Psychiatric illness during pregnancy
Early detection, individualized care can promote health for mother and infant
The key to successful intervention is finding a balance between managing psychiatric concerns, facilitating adequate coping with psychosocial stressors, and, if necessary, aggressively treating pregnancy-related physical illnesses. Successful treatment response depends on early detection and initiating individualized care as soon as possible.
Lack of insurance, childcare, or transportation can make it difficult for a pregnant woman to receive psychiatric treatment. All pregnant women are eligible for Medicaid if private insurance is unavailable to them, and clinicians can help patients apply for assistance. Some programs—for example, Michigan’s state-funded Maternal Infant Health Programs—offer help with transportation to appointments, such as cabs and reimbursement for gas, in addition to nutrition guidance, counseling, home visits, and referrals to community resources such as childbirth classes, infant mental health specialists, and/or substance abuse treatment (see Related Resources ).
Offering childcare during psychotherapy sessions can be particularly helpful, and may provide valuable experience for a student or resident interested in working with at-risk children. Women may be more likely to engage in care if psychotherapy sessions are conducted by phone or in their homes. A positive experience with mental health care during pregnancy may increase the likelihood that women will remain engaged in treatment after childbirth, therefore lessening the negative effects of perinatal psychopathology on mother and child.
Early detection. Women’s health care providers play a fundamental role in guiding decision-making about mental health care, providing referrals, and most important, allowing women to talk about perinatal psychopathology without fear of stigma.
When a woman becomes pregnant, it is critical to determine if she is at risk for developing psychopathology or presents with active illness. Many OB clinics screen for depression several times during pregnancy and early postpartum. The most commonly used screening tool is the Edinburgh Postpartum Depression Scale (EPDS),16 a 10-item self-report measure that is sensitive to cognitive and affective symptoms of depression. If a woman scores >15 during pregnancy or >13 postpartum, further assessment is indicated.17 The anxiety subscale (items 5 and 6) of the EPDS has been validated for screening perinatal anxiety using a cut-off score >4.18 Depression can be quickly assessed using the 2-question Patient Health Questionnaire (PHQ-2) or the 9-question PHQ-9.19,20 All 3 scales are free and available on the Internet (Table 1).21
These screening tools offer clinicians an opportunity to assess for risk factors that may increase the likelihood of illness onset or worsened prognosis (Table 2).5,22 All women who present with pregnancy-related medical illness, such as preeclampsia or gestational diabetes, should be screened for co-occurring depression or anxiety because psychiatric comorbidity is common.
Individualized care. Have an open mind about the kind of care to offer and collaborate with the patient when discussing treatment options.5 Some pregnant women may reject traditional treatments, such as pharmacotherapy or psychotherapy, because of concern about harm to the unborn baby or reluctance to work through past or present conflicts in therapy during a vulnerable time.9 Women may assume that medication will be the only treatment offered, or even fear that they will be forced to take antidepressants. Women often do not follow through on mental health referrals, even when they are appropriately screened and identified to be at risk, and an OB nurse explains the risks of untreated psychopathology.11
A multidisciplinary, collaborative care model is vital for positive pregnancy outcomes. Connecting obstetricians and midwives with psychologists, psychiatrists, social workers, and infant mental health specialists to coordinate treatment ensures that at-risk pregnant and postpartum women get the care they need. A nonjudgmental approach is essential to engage pregnant women in care. Assure women that pharmacotherapy is not required when receiving mental health treatment, but is an option they can choose.
Table 1
Screening for psychiatric illness during pregnancy
| Screening tool | Sensitivity/specificity | Administration | Availability |
|---|---|---|---|
| Edinburgh Postpartum Depression Scale | Sensitivity = 0.86 Specificity = 0.78 Positive screen: >10 | Self-administered in 5 to 10 minutes. Could be self-scored | https://bit.ly/PPDscale |
| Patient Health Questionnaire-2 (PHQ-2) | Sensitivity = 0.83 Specificity = 0.92 Positive screen: >3 | Self- or clinician-administered in <1 minute | www.phqscreeners.com The 2 questions from the PHQ-9 for mood and anhedonia are used |
| Patient Health Questionnaire-9 (PHQ-9) | Sensitivity = 0.88 Specificity = 0.88 Positive screen: >10 | Self-administered and self-scored, 5 to 10 minutes | www.phqscreeners.com |
| Source: Reference 21 | |||
Treatment choices
Pharmacotherapy. If a woman has only mild symptoms or has been symptom-free for ≥6 months, it may be safe to decrease or discontinue antidepressants during pregnancy or while trying to conceive, but such patients should be monitored closely for signs of relapse.23 In a study of 201 depressed pregnant women, 68% of those who discontinued medication experienced symptom relapse compared with 26% of those who continued medication.24 If a depressed woman has a history of relapse or severe symptoms, including suicide attempts and inpatient psychiatric admissions, it is recommended that she remain on antidepressants or mood stabilizers, regardless of pregnancy status.25 If medications are necessary during pregnancy— ie, the benefits to the mother outweigh the risks to the unborn baby—the following precautions could help decrease fetal exposure:23
