Management of Perinatal Mood and Anxiety Disorders

Treatment with medication and/or specialist referral should be considered for patients who screen positive for PMADs.27 Depending on the severity of the mood disorder, a nonpharmacological approach such as psychotherapy may be taken first and can be used in combination with pharmacotherapy.33

A 2021 systematic review by Dominguez-Solis et al revealed moderate to strong evidence that nonpharmaceutical interventions could reduce anxiety in the perinatal period. They determined that cognitive behavioral therapy (CBT), massages by partners, yoga, and music therapy were most effective.34 Findings from a 2020 randomized controlled study by Zemestanti et al showed similar results. They found that mindfulness-based CBT successfully improved symptoms of depression and anxiety among 38 pregnant women.35

Medication selection should be made based on the agent’s safety profile and the patient’s symptoms, history of medication use, and preferences, according to ACOG. Clinicians who do not specialize in psychiatric management should refer patients to a psychiatrist for pharmacotherapy.33

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A risk-benefit analysis is needed when considering pharmacotherapy for PMADs.36-38 Benzodiazepines, which provide quick relief from anxiety and panic disorders, are associated with neonatal side effects such as preterm delivery, low birth weight, and floppy infant syndrome as well as a slightly increased incidence of cleft lip or palate (absolute risk is increased by 0.01%).33,36-38 Exposure to benzodiazepines should be avoided during the first 3 months of pregnancy, but these agents are not contraindicated in later stages of pregnancy. If necessary, a benzodiazepine with a shorter half-life may be prescribed.38

Use of selective serotonin reuptake inhibitors (SSRIs) in pregnancy has been linked to reductions in birth weight, low birth weight, and small for gestational age; however, not all studies show this association.33,36 In a literature review by Womersley et al, paroxetine and fluoxetine were associated with significant fetal malformations in utero.39 Specifically, paroxetine was linked to cardiac defects including septal defects and right ventricular outflow obstruction in the neonate, and hence should be avoided in pregnancy.36,39 Sertraline and citalopram were found to be the safest SSRIs to use in pregnancy.39 Data on the impact of MAOIs, venlafaxine, mirtazapine, and bupropion in pregnancy are limited and therefore should not be considered as first-line agents if possible.37

A number of studies have concluded that lithium, valproate, and carbamazepine should be avoided in pregnancy, particularly during the first trimester, given the increased risk for fetal malformations an abnormalites.36

Prevention of Hypertensive Disorders of Pregnancy

Evidence suggests that daily low-dose aspirin (81 mg) can help prevent preeclampsia and reduce the risk for perinatal death.40 The USPSTF recommends daily aspirin use after 12 weeks of gestation for pregnant persons who are at high risk.40 ACOG supports this strategy and recommends initiating this regimen for high-risk patients between 12 and 28 weeks of gestation, but ideally before 16 weeks of pregnancy, until delivery.41

High-risk patients are defined as pregnant individuals who have a history of preeclampsia, are carrying multiple fetuses, or have comorbidities such as chronic hypertension, type 1 or type 2 diabetes, kidney disease, or autoimmune disease as well as those who carry multiple moderate-risk factors.40 Moderate-risk factors include nulliparity, age 35 or older, obesity, lower income, in vitro conception, and personal history factors such as previous adverse pregnancy outcome.40 Non-Hispanic Black persons are at increased risk for preeclampsia because of barriers to health care resulting from environmental, social, and historical inequities.40 Contraindications to the low-dose aspirin regimen include nasal polyps, aspirin/NSAID allergy, and/or asthma with a history of aspirin-induced acute bronchospasm.41

A pill combining calcium with aspirin may be most valuable in preventing HDP, according to findings from a review conducted by Browne et al.42 The authors also evaluated the effects of vitamin D, vitamin B12, and folic acid supplementation on preventing HDP and determined the findings were inconclusive.42 Diet and lifestyle changes also have the potential to reduce the risk for preeclampsia. In a 2014 literature review, Allen et al found that dietary interventions reduced the risk for preeclampsia by 33%.43 These dietary changes varied by study but included interventions such as a diet with a high intake of vegetables, fruits, and vegetable oil; a cholesterol-lowering diet; and prescription of a balanced nutritional regimen in patients with obesity.

Patient Education

Pregnant patients should be educated on the signs and symptoms of perinatal depression and anxiety. If patients experience any of these symptoms, they should contact their ob-gyn or primary care provider (Table). To aid in this discussion, the PSI created a self-evaluation tool for patients to complete, which allows clinicians to gauge mental health concerns and risk factors.44 Providers must inform patients that they should not self-discontinue any current psychotropic medications. Untreated psychiatric illness can lead to decreased compliance with prenatal care, inadequate nutrition, exposure to other medications or herbal remedies, increased alcohol and tobacco use, deficits in mother-infant bonding, and issues within the family environment.36

Conclusion

Further research is needed to better understand the relationship between HDP and PMADs. Rates of anxiety and depression have increased during the ongoing COVID-19 pandemic. Therefore, it is essential to screen for and treat mental health conditions at prenatal visits and offer patient education on this topic. Obstetric and family practice clinicians must offer preventative interventions for preeclampsia to all high-risk patients including those who are experiencing symptoms of PMADs.

Gina Scandaglia, PA-S, is a PA student at St John’s University in Queens, New York; Corinne I. Alois, MS, PA-C, is an assistant professor in the PA program at St. John’s University; Louise Lee, EdD, MHA, PA-C, is an associate professor and director of PA studies at St. John’s University.

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From the May/June 2022 Issue of Clinical Advisor

Topics:

Anxiety Disorders Depression General Psychiatry Hypertension Obstetrics and Gynecology Pregnancy Women's Health