Maternal Perinatal Mood and Anxiety Disorders: The Role of the Pediatrician
Carol D. Berkowitz, MD, FAAP
You are evaluating a 3-week-old boy who is the product of a 39-week gestation pregnancy to a 30-year-old gravida 1, para 1 mother who has been breastfeeding the newborn. The newborn’s birth weight was 3,650 g (8.0 lb), and the newborn now weighs 3,380 g (7.5 lb). The mother expresses concern about her ability to breastfeed. She also admits to being exhausted and feeling detached from the baby. She is overwhelmed by being a mom, something she had looked forward to since she was a little girl. She has difficulty concentrating and has no appetite. She asks you if it is normal to feel this way.
1. What is the spectrum of perinatal mood and anxiety disorders?
2. What are the signs and symptoms of perinatal mood and anxiety disorders?
3. What are the risks to newborns of mothers who experience perinatal mood and anxiety disorders? To older children?
4. What is the role of the pediatrician in assessing mothers for perinatal mood and anxiety disorders?
5. What screening instruments are available to assist in assessing mothers for perinatal mood and anxiety disorders?
6. What are the risks and benefits of the use of psychopharmacology during pregnancy and postpartum if breastfeeding?
7. What resources are available to offer to mothers who may be experiencing perinatal mood and anxiety disorders?
The term perinatal mood and anxiety disorders (PMADs) is the preferred nomenclature to denote the spectrum of mental health issues facing mothers (and fathers) related to the pregnancy and birth of a neonate. Peripartum depression had been used to encompass a cadre of mental health problems that new mothers may experience, but now there is recognition that mental health issues can be present preconception, through pregnancy, and into the infant’s first postnatal year. These issues include not only depression but other mental health disorders. Despite public disclosures and open discussions by celebrities such as Brooke Shields and Gwyneth Paltrow, these conditions are under-recognized, and as a result, many mothers go undiagnosed and untreated. The stigma related to mental health is a barrier to maternal disclosure and seeking help. Too often, maternal symptoms are dismissed as fatigue related. The pediatrician is in an ideal position to assess a mother for these symptoms following the birth of a baby because the pediatrician usually sees the mother-baby dyad prior to the obstetric postpartum visit at 6 weeks following the baby’s birth. The recommended time points for screening for PMADs coincide with health supervision visits: 2 weeks, 2 months, and 6 months. In addition, women are likely to follow up with their baby’s pediatric appointments more than their own. While fatigue is a common report of new mothers as well as new fathers, other symptoms, particularly those of impaired functioning and diminished ability to care for the baby, may suggest a more significant disturbance.
Maternal depression is the number 1 complication of pregnancy, exceeding diabetes and hypertension. The incidence of perinatal depression varies with the population studied, with the estimated range being from 5% to 25%. Between 15% and 25% of pregnant women experience depressive symptoms while pregnant, and approximately 13% of women take an antidepressant at some time during their pregnancy. Women who experience depressive symptoms during pregnancy are twice as likely to be depressed postpartum as those with no depressive symptoms while pregnant. The prevalence of PMADs is much higher at 40% to 60% in certain groups, including women in low-income households, certain ethnic minorities (including Hispanic, black, and Native American), pregnant and parenting teenagers, mothers of multiple births, women who served in the military, and members of the lesbian, gay, bisexual, transgender, questioning/queer, intersex (LGBTQI) community. The World Health Organization notes that depression is the fourth leading cause of disease burden in the world. In spite of the high prevalence across all groups, fewer than 50% of cases of PMADs are identified.
Often, there is reluctance on the part of obstetricians or psychiatrists to treat pregnant women with antidepressants because of concerns about the potential adverse effects of the medications on the developing fetus. These potential effects include fetal malformations, cardiac defects, pulmonary hypertension, and reduced birth weight. However, untreated PMADs in pregnancy increase the risk of preterm delivery, low birth weight, and a newborn’s own ability to regulate emotions and stress. The American College of Obstetricians and Gynecologists and the American Psychiatric Association have issued joint guidelines on the management of pregnant women with depression, which include indications for psychotherapy as well as psychopharmacology in the pregnant woman. Pediatricians are usually not involved in this part of the decision-making process but should be knowledgeable about the possible complications that the newborn may experience following birth from exposure to antidepressants or untreated maternal mental illness. The issue of psychotherapeutics in breastfeeding mothers is also relevant to the pediatrician. Approximately 6% to 10% of fathers experience peripartum depression, with the highest rates seen between 3 and 6 months following the birth of the baby. Paternal rates of depression are higher when there is maternal depression, and the effect on the infant is greater than if the father is not affected. Depressed fathers have an increased rate of substance use.
There is a wide range of symptomatology that can be categorized as PMADS (Box 24.1). Baby blues or maternity blues are used to describe the very common experience of new mothers, said to affect 50% to 80% of postpartum women in the first few days after delivery. There is no Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) categorization of baby blues. Generally, symptoms improve over 1 to 2 weeks and functioning is not impaired, although baby blues may herald later depression. Mothers experience sadness, crying, mood swings, anxiety, and worrying.
A diagnosis of peripartum depression meets the criteria of depression according to DSM-5, which include a depressed mood, diminished pleasure (anhedonia), changes in appetite and sleep, psychomotor agitation or retardation, fatigue, feelings of worthlessness or inappropriate guilt, decreased ability to concentrate, and recurrent thoughts of death or suicide. Suicide is the leading cause of death in mothers during the first year postpartum. Technically, symptoms of depression must begin within 4 weeks of delivery and may persist for 1 year, although the onset is often insidious and does not come to medical attention until later than 1 month postpartum.
Postpartum psychosis is less frequent, occurring in 1 to 3 per 1,000 deliveries within the first 4 weeks after delivery. There is severe impairment, with paranoia, mood shifts, hallucinations, delusions, and suicidal and homicidal ideation. Sometimes there is a history of a preexisting bipolar disorder. Affected mothers require hospitalization, in part because the infanticide rate is 4% to 5%.
Box 24.1. Perinatal Mood and Anxiety Disorders Symptomatology
•First few days after delivery
•Resolves in 1–2 weeks
•Meets Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, criteria for depression
•Change in appetite
•Change in sleep
•Feelings of worthlessness or guilt
•Inability to concentrate
•Recurrent thoughts of death or suicide
•Usually requires hospitalization