What you can expect from a psychiatrist
Reprinted from the "Having a Baby" issue of Visions Journal, 2012, 7 (3), pp. 23-25
Many people think that pregnancy and the postpartum period are a time of joy. Often, they are, but for a significant proportion of women, this is not the case: their joy and anticipation is mixed with symptoms of either pre-existing or new mental health issues.
These are the women I see in consultation and follow-up in the reproductive mental health programs where I work.
Postpartum depression occurs in at least 13% of women.1 Increasingly, we hear about postpartum depression in the media from the many women who speak out about their experiences with this difficult condition. But many people are surprised to learn that the incidence of depression in pregnancy itself is 10% to 15%.2
Anxiety disorders, which can be severe and disabling, are also reasonably common in both pregnancy and after the birth.
Women with bipolar and other psychiatric disorders who plan to get pregnant should be aware there are risks of worsening mental health during this time.
Though women often experience new onset symptoms or a worsening of illness during this time, it is not inevitable. A sound preventative plan will yield great benefits for wellness.
Assessing and planning
When I receive a referral from a midwife or physician, I first sit down with my patient and do a full assessment. I gather important information, such as her past history of mental health issues and her current symptoms. Most importantly, we talk about how her symptoms might be causing distress for her, her children or family, and how they affect her daily functioning.
Symptoms can be mild, moderate or severe. Severe symptoms of depression may include marked mood disturbance, withdrawal from activities of daily life, impairments in eating or caring for oneself or one’s children, or suicidal thinking. Severe anxiety may include debilitating panic attacks, obsessions or compulsions, or scary thoughts about the safety of a newborn. Less commonly, women can experience manic symptoms or psychosis.
Establishing a diagnosis is only the first step to treatment. Together, we establish a preventative plan that combines both evidence-based counselling and support, and careful medication strategies when needed.
Self-care and support
I often start by teaching self-care strategies. Self-care includes striving for adequate sleep, good nutrition, moderate exercise and building in time for oneself. This can be difficult during pregnancy, as sleep disruption, nausea and the responsibilities of career and child care can be hard to work around. However, it is often more challenging after the baby is born, because parenting a newborn 24 hours a day (often while sleep deprived) can be tough to manage.
The transition to parenthood can be jarring, and finding time to eat regularly, shower and even get a little quiet time takes planning. Self-care is always a core part of treatment, and for more mild-to-moderate symptoms, it can be very effective.
There is much evidence for the effectiveness of counselling and support in the treatment of mood and anxiety disorders in pregnancy and postpartum. Groups that offer peer support (often facilitated by a group leader) are invaluable to women who might not realize that other women are going through the same thing. This starts to address the guilt that many women feel about not being “happy” during this time in their lives.
More specific counselling, such as cognitive-behavioural therapy and interpersonal therapy, are shown to be effective treatments for postpartum depression and anxiety. Cognitive-behavioural therapy starts with self-care and then moves on to challenging negative or anxious thought patterns. Interpersonal therapy focuses on dealing with role transitions.
Medication during breastfeeding and pregnancy
Some women seek advice regarding the use of psychiatric medication during pregnancy and breastfeeding. For new onset mild mood or anxiety disorders, I tend to suggest using the non-medication strategies above.
If symptoms are moderate to severe, I discuss the risks of the medication for both my patient and her fetus in pregnancy, or for her child when breastfeeding. The other side of this equation is the risk of untreated mental health disorders for the patient, her pregnancy or child. These can present a substantial risk as well. Once my patient and I discuss these issues, she can make an informed decision about whether or not she will use medication.
Many women are already being treated for a mental health condition with medications, and may have a planned or an unplanned pregnancy. I encourage women who are taking psychiatric medications to talk to their doctors when planning a pregnancy in order to determine the risks and benefits of continuing medication in pregnancy. I see many women in my clinic referred to me for this reason.
Generally, if a woman’s mental health symptoms have been moderate to severe, she should choose the safest medications for a pregnancy and breastfeeding at the doses that ensure her stability. For less severe current symptoms or illness history, each woman needs to make an informed choice about the best options, be it slowly reducing or discontinuing medications (with close medical supervision) or staying on maintenance medications. This can be a complex decision, best made between each woman and her doctor.
Not uncommonly, a woman has an unplanned pregnancy while taking psychiatric medications. The most important thing in this situation is a visit to a health care provider to discuss the situation, rather than abruptly stopping all of the medications. Even if the ultimate decision is to decrease or stop medication, doing so abruptly increases the chance of relapse.
The most common medications that are used in pregnancy and lactation include antidepressants or anti-anxiety medications. Mood stabilizing medications or antipsychotic medications are also used when needed. Each medication has a unique safety profile in pregnancy or breastfeeding, so it is important to sit down with your doctor and choose the safest option.
What is the safest option? This is a difficult question, because the answer depends on each woman’s symptoms and history of medications that she’s tried in the past. Often (but not always), the safest options are medications that have been around for a number of years rather than newer medications with less data about their use in pregnancy and breastfeeding. For example, the first-line medications to treat a more severe depressive episode or anxiety disorder would be the specific seritonergic reuptake inhibitors (SSRIs), the first of which (fluoxetine, or Prozac) was approved for use in the United States in 1987.
The treatment options for bipolar disorder are more complex and require an in-depth discussion to determine the safest options. But it is clear that some medications should be avoided throughout pregnancy—and if you might become pregnant—most notably, valproic acid/valproate.
A reliable source for information on the safety of medications in both pregnancy and breastfeeding is Motherisk (www.motherisk.org).
I am always mindful of transitions that women face during pregnancy and postpartum, even the less obvious ones. Weaning from breastfeeding may be a time of increased risk for the emergence of mood or anxiety symptoms. Return to work, which often occurs after up to a year of maternity leave, can be a positive time of regaining balance in one’s life, but it can also provoke sadness and loss. Women with a seasonal pattern of worsening mood in the winter may benefit from the addition of light therapy.
Remember . . . reach out!
Depression, anxiety and other psychiatric disorders are common in pregnancy and postpartum. Acknowledging this fact is the first step in fighting the isolation and guilt that so many women feel when experiencing these symptoms during this important time in their lives. You are not alone. Reach out to a family physician, midwife, nurse, mental health professional or other supportive person in your life. Then, the journey to recovery and wellness can begin.
About the authorTricia is a psychiatrist specializing in reproductive mental health. She is the Physician Leader for the Reproductive Mental Health Program at St. Paul’s Hospital in Vancouver and directs the Reproductive Mental Health Program at Royal Columbian Hospital in New Westminster
Beck, C.T. (2001). Predictors of postpartum depression: An update. Nursing Research, 50(5), 275-85.
Bennett, H.A., Einarson, A., Taddio, A. et al. (2004) Prevalence of depression during pregnancy: Systematic review. Obstetrics and Gynecology, 103(4), 698-709.