Perinatal mental illness has a significant implication on maternal health, birth outcomes, and the offspring’s 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 women’s 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.
Over 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 first year postpartum. Thus, health services in several countries are focused on implementing clinical management systems that ensure the delivery of high-quality services for this group of vulnerable women. These policies have reduced PNMH-related maternal mortality. However, the impact of these services on other maternal, fetal, and child outcomes is less clear. The recommendation for effective multidisciplinary PNMH services has not been complemented by clear guidance about service structure, and currently service delivery is highly variable.
The purpose of this review is to summarize the current literature on perinatal psychiatric illness, focusing on the magnitude of the problem, and review current screening policies, examining risk factors and critically evaluating the impact of suggested evidence based managements on maternal, fetal, and child outcomes.
Classification
Perinatal psychiatric disorders ( Figure 1 ) are wide ranging and can arise for the first time during the perinatal period or may represent a relapse of a preexisting condition. In Western societies, estimates of mental health problems during the perinatal period range considerably, with substantial heterogeneity in different population studies. Mood and anxiety disorders are the most prevalent mental illnesses found during this period. Literature reports higher rates of perinatal psychiatric disorders in low- and lower-middle-income countries. Less than 8% of women suspected to have perinatal mental illnesses are currently receiving any type of mental health care in these countries. There is a well-documented variation in prevalence by ethnic origin.
Mood disorders
Mood disorders include perinatal depression and bipolar affective disorder (BPAD). Perinatal depression can occur either during pregnancy or within the first 12 months after delivery. This diagnosis is made if the woman suffers with consistently low mood along with a fixed number of biological or cognitive symptoms for at least 2 consecutive weeks. Epidemiological studies in Western societies reported rates of antenatal and postnatal depressive episodes ranging between 5%, 33%, and 10-15%, respectively.
Higher prevalence rates seem to occur in low-income settings. It is imperative to differentiate postnatal depression from postnatal blues. The latter is regarded as a normal variation of emotional change occurring after childbirth in which as high as 50-85% of women can experience symptoms of mild depressive symptoms, anxiety, irritability, mood swings, and increased tearfulness. Postnatal blues typically peak on the fourth or fifth day postpartum and usually resolve spontaneously by day 10.
BPAD is characterized by episodes of mania or hypomania, typically alternating with episodes of depression. Childbirth is often related to the initial onset of BPAD. Up to 50% of women with a history of BPAD have a risk of relapse perinatally, especially after childbirth, when this risk is higher for BPAD than any other form of mental illness. Studies indicate that the risk of relapse is highest in the first 2 weeks postpartum, typically commencing as early as between days 2 and 4.
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 specific phobias. Their reported prevalence rates range from 4.5% to 15%. Some authors suggest that following childbirth, an increasing proportion of women experience PTSD. However, other studies report higher rates of OCD and GAD in postpartum women compared with general population.
Among specific phobias, tokophobia (a morbid fear of childbirth) is gaining increased attention in clinical practice, especially for the high perinatal comorbidity with mood and anxiety disorders and the frequent request of elective cesarean section. Preliminary reports have shown that treatment for tokophobia and comorbid psychiatric conditions during pregnancy can lead to a significant reduction of the fear of vaginal delivery with a withdrawal in request for cesarean sections.
Psychotic disorders
The lifetime prevalence of schizophrenia is approximately 1-2%. Key manifestations of disease include psychotic symptoms such as hallucinations and delusions, affective disturbances such as emotional blunting, and significant occupational and social dysfunction. The risk of relapse during the first 3 months postpartum is approximately 24-25%, especially following treatment discontinuation.
Puerperal psychosis
This is reported to occur following 1-2 per 1000 births, and has its onset commonly within the first 2 weeks postpartum. Women usually develop paranoid, grandiose, or bizarre delusions, mood lability, and perplexity. These features represent a dramatic change from previously perceived normal functioning. It is estimated that approximately two-thirds of women suffering from a puerperal psychosis will experience a relapse after subsequent deliveries. Preexisting BPAD is one of the greatest risk factors.
Substance-use disorders
Alcohol and tobacco are the most prevalent substances consumed by childbearing-aged women, followed by various illicit drugs, especially methamphetamines. Alcohol use during pregnancy is one of the leading preventable causes of birth defects, intellectual disability, and neurodevelopmental disorders, whereas mothers using illicit drugs are at high risk of psychiatric comorbidity and poorer obstetric outcomes. Because of the paucity of research, further investigations into the magnitude and management 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 diagnosis, appropriate liaison with relevant professionals, timely discussion regarding treatment, and finalizing management 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. Efficient strategy of screening relies on identifying clinically vulnerable subgroups. The Table summarizes the known risk factors of the common perinatal mental disorders (PNMDs).
| PNMDs | Risk factors |
|---|---|
| AND | Previous PPD and nonperinatal depression Recent adverse life events Low socioeconomic status Insufficient emotional/social support Unplanned pregnancy Unfavorable obstetric /pregnancy outcomes Chronic physical illness Previous miscarriages Domestic violence |
| PPD | Past history of psychiatric disorders Depression/anxiety during current pregnancy Maternity blues Biological factors (genetic, hormonal, others) Recent adverse life events Low socioeconomic status Insufficient emotional/social support Poor marital relationship Unplanned pregnancy Immigration/premigration stress Personality traits Unfavorable obstetric/pregnancy outcomes Unfavorable neonatal outcomes Chronic/current physical illnesses History of PMS and PMDD History of physical/sexual abuse Multiple births Domestic violence Childcare stress/infant temperament |
| PPs | Previous episodes of PPs Personal history of psychotic disorders and BPAD Family history of PPs and BPAD Insufficient emotional/social support Sleep disturbance |
| PNADs | Personal history of ADs Insufficient emotional/social support Previous miscarriages History of physical/sexual abuse Multiple births Unfavorable pregnancy /neonatal outcomes Maternity blues |
| PTSD | Unfavorable obstetric/pregnancy and neonatal outcomes Perinatal death |
A past history of postpartum and nonperinatal depression and psychosocial factors are the most important predictors of antenatal depression. Likewise, postpartum depression (PPD) is caused by a combination of biological and psychosocial determinants. There is preliminary evidence that genetic factors may contribute to as much as one third of its etiological variance. Hormones, such as estrogen and progesterone, as well as thyroid dysfunction have been suggested as potential biological factors involved in its psychopathology. Recent researches have also focused on the role of omega-3 fatty acids and specific polymorphisms of serotonin metabolism enzymes in the development of PPD, but the findings thus far have been inconclusive. To date, the strongest predictors of PPD is a past history of psychopathology and depression or anxiety during the current pregnancy.
Recent evidence also found other important predictors, such as a history of premenstrual syndrome and premenstrual dysphoric disorder, and a history of physical or sexual abuse and domestic violence. The levels of childcare stress, infant temperament, and vulnerable maternal personality traits seem to be other important and stable determinants of PPD.
Finally, small but significant predictors include obstetric and pregnancy complications, especially hyperemesis and premature contractions, and socioeconomic status, which conversely represents a strong predictor of PPD in the developing world. The disparity in the rates of perinatal mental disorders between women living in high- and low-income settings suggests social rather than biological determinants.
Predictors of puerperal psychosis include previous episodes or family history; personal history of psychotic disorders, especially schizophrenia; personal or family history of BPAD ; medication nonadherence; poor social support ; younger age; and unplanned pregnancy. Sleep disturbances have also been found as an important risk factor for puerperal psychosis relapse in susceptible women.
Considering anxiety disorders, previous lifetime episodes, low social support, a history of child abuse, and a perception of high peripartum stress are all risk factors for experiencing anxiety disorders during the perinatal period. Multiparity has also been identified as another potential contributor to generalized anxiety in pregnancy. With regard specifically to PTSD, during the postpartum period, PTSD has been found to be associated with behavioral health risks and PTSD at the onset of pregnancy. 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 perinatal death.
Finally, women with a past or current psychiatric disorder, especially puerperal psychosis and severe depression, a substance-use disorder, and intimate partner problems have been found at increased risk of postpartum suicide attempt compared with controls.
Inquiries about psychiatric symptoms should be made at the initial antenatal visits. Attention should be paid to any sign of poor self-care and over- or underactivity. 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 previous personal or family history of psychopathology. 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 countries. The British National Institute for Health and Clinical Excellence guidelines specifically recommend the utilization of the Whooley questions to screen for antenatal depression. However, some authors highlighted a lack of evidence in its effectiveness and also a need for further research to identify 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. All pregnant women identified as high risk should have a shared multidisciplinary care plan for their late pregnancy and early postnatal management.
Prediction
Antenatal screening for mental health issues and risk factors allows early diagnosis, appropriate liaison with relevant professionals, timely discussion regarding treatment, and finalizing management 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. Efficient strategy of screening relies on identifying clinically vulnerable subgroups. The Table summarizes the known risk factors of the common perinatal mental disorders (PNMDs).
| PNMDs | Risk factors |
|---|---|
| AND | Previous PPD and nonperinatal depression Recent adverse life events Low socioeconomic status Insufficient emotional/social support Unplanned pregnancy Unfavorable obstetric /pregnancy outcomes Chronic physical illness Previous miscarriages Domestic violence |
| PPD | Past history of psychiatric disorders Depression/anxiety during current pregnancy Maternity blues Biological factors (genetic, hormonal, others) Recent adverse life events Low socioeconomic status Insufficient emotional/social support Poor marital relationship Unplanned pregnancy Immigration/premigration stress Personality traits Unfavorable obstetric/pregnancy outcomes Unfavorable neonatal outcomes Chronic/current physical illnesses History of PMS and PMDD History of physical/sexual abuse Multiple births Domestic violence Childcare stress/infant temperament |
| PPs | Previous episodes of PPs Personal history of psychotic disorders and BPAD Family history of PPs and BPAD Insufficient emotional/social support Sleep disturbance |
| PNADs | Personal history of ADs Insufficient emotional/social support Previous miscarriages History of physical/sexual abuse Multiple births Unfavorable pregnancy /neonatal outcomes Maternity blues |
| PTSD | Unfavorable obstetric/pregnancy and neonatal outcomes Perinatal death |
A past history of postpartum and nonperinatal depression and psychosocial factors are the most important predictors of antenatal depression. Likewise, postpartum depression (PPD) is caused by a combination of biological and psychosocial determinants. There is preliminary evidence that genetic factors may contribute to as much as one third of its etiological variance. Hormones, such as estrogen and progesterone, as well as thyroid dysfunction have been suggested as potential biological factors involved in its psychopathology. Recent researches have also focused on the role of omega-3 fatty acids and specific polymorphisms of serotonin metabolism enzymes in the development of PPD, but the findings thus far have been inconclusive. To date, the strongest predictors of PPD is a past history of psychopathology and depression or anxiety during the current pregnancy.
Recent evidence also found other important predictors, such as a history of premenstrual syndrome and premenstrual dysphoric disorder, and a history of physical or sexual abuse and domestic violence. The levels of childcare stress, infant temperament, and vulnerable maternal personality traits seem to be other important and stable determinants of PPD.
Finally, small but significant predictors include obstetric and pregnancy complications, especially hyperemesis and premature contractions, and socioeconomic status, which conversely represents a strong predictor of PPD in the developing world. The disparity in the rates of perinatal mental disorders between women living in high- and low-income settings suggests social rather than biological determinants.
Predictors of puerperal psychosis include previous episodes or family history; personal history of psychotic disorders, especially schizophrenia; personal or family history of BPAD ; medication nonadherence; poor social support ; younger age; and unplanned pregnancy. Sleep disturbances have also been found as an important risk factor for puerperal psychosis relapse in susceptible women.
Considering anxiety disorders, previous lifetime episodes, low social support, a history of child abuse, and a perception of high peripartum stress are all risk factors for experiencing anxiety disorders during the perinatal period. Multiparity has also been identified as another potential contributor to generalized anxiety in pregnancy. With regard specifically to PTSD, during the postpartum period, PTSD has been found to be associated with behavioral health risks and PTSD at the onset of pregnancy. 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 perinatal death.
Finally, women with a past or current psychiatric disorder, especially puerperal psychosis and severe depression, a substance-use disorder, and intimate partner problems have been found at increased risk of postpartum suicide attempt compared with controls.
Inquiries about psychiatric symptoms should be made at the initial antenatal visits. Attention should be paid to any sign of poor self-care and over- or underactivity. 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 previous personal or family history of psychopathology. 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 countries. The British National Institute for Health and Clinical Excellence guidelines specifically recommend the utilization of the Whooley questions to screen for antenatal depression. However, some authors highlighted a lack of evidence in its effectiveness and also a need for further research to identify 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. All pregnant women identified as high risk should have a shared multidisciplinary care plan for their late pregnancy and early postnatal management.
Effects on short-term outcomes
Mental illness in the perinatal period can have a significant impact on maternal health, birth outcomes, and fetal development. The British Confidential Enquiries into Maternal Deaths reported that psychiatric disorders contributed to 12% of all maternal deaths in 2002-2005. Currently, suicide is a leading cause of perinatal maternal deaths in industrialized countries, but there is still little research on its prevalence and correlates, especially in the developing world.
Among female suicide victims of reproductive age, recent data show a high prevalence of an existing mental health diagnosis or a past history of serious affective disorder (59%), such as puerperal psychosis and severe depression ; substance use; and intimate partner problems. Furthermore, maternal suicide can be associated with a risk of infanticide. 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. Among these women, the frequency of sexual activity may be normal, but contraceptive use may be lower and autonomous reproductive decision-making compromised. Women with mental illnesses often start their pregnancy without having their medications optimized and often stop taking them abruptly when they find out they are pregnant, which frequently leads to a relapse of their psychiatric symptoms. They are more likely to default antenatal care appointments, use substances, have a poor diet, and be overweight, all of which are lifestyle factors associated with poor obstetric outcomes.
It is increasingly recognized that severe mental illnesses can be an underlying cause of pregnancy-related medical disorders and obstetric complications. 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 inflammatory markers and altering proinflammatory cytokines regulation.
Another possible biological mechanism is represented by the overactivity of the maternal neuroendocrine system caused by maternal psychosocial stress and preexisting psychiatric symptoms. 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 intrauterine growth retardation, lower Apgar scores, congenital malformations, and perinatal loss.
Women with mental disorders more frequently misuse substances. Prenatal exposure to cocaine and amphetamines 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 restriction, and birth defects; moreover, fetal alcohol syndrome is a common cause of long-term sequelae for the infant. Prenatal tobacco exposure can induce spontaneous abortion, ectopic pregnancy, placental insufficiency, low birthweight, fetal growth restriction, and preterm delivery, whereas marijuana use has been found related to fetal growth restriction. All these substances can also predispose to neonatal withdrawal syndrome, which, interestingly, increased in the past 25 years.
Psychotropic medications may also have an impact on outcomes. Prenatal antidepressant use has been found associated with lower gestational age at birth, preterm birth, and small increased risk of persistent pulmonary hypertension of the newborn. Exposures of concern include that of untreated maternal illness as well as medication exposure. Conversely, no significant risk of stillbirth, neonatal mortality, postnatal mortality, and major congenital malformations has been found, apart from a slight increased risk of cardiac malformations associated with first-trimester paroxetine exposure.
With regard to antipsychotics, there is no conclusive evidence of their structural teratogenicity. There are 2 case reports of pregnancy loss in women taking atypical antipsychotic aripiprazole, whereas other observational studies found no increased risk of stillbirth, gestational age at birth, and perinatal syndromes in pregnant 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. Transient complications have been documented in neonates exposed to typical antipsychotics, including withdrawal symptoms, extrapyramidal signs, neonatal jaundice, and intestinal obstruction. Other authors found an association between low birthweight and the use of typical antipsychotics in pregnancy and large-for-gestational-age babies and the use of atypical antipsychotics, especially olanzapine and clozapine. An increased risk of gestational diabetes has been found related to the use of olanzapine and clozapine.
Prenatal exposure to lithium may be associated with a small increase in Ebstein’s anomaly (probably overvalued in the past), cardiac arrhythmias, hypoglycemia, nephrogenic diabetes insipidus, polyhydramnios, reversible changes in thyroid function, hyperparathyroidism, premature delivery, abnormally large infants, floppy infant syndrome, lethargy, and poor suck reflexes.
Among other mood stabilizers, prenatal exposure to valproic acid (VPA) has been found related with neural tube defects, craniofacial, limb and cardiovascular anomalies, genitourinary malformations, low birthweight, neonatal hepatotoxicity, coagulopathies, hypoglycemia, and an increased risk of withdrawal symptoms and cognitive impairment. Carbamazepine has teratogenic risks similar to VPA but less frequent and severe, whereas fetal exposure to lamotrigine has not been found to be related to major anomalies, excluding an increased risk of midline facial clefts.
Evidence from the treatment of epilepsy, however, suggests an increased risk of major congenital malformations following prenatal exposure to anticonvulsants, particularly at higher doses and in polytherapy.
Lastly, benzodiazepine use during the first trimester may be associated with cleft lip and palate, skeletal abnormalities, and central nervous system dysfunction. Neonatal toxicity includes withdrawal symptoms and floppy infant syndrome.
The contribution of various genetic factors in directing the variability of fetal drug exposure is still mostly unclear. The use of pharmacogenomics to predict maternal plasma drug concentrations 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 treatment decisions.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
