Continuing Education| Volume 14, ISSUE 7, P507-513, July 2018

Perinatal Mood and Anxiety Disorders

DOI:https://doi.org/10.1016/j.nurpra.2018.03.010
Perinatal Mood and Anxiety Disorders
Next ArticleThe Journal for Nurse Practitioners Continuing Education Credit Application

      Highlights

      • •
        This article discusses the need to establish mental health protocols in settings that serve women.
      • •
        Suicidal ideation or intention among women with depression is assessed.
      • •
        Nonpharmacologic interventions for mild to moderate perinatal mood and anxiety disorder are offered.
      • •
        Nurse practitioners need to consider medication safety when prescribing for pregnant and breastfeeding women.

      Abstract

      Perinatal mood and anxiety disorders (PMADs) are a public health issue that has a profound negative effect on women, families, and communities. It is estimated that 15% to 21% of pregnant and postpartum women experience PMAD, which includes depression, anxiety, obsessive-compulsive disorder, posttraumatic stress disorder, and postpartum psychosis. The purpose of this article is to provide an overview of perinatal mood and anxiety disorders in an effort to improve recognition, screening, diagnosis, treatment, and referral by nurse practitioners and midwives.

      Keywords

      This CE learning activity is designed to augment the knowledge, skills, and attitudes of nurse practitioners and assist in their appropriate utilization of nonpharmacological and pharmacologic treatment as measured by a score of at least 70% on the CE evaluation quiz.
      At the conclusion of this activity, the participant will be able to:
      • A.
        Describe diagnostic criteria for perinatal mood and anxiety disorders
      • B.
        Identify interventions to treat perinatal mood and anxiety disorders
      • C.
        Identify medications used in treating mood disorders to avoid during pregnancy and lactation
      The author, reviewers, editors, and nurse planners all report no financial relationships that would pose a conflict of interest.
      The author does not present any off-label or non-FDA-approved recommendations for treatment.
      This activity has been awarded 1 Contact Hours of which 0.5 credits are in the area of Pharmacology. The activity is valid for CE credit until September 1, 2020.
      Perinatal mood and anxiety disorders (PMADs) are a challenging public health issue that has a profound negative effect on women, families, and communities.

      Sontag-Padilla L, Lavelle T, Dana S. Costs and benefits of treating maternal depression. www.rand.org/pubs/external_publications/EP50514.html. May 1, 2014. Accessed December 10, 2017.

      It is estimated that 15% to 21% of pregnant and postpartum women experience symptoms of PMAD, which includes depression, anxiety, obsessive-compulsive disorder, posttraumatic stress disorder (PTSD), and postpartum psychosis.

      Postpartum Support International. Perinatal mood and anxiety disorders fact sheet. http://postpartum.net/wpcontent/uploads/2014/11/PSI-PMD-FACT-SHEET-2015.pdf Updated 2014. Accessed December 18, 2017.

      Risk factors for developing PMAD include low socioeconomic status, low educational attainment, a history of mental illness, delivering a preterm baby, exposure to interpersonal violence, and a lack of social support.

      National Institute of Child Health and Human Development. Information for moms to be and moms. National Child and Maternal Health Education Center. https://www.nichd.nih.gov/ncmhep/MMHM/Pages/Momstobe.aspx Updated 2016. Accessed December 10, 2017.

      , 

      Committee on Obstetric Practice. The American College of Obstetricians and Gynecologists Committee Opinion no. 630. Screening for perinatal depression. Obstet Gynecol. 2015;125:1268–1271. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co630.pdf?dmc=1&ts=20180121T1925204741. 2015. Accessed January 18, 2018.

      Mood and anxiety disorders during the perinatal period can impair the maternal behavioral response, leading to long-term behavioral problems among exposed children.
      • Hoffman C.
      • Dunn D.M.
      • Njoroge W.F.M.
      Impact of postpartum mental illness upon infant development.
      Curr Psychiatry Rep. 2017; 19: 100https://doi.org/10.1007/s11920-017-0857-8
      , 
      • Walker L.O.
      • Murphey C.L.
      • Nichols F.
      The broken thread of health promotion and disease prevention for women during the postpartum period.
      J Perinat Educ. 2015; 24: 81-92https://doi.org/10.1891/1058-1243.24.2.81
      , 
      • Goodman J.H.
      • Guarino A.J.
      • Prager J.
      Perinatal dyadic psychotherapy: design, implementation, and acceptability.
      J Fam Nurs. 2013; 19: 295-323
      , 
      • Glynn L.M.
      • Howland M.A.
      • Sandman C.A.
      • et al.
      Prenatal maternal mood patterns predict child temperament and adolescent mental health.
      J Affect Disord. 2017; 228: 83-90https://doi.org/10.1016/j.jad.2017.11.065
      Treatment often relies on the use of psychotropic medications, which may not be indicated for mild to moderate PMAD and may not be an acceptable option for a pregnant or breastfeeding woman.

      American Academy of Pediatrics. Use of antidepressants during pregnancy and risk of asthma. J Pediatr. 2015. https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/Use-of-Antidepressants-During-Pregnancy-and-Risk-of-Asthma.aspx. 2015. Accessed December 12, 2017.

      , 
      • Boukhris T.
      • Sheehy O.
      • Mottron L.
      • Bérard A.
      Antidepressant use during pregnancy and the risk of autism spectrum disorder in children.
      JAMA Pediatr. 2016; 170: 117-124https://doi.org/10.1001/jamapediatrics.2015.3356
      There are generally many opportunities to screen, diagnose, and initiate treatment for PMAD during health care encounters related to pregnancy, postpartum, and breastfeeding. This article presents a comprehensive overview of PMAD and the role of the nurse practitioner (NP)/midwife in the clinical management of PMAD.

      Maternal Mental Health/Mental Illness During the Perinatal Period

      The delivery of care to women during the perinatal period is largely focused on achieving and maintaining optimal health; assessing risks to both the mother and the fetus; and treating health conditions as they arise during the preconception, prenatal, and postpartum period. Mental health is essential to a healthy perinatal period and maternal role adaptation. Mental health is defined as emotional, spiritual, and social well-being.

      World Health Organization. Mental health: a state of wellbeing. http://www.who.int/features/factfiles/mental_health/en/. August 2014. Accessed November 10, 2017.

      The World Health Organization maintains that mental health is reaching one’s own potential, developing and sustaining healthy relationships, and contributing toward one’s own community.

      World Health Organization. Mental health: a state of wellbeing. http://www.who.int/features/factfiles/mental_health/en/. August 2014. Accessed November 10, 2017.

      Mental health is necessary for managing daily stressors, decision making, and maintaining relationships. Pregnancy is often a time of both physical and mental well-being, but it can also be a major stressor in a woman’s life. A pregnancy may be unwanted or mistimed, social support during the perinatal period may be inadequate, and the financial strain of a new baby may be difficult for some women and families. These stressors are known to increase the risk for developing signs and symptoms of mental illness for vulnerable individuals.

      National Institute of Child Health and Human Development. Information for moms to be and moms. National Child and Maternal Health Education Center. https://www.nichd.nih.gov/ncmhep/MMHM/Pages/Momstobe.aspx Updated 2016. Accessed December 10, 2017.

      , 

      Committee on Obstetric Practice. The American College of Obstetricians and Gynecologists Committee Opinion no. 630. Screening for perinatal depression. Obstet Gynecol. 2015;125:1268–1271. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co630.pdf?dmc=1&ts=20180121T1925204741. 2015. Accessed January 18, 2018.

      Women are 2 to 3 times more likely to develop a mood disorder compared with men, and the prevalence of mental illness among women 18 to 49 years old is significant.

      National Institute of Mental Health. Mental health statistics. https://www.nimh.nih.gov/health/statistics/prevalence/any-mental-illness-ami-among-us-adults.shtml. 2014. Accessed January 12, 2018.

      The National Institute for Mental Health estimates that 1 in 6 Americans is living with a mental illness in any given year and concludes that mental illnesses in the United States are common.

      National Institute of Mental Health. Mental illness. https://www.nimh.nih.gov/health/statistics/mental-illness.shtml#part_155771. November 2017. Accessed January 12, 2018.

      Although all mental illness may not be preventable, early recognition and appropriate treatment are crucial to improve health outcomes for women, neonates, and families. Little is known about the etiology of mental illness, but it is believed that genetic, biological, and environmental factors all play a role.

      National Institute of Mental Health. What caused this to happen? https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2015/what-caused-this-to-happen.shtml. January 12, 2015. Accessed January 12, 2018.

      Mental illness can be quite challenging to diagnose accurately because diagnosis often relies on subjective data (what the client reports to you) and clinical expertise including education, experience, use of screening tool(s), and taking a comprehensive history.
      • Zimmerman M.
      • Martinez J.H.
      • Morgan T.A.
      • Young D.
      • Chelminski I.
      • Dalrymple K.
      Distinguishing bipolar II depression from major depressive disorder with comorbid borderline personality disorder: demographic, clinical and family history differences.
      J Clin Psychiatry. 2013; 74: 880-886https://doi.org/10.4088/JCP.13m08428
      , 
      • Bouras N.
      Social challenges of contemporary psychiatry.
      Psychiatriki. 2017; 28: 119-202https://doi.org/10.22365/jpsych.2017.283.199
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      • Aboraya A.
      • Rankin E.
      • France C.
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      • John C.
      The reliability of psychiatric diagnosis revisited.
      Psychiatry (Edgmont). 2006; 3: 41-50
      Currently, there are no laboratory tests or diagnostic studies (eg, blood work or scan) available to help confirm a diagnosis of mental illness. It is important that every setting that provides services to women during the perinatal period should have a comprehensive plan to promote mental health and manage mental illness.

      Committee on Obstetric Practice. The American College of Obstetricians and Gynecologists Committee Opinion no. 630. Screening for perinatal depression. Obstet Gynecol. 2015;125:1268–1271. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co630.pdf?dmc=1&ts=20180121T1925204741. 2015. Accessed January 18, 2018.

      , 

      U.S. Preventive Services Task Force. Final recommendation statement: depression in adults: screening. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/depression-in-adults-screening. Published December 30, 2013. Accessed January 12, 2018.

      Screening

      Because no consensus exists on when to initiate screening for PMAD or how often screening should occur during the perinatal period, NPs may be uncertain about when and how screening should be implemented in the clinical setting. The American College of Obstetricians and Gynecologists recommends that women should be screened for depression and anxiety at least once during the perinatal period using a standardized screening instrument.

      Committee on Obstetric Practice. The American College of Obstetricians and Gynecologists Committee Opinion no. 630. Screening for perinatal depression. Obstet Gynecol. 2015;125:1268–1271. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co630.pdf?dmc=1&ts=20180121T1925204741. 2015. Accessed January 18, 2018.

      The US Preventive Services Task Force recommends that depression screening should be implemented annually for adults, including pregnant women, once a system or protocol for accurate diagnosis, treatment, and follow-up is established.

      U.S. Preventive Services Task Force. Final recommendation statement: depression in adults: screening. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/depression-in-adults-screening. Published December 30, 2013. Accessed January 12, 2018.

      Instruments for Screening

      Reliable and valid instruments for screening include the Edinburgh Postnatal Depression Scale, the Postpartum Depression Screening Scale, the Patient Health Questionnaire-9, the Generalized Anxiety Disorder Scale-7, and The Perinatal Anxiety Screening Scale (PASS) (Table).
      • Cox J.L.
      • Holden J.M.
      • Sagovsky R.
      Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale.
      Br J Psychiatry. 1987; 150: 782-786https://doi.org/10.1192/bjp.150.6.782
      , 
      • Beck C.T.
      • Gable R.K.
      Postpartum depression screening scale: development and Psychometric Testing.
      Nurs Res. 2000; 49: 272-282
      , 
      • Kroenke K.
      • Spitzer R.L.
      The PHQ-9: a new depression diagnostic and severity measure.
      Psychiatr Ann. 2002; 32: 509-515
      https://doi.org/10.3928/0048-5713-20020901-06
      , 
      • Spitzer R.L.
      • Kroenke K.
      • Williams J.B.
      A brief measure for assessing generalized anxiety disorder: the GAD-7.
      Arch Intern Med. 2006; 166: 1092-1097https://doi.org/10.1001/archinte.166.10.1092
      , 
      • Fallon V.
      • Halford J.C.
      • Bennett K.M.
      • Harrold J.A.
      The Postpartum Specific Anxiety Scale: development and preliminary validation.
      Arch Womens Ment Health. 2016; 19: 1079-1090
      The Edinburgh Postnatal Depression Scale, the Patient Health Questionnaire-9, and the Generalized Anxiety Disorder Scale-7 are available at no cost and have been translated into Spanish and other languages. The PASS is the first instrument developed specifically to screen women for anxiety during the perinatal period.
      • Fallon V.
      • Halford J.C.
      • Bennett K.M.
      • Harrold J.A.
      The Postpartum Specific Anxiety Scale: development and preliminary validation.
      Arch Womens Ment Health. 2016; 19: 1079-1090
      The PASS identified 68% of women with anxiety and has the potential to be used in perinatal clinical settings. Increased screening frequency should be considered for women with risk factors for PMAD, a history of mental illness, or those who are currently symptomatic or under the care of a psychiatric provider. Screening should be the first step in detecting signs and symptoms of PMAD. A clinical examination is necessary to confirm the findings of a positive screening, making a diagnosis and developing an initial plan of care that the client agrees with. Each clinical setting is unique, and a thorough evaluation of available mental health resources in the community is necessary before initiating PMAD screening. The NP who conducted the screening should make the referral because this can help establish relationships with mental health professionals who serve the community and may provide opportunities for interdisciplinary comanagement. Referrals may be challenging for practitioners in rural settings and in areas where there is a dearth of mental health providers, especially multilingual mental health providers, but mental health services are increasingly available through telehealth, Skype, and models in which the mental health professional travels to the perinatal clinical setting. Women with positive PMAD screens should be fully informed of the screening outcome. Every woman should be given an opportunity to voice her questions, concerns, and preferences for referral.
      TableDepression and Anxiety Screening Instruments
      NameItemsLanguagesTimeSensitivitySpecificity
      Edinburgh Postnatal Depression Scale10English plus 35 others5 minutes or less57%-100%49%-100%
      Postpartum Depression Screening Scale35English and Spanish5-10 minutes80%-100%72%-98%
      Patient Health Questionnaire-99English and Spanish5 minutes or less80%-100%90%
      The Generalized Anxiety Disorder Scale-77English, Spanish5 minutes or less89%82%
      Perinatal Anxiety Screening Scale31English5-10 minutesNANA
      NA = not applicable.
      Screening for PMAD should not rely solely on reliable and valid instruments. Every NP who provides perinatal care should possess the clinical expertise to assess a woman’s affect, how she is coping with the pregnancy or postpartum period, if she has sufficient social support, and who is providing that support. NPs should also review the importance of self-care, including sufficient sleep, sound nutrition, exercise, and helping the new mother to understand that the transition to motherhood can be stressful. Observing interactions between the woman and her baby can help the practitioner determine how she is adjusting to her new role in the postpartum period. Each clinical encounter provides an opportunity to reinforce and support every woman during the perinatal period.

      Immediate Postscreening Considerations

      Women with a positive screen for PMAD will not necessarily be diagnosed with depression and/or anxiety. However, all women with a positive PMAD screen should be assessed for suicidal ideation and intention once a positive screen has been determined. Gavin et al
      • Galvin A.R.
      • Tabb K.M.
      • Melville J.L.
      • Guo Y.
      • Katon W.
      Prevalence and correlates of suicidal ideation during pregnancy.
      Arch Womens Ment Health. 2011; 14: 239-246https://doi.org/10.1007/s00737-011-0207-5
      found that 2.7% of pregnant women (n = 2159) reported suicidal ideation, and Onah et al
      • Onah M.N.
      • Field S.
      • Bantjes J.
      • Honikman S.
      Perinatal suicidal ideation and behavior: psychiatry and adversity.
      Arch Womens Ment Health. 2017; 20: 321-331
      found depression to be the strongest predictor for suicidal ideation.
      NPs may be reluctant to inquire about suicidal ideation or intention, especially during pregnancy, but this assessment may be lifesaving. Assessing for suicidal ideation can be accomplished by asking the woman if she thinks of suicide, if she thinks of killing herself, or if she thinks the world would be a better place without her. Inquiring if a patient is suicidal will not cause them to become suicidal. When assessing suicidal intention, it is important to assess if the patient has a plan and the means to commit suicide. Treatment algorithms and a response protocol should be available in the clinical setting to assist NPs manage this potential health care crisis.

      Council on Patient Safety in Women’s Health Care. Maternal Mental Health: Depression and Anxiety. http://safehealthcareforeverywoman.org/patient-safety-bundles/maternal-mental-health-depression-and-anxiety/. 2016. Accessed January 12, 2018.

      , 
      • Kendig S.
      • Keats J.P.
      • Hoffman M.C.
      • et al.
      Consensus bundle on maternal mental health: perinatal depression and anxiety.
      J Midwifery Womens Health. 2017; 62: 232-239
      The maternal mental health bundle developed by the Council on Patient Safety in Women’s Health Care is available online and provides comprehensive information and resources to establish an interdisciplinary approach to managing depression and anxiety in a safe supportive setting.

      Council on Patient Safety in Women’s Health Care. Maternal Mental Health: Depression and Anxiety. http://safehealthcareforeverywoman.org/patient-safety-bundles/maternal-mental-health-depression-and-anxiety/. 2016. Accessed January 12, 2018.

      , 
      • Kendig S.
      • Keats J.P.
      • Hoffman M.C.
      • et al.
      Consensus bundle on maternal mental health: perinatal depression and anxiety.
      J Midwifery Womens Health. 2017; 62: 232-239
      Mental illness is primarily managed in the primary care setting; therefore, it is imperative for NPs to develop basic skills in assessing psychiatric conditions. Materials, webinars, and educational programs on mental illness are available for NPs to expand their knowledge and clinical skills (see Resources).

      Diagnosis and Management of Perinatal Depression

      Many women (40%-80%) experience baby blues in the immediate postpartum period.

      National Institute of Mental Health. Postpartum depression facts. https://www.nimh.nih.gov/health/publications/postpartum-depression-facts/index.shtml. Accessed November 22, 2017.

      Symptoms include sadness, worry, and fatigue. Symptoms are generally transient, last about 2 weeks, resolve without intervention, and do not progress in severity.

      National Institute of Mental Health. Postpartum depression facts. https://www.nimh.nih.gov/health/publications/postpartum-depression-facts/index.shtml. Accessed November 22, 2017.

      , 

      National Institute of Child Health and Human Development. Mom’s mental health matters: depression and anxiety around pregnancy. https://www.nichd.nih.gov/ncmhep/initiatives/moms-mental-health-matters/moms/pages/default.aspx. Accessed November 22, 2016.

      It is important to educate women and their families about the baby blues and to seek assistance if symptoms do not resolve or if they increase in severity. The American Psychiatric Association (APA) establishes the diagnostic criteria for mental illness in the US. The APA first recognized major depressive disorder (MDD) with a postpartum onset in 1994.

      Segre LS, Davis WN. Postpartum depression and perinatal mood disorders in the DSM. Postpartum support international. http://www.postpartum.net/wp-content/uploads/2014/11/DSM-5-Summary-PSI.pdf. 2016. Accessed December 1, 2016.

      Currently, the only mental illness recognized by the APA associated with pregnancy and the postpartum period is MDD with a peripartum onset.
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders, Fifth ed.
      American Psychiatric Association, Arlington, VA2013
      For a diagnosis of MDD to be made, the following symptoms must be present for a minimum of 2 weeks: depressed mood, anhedonia, weight loss or loss of appetite, weight gain or increase in appetite, insomnia or hypersomnia, psychomotor agitation or retardation (as observed by others), fatigue or loss of energy, guilt or feelings of worthlessness, inability to focus or concentrate, recurrent thoughts of death, suicidal ideation, or suicide plan or attempt. The symptoms must cause significant distress and cannot be attributable to substance abuse or a medical condition. MDD can be classified as mild, moderate, severe, with psychotic features, in partial or full remission, or unspecified.
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders, Fifth ed.
      American Psychiatric Association, Arlington, VA2013
      Differential diagnoses to consider are mood disorder because of a medical condition, substance use/abuse, bipolar disorder I or II, attention-deficit disorder, adjustment disorder, or sadness. Other depression types include dysthymia, premenstrual dysphoric disorder, and unspecified depressive disorder. The full diagnostic criteria for these disorders can be fully explored in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders, Fifth ed.
      American Psychiatric Association, Arlington, VA2013
      Developing a treatment plan for a depressive disorder should begin with consideration for the woman’s preferences, the diagnosis, and the severity of symptoms. Treatment modalities are classified as pharmacologic and nonpharmacologic. Initially, the diagnostician may recommend a combination of medication and a therapeutic intervention. The recommended therapeutic interventions for MDD are cognitive behavioral therapy (CBT), interpersonal psychotherapy, or group therapy, but few therapeutic interventions have been developed to treat PMAD specifically. A systematic review of group therapy for women with postpartum depression found improvement in depression scores among the participants.
      • Goodman J.H.
      • Santangelo G.
      Group treatment for postpartum depression: a systematic review.
      Archs Womens Ment Health. 2011; 14: 277-293https://doi.org/10.1007/s00737-011-0225-3
      Goodman et al
      • Goodman J.H.
      • Guarino A.J.
      • Prager J.
      Perinatal dyadic psychotherapy: design, implementation, and acceptability.
      J Fam Nurs. 2013; 19: 295-323
      tested an intervention, perinatal dyadic psychotherapy (PDP), consisting of 8 nurse-led home visits that addressed maternal and infant mental health and found significant improvement in the mother-baby relationship and a decrease in the symptoms of depression. The study concluded that the program was safe, feasible, and acceptable to the women.
      • Goodman J.H.
      • Guarino A.J.
      • Prager J.
      Perinatal dyadic psychotherapy: design, implementation, and acceptability.
      J Fam Nurs. 2013; 19: 295-323
      In a follow-up study, Goodman et al
      • Goodman J.H.
      • Prager J.
      • Goldstein R.
      • Freeman M.
      Perinatal dyadic psychotherapy for postpartum depression: a randomized controlled pilot trial.
      Arch Womens Ment Health. 2015; 18: 493-506https://doi.org/10.1007/s00737-014-0483-y
      randomized 42 mothers at 6 weeks’ postpartum to either PDP or usual care with additional depression monitoring.
      • Goodman J.H.
      • Prager J.
      • Goldstein R.
      • Freeman M.
      Perinatal dyadic psychotherapy for postpartum depression: a randomized controlled pilot trial.
      Arch Womens Ment Health. 2015; 18: 493-506https://doi.org/10.1007/s00737-014-0483-y
      The results concluded that both programs had equal benefit in treating PPD and recommend further research to determine benefits of PDP. Studies such as these support the use of nonpharmacologic interventions for PPD.
      A study published in 2007 concluded that 13% of all pregnant women use antidepressants, but no data were available to reflect the current use of these medications during pregnancy.
      • Cooper W.O.
      • Willy M.E.
      • Pont S.J.
      • Ray W.A.
      Increasing use of antidepressants in pregnancy.
      Am J Obstet Gynecol. 2007; 196: 544.e1-544.e5https://doi.org/10.1016/j.ajog.2007.01.033
      The use of antidepressant medications remains controversial during pregnancy and breastfeeding. Fluoxetine and paroxetine have been associated with cardiac defects, anencephaly, craniosynostosis, and abdominal wall defects.
      • Reefhuis J.
      • Devine O.
      • Friedman J.M.
      • Louik C.
      • Honein M.A.
      Specific SSRIs and birth defects: Bayesian analysis to interpret new data in the context of previous reports.
      BMJ. 2015; 351 (Accessed December 1, 2016): h3190
      www.bmj.com/content/351/bmj.h3190
      , 
      • diScalea T.L.
      • Wisner K.L.
      Antidepressant medication use during breastfeeding.
      Clin Obstet Gynecol. 2009; 52: 483-497https://doi.org/10.1097/GRF.0b013e3181b52bd6
      Sertraline was not associated with any birth defects.
      American College of Obstetricians and Gynecologists Practice Bulletin: clinical management guidelines for obstetricians/gynecologists: use of psychiatric medications during pregnancy and lactation.
      Obstet Gynecol. 2008; 111: 1001-1020https://doi.org/10.1097/AOG.0b013e31816fd910
      There are many considerations when determining the risks and benefits of any medication during pregnancy. Referral to an experienced psychiatric provider or psychopharmacologist for a medication evaluation is an important step because there are risks in not treating perinatal depression adequately. diScalea and Wisner
      • diScalea T.L.
      • Wisner K.L.
      Antidepressant medication use during breastfeeding.
      Clin Obstet Gynecol. 2009; 52: 483-497https://doi.org/10.1097/GRF.0b013e3181b52bd6
      found limited applicable information about the use of psychotropic medications because of a small sample size and case studies. The American College of Obstetricians and Gynecologists and the Academy of Breastfeeding Medicine concur that the risks and benefits of psychotropic medications should be reviewed on a case-by-case basis, that full disclosure about the potential risks and benefits be provided to the woman to help her make an informed decision, and that nonpharmacologic interventions should be the first line of treatment for all women with mild to moderate depression.
      American College of Obstetricians and Gynecologists Practice Bulletin: clinical management guidelines for obstetricians/gynecologists: use of psychiatric medications during pregnancy and lactation.
      Obstet Gynecol. 2008; 111: 1001-1020https://doi.org/10.1097/AOG.0b013e31816fd910
      , 
      • Sriraman N.K.
      • Melvin K.
      • Meltzer-Brody S.
      Academy of Breastfeeding Medicine Clinical Protocol #18. Use of antidepressants in breastfeeding mothers.
      Breastfeed Med. 2015; 10: 290-299

      Diagnosis and Management of Anxiety During the Perinatal Period

      As stated earlier, the DSM-5 does not recognize any anxiety disorder that is related solely to the perinatal period. Generalized anxiety disorder (GAD) is diagnosed when excessive anxiety and worry about events or activities occur more days than not for a minimum of 6 months, the anxiety and worry are difficult to control, and 3 or more of the following symptoms are experienced: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance.
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders, Fifth ed.
      American Psychiatric Association, Arlington, VA2013
      Like depression, the symptoms must cause significant distress and cannot be attributable to substance abuse or a medical condition. Differential diagnoses to consider are anxiety caused by a medical condition, social anxiety, substance abuse, obsessive-compulsive disorder (OCD), PTSD, depression, bipolar disorder I or II, or psychosis. Anxiety is not classified as mild, moderate, or severe according to the DSM-5.
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders, Fifth ed.
      American Psychiatric Association, Arlington, VA2013
      Other types of anxiety include social anxiety, agoraphobia, and panic disorder. The full diagnostic criteria for these disorders is available in the DSM-5.
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders, Fifth ed.
      American Psychiatric Association, Arlington, VA2013
      The treatment plan should include input from the woman and should be based on the severity of symptoms. Nonpharmacologic interventions include CBT, relaxation therapy, and mindfulness-based CBT (MBCBT), but none are specific to anxiety during the perinatal period. Goodman et al
      • Goodman J.H.
      • Guarino A.
      • Chenausky K.
      • et al.
      CALM pregnancy: results of a pilot study of mindfulness-based cognitive therapy for perinatal anxiety.
      Arch Womens Ment Health. 2014; 17: 373https://doi.org/10.1007/s00737-013-0402-7
      tested an intervention using MBCBT with 17 pregnant participants who met the diagnostic criteria for GAD. Of the 17 participants, only 1 participant experienced persistent symptoms of anxiety. These interventions offer an alternative for women and practitioners who would like to use a nonpharmacologic approach, when indicated. Pharmacologic treatment of GAD relies largely on antidepressants (selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors) and anxiolytics. Concerns about the effects of antidepressants were reviewed in the paragraph addressing MDD and apply here. Anxiolytics include the generic drugs diazepam and alprazolam, and both have been associated with neonatal lethargy, neonatal sedation, and poor feeding.
      • diScalea T.L.
      • Wisner K.L.
      Antidepressant medication use during breastfeeding.
      Clin Obstet Gynecol. 2009; 52: 483-497https://doi.org/10.1097/GRF.0b013e3181b52bd6
      There is no evidence that anxiolytics have an association with increased risk for the development of a cleft lip or palate.

      Diagnosis and Management of OCD

      OCD is diagnosed when the following criteria are met: recurrent and persistent thoughts; urges or images that are intrusive and unwanted (obsession); and the thought, urge, or image is neutralized by a repetitive behavior (compulsion). The obsessions and/or compulsions must be time-consuming, cause distress to the individual, and impair functioning.
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders, Fifth ed.
      American Psychiatric Association, Arlington, VA2013
      The symptoms are not attributable to other illness or mental disorder. Few data exist about the association between OCD and the perinatal period. Of interest, The Royal College of Psychiatrists, the British equivalent of the APA, supports the concept of perinatal OCD as a distinct diagnosis and disorder.

      Royal College of Psychiatrists. Perinatal obsessive compulsive disorder. www.rcpsych.ac.uk/healthadvice/problemsdisorders/perinatalocd.aspx. 2016. Accessed December 1, 2017.

      Treatment of OCD consists of CBT and antidepressants if symptoms are severe.

      Diagnosis and Management of PTSD

      According to the DSM-5, PTSD can occur in individuals over the age of 6 when they have experienced a traumatic event, witnessed a traumatic event, learned of a traumatic event that has occurred to a close relative or friend, or experienced repeated exposures to events that cause trauma (usually work related). Additionally, a diagnosis of PTSD requires recurrent, intrusive, and involuntary memories; flashbacks; psychological distress; physiologic reaction; avoidance of PTSD triggers; and alteration in mood, reactivity, and arousal.
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders, Fifth ed.
      American Psychiatric Association, Arlington, VA2013
      Individuals at risk for PTSD include women who have been exposed to physical and/or sexual violence, and there is a growing body of literature that supports the experience of birth as traumatic.
      • Beck C.T.
      • Watson S.
      Posttraumatic growth after birth trauma: “I was broken, now I’m unbreakable”.
      MCN Am J Matern Child Nurs. 2016; 41: 264-271https://doi.org/10.1097/NMC.0000000000000259
      , 
      • Beck C.T.
      • Gable R.
      • Sakala C.
      • Declerq E.R.
      Posttraumatic stress disorder in new mothers: results from a two-stage U.S. national survey.
      Birth. 2011; 38: 216-227https://doi.org/10.1111/j.1523-536X.2011.00475.x
      Women who meet these criteria should be screened for PTSD. There are no postbirth PTSD treatment protocols published in the literature, but prevention is key. Treatment recommendations for PTSD include CBT, MBCBT, and prolonged exposure therapy including eye movement desensitization and reprocessing.

      The U.S. Department of Veteran’s Affairs. PTSD: National Center for PTSD. www.ptsd.va.gov/public/treatment/therapy-med/treatment-ptsd.asp. 2016. Accessed December 15, 2017.

      The US Department of Veteran’s Affairs funds and supports research on PTSD through the National Center for PTSD.

      The U.S. Department of Veteran’s Affairs. PTSD: National Center for PTSD. www.ptsd.va.gov/public/treatment/therapy-med/treatment-ptsd.asp. 2016. Accessed December 15, 2017.

      This center has many resources available online that may be used to treat women who experience postbirth PTSD, although there is no evidence to support this statement. Pharmacologic management recommends antidepressants as the first line of treatment.

      Committee on Obstetric Practice. The American College of Obstetricians and Gynecologists Committee Opinion no. 630. Screening for perinatal depression. Obstet Gynecol. 2015;125:1268–1271. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co630.pdf?dmc=1&ts=20180121T1925204741. 2015. Accessed January 18, 2018.

      Discussion

      All clinical settings that provide care to women during the perinatal period should have a comprehensive protocol that goes beyond screening because we increasingly recognize and understand the impact of mental illness on women, neonates, and families. It is important for all NPs who provide care to women during the perinatal period to understand that any and all mental illnesses may cause significant morbidity and that a thorough evaluation is vital. Having systems in place to diagnose, manage, and refer women is a pivotal component to this process and may be difficult but not insurmountable. Mental illness can be complex and difficult to diagnose and manage. There is a dearth of data available about how NPs in generalist settings deliver mental health services.
      • Ford E.
      • Shakespeare J.
      • Elias F.
      • Ayers S.
      Recognition and management of perinatal depression and anxiety by general practitioners: a systematic review.
      Fam Pract. 2017; 34: 11-19
      Establishing relationships with psychiatric specialists who have expertise in the treatment of PMAD is essential. Having a thorough understanding of the needs and expectations of the women we care for is also extremely important and cannot be overstated.
      There is a great deal of research to be conducted in this area. Developing and testing of culturally sensitive interventions for PMAD should be made a priority for women with mild to moderate symptoms. It is simply not enough to write a prescription and/or refer a woman to a psychiatric provider with no means for follow-up. Understanding the relationship between pregnancy and the development or worsening of a preexisting mental illness has not been sufficiently explored by the scientific community. PMAD needs further attention and consensus from the health care community. We Clinicians need to agree that the diagnoses are genuine and may be related to pregnancy in selected cases and institute protocols based in evidence to effectively treat women. Terminologies should be standardized to reduce confusion and to facilitate reimbursement for services. There is also a shortage of mental health providers, especially in rural areas, making treatment more difficult. Lastly, most interventions focus on the postpartum period, leaving questions about the feasibility and applicability of these programs during pregnancy. Further testing of successful programs should be conducted with larger samples and attention to tailoring them to diverse cultures and languages.

      Conclusion

      The goal of this article was to provide an overview of PMADs in an effort to improve recognition, screening, diagnosis, and interdisciplinary care by midwives and other NPs. The information can be used to begin the advancement of mental health services to women during the perinatal period and across the life span.

      Resources

      American College of Obstetricians and Gynecologists
      http://www.acog.org/Womens-Health/Depression-and-Postpartum-Depression
      Postpartum Support International
      http://www.postpartum.net/professionals/psi-professional-training-program/
      Council on Patient Safety in Women’s Health Care
      http://safehealthcareforeverywoman.org/patient-safety-bundles/maternal-mental-health-depression-and-anxiety/#1472748390450-e4795257-d991
      Eunice Kennedy Shriver National Institute of Child Health and Human Development: National Child & Maternal Health Education Program
      https://www.nichd.nih.gov/ncmhep/initiatives/moms-mental-health-matters/moms/pages/default.aspx

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      Biography

      Lorraine Byrnes, PhD, FNP-BC, PMHNP-BC, CNM, FAANP, is the associate dean of undergraduate nursing programs and an associate professor at Hunter College, City University of New York in New York. She is available at .

      Article info

      Footnotes

      In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.

      Identification

      DOI: https://doi.org/10.1016/j.nurpra.2018.03.010

      Copyright

      © 2018 Elsevier Inc. All rights reserved.

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