Treatment of Perinatal Mood and Anxiety Disorders: A Review
Misri, Shaila, Kendrick, Kristin, Canadian Journal of Psychiatry
Objectives: To review the nonpharmacologic and pharmacologic treatment modalities for perinatal mood and anxiety disorders and to discuss the importance of weighing the risks and the benefits of exposing the fetus or baby to maternal mental illness as opposed to exposure to antidepressant medications.
Methods: We conducted a literature search of the PubMed and MEDLINE databases. Key words included the following: perinatal, pregnancy, postpartum, depression, anxiety, pharmacologic, nonpharmacologic, psychotherapy, and treatment.
Results: Recent literature reflects that both pharmacologic and nonpharmacologic treatments for perinatal women are associated with positive and negative outcomes. No treatment decision was found to be risk-free. The detrimental effects of untreated mental illness on the mother, as well as on the baby, highlight the need for treatment intervention. The long-term effects of exposure to either medications or maternal mental illness are unknown, as yet.
Conclusion: Women with perinatal depression and anxiety disorders require timely and efficient management with a goal of providing symptom relief for the suffering mother while simultaneously ensuring the baby's safety. Although knowledge in the area of appropriate intervention is constantly evolving, rigorous and scientifically sound research in the future is critical.
(Can J Psychiatry 2007;52:489-498)
* Leaving maternal mental illness untreated has consequences, not only for the mother but also for the developing fetus, the infant, and the child or adolescent.
* Pharmacologic treatment of perinatal mood and anxiety disorders needs careful risk-benefit analysis.
* Psychotherapy should be considered for less severe maternal mental illnesses.
* No treatment decision is risk-free: the baby is exposed, either to the medication or to the effects of maternal illness itself.
* Medication use in pregnancy and postpartum is controversial at die present time.
* Nonpharmacologic treatments in the perinatal population, although promising, require further research in regard to their efficacy and sustainability.
Key Words: perinatal, pregnancy, postpartum, depression, anxiety, pharmacologic, nonpharmacologic, treatment
Abbreviations used in this article
CBT cognitive-behavioural therapy
IPT interpersonal therapy
MAOI monoamine oxidase inhibitor
PPHN persistent pulmonary hypertension
SNRI selective norepinephrine reuptake inhibitor
SSRI selective serotonin reuptake inhibitor
TCA tricyclic antidepressant
Mental illness is one of the most commonly encountered complications of the perinatal period and is fraught with controversy and uncertainty in regard to treatment.1,2 Many women refuse medication for mental illness during pregnancy because of the possible risk of teratogenicity and concern over adverse neonatal effects at birth and potential negative infant development in the short and long term. In this population, treatment success with psychotherapy is limited. Nonetheless, failure to effectively treat pregnant women suffering from depression or anxiety can lead to compromised prenatal care, increased risk of obstetrical complications, postpartum exacerbation, self-medication and (or) substance abuse, impaired bonding, and fetal exposure to the detrimental effects of the illness itself.3-8 Postnatally, the foremost apprehension is the possible risk to infants of exposure to medications through breast milk together with the effect of medications on infants' development. However, untreated postpartum mood and anxiety disorders negatively affect mother-infant interaction and bonding and have short- and long-term detrimental effects on children.9 It is critical to weigh the risks and benefits of exposing the fetus or baby to maternal mental illness against the risks and benefits of exposure to psychotropic medications in the perinatal period. …