Jill A. RachBeisel

A mother’s mental health before, during, and following pregnancy is a key factor in her wellbeing and her baby’s. It has been well established that the occurrence of an episode of mental illness during pregnancy has a significant influence on the health of the pregnancy, development of the fetus, and success of the mother and child following delivery. Caring for a woman with mental illness during pregnancy is complex and includes consideration of issues such as nutrition, the use of psychotropic medications, psychosocial supports, mother—infant bonding, and the care of both mother and child in the postpartum period.

Women with complicating conditions including anxiety, mood, and psychotic disorders face difficult decisions about whether or not to have a child or about treatment choices during pregnancy and while breast-feeding. Careful consideration must be given to the health and well-being of both mother and baby. The risk to the fetus of treating the mother’s illness must be weighed against risk of no treatment at all to the mother and the baby. In such complicated situations it is critical that the obstetrician work closely with the psychiatrist in considering the best options to present to the expectant mother in managing her illness while maintaining the highest safety to her unborn child.

This chapter covers the essential critical issues in helping women with a history of mental health issues decide if they want to become pregnant as well as the assessment, diagnosis, and treatment of psychiatric disorders during and immediately following pregnancy. Because this subject matter is so vast, peripheral issues related to infertility, miscarriage, elective termination, loss of a child shortly following delivery, and menopause are not addressed in this chapter but are covered in other chapters of this book.

The too-often-voiced opinion that a woman with a mental illness should not get pregnant or attempt another pregnancy (if her first mental health episode was associated with a prior pregnancy) is simply not true. Although for some women with a history of psychiatric symptoms— either apart from or related to a prior pregnancy—becoming pregnant again may present too great a risk, for many, having a baby remains a viable option. However, careful attention must be paid to early signs and symptoms of illness, and appropriate monitoring is critical for a successful pregnancy and delivery of a healthy baby and happy mother. Equally important is the early detection of symptoms of emotional distress during or following delivery to ensure appropriate, timely treatment and to avoid long-term serious and, at times, potentially devastating complications for both mother and baby.

Discussing the possibility of having a baby is perhaps one of the most important issues to address when caring for a woman in her childbearing years with a history of mental illness. Ideally, such a discussion should occur when a couple is planning marriage and making future plans rather than after marriage or at the first prenatal visit, when the woman presents with an unexpected pregnancy. The discussion should cover several important topics including the heritability of the mental illness and risk factors to the mother and baby during and after delivery. The purpose of these discussions is to have a well-informed patient who can make the decision that is best for herself and her baby.

Since the 1970s, there has been growing interest in the inheritability of psychiatric illness. The likelihood that a particular psychiatric illness will be transmitted to the unborn child is determined by many factors, including the presence of biologic (susceptibility genes) and environmental (psychosocial stressors) factors.

To date, no single gene has been linked to the transmission of a mental illness from one generation to the next. On the other hand, studies have clearly demonstrated that many psychiatric disorders have a genetic component. Indeed, babies born to parents with schizophrenia, bipolar disorder, eating disorders, and anxiety disorders have a significantly greater risk of developing those illnesses in their lifetime compared to babies born to parents with little or no psychiatric illness.

There has been a longstanding controversy regarding the impact of pregnancy on the course of mental illness. The theory that pregnancy protects the mother from an episode of illness directly conflicts with the idea that pregnancy is a time of increased vulnerability. Thus, the current clinical approach is one of individualization.

Factors that impact the effect of pregnancy on a woman’s psychiatric illness include emotional stability, attitudes toward femininity and pregnancy, cultural attitudes, relationships with her significant other and her own mother, and degree of preparation for parenthood.

It has been shown that the less prepared for parenthood a mother is, the more stressful the pregnancy will be for her. Increased stress during pregnancy leads to an increased likelihood of emotional instability and an exacerbation any underlying mental illness. Careful assessment of these factors will help to identify patients at risk for more complications during the pregnancy, and whether they ultimately may require medications, enhanced psychosocial support, or acute psychiatric care.

Even among expectant mothers without a history of mental illness, 20% will experience an episode of depression sometime in their life. However, it is more likely that such an event will occur during a pregnancy, particularly in the face of psychosocial stressors such as poverty and poor interpersonal support.

For an expectant mother with mental illness, risks to the developing child come from two sources: exposure to the medications and the untreated psychiatric illness. Medication exposure can cause considerable risk, especially with the use of agents for bipolar illness. At the same time, it has been well documented that mothers who sufer from significant stress during pregnancy, including an exacerbation of their illness, are prone to have low birth weight babies, increased rates of schizophrenia, and preterm births. Further, a child’s emotional, cognitive, and physical health and development are affected by their mother’s mental health while pregnant. A more detailed discussion of impact of medicine versus lack of treatment of the mother’s illness on the fetus is presented later in this chapter.

The greatest postpartum complication for the mother is a sudden onset of existing or new psychiatric illness, typically referred to as postpartum depression. Approximately 20% of mothers experience some symptoms of depression within the first year after birth, most of whom are not identified or treated. The most severe forms of post-partum psychiatric illness typically occur within the first month following delivery and can greatly interfere with mother—infant bonding, self-care, and care of the baby.

The greatest risk for the newborn stems from two factors: 1) heightened medication exposure during breastfeeding due to an immature liver that no longer has the mother’s liver to help with metabolism of the psychotropic medications, thus leading to toxicity and/or withdrawal phenomenon; and 2) onset or worsening psychiatric symptoms in the mother interfering with attachment, feeding, and basic care. In the worst cases, infants are unintentionally at risk for neglect or abuse due to the depressed mother’s inability to care for her newborn child.

A rare but very real event is infanticide, a situation where the mother is most often depressed, has failed to attach or bond with her baby, and feels the baby would be better of dead and, thus, spared unhappiness and pain. The mother may attempt to kill herself as well. The majority of infanticides are not associated with psychosis but rather a severe depression.

Many of the risks factors are avoidable with close management, frequent assessment, and preventative strategies to minimize stress and promote a healthy, supportive pregnancy and postpartum periods.

Pregnancy should be one of the most special and happiest times of a woman’s life. However, for many women, it is a period of fearfulness, confusion, anxiety, stress, and, ultimately, depression. Complicating factors such as unexpected pregnancy, teenage pregnancy, poverty, lack of social support, and isolation create a psychological environment that is sometimes challenging for the expectant mother. At a time when she is most in need of expressing her feelings and being understood, many women find it difficult to reveal the conflicts they are experiencing.

Many times, fears of being seen as self-centered and thankless prevent them from speaking out about their emotional turmoil. As a result, depression in pregnancy remains under-recognized and under-treated, leaving the mother and developing fetus at greater risk for other adverse outcomes.

Depression

Etiology and Frequency

Depression occurs almost twice as often in women than men: a 21% lifetime prevalence of major depression in women versus 13% in men. This greater susceptibility to depression has been attributed to diferences in mono-amine transmitter function and processing between men and women.

Another possible underlying risk factor that may contribute to higher rates of depression in women is the fundamental requirement that the woman’s brain must constantly adapt to fluctuating hormone levels. At no other time is this truer than during pregnancy and delivery. Although this is a topic of great research interest, it is still poorly understood, and effective preventative therapies have not been discovered. Thus, there is a need to carefully monitor, identify, and provide treatment of depression as it occurs.

Decision not to use medications: It is important to understand the impact of untreated depression on the mother and fetus in order for the expectant mother and her doctor to decide the best course of action. Consequences of untreated depression can result in maternal behaviors that are particularly harmful to both herself and her child. These include a general disregard for a healthy life style or continued smoking, alcohol or substance use, poor prenatal care, and poor nutrition despite medical advice to the contrary.

The depression also can lead to an increased risk of suicide. Overall, untreated depression during pregnancy is a significant risk for postpartum depression, which also poses serious risks to mother and new baby.