frequent awakenings, fewer hours of total sleep, reduced sleep efficiency, shorter rapid eye movement sleep latency, and circadian phase shifts, all of which may lead to changes in mood.

Consequences of untreated illnessTop

Depressive and anxiety disorders throughout the perinatal period may not only cause impairment in functioning and affect interpersonal relationships, but they can also increase the risk of adverse outcomes in the offspring. The mechanism for the association between mental distress during the perinatal period and adverse outcomes in the offspring is not fully understood. Dysregulation in the maternal-placental-fetal axis as well as irregular patterns of inflammation throughout pregnancy have been suggested to be common physiologic pathways. Environmental factors associated with depression and anxiety such as maternal smoking, drug or alcohol abuse, poor nutrition, and low socioeconomic status also play a role.

1. Untreated perinatal depressive disorders: In its most severe form, perinatal depression can lead to suicide in mothers, one of the leading causes of maternal and neonatal mortality. Approximately 7% to 10% of mothers often consider attempting suicide in the perinatal period. In addition, infant mortality within the first year post partum is nearly twice as likely to occur if the mother has postnatal depression (risk ~1.9).

When untreated, antenatal depression is associated with poorer nutrition and medical care as well as recreational substance misuse. Also, untreated depression during pregnancy has been associated with an increase in risk of a variety of poor obstetrical outcomes including gestational hypertensive disorders (relative risk ~1.3), pre-eclampsia (risk ~1.5), preterm birth (risk ~1.4-2.4), low birth weight (risk ~1.7-2.0), low Apgar scores (risk ~1.5-1.9), intrauterine growth restriction (risk ~4.4), reduced body growth (4.4 g less per week), poor head growth (0.08 mm less per week), and a smaller head circumference. Postnatally, untreated antenatal depression is associated with decreased breastfeeding outcomes (risk ~0.5-0.8) and impaired mother-infant bonding.

The deleterious effects of untreated PPD on mothers and their families include impaired mother-infant bonding, negative parenting practices, and poor breastfeeding outcomes. Furthermore, PPD has been linked to an increased risk of infant malnutrition (risk ~1.4), infant hospitalization (risk ~1.4), and with the infant developing illnesses (risk ~2.6). Also, PPD can increase the risk of relationship problems with the partner and the partner developing depression themselves (risk ~1.2-1.7).

Lastly, untreated perinatal depression is also linked to poor socio-emotional, cognitive, language, motor, and behavioral outcomes in the offspring from infancy to adolescence. Also, recent evidence has indicated that maternal perinatal depression may clinically elevate the risk of child maltreatment as well (risk ~3.0). Furthermore, the offspring of mothers with perinatal depression are at a higher risk of developing a mental illness later on in adolescence and adulthood, such as a depressive disorder (risk ~1.8).

2. Untreated perinatal anxiety disorders: Less is known about the adverse effects of untreated antenatal anxiety, but it also appears to be associated with several adverse obstetrical outcomes including preterm birth (risk ~1.5), spontaneous preterm birth (risk ~1.4), low birth weight (risk ~1.8; mean birth weight ~56 g lower overall), small baby size for gestational age (risk ~1.5), and a smaller head circumference (0.25 cm less). Also, untreated antenatal anxiety clinically elevates the risk of the mother in experiencing a subsequent episode of PPD (risk ~2.5) and reduces the likelihood of the mother to breastfeed their infant (risk ~0.6). As for PPA, it is also linked to poor breastfeeding outcomes as well as impaired maternal-infant bonding and mother-infant interactions. Lastly, untreated perinatal anxiety is associated with poor socio-emotional, cognitive, language, motor, and behavioral outcomes in the offspring from infancy to adolescence.

ManagementTop

Treatment During Pregnancy

During pregnancy, mothers with depression and anxiety must make choices about treatment with pharmacologic interventions in the absence of high-quality evidence and a complete lack of systematic studies comparing these interventions directly. Despite this, such decisions must take into account the limited knowledge of the risks associated with fetal exposure (see Perinatal Use of Psychotropic Medications and Electroconvulsive Therapy) and those of untreated mental illness (see Consequences of Untreated Illness, above).

1. Mild to moderate MDD during pregnancy: Generally accepted first-line treatments for DSM-5–defined mild to moderate MDD during pregnancy include individual or group cognitive behavioral therapy (CBT) or interpersonal psychotherapy (IPT) (definitions of MDD severity: see Depressive Disorders). These psychologic therapies have a significant effect on reducing the severity of gestational depression compared with controlled interventions (Hedges g, 0.83; number needed to treat [NNT], 3.4).Evidence 1Weak recommendation (benefits likely outweigh downsides, but the balance is close or uncertain; an alternative course of action may be better for some patients). Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Quality of Evidence lowered due to heterogeneity and publication bias. Cuijpers P, Franco P, Ciharova M, et al. Psychological treatment of perinatal depression: a meta-analysis. Psychol Med. 2021:1-13. doi:10.1017/S0033291721004529.

In acknowledgement of the importance of the need for rapid treatment effects and risks associated with depressive symptoms during pregnancy, previously effective antidepressants for individual mothers may also be considered very early in treatment decision-making (assuming that they understand the risks and benefits and prefer it upon balancing these against the risks of other treatments and untreated depression). Since selective serotonin-reuptake inhibitors (SSRIs) are effective across the range of severity of MDD, despite a relative absence of randomized clinical trials (RCTs) during pregnancy, sertraline, citalopram, and escitalopram are the optimal choices, given their effectiveness and relative safety compared with other SSRIs. However, these antidepressants are generally considered second-line treatments, behind CBT and IPT, given the concerns regarding their use that some patients have during gestation and/or lactation.Evidence 2Weak recommendation (benefits likely outweigh downsides, but the balance is close or uncertain; an alternative course of action may be better for some patients). Low Quality of Evidence (low confidence that we know true effects of the intervention). No experimental or directly comparative studies available. If patients are not able to tolerate antidepressant medications or are not willing to take them, referral to professionals able to deliver evidence-based psychotherapies is indicated. Before antidepressants are prescribed, bipolar disorder should be excluded by the clinician.

Based on the strength of evidence in the general population samples, combination treatment with sertraline, citalopram, and escitalopram plus CBT or IPT are also reasonable. The remainder of the SSRIs (except paroxetine) and newer antidepressants are generally viewed as third-line therapies, given relatively less reproductive data and more limited use in perinatal clinical practice. Tricyclic antidepressants (with the exception of clomipramine) are also considered third-line interventions, along with mindfulness-based interventions, psychodynamic therapies, and supportive psychotherapies, bright light therapy, repetitive transcranial magnetic stimulation, and complementary/alternative treatments (such as structured exercise of moderate intensity, eg, walking in particular) as well as depression-specific acupuncture. The evidence behind any of these third-line interventions is of low or very low quality. Current evidence suggests that the use of mobile applications aimed to reduce depression during pregnancy may not be an effective intervention.

Despite increased risks of cardiovascular malformations (see Perinatal Use of Psychotropic Medications and Electroconvulsive Therapy), paroxetine and clomipramine can be used in pregnancy but should be reserved for cases with very strong indications (eg, previous good response, ongoing stability on the medication, preference after careful consideration of risks and benefits by the patient). Monoamine oxidase inhibitors (MAOIs) are not recommended during pregnancy given their propensity to interact with certain analgesic and anesthetic agents. Early consultation with an anesthetist is recommended if MAOIs are used.

2. Severe MDD during pregnancy: For severe major depressive episodes, sertraline, citalopram, and escitalopram, alone or in combination with CBT or IPT, should be considered as first-line treatments given their efficacy in nonperinatal populations. The remaining SSRIs (except paroxetine), newer antidepressants, and tricyclic antidepressants are generally considered second line. Electroconvulsive therapy (ECT) is recommended as third-line treatment given its superior effectiveness as well as relative safety and tolerability in pregnancy. Combination pharmacotherapy can also be considered, but since its use in pregnancy is limited to sparse case reports, very little is known about its short-term and long-term risks to the fetus (which are likely to be in excess of monotherapy) and it should be used only if absolutely necessary in a specialized setting.

3. Anxiety during pregnancy: Although there is far less evidence examining the efficacy of treatment options for anxiety disorders during pregnancy, it is generally recommended that the first-line treatment for DSM-5–defined mild to moderate antenatal anxiety to be either individual or group CBT. CBT has a significant effect on reducing symptoms of antenatal anxiety when tested against controlled interventions (standardized mean difference [SMD], 0.63-0.71). Pregnant persons with mild anxiety may also benefit from low-intensity psychologic therapies (eg, facilitated self-help), mindfulness-based interventions, structured exercises with moderate intensity, and yoga-based interventions. Mobile applications aimed at delivering interventions to help alleviate antenatal anxiety do not appear to be useful to date.

In the case of pregnant mothers exhibiting severe anxiety disorders or among those who are not responding to psychologic interventions and require rapid relief of symptoms, the following SSRIs may be considered: sertraline, citalopram, and escitalopram. In general, benzodiazepines are not a widely considered treatment option for mothers who have a mild to moderate anxiety disorder during pregnancy, but they are sometimes used. Pregnant mothers with a severe anxiety disorder who are not responding to the recommended SSRIs mentioned above may benefit from a short-term use of benzodiazepines. Among these medications, only lorazepam has been recommended for use in perinatal individuals. A major complication of using benzodiazepines during the third trimester and close to delivery is that it can cause withdrawal symptoms (eg, irritability, restlessness, and tremors) and signs of intoxication (eg, lethargy, respiratory distress, and hypothermia) in the neonate. If the individual has a past or current history of substance misuse/dependence disorder, a short-term use of a second-generation antipsychotic with anxiolytic properties (eg, quetiapine) can be considered. However, the prescription of any medication for mothers in the perinatal period must be accompanied by a discussion of the benefits and drawbacks of treatment, as well as the risks of untreated mental illness to the mother, fetus/infant, partner, and other children in the household.

4. Augmenting agents for treatment-resistant depressive and anxiety disorders during pregnancy: Certain second-generation antipsychotics can be considered as augmenting agents only for those who are unresponsive to the interventions described above for severe gestational depression or anxiety. If this approach is taken, it must be done with caution given that there is a paucity of RCTs investigating the efficacy and safety of pharmacologic adjuvants for treatment-resistant depression and anxiety among mothers during the perinatal period. It is essential that the clinician consults and maintains constant communication with a psychiatrist as the mother continues to receive a second-generation antipsychotic throughout pregnancy in order to prevent any detrimental effects to the mother and their fetus (see Perinatal Use of Psychotropic Medications and Electroconvulsive Therapy).

Based on RCTs involving general population samples, one Cochrane review indicates that quetiapine may be useful in augmenting the effects of antidepressants in treatment-resistant depression. Furthermore, adding quetiapine, risperidone, or aripiprazole may augment the effects of SSRIs among those with treatment-resistant OCD. In general, clozapine should not be used during pregnancy. 

The decision to use any medication during pregnancy is both complex and limited by the lack of direct and high or even moderate quality of evidence. Establishing causal links is very difficult, as events occur also without any interventions, may relate to the original condition, and the risk of bias is high. Observational studies suggest a possibility of adverse outcomes of both the underlying condition (depression or anxiety) and its treatment (SSRIs, benzodiazepines, antipsychotics). In general, even if statistically significant, those increased risks represent a minor absolute increase in risk (ie, relative risk of 2.0 may describe an increase in risk from 0.1% to 0.2% or from 5% to 10%). In the Canadian environment the use of medication over a prolonged period of time, or in combination, or with augmenting therapies should occur in the setting allowing for specialized advice, if available (see Perinatal Use of Psychotropic Medications and Electroconvulsive Therapy).

Treatment During the Postpartum Period

This section outlines general treatment recommendations for postpartum mothers and birthing parents who choose to breastfeed their infants. Those who do not may benefit from referring to general population guidelines for treating depressive disorders (Depressive Disorders).

1. Mild to moderate MDD in the postpartum period: For mothers with a DSM-5 defined mild to moderate major depressive episode who are breastfeeding, first-line treatments include CBT and IPT. These psychologic therapies have been shown to have a moderate effect on reducing postnatal depressive symptoms compared with controlled interventions (Hedges g, 0.61; NNT, 4.9). As mentioned above, if these psychotherapies are not available in a given setting, referral to other providers able to deliver CBT or IPT is warranted. However, if such therapies are not available in the regions in which mothers and birthing parents live, antidepressants may need to be used as first-line treatments.

In the presence of adequate psychotherapeutic resources, second-line agents include those for which data exist on the effectiveness during the postpartum period, which minimize exposure during lactation, and pose the least known risk during the childbearing years: sertraline, citalopram, and escitalopram. A recent Cochrane review has demonstrated that SSRIs alone have a modest effect on reducing depressive symptoms compared with placebo interventions among mothers with postnatal depression (SMD, 0.30, which denotes a small average difference although individual patients may benefit more or less). Combination treatment with these agents plus CBT or IPT are also second line (mainly owing to the lack of studies examining their effectiveness in postpartum samples).

As in pregnancy, mindfulness-based interventions as well as complementary or alternative therapies such as structured exercise with moderate intensity (eg, walking particularly) and depression-specific acupuncture are accepted as third-line treatments. Moreover, some evidence also supports the use of newer therapies such as assisted internet-based interventions that either focus on behavioral activation or CBT and therefore may also be used as third-line options. Unfortunately, mobile phone–based interventions aimed at reducing postnatal depression do not appear to be effective.

Despite the presence of RCT support for the efficacy in PPD, fluoxetine and paroxetine are third-line treatments. This is because fluoxetine has a long half-life and has been associated with higher rates of minor adverse reactions in breastfed infants compared with other SSRI (see Perinatal Use of Psychotropic Medications and Electroconvulsive Therapy), while paroxetine still poses a risk of cardiovascular malformations in potential subsequent pregnancies. The remainder of the new antidepressants are also third-line treatments for mild to moderate MDD because of the more limited clinical experience in lactating mothers. Tricyclic antidepressants are also recommended at this level, and in particular nortriptyline, because of evidence in the postpartum setting and a solid track record in lactation. Doxepin should be avoided, if possible, in the postpartum setting owing to reports of significant adverse reactions in breastfed infants.

Finally, repetitive transcranial magnetic stimulation and bright light therapy may also be effective for the treatment of mild to moderate unipolar depressive episodes and are considered as third-line therapies.

2. Severe MDD in the postpartum period: For severe PPD, sertraline, citalopram, and escitalopram are first-line choices, and third-line medications for mild to moderate depression (see above) are considered second line for mothers with severe depression. ECT is an extremely effective treatment that is listed as third line owing to its adverse-effect profile.

The use of brexanolone is beyond the scope of this chapter (and likely of uncertain risk-benefit balance).

3. Postpartum anxiety: Although no formal guidelines exist for PPA, based on nonperinatal populations, first-line treatment for DSM-5-defined mild to moderate anxiety disorders in the postpartum period (eg, GAD or panic disorder) is individual or group CBT. A meta-analysis of RCTs has shown that CBT has a moderate average effect on reducing symptoms of anxiety compared with controlled interventions among mothers with postpartum anxiety disorders (SMD, 0.63-0.71). Other nonpharmacologic interventions that can be considered for mild PPA can include facilitated self-help and mindfulness-based interventions.

As for postpartum mothers with severe anxiety or those who are not responding to psychologic therapies, the following SSRIs may be considered as a treatment option: sertraline, citalopram, and escitalopram. As during pregnancy, benzodiazepines should generally not be offered to breastfeeding postpartum mothers with mild to moderate anxiety. However, a short-term use of a short-acting benzodiazepine that has low rates of breast milk passage, such as lorazepam, may be considered in those with severe anxiety who are not responding to the SSRIs recommended above. If the patient has a history or current substance misuse/dependence disorder, a short-term use of a neuroleptic that has limited breastmilk passage, such quetiapine, might also be considered, although it is important to be aware that 2 breastfeeding patients using quetiapine reported mild delays in their infants.

4. Augmenting agents for treatment-resistant depressive and anxiety disorders in the postpartum period: Like during pregnancy, certain second-generation antipsychotics can be considered as an augmenting agent only for severe treatment-resistant depressive or anxiety disorders during the postpartum period. However, clinicians must be cautious with their use as there is a lack of RCTs testing the efficacy and safety of second-generation antipsychotics in combination with antidepressants for treatment-resistant depression or anxiety among mothers in the postpartum period. The recommendations described below are derived from RCTs conducted among nonperinatal samples. Therefore, it is essential that clinicians who use this approach consult and maintain constant communication with a psychiatrist as the postnatal mother continues to receive a second-generation antipsychotic along with their antidepressant. This includes the potential risks of weight gain, dysglycemia, extrapyramidal symptoms, and tardive dyskinesia. These should be monitored regularly, and medications should be used with eventual tapering in mind given the young age of childbearing individuals.

Postnatal mothers with treatment-resistant depression may benefit from quetiapine or olanzapine given that they have been shown to be effective as an augmenting agent for treatment-resistant depressive cases from the general population and because they have minimal breast milk passage. Quetiapine and olanzapine have also been shown to be useful as augmenting agents for treatment-resistant OCD cases in the general population and therefore may be considered as augmenting agents for postnatal treatment-resistant OCD. Risperidone may also be considered for postnatal treatment-resistant OCD, but it accumulates more markedly in breast milk compared with either quetiapine or olanzapine. Clozapine should be used with extreme caution as an augmenting agent among lactating mothers because several adverse events have been reported among breastfed infants (see Perinatal Use of Psychotropic Medications and Electroconvulsive Therapy).

In addition to being cognizant of the mother developing adverse effects commonly associated with antipsychotics (eg, weight gain, metabolic syndrome, sedation, and extrapyramidal symptoms), clinicians must also be aware of the reported associations between postnatal antipsychotic use and adverse events in breastfed infants (see Perinatal Use of Psychotropic Medications and Electroconvulsive Therapy). Lastly, maternal prolactin levels are also required to be monitored among postpartum mothers who choose to use antipsychotics as augmenting agents.

ConclusionTop

Timely detection and appropriate treatment of perinatal depressive and anxiety disorders are critical in preventing several adverse outcomes for the mother, their families, and their infants. Although common, as many as two-thirds of cases with perinatal depression or anxiety are not recognized in clinical practice. Furthermore, only as few as <10% of them receive the appropriate treatment that they need. If not identified and successfully treated, perinatal depressive and anxiety disorders can increase the risk of poor maternal outcomes (eg, maternal suicide), obstetric complications, relationship problems with partners, impaired maternal-infant attachment, poor breastfeeding outcomes, as well as a wide range of developmental problems in the offspring. Accurately identifying these mental health problems and treating them with evidence-based interventions can improve the lives of mothers, birthing parents, and their families.

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