In perinatal mood and anxiety disorders

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Perinatal mood and anxiety: Treatment

Mild to moderate depression and anxiety

Consider psychotherapy

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

  • 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
  • hydration
  • daily light exercise
  • focus on personal time

Moderate to severe depression and anxiety

Consider pharmacotherapy

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.

Inform patients

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
  • hospitalization
  • ECT

Adjunctive measures

  • 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.

Pre-pregnancy consultation

  • 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.

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