CHAPTER 61: Psychiatric Disorders

The subject of mental illness was only briefly addressed by Williams in 1903, when it appears that acute puerperal psychoses were manifestations of eclampsia or sepsis. More than 100 years later, we have learned that 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 it may signal the onset of a new condition. This 25th edition of Williams Obstetrics marks only the second edition with a focused chapter dedicated to psychiatric illnesses. To emphasize the rising national interest, American College of Obstetricians and Gynecologists President Dr. Gerald F. Joseph Jr. declared postpartum depression as an initiative in 2009.

Psychiatric disorders during pregnancy are associated with less prenatal care, substance use, poor obstetrical and neonatal outcomes, and higher rates of postpartum psychiatric illness (Frieder, 2008). Despite these known risks, obstetrical providers often are reluctant to confront or fail to identify some of these mental health issues during pregnancy. For example, Lyell and colleagues (2012) found that the diagnosis of depression was not documented in nearly half of the records of depressed women. Yet, perinatal mood disorders can have far-reaching consequences beyond the immediate effect on maternal mental health and social function by adversely affecting the mother-child relationship (Weinberg, 1998).

Also, suicide is a primary cause of death among women during the perinatal period in the United States, and major depression is among the strongest predictors of suicidal ideation (Melville, 2010). Between 2004 and 2012, self-harm, suicide, or drug overdose was the leading cause of maternal death in Colorado (Metz, 2016). In a 10-year analysis of Washington state hospitalizations, Comtois and associates (2008) studied 355 women with a postpartum suicide attempt. Substance abuse was linked with a sixfold higher and prior psychiatric hospitalization with a 27-fold greater risk for suicide. These rates rose further if there were multiple hospitalizations. Also of note, 54 percent of pregnancy-associated suicides involve intimate-partner conflict (Palladino, 2011).

Biochemical factors and life stressors can markedly influence mental health and mental illness during the perinatal period. Intuitively, pregnancy exacerbates some coexisting psychological disorders. Namely, an increased risk for mood disorders is linked with pregnancy-related shifts in sex steroid and monoamine neurotransmitter levels, dysfunction of the hypothalamic-pituitary-adrenal axis, thyroid dysfunction, and alterations in immune response (Yonkers, 2011). These changes, coupled with familial clustering of depression cases, suggest that there may be a subgroup of women at risk for developing a unipolar major depressive disorder during pregnancy.

Women respond in various 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 (Romero, 2014; Vythilingum, 2008). However, according to Littleton and coworkers (2007), 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 and colleagues (2009) screened for depression in 81 women who had an increased risk for a fetus with aneuploidy. Half of these women had a positive depression screening score, whereas only 2.4 percent of those with a normal pregnancy did so.

Several steps can be taken to diminish psychological stress in the event of a poor obstetrical outcome. For example, following a stillbirth, Gold (2007) encouraged parental contact with the newborn and provision of photographs and other infant memorabilia. Addressing associated sleep disorders also seems reasonable (Juulia Paavonen, 2017; Romero, 2014).

The Puerperium

This is a particularly stressful time for women, and risks for mental illness are increased. Up to 15 percent of women develop a nonpsychotic postpartum depressive disorder within 6 months of delivery (Tam, 2007; Yonkers, 2011). A few have a psychotic illness following delivery, and half of these manifest a bipolar disorder. Depressive disorders are more likely in women with obstetrical complications such as severe preeclampsia or fetal-growth restriction, especially if associated with early delivery. Houston and coworkers (2015) found that expectations at delivery also increased the risk for postpartum depression.

Importantly, stressors beyond those directly related to the pregnancy can raise perinatal depression rates. Tarney and colleagues (2015) identified spouse deployment as a factor for postpartum depression in a study at Womack Army Medical Center. But, among women with a history of bipolar disorder, these elements play a lesser role in the development of mania or depression (Yonkers, 2011).

Maternity Blues

Also called postpartum blues, this is a time-limited period of heightened emotional reactivity experienced by half of women within the first week after parturition. Prevalence estimates for the blues range from 26 to 84 percent depending on diagnostic criteria (O’Hara, 2014). This emotional state generally peaks on the fourth or fifth postpartum day and normalizes by day 10 (O’Keane, 2011).

The predominant mood is happiness, but affected mothers are more emotionally labile. They also may have insomnia, weepiness, depression, anxiety, poor concentration, and irritability. Mothers may be transiently tearful for several hours and then recover completely, only to be tearful again the next day. Supportive treatment is indicated, and affected women are reassured that the dysphoria is transient and most likely due to biochemical changes. They should be monitored for development of depression and other severe psychiatric disturbances.

Perinatal Evaluation and Screening

Both the American College of Obstetricians and Gynecologists (2016a) and the United States Preventative Services Task Force now recommend screening at least once during the perinatal period for depression and anxiety (Siu, 2016). Identification of psychiatric disorders in pregnancy can be challenging because changes in behavior and mood are often attributed to pregnancy. To differentiate these, Yonkers (2011) recommends assessment of cognitive symptoms—for example, loss of concentration. Excessive symptoms of anxiety and insomnia—even during periods of infant sleep—can also suggest postpartum depression. Specific factors for depression are reviewed and include a prior personal or family history of depression.

Universal-screening programs for depression continue to evolve (Venkatesh, 2016). At Parkland Hospital, mental illness screening is generally done at the first prenatal visit using a brief risk-based query and again postpartum using a universal-applied screening tool for postpartum depression. Questions search for psychiatric disorders, related therapy, prior or current use of psychoactive medications, and current symptoms. Women with a history of sexual, physical, or verbal abuse; substance abuse; and personality disorders are also at greater risk for depression (Akman, 2007; Janssen, 2012). History of neglect and abuse are especially powerful antecedents of depression in adolescent pregnancy (Meltzer-Brody, 2014). Smoking and nicotine dependence and obesity also raise rates of all mental disorders in pregnancy (Goodwin, 2007; Molyneaux, 2014). Finally, because eating disorders may be exacerbated by pregnancy, affected women are followed closely (Schizophrenia Spectrum Disorders).

Several screening instruments shown in Table 61-1 are available and have been validated for use during pregnancy and the puerperium. Use of one of these screening tools is encouraged because symptom- or risk-based screening alone may be insufficient (American College of Obstetricians and Gynecologists, 2016a). Cerimele and colleagues (2013) found that obstetricians and gynecologists failed to identify 60 percent of depressed women in clinical practice. As mentioned earlier, at Parkland Hospital, all women are screened during their first postpartum visit using the Edinburgh Postnatal Depression Scale (EPDS). In an analysis of more than 17,000 women, 6 percent had scores that indicated either minor or major depressive symptoms, and 12 women had thoughts of self-harm (Nelson, 2013). Similarly, Kim and coworkers (2015) assessed suicidal ideation in more than 22,000 women screened using the EPDS both during pregnancy and postpartum. They found rates of depression as high as 3.4 percent during the puerperium. A small fraction of those with thoughts of self-harm had a credible plan, intent, and means for attempted suicide. Obviously, suicidal ideation warrants prompt psychiatric consultation for evaluation and management.

Screening for perinatal depression without appropriate subsequent treatment is insufficient (American College of Obstetricians and Gynecologists, 2016a). That said, mechanisms to ensure adequate ensuing care can be problematic. In the study by Nelson and associates (2013) more than three fourths of the 1106 women with abnormally elevated EPDS scores did not keep their later appointment, which offered more formal psychiatric evaluation. Barriers include difficulties with access to care, personal perception of depression, and societal stigmata (Flynn, 2010; Smith, 2008). Women referred to a behavioral health provider located at the same site as their obstetrical care are four times more likely to access treatment than those referred elsewhere (Smith, 2009). To take advantage of this, at Parkland Hospital, mental health counselors also practice at postpartum clinic sites. Other promising interventions for puerperal depression include home visits, telephone-based peer support, and interpersonal psychotherapy (Dennis, 2013; Lavender, 2013; Yonemoto, 2017). A report from Kaiser Permanente, which describes the benefits and hurdles to system-based perinatal mental health care, provides a glimpse into the possible future of universal perinatal screening and treatment (Avalos, 2016; Flanagan, 2016).

Treatment Considerations

Many psychiatric disorders can be improved with counseling and psychotherapies. In some instances, psychotropic medications are needed. Treatment decisions are ideally shared between patients and their health-care providers. In particular, women taking psychotropic medication are informed of likely side effects. Many of these drugs are discussed in Chapter 12 and by the American College of Obstetricians and Gynecologists (2016b) in their Practice Bulletin No. 92. Some of these drugs are discussed subsequently.

Pregnancy Outcomes

Emerging information on psychiatric disorders and pregnancy outcomes suggest a link between maternal psychiatric illness and untoward outcomes such as preterm birth, low birthweight, and perinatal mortality (Grigoriadis, 2013; Steinberg, 2014; Straub, 2012; Yonkers, 2009). In a study of 16,334 deliveries, Shaw and coworkers (2014) identified a significant association between posttraumatic stress disorder and spontaneous preterm delivery. Domestic abuse—another aforementioned risk factor for perinatal mood disorder—is also linked with adverse perinatal outcomes (Yost, 2005). Finally, Littleton and associates (2007) reviewed 50 studies and concluded that anxiety symptoms, which are commonly comorbid with depression, had no adverse effect on perinatal outcomes.

The Diagnostic and Statistical Manual, Fifth Edition (DSM-5) is the most recent version by the American Psychiatric Association (2013). It assists in classifying mental disorders and specifies criteria for each diagnosis.

Of categories, depressive disorders are common. According to the National Institute of Mental Health (2010), the lifetime prevalence of depressive disorders in the United States is 21 percent. Historically, depressive disorders include major depression—a unipolar disorder—and manic-depression—a bipolar disorder with both manic and depressive episodes. It also includes dysthymia, which is chronic, mild depression.

Major Depression

This is the most common depressive disorder, and the 12-month prevalence of major depressive episodes among U.S. women is 8.2 percent (Center for Behavioral Health Statistics and Quality, 2015). In 2011 to 2014, 16 percent of U.S. women had used an antidepressant in the prior month (Pratt, 2017). The diagnosis is made by identifying symptoms listed in Table 61-2, but very few patients manifest all of these.

Major depression is multifactorial and prompted by genetic and environmental factors. Families of affected individuals often also have members suffering with alcohol abuse and anxiety disorders. Provocative conditions leading to depression include life events that prompt grief reactions, substance abuse, use of certain medications, and other medical disorders. Although life events can trigger depression, genes influence the response to these events and render the distinction between genetic and environmental factors difficult. One genome-wide linkage analysis of more than 1200 mothers suggests that variation in chromosomes 1 and 9 raises susceptibility to postpartum mood symptoms (Mahon, 2009).

Pregnancy and Depression

It is unquestionable that pregnancy is a major life stressor that can precipitate or exacerbate depressive tendencies. In addition, various pregnancy-induced effects are implicated. Hormones certainly affect mood, as evidenced by premenstrual syndrome and menopausal depression. Estrogen has been linked to increased serotonin synthesis, decreased serotonin breakdown, and serotonin-receptor modulation (Deecher, 2008). Concordantly, women who experience postpartum depression often have higher predelivery serum estrogen and progesterone levels and experience a greater decline postpartum (Ahokas, 1999).

Dennis and associates (2007) queried the Cochrane Database and reported that the prevalence of antenatal depression averaged 11 percent. Melville and coworkers (2010) found it in nearly 10 percent of more than 1800 women enrolled for prenatal care at a single university clinic. Others have reported the incidence to be much higher depending on the population studied (Gavin, 2005; Hayes, 2012; Lee, 2007).

Postpartum Depression

Major or minor depression develops postpartum in 10 to 20 percent of women (Mental Health America, 2016). Available data indicate that unipolar major depression may be slightly more prevalent during the puerperium than among women in the general population (Yonkers, 2011). Postpartum depressive symptoms are associated with young maternal age, antenatal depression, unmarried status, smoking, newborns requiring intensive care, and those with a history of stressors during pregnancy (Ko, 2017; Silverman, 2017). Specifically, physical or verbal abuse during pregnancy is a potent risk for postpartum depression (McFarlane, 2014). Finally, serious adverse obstetrical events, especially those involving the neonate, are strongly linked to postpartum depression (Nelson, 2013, 2015).

Depression is frequently recurrent. Up to 70 percent of women with previous postpartum depression have a subsequent episode. Women with both prior puerperal depression and a current episode of “maternity blues” carry an inordinately high risk for major depression. Indeed, 2 to 9 months postpartum, assistance with postpartum depression was the fourth most common challenge identified in women in the Pregnancy Risk Assessment Monitoring System—PRAMS (Kanotra, 2007).

Postpartum depression is generally underrecognized and undertreated. Major depression during pregnancy or after delivery can have devastating consequences for affected women, their children, and families. One of the most significant contributions to the mortality rate among new mothers is suicide, which is most frequent among women with mental illness (Koren, 2012; Palladino, 2011). If left untreated, up to 25 percent of women with postpartum depression will be depressed 1 year later. As the duration of depression increases, so too does the number of sequelae and their severity. Maternal depression during the first weeks and months after delivery can lead to insecure attachment and later behavioral problems in the child.

Depression Treatment

Therapy for mood disorders during pregnancy and postpartum has undergone a significant evolution during the past decade. Babbitt (2014) and Pozzi (2014) and their associates have reviewed principles of antenatal and intrapartum care of women with major mental disorders. In general, for mild and mild-moderate depression, psychological treatment options, such as cognitive behavioral therapy, are considered first (Yonkers, 2011). Antidepressant medications together with some form of psychotherapy are indicated for moderate to severe depression during pregnancy or the puerperium (American College of Obstetricians and Gynecologists, 2016b).

Shown in Figure 61-1 is one algorithm regarding treatment of mood disorders. Some of these medications are listed in Table 61-3. For women with severe depression, a selective serotonin-reuptake inhibitor (SSRI) is selected initially. In contrast, tricyclic antidepressants and monoamine oxidase inhibitors are infrequently selected in contemporary practice. If depressive symptoms improve during a 6-week trial, the medication is continued for a minimum of 6 months to prevent relapse (Wisner, 2002). At least 60 percent of women taking antidepressant medication before pregnancy have symptoms during pregnancy. According to Hayes and colleagues (2012), approximately three fourths of women taking antidepressants before pregnancy stopped taking them before or during early pregnancy. For those who discontinue treatment, almost 70 percent have a relapse compared with approximately 25 percent who continue therapy. If the response is suboptimal or a relapse occurs, another SSRI is substituted, or psychiatric referral is considered.

Various dietary deficiencies have suggested links to perinatal depression (Yonkers, 2011). Supplements that include omega-3 fatty acids, iron, folate, riboflavin, vitamin D, calcium, and docosahexaenoic acid (DHA) have been studied (Keenan, 2014; Miller, 2013). However, evidence currently is insufficient to support use of these dietary supplements for this purpose.

Importantly, in a metaanalysis by Huang and coworkers (2014), women using antidepressants during pregnancy have higher rates of preterm birth and low-birthweight neonates. Nevertheless, in their review, Ray and Stowe (2014) concluded that the relative reproductive safety data are reassuring and that antidepressants remain a viable treatment option. Furthermore, recurrence sometime after medication is discontinued develops in 50 to 85 percent of women with an initial postpartum depressive episode. Women with a history of more than one depressive episode carry greater risk (American Psychiatric Association, 2000). Surveillance includes monitoring for thoughts of suicide or infanticide, emergence of psychosis, and response to therapy. For some women, the course of illness is severe enough to warrant hospitalization.

Fetal and Neonatal Effects of Therapy

Some known and possible fetal and neonatal effects of treatment are listed in Table 61-3. Some studies suggest that SSRIs pose an elevated teratogenic risk for fetal cardiac defects, and these have mainly focused on paroxetine (Paxil). Associations were most consistent for ventricular septal defects. The estimated risk is no greater than 1 in 200 exposed newborns (Koren, 2012). Nevertheless, the American College of Obstetricians and Gynecologists (2016b) recommends that paroxetine be avoided in women who are either pregnant or planning pregnancy. In women exposed to paroxetine in the first trimester, fetal echocardiography is considered. Jimenez-Solem and coworkers (2013) in their analysis of SSRIs found no association between exposure to SSRIs during pregnancy and perinatal mortality. Andersen and associates (2014) found that women discontinuing SSRI treatment in early pregnancy had a small increased risk of miscarriage, but that this was similar to the risk in women discontinuing SSRI treatment months before pregnancy. Taken together, these investigators concluded that treatment with SSRIs during pregnancy should not be discontinued for fear of miscarriage.

Of other potential effects, the risk of persistent pulmonary hypertension of the newborn rose sixfold in neonates exposed to SSRIs after 20 weeks’ gestation (Chambers, 2006). This translates to an overall risk of pulmonary hypertension that would be less than 1 in 100 exposed newborns (Koren, 2012). In contrast, a population-based cohort study of 1.6 million pregnancies identified a twofold greater rate in exposed neonates. This yields an estimated attributable risk of 2 cases per 1000 births (Kieler, 2012). In a study of more than 120,000 gravidas prescribed antidepressants, Huybrechts and coworkers (2015) found an attributed risk of 1 case per 1000 births.

In sum, the maternal risk associated with discontinuing or tapering SSRI use during pregnancy must be weighed against marginally increased neonatal risks (Ornoy, 2017). Women who abruptly discontinue either serotonin- or norepinephrine-reuptake inhibitor therapy typically experience some form of withdrawal.

Not surprisingly, up to 30 percent of exposed neonates may also exhibit withdrawal symptoms. Symptoms are similar to opioid withdrawal, but typically are less severe. Neonatal SSRI withdrawal is usually self-limited, and the newborn rarely remains in the nursery more than 5 days (Koren, 2009). Currently, convincing evidence of long-term neurobehavioral effects of fetal exposure to these medications is lacking (Koren, 2012). Grzeskowiak and coworkers (2016) found no increased risk of behavioral problems in 7-year-old children exposed to antidepressants prior to their birth.

Some psychotropic medications pass into breast milk. In most cases, however, levels are very low or undetectable. Effects may be transient irritability, sleep disturbances, and colic.

Electroconvulsive Therapy

This form of depression treatment is occasionally necessary during pregnancy for women with major mood disorders unresponsive to pharmacotherapy. Women undergoing electroconvulsive therapy (ECT) should be fasting for at least 6 hours. They are given a rapid-acting antacid before the procedure, and their airway is protected to decrease the likelihood of aspiration. After midpregnancy, a wedge is placed under the right hip to prevent sudden maternal hypotension from aortocaval compression. Other important preparatory steps include assessment of the cervix, discontinuation of nonessential anticholinergic medication, uterine and fetal heart rate monitoring, and intravenous hydration. During the procedure, excessive hyperventilation is avoided. In most cases, maternal and fetal heart rate and maternal blood pressure and oxygen saturation remain normal throughout the procedure.

With proper preparation, the risks to both mother and fetus appear to be reasonable (Pinette, 2007). That said, adverse maternal and perinatal outcomes have followed ECT. Balki and associates (2006) reported a pregnancy in which fetal brain damage likely was caused by sustained maternal hypotension associated with treatment of status epilepticus stimulated by ECT.

At least two extensive reviews have evaluated ECT outcomes in pregnancy. In the earlier one, Miller (1994) found 300 cases and reported complications in 10 percent. These included fetal arrhythmias, vaginal bleeding, abdominal pain, and self-limited contractions. Women not adequately prepared had increased risks for aspiration, aortocaval compression, and respiratory alkalosis. In the more recent review, Andersen and Ryan (2009) described 339 cases, undoubtedly with some homology with the earlier study. In most cases, ECT therapy was done to treat depression, and it was 78-percent effective. They reported a 5-percent maternal ECT-related complication rate. There was a 3-percent associated perinatal complication rate, which included two fetal deaths. For all of these reasons, we agree with Richards (2007) that ECT in pregnancy is not “low risk” and that it should be reserved for women whose severe depression is resistant to intensive pharmacotherapy.

Bipolar and Related Disorders

According to the National Institute of Mental Health (2010), the lifetime prevalence for manic-depression illness is 3.9 percent. The prevalence of bipolar disorder does not vary between gravidas and nonpregnant reproductive-aged women (Yonkers, 2011). It has a strong genetic component and has been linked to possible mutations on chromosomes 16 and 8 (Jones, 2007). The risk that monozygotic twins are both affected is 40 to 70 percent, and the risk for first-degree relatives is 5 to 10 percent (Muller-Oerlinghausen, 2002).

Periods of depression last at least 2 weeks. At other times, patients are manic, in which mood is abnormally raised, expansive, or irritable. Potential organic causes of mania include substance abuse, hyperthyroidism, and central nervous system (CNS) tumors. These are all excluded during an acute event. Importantly, pregnancy frequently prompts medication discontinuation, which poses a twofold increased risk for relapse (Viguera, 2007). Affected women are considered high risk, and as many as 20 percent of patients with manic-depression illness commit suicide.

Bipolar Disorder in Pregnancy

This has also been associated with adverse perinatal outcomes, for example, preterm birth (Mei-Dan, 2015). Di Florio and associates (2013) found that those women who experience pregnancy complications are more likely to exhibit periods of mania or depression. Women who tend to be manic present with exacerbations earlier in the postpartum period.

Typical therapy for bipolar disorder includes mood stabilizers such as lithium, valproic acid, and carbamazepine, as well as antipsychotic medications (see Table 61-3). Treatment of bipolar disorder in pregnancy is complex and is ideally managed concurrently with a psychiatrist. Decisions include risks versus benefits of using mood stabilizers, some of which are teratogenic. For example, lithium has been linked to Ebstein anomaly in exposed fetuses. More recent data, however, suggest a lower risk of cardiac malformations than previously indicated (Micromedex, 2016; Patorno, 2017). Nevertheless, many recommend fetal echocardiography for lithium-exposed fetuses. Some limited evidence suggests that lithium in breast milk, when its elimination is impaired as in dehydration or immaturity, can adversely affect the infant (Davanzo, 2011). However, lithium use in mothers with a healthy, term fetus is considered moderately safe. A more detailed discussion of other mood stabilizers and antipsychotic medications side effects can be found in Chapter 12 (Immunosuppressant Medications).

Postpartum Psychosis

This severe mental disorder is usually a bipolar disorder, but it may be due to major depression (American Psychiatric Association, 2013). Its incidence is estimated to be 1 in every 1000 deliveries, and it is more common in nulliparas, especially those with obstetrical complications (Bergink, 2011; Blackmore, 2006). In most cases, illness manifests within 2 weeks of delivery. In one study of postpartum women with their first lifetime episode of psychosis, the median onset of psychiatric symptoms was 8 days after delivery, and the median duration of the episode was 40 days (Bergink, 2011). Because those with underlying psychiatric disease have a 10- to 15-fold risk for recurrence postpartum, close monitoring is imperative.

The most important risk for postpartum psychosis is a history of bipolar disease. These women typically exhibit symptoms within 1 to 2 days after delivery (Heron, 2007, 2008). Manic symptoms include feeling excited or elated, being active or energetic, feeling “chatty,” and suffering insomnia. Affected women have signs of confusion and disorientation but may also have lucid episodes.

Postpartum psychosis has a 50-percent recurrence risk in the next pregnancy. As a result, Bergink and associates (2012) recommend initiating lithium therapy immediately after delivery in women with a history of postpartum psychosis.

The clinical course of bipolar illness with postpartum psychosis is comparable with that for nonpregnant women. Patients usually require hospitalization, pharmacological treatment, and long-term psychiatric care. Psychotic women may have delusions leading to thoughts of self-harm or harm to their infants. Unlike women with nonpsychotic depression, these women commit infanticide, albeit uncommonly (Kim, 2008). In most instances, women with postpartum psychosis ultimately develop relapsing, chronic psychotic manic-depression.

Anxiety Disorders

These relatively common disorders—18 percent prevalence overall—include panic attack, panic disorder, social anxiety disorder, specific phobia, separation anxiety disorder, and generalized anxiety disorder. All are characterized by irrational fear, tension, and worry, which are accompanied by physiological changes such as trembling, nausea, hot or cold flashes, dizziness, dyspnea, insomnia, and frequent urination (Schneier, 2006). They are treated with psychotherapy and medication, including SSRIs, tricyclic antidepressants, monoamine oxide inhibitors, or others.

Anxiety Disorders in Pregnancy

Despite the relative high prevalence in childbearing-aged women, little specific attention has been directed to anxiety disorders in pregnancy. Most reports conclude that rates between pregnant and nonpregnant women do not differ. One recent analysis of 268 gravidas with generalized anxiety disorder demonstrated that both symptoms and severity of anxiety decline across pregnancy (Buist, 2011).

From their review, Ross and McLean (2006) concluded that some of the anxiety disorders may have important maternal-fetal implications. Some have been linked to preterm birth, fetal-growth restriction, and poor neurobehavioral development (Van den Bergh, 2005). Children with a history of in utero exposure to maternal anxiety are felt to be at increased risk for various neuropsychiatric conditions such as attention-deficit/hyperactivity disorder (ADHD). Hunter and coworkers (2012) analyzed infants of 60 mothers with an anxiety disorder and found that auditory sensory gating—a reflection of inhibitory neurotransmission—was impaired, particularly in offspring of untreated women. Conversely, Littleton and associates (2007) found no excessive adverse pregnancy outcomes with “anxiety symptoms.” One important exception is their link with postpartum depression (Vythilingum, 2008).

Anxiety Disorder Treatment

Anxiety disorders can be effectively treated during pregnancy with psychotherapy, cognitive-behavioral therapy, or medications. Mood and anxiety disorders coexist in more than half of women identified with either diagnosis (Frieder, 2008). Thus, antidepressants listed in Table 61-3 are often the first line of pharmacotherapy.

Benzodiazepines are also commonly used to treat anxiety or panic disorders before and during pregnancy. Earlier case-control studies linked use of these CNS depressants to a possible increased risk for cleft lip and palate. A metaanalysis of more than 1 million exposed pregnancies, however, did not identify a teratogenic risk (Enato, 2011). Benzodiazepines, especially when taken during the third trimester, can cause neonatal withdrawal syndrome, which persists for days to weeks after delivery.

This major form of mental illness affects 1.1 percent of adults (National Institute of Mental Health, 2016). Schizophrenia spectrum disorders are defined by abnormalities in one or more of the following domains: delusions, hallucinations, disorganized thinking, grossly disorganized or abnormal motor behavior, and negative symptoms. Brain-scanning techniques such as positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) show that schizophrenia is a degenerative brain disorder. Subtle anatomical abnormalities are present early in life and worsen with time.

Schizophrenia has a major genetic component, and there is a 50-percent concordance in monozygotic twins. If one parent has schizophrenia, the risk to offspring is 5 to 10 percent. Some data, including a strong association between schizophrenia and the velocardiofacial syndrome, suggest that associated genes are located on chromosome 22q11 (Murphy, 2002). But sophisticated gene mapping studies clearly show that schizophrenia is not related to a single gene or mutation. Instead, multiple DNA variants likely interact to lead to schizophrenia (Kukshal, 2012). Other putative risks for subsequent schizophrenia in an exposed fetus include maternal iron-deficiency anemia, diabetes, and acute maternal stress (Insel, 2008; Malaspina, 2008; Van Lieshout, 2008). These remain unproven, as does the association with maternal influenza A infection.

Signs of illness begin approximately at age 20 years, and commonly, work and psychosocial functioning deteriorate over time. Women have a slightly later onset than men and are less susceptible to autism and other neurodevelopmental abnormalities. Thus, many investigators theorize that estrogen is protective. Affected women may become pregnant before symptoms manifest. With appropriate treatment, patients can experience a decrease or cessation of symptoms. Within 5 years from the first signs of illness, 60 percent have social recovery, 50 percent are employed, 30 percent are mentally handicapped, and 10 percent require continued hospitalization (American Psychiatric Association, 2013).

Schizophrenia in Pregnancy

Most studies have not found adverse maternal outcomes, although researchers in a Swedish study noted increased rates of low birthweight, fetal-growth restriction, and preterm delivery (Bennedsen, 1999). In a study of more than 3000 pregnancies in schizophrenic women, Jablensky and coworkers (2005) reported that placental abruption was increased threefold and “fetal distress”—vaguely defined—was increased 1.4-fold.

Because schizophrenia has a high recurrence if medications are discontinued, continued therapy during pregnancy is advised. After 40 years of use, no evidence links the conventional or “typical” antipsychotic drugs listed in Table 61-3 and adverse fetal or maternal sequelae (McKenna, 2005; Robinson, 2012; Yaeger, 2006). Because less is known about “atypical” antipsychotics, the American College of Obstetricians and Gynecologists (2016b) recommends against their routine use in pregnant and breastfeeding women. In response to adverse event reports, the Food and Drug Administration (2011) issued a safety communication alerting health-care providers concerning some antipsychotic medications. These have been associated with neonatal extrapyramidal and withdrawal symptoms similar to the neonatal behavioral syndrome seen in those exposed to SSRIs.

These include anorexia nervosa, in which the patient refuses to maintain minimally normal body weight, and bulimia nervosa, in which binge eating is usually followed by purging or excessive fasting to maintain normal body weight (Zerbe, 2008). Eating behavior disturbances largely affect adolescent females and young adults. With anorexia and bulimia, the lifetime prevalence for each is 2 to 3 percent (National Institute of Mental Health, 2016).

Bulik and coworkers (2009) studied pregnancy outcomes in almost 36,000 Norwegian women screened for eating disorders. Approximately 0.1 percent had anorexia nervosa, 0.85 percent had bulimia nervosa, and 5.1 percent reported a binge-eating disorder. This 6-percent pregnancy prevalence is similar to the 6-month prevalence for nonpregnant individuals (National Institute of Mental Health, 2016). The last subtype had a higher risk for large-for-gestational age neonates with a concomitantly increased cesarean delivery rate. All eating disorders begin with the desire to be slim, and women with chronic eating disorders may migrate between subtypes (Andersen, 2009).

Eating Disorders in Pregnancy

Early pregnancy complication rates are increased with both eating disorders, but especially in women with bulimia nervosa (Andersen, 2009; Hoffman, 2011). Generally, eating disorder symptoms improve during pregnancy, and remission rates may reach 75 percent. In contrast, typical cases of hyperemesis gravidarum may actually be a new or relapsing case of bulimia nervosa or of binge-purge type anorexia nervosa (Torgerson, 2008). As perhaps expected, anorexia is associated with low-birthweight neonates (Micali, 2007). Additional risks associated with eating disorders include poor wound healing and difficulties with breastfeeding (Andersen, 2009). At a minimum, closely monitoring gestational weight gain in women with a suspected history of an eating disorder seems prudent.

Care for these women involves a multidisciplinary team that includes an obstetrician, mental health provider, and either dietician or nutritionist (American Dietetic Association, 2006). Psychological treatment is the cornerstone for treatment in women with eating disorders and frequently includes cognitive-behavioral therapy. Anorexia nervosa often responds to motivational interactions with meal planning (Cardwell, 2013). After delivery, women with eating disorders are more prone to postpartum depression. Women with bulimia are at particular risk for disease rebound after delivery because of body image concerns.

These disorders are characterized by the chronic use of certain coping mechanisms in an inappropriate, stereotyped, and maladaptive manner. They are rigid and unyielding personality traits. The American Psychiatric Association (2013) recognizes three clusters of personality disorders:

1. Paranoid, schizoid, and schizotypal personality disorders, which are characterized by oddness or eccentricity.

2. Histrionic, narcissistic, antisocial, and borderline disorders, which are all characterized by dramatic presentations along with self-centeredness and erratic behavior.

3. Avoidant, dependent, compulsive, and passive-aggressive personalities, which are characterized by underlying fear and anxiety.

Genetic and environmental factors are important in the genesis of these disorders, whose prevalence may be as high as 20 percent. Although management is through psychotherapy, most affected individuals do not recognize their problem, and thus only 20 percent seek help. In an observational study of 202 women with borderline personality disorder, De Genna and associates (2012) noted that such women become pregnant during the most severe trajectory of their illness. They are at increased risk for teen and unintended pregnancies.

Personality disorders during pregnancy are probably no different than in nonpregnant women. Akman and colleagues (2007) reported that avoidant, dependent, and obsessive-compulsive disorders are associated with an excessive prevalence of postpartum major depression. Magnusson and associates (2007) found a link between some personality traits—not disorders—and excessive alcohol consumption, but not necessarily addiction or dependence. Conroy and coworkers (2010) found that a mother’s ability to care for her newborn was impaired only when a personality disorder was coupled with depression.