Expert Reviews
org
OBSTETRICS
Perinatal psychiatric disorders: an overview
Elena Paschetta, MD; Giles Berrisford, MD; Floriana Coccia, MD; Jennifer Whitmore, MD; Amanda G. Wood, PhD;
Sam Pretlove, MD; Khaled M. K. Ismail, PhD
O ver the past decade, Perinatal
Mental Health (PNMH) has
gained increased attention in policy
documents, medical literature, and the
media. This was particularly triggered
by reports from the United Kingdom,
demonstrating that PNMH was the
leading cause of maternal mortality
within the rst year postpartum.1 Thus,
health services in several countries are
focused on implementing clinical man-
agement systems that ensure the delivery
of high-quality services for this group of
vulnerable women.2,3 These policies
have reduced PNMH-related maternal
mortality.4 However, the impact of
these services on other maternal, fetal,
and child outcomes is less clear. The
recommendation for effective multidis-
ciplinary PNMH services has not been
complemented by clear guidance about
From the Birmingham Womens National Health
Service Foundation Trust (Drs Paschetta,
Pretlove, and Ismail); Perinatal Mental Health
Service, Birmingham and Solihull Mental Health
Foundation Trust (Drs Berrisford, Coccia, and
Whitmore); School of Psychology, College of Life
and Environmental Sciences (Dr Wood), and
School of Clinical and Experimental Medicine,
College of Medical and Dental Sciences
(Dr Ismail), University of Birmingham,
Birmingham, UK.
Received May 31, 2013; revised Oct. 2, 2013;
accepted Oct. 4, 2013.
There was no specic funding for this review.
E.P. is a Clinical Research Fellow at Birmingham
Womens National Health Service Foundation
Trust funded by the Department of
Neuroscience, Postgraduate School of
Psychiatry, Psychiatric Clinic, University of
Turin (Italy).
The authors report no conict of interest.
Reprints: Khaled M. K. Ismail, PhD, Academic
Department, Birmingham Womens National
Health Service Foundation Trust, Edgbaston,
Birmingham B15 2 TG, UK.
k.ismail@bham.ac.uk.
0002-9378/$36.00
2014 Mosby, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2013.10.009
www.AJOG .
Perinatal mental illness has a significant implication on maternal health, birth outcomes,
and the offsprings development. Prevalence estimates of perinatal psychiatric illnesses
range widely, with substantial heterogeneity in different population studies, with a lower
prevalence rate in high- rather than low- or middle-income countries. Because of the
potential negative impact on maternal and child outcomes and the potential lability of
these disorders, the perinatal period is a critical time to identify psychiatric illnesses.
Thus, obstetricians and midwives play a crucial role in assessing womens mental health
needs and to refer identified women promptly for multidisciplinary specialist assessment.
However, there is still limited evidence on best practice assessment and management
policies during pregnancy and postpartum. This review focuses on the prevalence of
common perinatal mental disorders and antenatal screening policies to identify women at
risk. The effect of these conditions and their management on pregnancy, fetal outcomes,
and child development are discussed.
Key words: childbirth, mental illness, offspring, postpartum, pregnancy
service structure, and currently service There is a well-documented variation
delivery is highly variable.5 in prevalence by ethnic origin.17,18
The purpose of this review is to
summarize the current literature on Mood disorders
perinatal psychiatric illness, focusing Mood disorders include perinatal
on the magnitude of the problem, depression and bipolar affective disorder
(BPAD). Perinatal depression can occur
and review current screening policies,
examining risk factors and critically either during pregnancy or within the
evaluating the impact of suggested evi- rst 12 months after delivery. This diag-
dence based managements on maternal, nosis is made if the woman suffers with
fetal, and child outcomes. consistently low mood along with a xed
number of biological or cognitive symp-
toms for at least 2 consecutive weeks.
Classification Epidemiological studies in Western soci-
Perinatal psychiatric disorders (Figure 1) eties reported rates of antenatal and
are wide ranging and can arise for the postnatal depressive episodes ranging
rst time during the perinatal period between 5%,12,19 33%,6,8,9,11,20-26 and 10-
or may represent a relapse of a preex- 15%,6,19,23,27-29 respectively.
isting condition. In Western societies, Higher prevalence rates seem to occur
estimates of mental health problems in low-income settings.30-34 It is imper-
during the perinatal period range ative to differentiate postnatal depres-
considerably, with substantial heteroge- sion from postnatal blues. The latter is
neity in different population studies.6-8 regarded as a normal variation of
Mood and anxiety disorders are the emotional change occurring after child-
most prevalent mental illnesses found birth35 in which as high as 50-85% of
during this period.7-12 Literature reports women can experience symptoms of
higher rates of perinatal psychiatric dis- mild depressive symptoms, anxiety,
orders in low- and lower-middle-income irritability, mood swings, and increased
countries.13-15 Less than 8% of women tearfulness. Postnatal blues typically
suspected to have perinatal mental ill- peak on the fourth or fth day post-
nesses are currently receiving any type of partum and usually resolve spontane-
mental health care in these countries.16 ously by day 10.36,37
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FIGURE 1
Classification of common perinatal mental disorders
This figure summarizes common perinatal psychiatric disorders that can occur during the perinatal period.
GAD, generalized anxiety disorder; OCD, obsessive-compulsive disorder; PNMD, perinatal mental disorders; PTSD, posttraumatic stress disorder.
Paschetta. Perinatal Mental Health. Am J Obstet Gynecol 2014.
BPAD is characterized by episodes of
mania or hypomania, typically alter-
nating with episodes of depression.
Childbirth is often related to the initial
onset of BPAD.38,39 Up to 50% of women
with a history of BPAD have a risk of
relapse perinatally,40,41 especially after
childbirth, when this risk is higher for
BPAD than any other form of mental
illness.42 Studies indicate that the risk of
relapse is highest in the rst 2 weeks
postpartum, typically commencing as
early as between days 2 and 4.43
Anxiety disorders
A wide range of anxiety disorders
are seen perinatally; these include
obsessive compulsive disorder (OCD),
posttraumatic stress disorder (PTSD),
generalized anxiety disorder (GAD),
panic disorder, and specic phobias.
502 American Journal of Obstetrics & Gynecology JUNE 2014
Their reported prevalence rates range
from 4.5%34 to 15%.20,22,31,44 Some au-
thors suggest that following childbirth,
an increasing proportion of women
experience PTSD.45-48 However, other
studies report higher rates of OCD and
GAD in postpartum women compared
with general population.49-52
Among specic phobias, tokophobia
(a morbid fear of childbirth) is gaining
increased attention in clinical practice,
especially for the high perinatal comor-
bidity with mood and anxiety disor-
ders53 and the frequent request of
elective cesarean section. Preliminary
reports have shown that treatment for
tokophobia and comorbid psychiatric
conditions53 during pregnancy can lead
to a signicant reduction of the fear of
vaginal delivery with a withdrawal in
request for cesarean sections.54-57
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Psychotic disorders
The lifetime prevalence of schizophrenia
is approximately 1-2%.58 Key manifes-
tations of disease include psychotic
symptoms such as hallucinations and
delusions, affective disturbances such
as emotional blunting, and signicant
occupational and social dysfunction.
The risk of relapse during the rst 3
months postpartum is approximately
24-25%,59,60 especially following treat-
ment discontinuation.61,62
Puerperal psychosis
This is reported to occur following 1-2
per 1000 births,29,63-65and has its onset
commonly within the rst 2 weeks
postpartum.42,66 Women usually develop
paranoid, grandiose, or bizarre de-
lusions, mood lability, and perplexity.
These features represent a dramatic
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change from previously perceived nor-
mal functioning.67 It is estimated that
approximately two-thirds of women
suffering from a puerperal psychosis will
experience a relapse after subsequent
deliveries.68 Preexisting BPAD is one of
the greatest risk factors.69
Substance-use disorders
Alcohol and tobacco are the most
prevalent substances consumed by
childbearing-aged women, followed by
various illicit drugs,70,71 especially
methamphetamines.72 Alcohol use dur-
ing pregnancy is one of the leading
preventable causes of birth defects, in-
tellectual disability, and neurodevelop-
mental disorders,73 whereas mothers
using illicit drugs are at high risk
of psychiatric comorbidity and poorer
obstetric outcomes.74 Because of the
paucity of research, further investiga-
tions into the magnitude and manage-
ment of these conditions are required.
Substance misuse as an isolated perinatal
psychiatric disorder is beyond the scope
of this review.
Prediction
Antenatal screening for mental health
issues and risk factors allows early diag-
nosis, appropriate liaison with relevant
professionals, timely discussion regard-
ing treatment, and nalizing manage-
ment plans throughout the perinatal
period. This can help reduce the negative
impact of the mental illness on the
woman, her child, and her extended
family. Efcient strategy of screening
relies on identifying clinically vulnerable
subgroups. The Table summarizes the
known risk factors of the common
perinatal mental disorders (PNMDs).
A past history of postpartum and
nonperinatal depression75-77and psycho-
social factors are the most important
predictors of antenatal depression.78,79
Likewise, postpartum depression (PPD)
is caused by a combination of biolog-
ical80 and psychosocial determinants.
There is preliminary evidence that
genetic factors may contribute to as
much as one third of its etiological
variance.80 Hormones, such as estrogen
and progesterone,81 as well as thyroid
dysfunction have been suggested as
Obstetrics Expert Reviews
TABLE
Risk factors for PNMDs
PNMDs Risk factors
AND Previous PPD and nonperinatal depression75-77
Recent adverse life events27,76,77,101,102,105,107,235-241
Low socioeconomic status15,27,76,77,90,101,102,105,107,108,110-112,235-241
Insufficient emotional/social support26,105
Unplanned pregnancy76,77,79
Unfavorable obstetric79/pregnancy outcomes242-244
Chronic physical illness245
Previous miscarriages246
Domestic violence95
PPD Past history of psychiatric disorders8,85,86
Depression/anxiety during current pregnancy87,88
Maternity blues247
Biological factors (genetic, hormonal, others)80-84
Recent adverse life events27,76,77,101,102,105,107,235-241
Low socioeconomic status15,27,76,77,90,101,102,105,107,108,110-112,235-241
Insufficient emotional/social support15,113,101,102,105,107,235-240
Poor marital relationship101,102,105,107,235-240
Unplanned pregnancy15,113
Immigration/premigration stress248,249
Personality traits90,101,102
Unfavorable obstetric/pregnancy outcomes8,83,105
Unfavorable neonatal outcomes250,251
Chronic/current physical illnesses113,252
History of PMS89,90 and PMDD91,92
History of physical/sexual abuse93,94,253,254
Multiple births255,256
Domestic violence15,95-100
Childcare stress/infant temperament90,101,102
PPs Previous episodes of PPs114
Personal history of psychotic disorders and BPAD114
Family history of PPs and BPAD114
Insufficient emotional/social support115-117
Sleep disturbance119
PNADs Personal history of ADs120,121
Insufficient emotional/social support 120,121
Previous miscarriages246
History of physical/sexual abuse120,121
Multiple births121,255,256
Unfavorable pregnancy243,244/neonatal250 outcomes
Maternity blues247
PTSD Unfavorable obstetric/pregnancy and neonatal outcomes123,124,251
Perinatal death123,124
AD, anxiety disorders; AND, antenatal depression; BPAD, bipolar affective disorder; NICU, neonatal intensive care unit; PMS,
premenstrual syndrome; PMDD, premenstrual dysphoric disorder; PNAD, perinatal anxiety disorders; PNMD, perinatal mental
disorders; PPs, puerperal psychosis; PPD, postpartum depression; PTSD, posttraumatic stress disorder.
Paschetta. Perinatal Mental Health. Am J Obstet Gynecol 2014.
potential biological factors involved in and depression or anxiety during the
its psychopathology.82 Recent researches current pregnancy.87,88
have also focused on the role of omega-3 Recent evidence also found other
fatty acids83 and specic polymorphisms important predictors, such as a his-
of serotonin metabolism enzymes84 in tory of premenstrual syndrome89,90 and
the development of PPD, but the nd- premenstrual dysphoric disorder,91,92
ings thus far have been inconclusive. To and a history of physical or sexual
date, the strongest predictors of PPD is a abuse93,94and domestic violence.95-100
past history of psychopathology8,85,86 The levels of childcare stress, infant
JUNE 2014 American Journal of Obstetrics & Gynecology 503
Expert Reviews Obstetrics
temperament, and vulnerable maternal
personality traits90,101,102 seem to be
other important and stable determinants
of PPD.103,104
Finally, small but signicant pre-
dictors include obstetric and pregnancy
complications,8,83,105 especially hyper-
emesis and premature contractions,106
and socioeconomic status,90,101,107-112
which conversely represents a strong
predictor of PPD in the developing
world.15,113 The disparity in the rates of
perinatal mental disorders between
women living in high- and low-income
settings suggests social rather than bio-
logical determinants.113
Predictors of puerperal psychosis
include previous episodes or family
history; personal history of psychotic
disorders, especially schizophrenia; per-
sonal or family history of BPAD114;
medication nonadherence; poor social
support115-117; younger age; and un-
planned pregnancy.118 Sleep distur-
bances have also been found as an
important risk factor for puerperal psy-
chosis relapse in susceptible women.119
Considering anxiety disorders, previ-
ous lifetime episodes, low social support,
a history of child abuse, and a perception
of high peripartum stress are all risk
factors for experiencing anxiety disor-
ders during the perinatal period.120,121
Multiparity has also been identied as
another potential contributor to gener-
alized anxiety in pregnancy.121 With re-
gard specically to PTSD, during the
postpartum period, PTSD has been
found to be associated with behavioral
health risks and PTSD at the onset of
pregnancy.122 Other known risk factors
of postpartum PTSD include younger
age, severe preeclampsia, cesarean
section, lower gestational age, lower
birthweight, baby admitted to the
neonatal intensive care unit, and peri-
natal death.123,124
Finally, women with a past or current
psychiatric disorder, especially puerperal
psychosis and severe depression,4 a
substance-use disorder, and intimate
partner problems have been found at
increased risk of postpartum suicide
attempt compared with controls.125,126
Inquiries about psychiatric symptoms
should be made at the initial antenatal
504 American Journal of Obstetrics & Gynecology JUNE 2014
visits. Attention should be paid to any
sign of poor self-care and over- or un-
deractivity. Particular care should be
given to suicidal ideation or thoughts
of harming the baby, substance abuse,
and domestic violence. One of the
most important risk factor is a previ-
ous personal or family history of psy-
chopathology. It is essential to take a
focused history on past or present
severe mental illness, previous treatment
by a psychiatrist or specialist mental
health team, and any personal or
family history of perinatal mental health
problems.
The literature shows a wide variability
of antenatal screening tools for perinatal
psychiatric disorders in different coun-
tries.127 The British National Institute
for Health and Clinical Excellence
guidelines2 specically recommend the
utilization of the Whooley questions128
to screen for antenatal depression.
However, some authors127 highlighted a
lack of evidence in its effectiveness and
also a need for further research to iden-
tify universal screening tools.
When these strategies are instigated,
care must be taken to ensure that
all women are screened and assessed
because it has been recognized that
in practice, implementation can be
patchy.129 All pregnant women identi-
ed as high risk should have a shared
multidisciplinary care plan for their
late pregnancy and early postnatal
management.117
Effects on short-term outcomes
Mental illness in the perinatal period
can have a signicant impact on
maternal health, birth outcomes, and
fetal development. The British Con-
dential Enquiries into Maternal Deaths
reported that psychiatric disorders
contributed to 12% of all maternal
deaths in 2002-2005.130 Currently, sui-
cide is a leading cause of perinatal
maternal deaths in industrialized coun-
tries, but there is still little research on
its prevalence and correlates,131,132
especially in the developing world.133
Among female suicide victims of
reproductive age, recent data show a
high prevalence of an existing mental
health diagnosis126,132,134 or a past
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history of serious affective disorder
(59%), such as puerperal psychosis
and severe depression4 ; substance use;
and intimate partner problems.126,135
Furthermore, maternal suicide can
be associated with a risk of infanti-
cide.133,136 It is a rare event but can have
tragic consequences, so it is important
to highlight.
Up to 50% of pregnancies in the
general population are unplanned, and
the rate is even higher in women
suffering from mental illness.137 Among
these women, the frequency of sexual
activity may be normal, but contracep-
tive use may be lower and autonomous
reproductive decision-making compro-
mised.138 Women with mental illnesses
often start their pregnancy without
having their medications optimized and
often stop taking them abruptly when
they nd out they are pregnant, which
frequently leads to a relapse of their
psychiatric symptoms.40,42,66,69,115,139
They are more likely to default ante-
natal care appointments, use substances,
have a poor diet, and be overweight, all
of which are lifestyle factors associated
with poor obstetric outcomes.59,140-143
It is increasingly recognized that
severe mental illnesses can be an un-
derlying cause of pregnancy-related
medical disorders and obstetric compli-
cations.83,144-159 It is suggested that one
biological mechanism linking severe
mental illnesses and some pregnancy-
related complications is a result of the
promoting effect of these illnesses on
the immune system that subsequently
increases the levels of inammatory
markers and altering proinammatory
cytokines regulation.160
Another possible biological mecha-
nism is represented by the overactivity
of the maternal neuroendocrine system
caused by maternal psychosocial stress
and preexisting psychiatric symp-
toms.161,162 Several studies reported an
association between maternal mental
illness/stress and changes in the fetal heart
rate and vascular distribution as well as
negative fetal outcomes, including intra-
uterine growth retardation,83,154,161,163
lower Apgar scores,164,165 congenital
malformations,143,151,154,165-168 and peri-
natal loss.146,154,165,168-171
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Women with mental disorders more
frequently misuse substances.140 Pre-
natal exposure to cocaine and amphet-
amines is associated with several
adverse outcomes, such as spontaneous
abortion, preterm births, placental
abruption, congenital abnormalities,
neonatal poor feeding, lethargy, and
seizures. Alcohol use is associated with
spontaneous abortion, growth restric-
tion, and birth defects; moreover, fetal
alcohol syndrome is a common cause of
long-term sequelae for the infant. Pre-
natal tobacco exposure can induce
spontaneous abortion, ectopic preg-
nancy, placental insufciency, low
birthweight, fetal growth restriction,
and preterm delivery, whereas mari-
juana use has been found related to
fetal growth restriction.172,173 All these
substances can also predispose to
neonatal withdrawal syndrome, which,
interestingly, increased in the past 25
years.174
Psychotropic medications may also
have an impact on outcomes. Prenatal
antidepressant use has been found
associated with lower gestational age
at birth, preterm birth,175 and small
increased risk of persistent pulmonary
hypertension of the newborn.176 Expo-
sures of concern include that of
untreated maternal illness as well as
medication exposure.177,178 Conversely,
no signicant risk of stillbirth, neonatal
mortality, postnatal mortality,179,180 and
major congenital malformations181,182
has been found, apart from a slight
increased risk of cardiac malformations
associated with rst-trimester paroxe-
tine exposure.154,183,184
With regard to antipsychotics, there
is no conclusive evidence of their
structural teratogenicity.183,185 There are
2 case reports of pregnancy loss in
women taking atypical antipsychotic
aripiprazole,186 whereas other observa-
tional studies found no increased risk
of stillbirth, gestational age at birth,
and perinatal syndromes187,188 in preg-
nant women under antipsychotics.
There have been reports of self-limiting
extrapyramidal or possible withdrawal
symptoms in neonates exposed to
atypical agent risperidone in the third
trimester.188 Transient complications
Obstetrics
have been documented in neonates
exposed to typical antipsychotics, in-
cluding withdrawal symptoms, extrapy-
ramidal signs, neonatal jaundice, and
intestinal obstruction.183 Other authors
found an association between low
birthweight and the use of typical anti-
psychotics in pregnancy and large-for-
gestational-age babies and the use of
atypical antipsychotics, especially olan-
zapine and clozapine.189 An increased
risk of gestational diabetes has been
found related to the use of olanzapine
and clozapine.148,185
Prenatal exposure to lithium may
be associated with a small increase in
Ebsteins anomaly (probably overvalued
in the past),184 cardiac arrhythmias, hy-
poglycemia, nephrogenic diabetes insip-
idus, polyhydramnios, reversible changes
in thyroid function, hyperparathy-
roidism,190 premature delivery, abnor-
mally large infants, oppy infant
syndrome, lethargy, and poor suck
reexes.154,183,184,191
Among other mood stabilizers, pre-
natal exposure to valproic acid (VPA)
has been found related with neural
tube defects, craniofacial, limb and
cardiovascular anomalies, genitourinary
malformations, low birthweight, neo-
natal hepatotoxicity, coagulopathies,
hypoglycemia, and an increased risk
of withdrawal symptoms and cognitive
impairment.154,183,184,191 Carbamaze-
pine has teratogenic risks similar to VPA
but less frequent and severe,154,183,191
whereas fetal exposure to lamotrigine
has not been found to be related to
major anomalies, excluding an increased
risk of midline facial clefts.154
Evidence from the treatment of epi-
lepsy, however, suggests an increased
risk of major congenital malformations
following prenatal exposure to anticon-
vulsants,192,193 particularly at higher
doses192 and in polytherapy.193
Lastly, benzodiazepine use during
the rst trimester may be associated
with cleft lip and palate, skeletal abnor-
malities, and central nervous system dys-
function.194 Neonatal toxicity includes
withdrawal symptoms and oppy infant
syndrome.154,183,184,191
The contribution of various genetic
factors in directing the variability of fetal
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Expert Reviews
drug exposure is still mostly unclear.195
The use of pharmacogenomics to pre-
dict maternal plasma drug concentra-
tions and fetal drug exposure is expected
to increase in the future, but there is still
limited clinical use of currently available
methods of therapeutic monitoring of
drug concentrations in making treat-
ment decisions.196
Long-term effects
The multiple psychosocial difculties
experienced by women with mental
disorders can have adverse effects on the
development of mother-infant attach-
ment197 and the child.198 Children of
parents with psychiatric illnesses are at
increased risk of neglect or inadequate
care and the later development of psy-
chopathology.199-204 Several studies have
also shown a link between antenatal
stress/anxiety and behavioral/emotional
problems in the child.205-220
Mechanisms underlying these effects
have only just been started to be
studied in humans. Literature evidence
supports a link between prenatal mood
and the development of the fetal
brain.221 One potential pathway to
early deregulation is fetal programming
of the hypothalamic-pituitary-adrenal
axis.222,223 There is a strong correlation
between maternal and fetal levels of
cortisol,224 suggesting there is a pas-
sage of cortisol across the placenta.
Recent ndings show that cortisol and
pregnancy-specic anxiety indepen-
dently predicted child anxiety. Children
exposed to elevated prenatal maternal
cortisol and pregnancy-specic anxiety
are at increased risk for developing
anxiety problems during the preado-
lescent period.220 Fetal exposure to
maternal mental illnesses and psycho-
social stress result in subsequent risk for
poor health outcomes171 and a wide
spectrum of pediatric diseases in the
offspring.225
Many studies to date have not taken in
to account the impact of medication
exposure in key gestational stages on
longer-term outcomes in the child.226 It
is critical to disambiguate the effects of
medications used to manage these dis-
orders from the maternal psychiatric
illness itself.
505
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Management
FIGURE 2
Multidisciplinary nonpharmacological
Multidisciplinary models for managing PNMDs
interventions
All current guidelines2,3 recommend
obstetricians and hospital/community
midwives identify women (preferably
at their early pregnancy assessment) with
past or present severe mental illness
including schizophrenia and other psy-
choses, BPAD and moderate to severe
depression, a previous psychiatric treat-
ment, and a family history of perinatal
psychiatric disorder. Women identied
at risk need to be referred to specialist
perinatal mental health professionals
for further assessment, specic in-
terventions, and the monitoring of their
mental health both during pregnancy
and postpartum.
Some of these guidelines2 recognize
the need for a written care plan for
women so that information can be
shared between obstetric and specialist
This figure summarizes all the proposed multidisciplinary models for the management of perinatal
perinatal mental health services and
mental disorders.
all professionals involved in their care.
CPN, community psychiatric nurse; PNMD, perinatal mental disorders; PNMH, perinatal mental health.
Conditions such as substance abuse
Paschetta. Perinatal Mental Health. Am J Obstet Gynecol 2014.
and domestic violence should also be
considered as risk factors for perinatal
mental health morbidity and should be
managed by specialist services. risk of relapse. Based on individual need, for depression in both antenatal and
In women whose pregnancy or post- these women may be advised to start postnatal period.2,3 In pregnant women
partum year is complicated by serious prophylactic treatment during preg- with recurrent depressive disorder, it is
mental illness, apart from specic phar- nancy or soon after delivery and may be important to continue pharmacological
macological interventions, the available referred to mother and baby units as a treatment because moderate to severe
guidelines2 recommend establishing spe- precaution should their mental health depression is unlikely to respond to
cialized community perinatal teams to deteriorate. talking therapies. Moreover, discontin-
monitor their mental state during preg- Nonpharmacological treatment such uation of antidepressants can often lead
nancy and postpartum. Mother and as cognitive behavioral therapy and to relapse (75%) in the rst trimester.139
baby units are used to treat acutely ill interpersonal therapy228 may be of Women with a previous history of
women who cannot be safely managed benet, but evidence is limited for this puerperal psychosis and who are drug
in the community within the last weeks except for the treatment of depression.2 free during pregnancy should be advised
of pregnancy or after childbirth.227 The recommendations for screening to start an atypical antipsychotic and/or
Women who develop a puerperal psy- at booking have been widely but not a mood stabilizer at 32 weeks gestation.
chosis or who are at a very high risk universally implemented. It is of huge Because of the higher risk of relapse
of relapse227 should ideally be admitted concern that access to specialized peri- after subsequent pregnancies,68 during
with their baby to these specialized units. natal mental health services is still not which these women are reluctant to
This enables mothers to remain with readily available in most countries.5,229 consider medication in pregnancy, it is
their baby in a safe supervised environ- Figure 2 summarizes the proposed recommended to commence treatment
ment in which they can also be treated multidisciplinary models for managing immediately after delivery, preferably
for their psychiatric illness. perinatal mental disorders. before the discharge from hospital. This
Women with a past personal or family way therapeutic levels will be established
history of severe mental illness should be Pharmacological interventions when the woman enters the high-risk
carefully monitored by specialist mental Selective serotonin reuptake inhibitors period in the rst week postpartum.43
health professionals throughout the (SSRIs; with the exception of paroxe- Puerperal psychosis is usually very
perinatal period because of the higher tine)230 are advised as rst-line treatment responsive to treatment, but delays in

506 American Journal of Obstetrics & Gynecology JUNE 2014

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starting medication result in longer,
more severe, and more difcult-to-treat
episodes.231
Management of women with BPAD
during pregnancy should be tailored
to their individual history and circum-
stances. For many women discontinua-
tion of prophylactic medication poses
too many risks. Those women on
lithium who are keen to come off
medication prior to pregnancy should
have a slow reduction of lithium to
reduce the risk of relapse.2,232
Other commonly used mood stabi-
lizers such as carbamazepine and VPA are
known to be teratogenic and should be
avoided in pregnancy.2 Switching to an
atypical antipsychotic is recommended
in such women.2,233 For pregnant
women with schizophrenia, it is often
necessary to continue their antipsychotic
medication because of the high risk of
relapse.234 In these women the risk of
untreated psychiatric illness outweighs
any risk to the fetus from exposure to
psychotropic medications.184
For perinatal anxiety disorders, SSRIs
(excluding paroxetine)230 remain the
rst-line treatment for clinically signi-
cant symptoms both during pregnancy
and postpartum.
Conclusion
Perinatal psychiatric disorders can have a
signicant impact on maternal and child
outcomes, carrying a high morbidity
and mortality. The challenge for health
professionals is to effectively identify
women with perinatal mental health
problems and to ensure they are given
comprehensive management plans.
This article has highlighted the advan-
tages of an accurate antenatal assessment
and multidisciplinary evidence-based
models for improving patient care,
treatment, and outcomes for both
mother and infant in different settings.
Note: The rst 100 references associated
with this article are available below in
print. The complete reference list
accompanying this article is available
online only with the electronic version of
the article. To access the remaining
references, visit the online version of
Obstetrics
American Journal of Obstetrics and
Gynecology at www.ajog.org. - Zugaib M. Common mental disorders during
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2010;13:425-37.
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pregnant and postpartum women in the United
States. J Affect Disord 2011;135:128-38.
9. Nicholson WK, Setse R, Hill-Briggs F,
Cooper LA, Strobino D, Powe NR. Depressive
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early pregnancy. Obstet Gynecol 2006;107:
798-806.
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Olfson M, Grant BF, Hasin DS. Psychiatric dis-
orders in pregnant and postpartum women in
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2008;65:805-15.
11. Melville JL, Gavin A, Guo Y, Fan M-Y,
Katon WJ. Depressive disorders during preg-
nancy: prevalence and risk factors in a large
urban sample. Obstet Gynecol 2010;116:
1064-70.
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Buyukoz D. Is pregnancy associated with mood
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Gen Hosp Psychiatry 2010;32:213-5.
13. Faisal-Cury A, Menezes P, Araya R,
Zugaib M. Common mental disorders during
pregnancy: prevalence and associated factors
among low-income women in Sao Paulo, Brazil:
509.e1 American Journal of Obstetrics & Gynecology JUNE 2014
depression and anxiety during pregnancy. Arch
Womens Ment Health 2009;12:335-43.
14. Cook CAL, Flick LH, Homan SM,
Campbell C, McSweeney M, Gallagher ME.
Psychiatric disorders and treatment in low-
income pregnant women. J Womens Health
2010;19:1251-62.
15. Fisher J, de Mello MC, Patel V, et al. Prev-
alence and determinants of common perinatal
mental disorders in women in low-and lower-
middle-income countries: a systematic review.
Bull World Health Organ 2012;90:139-49.
16. Price SK, Proctor EK. A rural perspective on
perinatal depression: prevalence, correlates,
and implications for help seeking among low-
income women. J Rural Health 2009;25:158-66.
17. Wei G, Greaver LB, Marson SM,
Herndon CH, Rogers J. Postpartum depression:
racial differences and ethnic disparities in a tri-
racial and bi-ethnic population. Matern Child
Health J 2008;12:699-707.
18. Gavin AR, Melville JL, Rue T, Guo Y,
Dina KT, Katon WJ. Racial differences in the
prevalence of antenatal depression. Gen Hosp
Psychiatry 2011;33:87-93.
19. Ban L, Gibson JE, West J, Fiaschi L,
Oates MR, Tata LJ. Impact of socioeconomic
deprivation on maternal perinatal mental ill-
nesses presenting to UK general practice. Br J
Gen Pract 2012;62:671-8.
20. Andersson L, Sundstrom-Poromaa I,
Bixo M, Wulff M, Bondestam K, Astrom M. Point
prevalence of psychiatric disorders during the
second trimester of pregnancy: a population-
based study. Am J Obstet Gynecol 2003;189:
148-54.
21. Lee DTS, Chan SSM, Sahota DS, Yip ASK,
Tsui M, Chung TKH. A prevalence study of
antenatal depression among Chinese women.
J Affect Disord 2004;82:93-9.
22. Kim HG, Mandell M, Crandall C,
Kuskowski MA, Dieperink B, Buchberger RL.
Antenatal psychiatric illness and adequacy of
prenatal care in an ethnically diverse inner-city
obstetric population. Arch Womens Ment
Health 2006;9:103-7.
23. Dietz PM, Williams SB, Callaghan WM,
Bachman DJ, Whitlock EP, Hornbrook MC.
Clinically identied maternal depression before,
during, and after pregnancies ending in live
births. Am J Psychiatry 2007;164:1515-20.
24. Bilszta JLC, Gu YZ, Meyer D, Buist AE.
A geographic comparison of the prevalence and
risk factors for postnatal depression in an
Australian population. Aust N Z J Public Health
2008;32:424-30.
25. Senturk V, Abas M, Berksun O, Stewart R.
Social support and antenatal depression in
extended and nuclear family environments in
Turkey: a cross-sectional survey. BMC Psychi-
atry 2011;11:48.
26. Giardinelli L, Innocenti A, Benni L, et al.
Depression and anxiety in perinatal period:
prevalence and risk factors in an Italian sample.
Arch Womens Ment Health 2012;15:21-30.
27. Moses-Kolko EL, Roth EK. Antepartum and
postpartum depression: healthy mom, healthy
www.AJOG.org
baby. J Am Med Womens Assoc 2004;59:
181-91.
28. Freeman MP, Wright R, Watchman M, et al.
Postpartum depression assessments at well-
baby visits: screening feasibility, prevalence,
and risk factors. J Womens Health 2005;14:
929-35.
29. Berle JO. Psychiatric conditions in preg-
nancy and postpartum. Acta Obstet Gynecol
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