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Introduction

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Pregnancy and the puerperium are at times sufficiently stressful to provoke mental illness. Such illness may represent recurrence or exacerbation of a preexisting psychiatric disorder, or may signal the onset of a new disorder. Psychiatric disorders during pregnancy have been associated with less prenatal care, substance abuse, poor obstetrical and infant outcomes, and a higher risk of postpartum psychiatric illness (Frieder, 2008). Of pregnant women identified with psychiatric disorders, Andersson and colleagues (2003) in one Swedish study reported that more than 80 percent had a mood disorder. According to the Agency for Healthcare Research and Quality, the period prevalence of any depressive disorder during pregnancy in the United States is 18 percent (Yonkers, 2011). Unfortunately, most pregnant women with depressive disorders are not treated. In the Swedish study mentioned above, only 5 percent of women identified with psychiatric disorders received some form of treatment.

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Suicide is the fifth leading cause of death in the United States among women during the perinatal period, and major depression is among the strongest predictors of suicidal ideation (Melville, 2010). In both the United Kingdom and Australia, psychiatric illness is a leading cause of mortality for late maternal deaths—those between 43 and 365 days postpartum (Austin, 2007). Suicide by violent means was responsible for 65 percent of these. In a 10-year case-control analysis of Washington state hospitalizations, Comtois and associates (2008) studied 355 women with a postpartum suicide attempt. Significant risk factors and their associated rates included prior hospitalization for a psychiatric diagnosis—27-fold, and for substance abuse—sixfold. These rates were further increased if there were multiple hospitalizations.

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Psychological Adjustments to Pregnancy

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Biochemical factors—including hormonal effects—and life stressors can markedly influence mental illness. Thus, intuitively, pregnancy exacerbates some coexisting mental disorders. Indeed, pregnancy-related shifts in sex steroids and monoamine neurotransmitter levels; dysfunction of the hypothalamic-pituitary-adrenal axis; thyroid dysfunction; and alterations in immune response are all associated with an increased risk for mood disorders (Yonkers, 2011). These changes, coupled with evidence of familiality of depression, suggest that there may be a subgroup of women at risk for developing a unipolar major depressive disorder during pregnancy.

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Women respond in a variety of ways to stressors of pregnancy, and some express persistent concerns regarding fetal health, child care, lifestyle changes, or fear of childbirth pain. Anxiety, sleep disorders, and functional impairment are common (Morewitz, 2003; Romero, 2014; Vythilingum, 2008). According to Littleton and coworkers (2007), however, anxiety symptoms in pregnancy are associated with psychosocial variables similar to those for nonpregnant women. The level of perceived stress is significantly higher for women whose fetus is at high risk for a malformation, for those with preterm labor or delivery, and for those with other medical complications (Alder, 2007; Ross, 2006). Hippman (2009) screened 81 women for depression who had an increased risk ...

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