Critical Issues in Perinatal Psychiatric Emergency Care
Critical Issues in Perinatal Psychiatric Emergency Care
This article reviews the common mental health conditions encountered in emergency care settings as these conditions relate to childbearing, including special considerations in evaluation and treatment options. A list of resources for patients and clinicians is also included (Table 1).Prenatal Psychiatric Illnesses
Pregnancy. Historically, pregnancy was considered a time of well-being for many women, even for women who had histories of mood disorders, such as depression or bipolar disorder. Some of this mythology may have been related to the idealized view that societies have of pregnant women. Some may have been the result of confusion between anxiety and depression, which can be affected differently by pregnancy. Some may also be related to assumptions made from early retrospective studies. Whatever the reasons for earlier misconceptions, recent prospective and larger epidemiologic studies indicate that the rates of depression among pregnant women are similar to those of women of similar age who are not pregnant.1
The prevalence of depression among pregnant women is approximately 10%.1,2 Women who may be at greater risk for depression during pregnancy include those who are young, are ambivalent about the pregnancy, have a personal or family history of depression, and are experiencing marital problems.3,4 Symptoms of depression during pregnancy are consistent with those found at other times in women's lives. However, it is often difficult for clinicians and patients to distinguish the cause of neurovegetative symptoms, such as fatigue, sleep disruption, weight gain, appetite changes, energy loss, and decreased concentration.5 Each of these hallmark symptoms of depression, in isolation, can be a simple effect of pregnancy. Therefore, many women disregard their depressive symptoms because they believe that they are a normal part of pregnancy.
The number and severity of symptoms and their relationship to stressors and mood and physical changes must be thoroughly assessed to ensure neither underdiagnosis nor overdiagnosis of depression. Thoroughly assessing risk factors, feelings about this pregnancy, future plans, mood, and anxiety are critical in distinguishing the cause of the neurovegetative symptoms. Although pregnancy appears to be a lower-risk time for suicide among women,6,7 it is not without risk of self-harm, suicide attempts, and for some women, completed suicide. Thus, suicidality must be assessed in any depressed woman, regardless of pregnancy status.
Bipolar I disorder affects approximately 1% to 2% of the population and is equally distributed among men and women. Women with bipolar disorder tend to experience a greater number of depressed, mixed, and rapid-cycling episodes than men.8 Many women with bipolar disorder experience an episode during their childbearing years and appear to be at greatest risk during the perinatal period. Among women with bipolar disorder, retrospective studies originally suggested a lower risk of recurrence of a mood episode.9 This is controversial.
Recent studies found high rates of relapse during pregnancy among women with bipolar disorder who discontinued their medication.10 The rates of a recurrent affective episode are similar for pregnant and nonpregnant women who discontinued maintenance lithium.11 Except for a history of chronic depression10 and the discontinuation of medications (especially rapid discontinuation), risk factors for an episode of depression or mania occurring during pregnancy among women with bipolar disorder have not yet been established.
Because of the high risk of teratogenicity of many mood stabilizers, women may abruptly discontinue their medications or be advised to discontinue their medications during or in preparation for pregnancy. The dose of some medications may actually need to be increased during pregnancy to maintain mood stability. Because providers and mothers are often trying to minimize fetal exposure to the medication, affective symptoms may recur because of inadequate treatment. Emergency physicians may see women who have an abrupt onset of depression, mania, or a mixed episode in the context of these medication issues. The decision to increase or restart medications is complicated, and a comprehensive risk-benefit analysis is critical (see "Treatment during pregnancy," below).12
Pregnancy loss. Therapeutic abortions and spontaneous pregnancy losses are often lumped together when the relationship between pregnancy loss and mental health is considered. Each event can affect a woman's mental health. No one event should be assumed to be of lesser or greater magnitude than another. The rate of depression among women who have undergone therapeutic terminations has not been established. While data indicate no increase in serious psychiatric sequelae, women who have a history of psychiatric illness, who feel coerced into the termination, who are ambivalent about the termination, and who have limited social supports have a greater risk of depression developing after a therapeutic termination.13
Miscarriage, defined as an involuntary pregnancy loss before 20 weeks' gestation, is relatively common, affecting 15% to 25% of recognized pregnancies. In contrast, perinatal loss, defined as an involuntary loss after 20 weeks' gestation, is relatively rare, affecting 1.2% of pregnancies. The relative risk for an episode of major depression within 6 months after a pregnancy loss is 2.5, but it is as high as 5 among women who do not have other living children.14 Among women with a history of depression, more than half will experience a recurrence of their depression in the 6 months after a pregnancy loss.14 Other risk factors for development of depression after pregnancy loss include being older and the gestational age of the fetus at the time of the loss.15
Some women may present immediately after a pregnancy loss in an acute crisis with severe grieving, but others may not present for weeks or months. Women are often not prepared for the extent of grief that they experience. Women who have repeated miscarriages may be at increased risk because of the repeated roller coaster of hope and grief. Miscarriages and therapeutic terminations are often private matters, rarely discussed outside the immediate couple and medical providers. Therefore, many women do not have the support from family and friends that would be available in the context of other deaths or losses.
In contrast, perinatal losses, including stillbirths, are often very public losses, because many pregnancies are obvious at the time of the loss. These women may have more support but are often faced with questions from persons who are not close to them who may ask about the baby and the delivery. Repeated discussion of the loss may be particularly difficult. Anniversary dates that may precipitate crises include the anniversary of the birth/loss as well as the anniversary of the original anticipated birth date. The birth of a subsequent child can also be a trigger for bereavement and even depression for some women who are still grieving a previous pregnancy loss. Many women who may require treatment for depression or anxiety after a pregnancy loss wish to become pregnant again quickly. These women often require special consideration when choosing medication.
Treatment during pregnancy. Treatment of mood and anxiety disorders can be anxiety-provoking for both providers and patients. A thorough risk-benefit analysis for mothers and neonates must be conducted (Table 2). Risks to the fetus include the risks of untreated mood and anxiety disorders as well as the risks of exposure to medication. Depression and anxiety during pregnancy have been associated with increased rates of premature delivery, low birth weight, and poor prenatal care. Women with severe psychiatric symptoms may be suicidal or homicidal or have symptoms that require psychiatric hospitalization. Anxiety during pregnancy has been associated with increased behavioral impairments in children.16-18 Depressed and anxious women can have difficulty in caring for themselves and may not be able to maintain adequate nutrition and sleep. They may also be more likely to self-medicate with tobacco, alcohol, drugs, herbal remedies, and over-the-counter medications.
The risks and range of treatment must also be considered. Many women with mild to moderate depression may benefit from psychotherapy and therefore may not require medications that carry risks for the mother and fetus. Few studies have tested the efficacy of specific psychotherapies during pregnancy. In one study, interpersonal psychotherapy was found to be more effective than parenting education as a treatment for depression during pregnancy.19 Electroconvulsive therapy is generally considered to be a relatively safe, quick, and effective treatment for women with severe depression, psychosis, or bipolar disorder.20
If medication is required, either alone or in combination with psychotherapy, the risks of the medication for the mother and fetus must be considered. No one antidepressant has been proved safer or more effective than another antidepressant for use during pregnancy. There are no randomized controlled studies of antidepressants during pregnancy. The studies that have been conducted lack sufficient power to determine absolute risk for a variety of outcomes.
Most studies have focused on major malformations as the outcome measure. Outcomes that must be discussed with the patient include major and minor malformations, miscarriages, neonatal toxicity and withdrawal, and neurodevelopmental and behavioral teratogenicity. Effects on mothers, such as sedation, weight gain, hypotension, and sexual dysfunction, must also be considered.
Medication choice should be directed by the woman's history of response to specific medications or classes of medications. In addition, it may be directed by targeting particular symptoms. The lowest effective dose is recommended. Often, pregnant women are given very low doses but their symptoms remain untreated. If the risk of the medication is accepted, then the goal should be remission of symptoms.
For women with unipolar depression or anxiety disorders, many consider the selective serotonin reuptake inhibitors (SSRIs) to be the first choice. Because data about medication use during pregnancy are primarily accumulated as case reports after the medication is approved for use in the general population, it takes years to gather enough information to develop a level of comfort with a specific medication. Some SSRIs (sertraline, paroxetine, fluoxetine, citalopram) have been available for many years, and we have enough data to suggest that there does not seem to be an increased risk of major malformations but there may be an increased risk of neonatal complications.21-27 These same findings are echoed in the information about the tricylic medications (nortriptyline and amitriptyline) and the newer selective norepinephrine reuptake inhibitor venlafaxine.26 For other antidepressants, insufficient data have been published to make these judgments.
For women with bipolar disorder, who often require multiple medications for mood stabilization and who may be particularly sensitive to the physiologic changes of pregnancy, the choices are more difficult. Lithium, valproate, and carbamazepine all have potentially significant major effects on fetal development with first-trimester exposure. First-trimester exposure to lithium has been linked to an increased risk of cardiovascular anomalies, specifically Ebstein anomaly. The risk is greater than that in the general population, but the risk of the development of a cardiac anomaly remains very low (0.05% to 0.1%).28 Once past the first trimester, concerns about lithium use include risk of toxicity with poor nutrition or excessive nausea and vomiting, weight gain, and goiter, as well as the need to increase doses throughout the pregnancy because of an increased glomerular filtration rate and blood volume.
The risk of neural tube defects with both valproate (5% to 9%)29 and carbamazepine (1%)30 is much greater than the risk of cardiac anomalies with lithium. Both valproate and carbamazepine also carry risks of other minor anomalies. Their use in the second and third trimesters is less concerning, but clinicians must remain aware of the potential risk of hepatotoxicity. Lithium toxicity in neonates has also been reported. Other mood stabilizers, such as lamotrigine, and atypical antipsychotics frequently used in bipolar disorder, such as risperidone, ziprasidone, aripiprazole, quetiapine, and olanzapine, do not have sufficient data to determine the risks associated with their use in pregnancy.Postpartum Psychiatric Disorders
Postpartum psychiatric disorders are commonly categorized as postpartum blues, postpartum depression, or postpartum psychosis. The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) does not classify postpartum psychiatric disorders in any such categories. The DSM-IV-TR allows the specifier "postpartum onset" to be applied to major depressive disorder, bipolar disorder (types I and II), and brief psychotic disorder if the onset of symptoms occurs within 4 weeks after childbirth.31 Many consider this brief time frame for the onset of postpartum symptoms to be too restrictive. Some believe "postpartum" should be considered up to 3 or 4 months after childbirth, while others argue for a year. Regardless, for many women, the postpartum period is a high-risk time for the evolution of a new mood disorder or an exacerbation or recurrence of a preexisting mood disorder.
Postpartum blues. "The blues" is the most prevalent postpartum affective experience, affecting up to 75% of all women after childbirth. It is a self-limited condition that typically begins within the first 2 to 5 days and resolves by the second week after delivery. Women who experience the blues often do not report feeling depressed; rather, they describe heightened emotional sensitivity, increased labile mood, crying, and irritability.32 No treatment is necessary for postpartum blues except support, education, and encouragement of attention to self-care, such as sleep and good nutrition. No risk factors have been identified.
Women who have a history of depression or mood instability may be fearful that the blues they experience are heralding the onset of a recurrence of their mood disorder. These women may benefit from additional support and guidance and should be monitored closely to make sure they are not experiencing the beginning of a postpartum depression or psychosis.
Depression. Postpartum depression affects approximately 10% to 15% of new mothers2,33 but affects certain groups of women at higher rates (such as teenaged mothers and women in lower socioeconomic groups). Despite considerable debate about whether postpartum depression is a distinct disorder from ma- jor depression experienced at other times in women's lives, the symptom profile is the same (depressed mood, anhedonia, sleep and appetite disturbances, fatigue, poor concentration, feelings of guilt, suicidal ideation). One of the differences in symptom presentation is that women report more anxiety (often related to infant health, care, and well-being), feelings of maternal inadequacy and guilt, irritability, somatic complaints, and ruminative or obsessive thoughts.
As in pregnancy, many women have difficulty in distinguishing these symptoms as part of a depression versus "normal" adjustment to a new infant. Some women have intrusive recurrent thoughts of harming their infants and are frightened by these thoughts. These women are often hesitant to disclose such thoughts with medical practitioners for fear that they will be considered "crazy" or that their children will be taken from them. Women with postpartum depression rarely act on these thoughts but often will do things to avoid the frightening obsession (eg, will not bathe the baby for fear of thinking about drowning the baby). Acknowledgment by the clinician that these thoughts are common and frightening may encourage disclosure. Clinicians must also assess the level of apathy and irritability, because very depressed women may be at risk for either neglecting their infants or acting out toward them.
Risk factors for postpartum depression are similar to those for depression during pregnancy and include a personal or family history of depression or postpartum depression, psychosocial stressors, adverse life events, and marital discord.3,4,33 The relationship between depression during pregnancy and postpartum depression has also been documented. About half of women who experience a depressive episode in the postpartum period experienced depression or depressive symptoms during their pregnancy.34 Thus, many depressed women who may not present until 3 months postpartum have been suffering for months. Depression during the postpartum period must be thoroughly evaluated, because it may represent either a unipolar depression or a bipolar depressive episode. This distinction is important, because each disorder has different prognostic risks and treatment choices.
Bipolar disorder.Women with bipolar disorder are at the highest risk for recurrence of an affective episode when untreated in the postpartum period.8 Viguera and colleagues11 found that women with bipolar disorder who discontinued their medication had a risk of experiencing an affective episode in the postpartum period almost 3 times as high as nonchildbearing women with bipolar disorder. Fortunately, data suggest that recurrent bipolar episodes may be prevented with prophylactic mood stabilizers, such as lithium.35,36
Treatment of postpartum mood disorders. Interpersonal psychotherapy37 and cognitive behavioral therapy38 have both been found to be effective for postpartum depression in controlled studies. Medication trials are limited to open-label trials with small sample sizes39,40 and one randomized controlled trial.38 In all these studies, medications were effective in managing postpartum depression. However, the limitations of open-label trials must be considered.
Treatment of women with bipolar disorder in the postpartum period has not been systematically evaluated. In clinical practice, the approach to bipolar disorder in the postpartum period has been to reinitiate the mood stabilizer that was most effective for the mother in an effort to prevent a recurrent episode. Clinicians must take into account the special needs of nursing mothers. If an episode occurs, rapid treatment with a mood stabilizer is suggested because of the high risk of postpartum psychosis (see below). If required, caution should be used when prescribing antidepressants in the postpartum period for women with bipolar disorder because of the possibility of triggering a manic or mixed episode.
Postpartum anxiety disorders. Anxiety disorders have not typically been considered as among the postpartum disorders. However, in the clinical situation, comorbid anxiety disorders or severe anxiety symptoms often go hand in hand with mood disorders. In addition, the obsessive thinking and compulsive behaviors often experienced by women in the postpartum period mandate clinicians to consider anxiety disorders, including obsessive-compulsive disorder (OCD), generalized anxiety disorder, and panic disorder.
Women may experience either a new onset or exacerbation of an anxiety disorder in the postpartum period.41-43 For some women who have OCD or a spectrum of OCD symptoms, the introduction of a new infant who requires the mother to be increasingly flexible can be very distressing. It is important to inquire about everyday cleaning and orderliness habits, because these can be a clue to the difficulty that some women may experience when a new infant interrupts their rituals or schedules. While there are no treatment studies specific to OCD during the perinatal period, the established approach of cognitive behavioral therapy, as well as use of an SSRI, is recommended. The same issues exist for the use of SSRIs for postpartum anxiety disorders as with postpartum depression.
Postpartum psychosis. Psychosis that occurs postpartum is a rare but serious psychiatric illness that usually requires urgent attention and often psychiatric hospitalization. Postpartum psychosis occurs in 1 to 2 per 1000 births in the general population,44 but its rate skyrockets among women with bipolar disorder to 260 per 1000.45 The symptoms start abruptly, often within 3 days of birth but almost always within 3 weeks. Symptoms include confusion, hallucinations, delusions, labile mood, and often mixed affective states.
Women with postpartum psychosis may complain of anxiety, obsessional thoughts, and severely disturbed sleep. They may experience suicidal and/or homicidal thoughts, many times directed toward their infants in the context of a delusion. They may be at high risk for harming themselves and/or their infants.
Postpartum psychosis is most intimately associated with bipolar disorder.46 However, women who experience psychosis may not have a history of bipolar disorder, and the psychosis may be its initial presentation. It is important to distinguish what may be a mixed affective episode from a unipolar depressive or anxiety disorder, because the treatment of postpartum depression may exacerbate the symptoms of postpartum psychosis.
Because of the close relationship between postpartum psychosis and bipolar disorder, in patients without a history of another psychiatric disorder for which the psychosis may represent an exacerbation (such as schizophrenia or psychotic depression), the approach to treating postpartum psychosis includes hospitalization for safety and rapid medication stabilization, a medication regimen of a mood stabilizer and an antipsychotic agent, and family involvement to support and plan for the patient's and infant's care during the treatment and recovery phases. In addition, if the patient is severely depressed and an antidepressant is required, the same caution regarding the use of antidepressants must be taken as in other patients with bipolar disorder. Electroconvulsive therapy may also be a consideration for the management of postpartum psychosis.Medical Evaluation
With any new or exacerbated mood or anxiety symptoms, a thorough medical workup is required to rule out an organic cause. Thyroid dysregulation, tumors, HIV infection, syphilis, cerebral embolism, seizures, electrolyte disturbances, diabetes, vitamin deficiencies (particularly vitamin B12), anoxia, toxic or drug exposures, and head injuries must be considered.Special Considerations in Breast-feeding Mothers
If mothers are breast-feeding, a risk-benefit assessment similar to the one conducted during pregnancy must be conducted (Table 3).47 The benefits of breast-feeding for both mothers and infants are clearly established and should be reviewed with the patient.48-51 For mothers with psychiatric illnesses, however, the benefits must be weighed against the risks.
Risks to the infant include the risks of untreated mood and anxiety disorders. Postpartum depression has been clearly associated with both long- and short-term effects on the infant, including cognitive, social, and behavioral disturbances.52-56 Many mothers feel inadequate or do not experience the anticipated bonding with their infant. Women who are severely depressed may be unable to care appropriately for their infants, and in severe cases, may neglect or harm them.56 Women with postpartum psychosis often require hospitalization because of the severity of their symptoms and risk of harm to their infants. Therefore, the length of time mothers are away from their new infants can be a source of guilt and difficulty in bonding once mothers return home. The mother may also be at increased risk for an exacerbation of her disorder because of the reliance on her for all feedings if she is nursing exclusively. Sleep disruption must be considered, because it can trigger a recurrence for some women, particularly those with bipolar disorder.
The risks of infant exposure to medication must also be considered. The potential risk is related to a number of factors, including the pharmacokinetics of the specific medication, the amount of medication in breast milk, the age and health of the infant, the infant's ability to metabolize the medication, the maternal dose, and timing of medication and nursing. While formula feeding may seem the easiest answer, many women wish to nurse their infants. These women need to make an informed decision based on the known and unknown risks and benefits.
In general, data on the use of medication during breast-feeding are limited to individual case reports or case series, either published or through cases reported to pharmaceutical companies. There are few data on breast milk levels of antidepressants or mood stabilizers. Even less is known about infant serum levels.47,57 Mothers and clinicians must make decisions based on very limited information. If mothers choose to breast-feed, they may lessen infant exposure by supplementing with formula, waiting until the infant is a little older, and pumping and dumping during peak breast milk levels. Some mothers may not wish to nurse but need support and approval from clinicians for this decision. Pediatricians, obstetricians, and psychiatrists can all assist and support mothers in this difficult decision.Conclusion
Reproductive events can be a high-risk time for some women to experience a new onset or exacerbation of a mood disorder. Emergency department (ED) clinicians can best serve their patients by being aware of the extent of mood and anxiety disorders that can occur during pregnancy, following pregnancy loss, and postpartum. Effective treatments exist, but a thorough assessment of the existing risk and benefits of available treatments must be conducted. In the ED setting, decisions regarding initiation of medication are often made. ED providers must be aware of these risks and benefits and discuss them with patients. *