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.
Psychiatry in primary care toolkit
The Psychiatry in Primary Care App has been decommissioned.
The revised print version of Psychiatry in Primary Care is avaible through the CAMH store.
Best practice guidelines for mental health disorders in the perinatal period (BC reproductive mental health program, 2014)
(NICE guideline CG192, 2014)