Perinatal mood and anxiety: Treatment
Mild to moderate depression and anxiety
Cognitive-behavioral therapy (CBT)
- CBT is best administered by CBT-trained providers.
- Regularly monitor effectiveness and sustainability of treatment.
Interpersonal therapy (IPT)
- Refer the patient to an experienced counsellor.
- IPT is effective in women experencing problems with role transitions.
Consider biomedical intervention
- Light therapy is most effective for people with seasonal mood variation.
- Recommend a trial with commercially available light boxes.
Consider lifestyle and personal health interventions
Help the patient make lifestyle and personal health changes, including:
- increased support (i.e., help of partner, family and friends)
- nutritious meals – address any disordered eating
- sleep – suggest help with nighttime feedings
- daily light exercise
- focus on personal time
Moderate to severe depression and anxiety
Ideally, pharmacotherapy should be accompanied by psychotherapy.
Table 17.1 summarizes information about dosages, off-label indications and risks.
Discuss fetal exposure to medications versus mental illness
- Tell the patient that no decision is risk-free.
- Explain that if the patient conceives while on antidepressant medication, the decision to discontinue medication must be weighed against a three to five times greater rate of relapse.
- Discuss warnings about neonatal withdrawal (Moses-Kokol et al., 2005), paroxetine (GlaxoSmithKline, 2005) and persistent pulmonary hypertension of the newborn (Chambers et al., 2006). Focus on study merits versus methodological challenges:
- Long-term studies up to six years of age show no cognitive effects of in utero exposure to SSRIs.
- Exposure to persistent postpartum depression is associated with delayed language and cognitive development.
- Treating maternal depression and anxiety helps to prevent these outcomes in children.
- Help the patient make an informed decision without bias.
The primary care provider should inform patients:
- of placental transfer of medication
- to continue nursing on the same medications used in pregnancy
- of excretion of medication into breast milk, which is generally negligible. A physician should monitor the breastfed infant.
Choice of pharmacotherapy
- No specific pharmacotherapy is "the best."
- Pharmacotherapy that has been effective in the past is likely to work again.
- Recommend pharmacotherapy that has been effective for the patient's family members.
- Check for interactions with other medications.
- Perinatal patients often fail to respond to antidepressants alone.
- Augmentation with other medications, including antipsychotics, is useful for patients who do not respond to antidepressants.
- Use benzodiazepines for no more than two weeks to stabilize extreme anxiety.
- Patients vary in response time and dose.
Compliance and discussion of side-effects
- Inform the patient that the most common side-effects – mild headache and GI upset – usually abate within one to two weeks.
- Advise the patient to avoid alcohol.
- Explain that alternative therapies (e.g., St. John's wort) may adversely interact with medications.
- Advise against abrupt discontinuation of medication. Slow taper is recommended.
Dose adjustment in pregnancy and postpartum
- Watch for mood changes in the late second and early third trimester.
- Dose increase may be required as plasma volume and hepatic metabolism change.
Duration of treatment
- For a single episode of depression, continue treatment for one year.
- Recurrent depressive episodes will likely require much longer-term maintenance therapy.
Psychosis and suicidality
Consider the following in acutely suicidal or psychotic pregnant and postpartum patients and explain the pros and cons to family members:
- emergency psychiatric consultation
- Lifestyle and personal health interventions
- Couples counselling
- Addiction medicine
- Educational support groups
Child protection issues
- Be especially aware if there is ongoing abuse of alcohol or other drugs in the home.
- You must alert the appropriate ministry immediately if you suspect harm, through neglect or abuse, being done to a child.
- Make every effort to establish a rapport of safety. Many women are terrified of their babies being taken away from them and this feeds into their anxiety.
- Emphasize that the goal is to restore the woman to a position where she can care for her child.
- Evaluate the patient's current mood state.
- Assess carefully whether depression is likely to occur in future pregnancies.
- Review treatment options based on the severity and frequency of symptoms.
- Discuss the possibility of medications in pregnancy.
- Assess safety on a case-by-case basis.
- Always invite the woman's partner to participate.
Best practice guidelines for mental health disorders in the perinatal period (BC reproductive mental health program, 2014)
(NICE guideline CG192, 2014)