Despite the widespread, long-standing notion that pregnancy is a time of happiness and emotional well-being, accumulating evidence suggests that pregnancy does not protect women from mental illness. Like their nonpregnant counterparts, pregnant women experience new onset and recurrent mood, anxiety and psychotic disorders. For example, like other women, as much as 20% of pregnant women experience minor or major depression (Gotlib et al., 1989; O'Hara, 1986). Moreover, premature discontinuation of antidepressants during pregnancy can precipitate a relapse of depressive symptoms (Nonacs and Cohen, 2002).
Like major depressive disorder, bipolar disorder (BD) affects pregnant women and poses substantial risk to the mother and fetus. Past history of BD tends to predict the course of illness during pregnancy. A study of recurrently ill women with BD who discontinued lithium (Eskalith, Lithobid) close to the time of conception suggested that the rate of relapse for pregnant women with BD is similar to the rate of relapse for nonpregnant, age-matched women with BD (Viguera et al., 2000). The study also indicated that the risk for postpartum decompensation is substantially increased even when lithium discontinuation is not associated with antepartum relapse.
The courses of schizophrenia, panic disorder and eating disorders vary--some women exhibit no change in symptoms, while some improve and others decompensate (Franko et al., 2001; McNeil et al., 1984; Wisner et al., 1996). Obsessive-compulsive disorder tends to worsen during pregnancy (Buttolph and Holland, 1990). Although there are no published studies on the course of generalized anxiety disorder in pregnancy, clinical experience suggests that pregnancy can exacerbate tension, worry and ruminations.
Symptomatic psychiatric illnesses have been associated with poor prenatal care, inadequate nutrition, impulsive behaviors, substance abuse and increased incidences of postpartum depression. Depression during pregnancy has been associated with preterm birth, smaller head circumferences, and lower birth weights and Apgar scores (Nonacs and Cohen, 2002).
Goals of treatment. The primary goal of treating psychiatric disorders during pregnancy is attaining mental health stability, while minimizing risks to the mother and fetus. Hence, sometimes the aim is reduction and management of symptoms rather than complete remission.
Factors relevant to treatment decision-making. It is important to consider the risks and benefits of all possible treatment options. Since more than half of all pregnancies in the United States are unplanned, knowing which medications have good track records in pregnancy is essential when prescribing psychotropic medications to women of childbearing age. Women with histories of psychiatric disorders should consult a perinatal psychiatrist (preferably with their partners) before attempting to become pregnant. Ideally, prior to conception, women should be stable and prepared to handle the stresses of both pregnancy and motherhood.
When advising a patient about treatment options, the severity of illness, history of symptoms off medications, current medications and plans for breast-feeding are important considerations. The presence of a stable support system (e.g., partner and family support) and the availability of child care assistance during the postpartum period are also important. All treatment decisions should be carefully documented and discussed with the patient and her partner, as well as other treating physicians.
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