What do Midwives Need to Know About Perinatal Mood and Anxiety Disorders?

Perinatal Mood and Anxiety Disorders are the most common complication of pregnancy. 15-20% of parents experience a perinatal mood or anxiety disorder. Rates among partners are similar to rates among the childbearing parent. Over 50% of the time postpartum depression, started during or before pregnancy, and is likely to worsen in the postpartum period if left untreated.

What are the Perinatal Mood and Anxiety Disorders?

• Depression
• Anxiety
• Bipolar Disorders (exist on a spectrum, a common time for first episode is during first pregnancy)
• Post Traumatic Stress Disorder 
• Obsessive-Compulsive Disorder

Some of the ways these disorders can impact pregnancy:

• Lower motivation for caring for self/pregnancy
• Decreased appetite and poor sleep which can affect fetal growth and development
• Increased substance use
• Impaired bonding with fetus, and baby after birth, with potentially lifelong impact if untreated
• Mania can lead to dangerous and impulsive acts
• Trauma may cause avoidance or fear of prenatal care and inability to trust providers
• In most extreme cases, suicide or accidental death
• Suicide is the second cause of death for women in the first year postpartum.

The Big Question: What About Medication?

• There is no “right” or “better” medication for pregnancy and lactation. Rather, a shared decision between parents and prescribers to find the regimen in which wellness and available safety data are carefully weighed.
• Seek consultation for your clients whenever possible with a trained perinatal prescriber.
• The “Category” system from the FDA where medications were labeled A thru D, and “X” was discontinued in 2014. The system was overly simplistic and almost all psychiatric medications were in the “C” category, leaving families who needed these medications for stability in a difficult situation.
• Instead of the category system, the FDA now uses a narrative, which details the use of medications for pregnancy, lactation and males of reproductive potential. This allows for a more meaningful risk vs. benefit conversation so that choices may be individualized.
• An area that requires special attention, is that of women with bipolar disorder. Untreated bipolar disorder is the largest risk factor for postpartum psychosis, a psychiatric emergency requiring hospitalization. Bipolar disorder during pregnancy may be treated with a mood stabilizer and/or antipsychotic medication.
• Trusted resources for learning about medications in pregnancy are listed here:

1. https://mothertobaby.org/ , also offers free genetic counseling regarding medication and pregnancy thru a toll free number
2. https://womensmentalhealth.org/, run by Massachusetts General Hospital and Harvard, as a resource center and database. Also runs a registry for medications in pregnancy so that more information can be gathered and analyzed.
3. https://reprotox.org/ Information system where individual medications can be looked up for up to date safety profiles for pregnancy and lactation. There is an annual fee but can access from most health systems computers.

Referrals

• Referral sources listed below can help you connect your clients and families to therapy, medication consultation, and support groups.
• Call your local coordinator (we have two for NYC) at Postpartum Support International: http://www.postpartum.net/
• PSI is also a great resource for information for you and your patients, free phone support, online support groups, and excellent trainings for providers.
• Postpartum Resource Center of New York, https://postpartumny.org/resourcedirectory/, comprehensive directory of services focused on perinatal mood and anxiety disorders. Also offering direct peer support through a statewide helpline.

Rebecca Feldman is a nurse midwife and psychiatric nurse practitioner, as well as a psychotherapist. Working to bring quality mental health care to all parents in need is her passion. She particularly loves the nuance and individuality involved in medication consultation and management for perinatal families. She sees clients as part of the Zucker Hillside Perinatal Psychiatry team in Queens, NY and in Manhattan at the Motherhood Center of New York. She loves questions from midwives and can be reached at rfeldmancnm@gmail.com

References

Bauer, A., Knapp, M., and Parsonage, M., (2015). Lifetime costs of perinatal anxiety and depression. Journal of Affective Disorders. 192, (83-90).

Biaggi, A., Conroy, S., Pawlby, S. and Pariante, C., (2015). Identifying women at risk of antenatal anxiety and depression: A systematic review. Journal of Affective Disorders. (191), 62-77.

O’Connor, T., Monk, C., and Burke, A., (2016). Maternal Affective Illness in the Perinatal Period and Child Development: Findings on the Developmental Timing, Mechanisms, and Intervention. Current Psychiatry Reports. (18)24.

Postpartum Support International, (2016). Pregnancy and Postpartum Mental Health. Retrieved from http://www.postpartum.net/learn-more/pregnancy-postpartum-mental-health

USPSTF, (2016). Depression in Adults. Retrieved from http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/depression-in-adults-screening1