Madeleine A. Becker MD, FACLP

Anxiety is not unusual during pregnancy and postpartum for new mothers. However, for some women, anxiety symptoms are more severe, and cause distress, avoidance of activities, interfere with their ability to function at home or at work, or care for their children. One-third of women will suffer from an anxiety disorder in their lifetime.

 Perinatal anxiety is common and often underreported, with the prevalence ranging from 4% to 33.4% (

 Multiple factors may contribute to anxiety during the perinatal period, including rapid hormone fluctuations, biological predispositions, as well as psychosocial challenges that accompany the transition to parenthood.

 American College of Obstetrics and Gynecology 

(ACOG) recommends screening women for depression and anxiety at least once during the perinatal period followed by appropriate referral and treatment when necessary. Although common and impairing, much less attention has been focused on the treatment of perinatal anxiety, both in the literature and in the media. Untreated mood and anxiety disorders during pregnancy have been associated with multiple adverse outcomes for both the mother and baby, including a worsening of medical conditions, lack of medical care, substance use, smoking, suicide, and infanticide. Anxiety itself is a strong predictor of postpartum depression.

 Anxiety disorders have also been associated with negative birth outcomes such as preterm birth, lower birth weight, earlier gestational age, increased odds for being small for gestational age, and smaller head circumference.

Current treatment recommendations for perinatal anxiety disorders include psychotherapy alone or in combination with pharmacotherapy. A variety of therapeutic modalities, such as cognitive behavioral therapy (CBT), have been shown to be both safe and effective for treating mild to moderate perinatal mood and anxiety disorders as an adjunctive measure or as monotherapy.

 Unfortunately, less resourced and geographically isolated communities may experience cultural, logistical, and financial barriers to accessing psychotherapy services.

For women with moderate to severe anxiety disorders that do not respond to psychotherapy and/or that is impairing functioning, ACOG recommends considering the initiation or re-initiation of pharmacotherapy with a selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitor (SNRI).

 These medications are well studied and can be very helpful and, in some cases, necessary for managing symptoms.

The choice to use medications is very personal; the woman’s obstetrician and/or psychiatrist should discuss this option with her. The decision should be based on risks and benefits, weighing the risk of exposure to medication on the unborn baby against the severity and risk of untreated illness. The most common risks associated with antidepressant medications exposure are low birth weight, preterm birth, poor neonatal adaptation syndrome, and persistent pulmonary hypertension of the newborn (

 Among women taking antidepressants, more than 50% will discontinue these medications during pregnancy.

 However, women should be encouraged to continue treatment during pregnancy and be provided with a variety of options, including non-pharmacological approaches.

An increasing number of women consider complementary and integrative approaches for alternatives or as adjunctives for treatment options during pregnancy. Complementary and integrative medicine emphasizes a 

to health care and includes natural products and mind body approaches such as mindfulness training and yoga.

 Women utilize complementary medicine more frequently than men; data from the 2007 National Health Interview Survey found that 39.9% of pregnant and 28% of postpartum women reported using some form of complementary or alternative medicine in the past 12 months.

 Additionally, pregnant women who participated in mind-body interventions, including mindfulness and yoga practice have reported an overall satisfaction with these interventions and described the practices as enjoyable, valuable, and beneficial.

 Specifically, becoming aware of the causes of anxiety and the ability to reflect on thoughts and emotions were reported as beneficial by women across all categories of interventions.

Findings indicate that exercise during pregnancy can be an important component of mental health treatment in addition to psychotherapy or medication management.

Some of the most common forms of integrative practice are mindfulness-based interventions. Mindfulness-based stress reduction (MBSR) provides training in mindfulness meditation techniques as a self-regulation approach to stress reduction and emotion management. Mindfulness-based cognitive therapy is an adaptation of cognitive behavioral therapy with a focus on developing 

 The use of various forms of meditation such as those used in mindfulness-based interventions has increased more than three-fold in the past 5 years.

 Multiple studies of mindfulness-based interventions have demonstrated significant reductions on multiple measures (self-reported and interview screening scales) of anxiety in pregnant women.

Yoga is a mind and body practice with origins in ancient Indian philosophy that combines postures, breathing, and meditation. Yoga has been associated with a reduction in sympathetic activity, balancing heart rate variability, normalizing HPA axis activity, and influencing monoamine changes.

 Over the past decade, yoga has become increasingly popular for promotion of fitness and relaxation, and prenatal yoga classes have become widely available both in studios and online.

The 2017 National Health Interview Survey (NHIS) found that yoga is the most common complementary practice used by US adults.

 Studies looking specifically at the practice of yoga in pregnant women have shown that anxiety symptoms (self-reported and interview screening scales) were significantly decreased in response to even a one-time 20-minute yoga session, and participants continued to show 

in anxiety symptoms with ongoing, regular practice.

 An instructor registered and trained in prenatal yoga is necessary for practice during pregnancy, as certain positions and overheating, “Hot Yoga” should be avoided during pregnancy.

Regular physical activity has also been shown to be beneficial for pregnant and postpartum women for both physical and mental health. ACOG recommends that healthy pregnant women should aim to get at least 2.5 hours of moderate-intensity activity per week. Physical activity has been associated with reduction of pregnancy-related complications, including the risk of weight gain and gestational diabetes, as well as enhancing overall psychological well-being.

 During pregnancy, exercise may reduce the symptoms of anxiety as well as increase overall quality of life. Women who report exercising more frequently during pregnancy have lower than average anxiety symptoms (self-report measures).

 Findings indicate that exercise during pregnancy can be an important component of mental health treatment in addition to psychotherapy or medication management.

Anxiety is common during the perinatal period and can have negative effects on mother and neonate. Women should be provided with multiple options for treatment and encouraged and supported to engage in care during this critical period. The high prevalence of 

 disorders indicates a need to broaden the evidence base for treatment interventions. Therapy and medications are evidence-based and effective options for treating anxiety disorders in pregnancy. However, it is important to take into account patient preferences regarding treatment during pregnancy, as well as access to care.

Complementary approaches are becoming increasingly used by women and may provide benefits for mental health treatment. Available evidence suggests that complementary approaches, specifically mindfulness-based interventions, yoga, and exercise have shown benefit for improving symptoms of perinatal anxiety disorders. Reductions in anxiety symptoms with mindfulness-based interventions, yoga, and exercise suggest an expanding and adjunctive role for complementary approaches to perinatal mental health treatment. More research is needed to systematically evaluate the use of nonpharmacological, integrative modalities for maternal mental health.

is a Consultation-Liaison Psychiatry Fellow, The George Washington University Medical Center/Inova Fairfax Hospital Department of Psychiatry, Falls Church, VA; 

is an MD Candidate, Sidney Kimmel Medical College, Philadelphia; 

is Associate Professor and Director, Graduate Medical Education, Integrative Women’s Mental Health, Department of Integrative Medicine and Department of Psychiatry and Human Behavior, Thomas Jefferson University and Jefferson Health, Philadelphia, PA. The authors have nothing to disclose regarding the subject of this manuscript.

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3. Fairbrother N, Young AH, Janssen P, et al. Depression and anxiety during the perinatal period. 

4. Figueiredo B, Conde A. Anxiety and depression symptoms in women and men from early pregnancy to 3-months postpartum: parity differences and effects. 

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6. Grigoriadis S, Graves L, Peer M, et al. Maternal anxiety during pregnancy and the association with adverse perinatal outcomes: systematic review and meta-analysis. 

7. Marchesi C, Ossola P, Amerio A, et al. Clinical management of perinatal anxiety disorders: a systematic review. 

8. O’Mahen H, Himle JA, Fedock G, et al. A pilot randomized controlled trial of cognitive behavioral therapy for perinatal depression adapted for women with low incomes. 

9. Cohen LS, Altshuler LL, Harlow BL, et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. 

10. National Center for Complementary and Integrative Health. Complementary, Alternative, or Integrative Health: What’s In a Name? 2018. 

https://www.nccih.nih.gov/health/complementary-alternative-or-integrative-health-whats-in-a-name.

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12. Evans K, Spiby H, Morrell JC. Non-pharmacological interventions to reduce the symptoms of mild to moderate anxiety in pregnant women: a systematic review and narrative synthesis of women’s views on the acceptability of and satisfaction with interventions. 

What do we really know about mindfulness-based stress reduction? 

14. Clarke TC, Barnes PM, Black LI, et al. Use of yoga, meditation, and chiropractors among US adults aged 18 and over. 

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Effects of yoga intervention during pregnancy: a review for current status

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Articles

Women should be provided with multiple options for treatment if they decide to engage in mental health care during this critical period.

Conventional and Integrative Approaches to Treating Anxiety in Pregnancy

Psychosomatic medicine, or medical psychiatry-also known as consultation-liaison (CL) psychiatry-specializes in the diagnosis and treatment of psychiatric disorders and psychiatric manifestations of complex medical illness.

 CL psychiatrists treat a challenging and diverse patient population both in the general hospital setting and in the outpatient setting. They specialize in the care of patients with comorbid psychiatric and medical illnesses, as well as patients whose psychiatric illness is a direct consequence of a primary medical condition.

Psychosomatic medicine psychiatrists also have expertise in managing psychiatric effects of medical treatments and medications. Their roles include consulting to the patient’s primary medical team, serving as a liaison between the psychiatry service and the primary medical service, and treating patients’ psychiatric disorders while active medical care is being provided.

 Consultation psychiatrists have the unique ability to do this work while navigating the logistics of managing psychiatric treatment of sometimes very complex patients in the general hospital setting.

 issues-the last article in that series appears on page 32 of this issue-includes articles on the management of some of the more challenging consultations seen in the general medical hospital. Topics in neuropsychiatry, oncology, and pediatrics were selected not only to illustrate interesting and challenging issues but also to represent the diversity of the field of psychosomatic medicine.

 (PNES). They review the history, epidemiology, diagnosis, and treatment of PNES. The authors provide an interesting look into the diagnosis with a discussion of the significance non-epileptic seizures hold in the context of a patient’s medical illness, and they suggest ways of communicating with patients who have this disorder.

, its diagnosis, incidence, and possible etiologies as well as its relationship to delirium. They present the broad and often confusing differential diagnosis for catatonia as well as treatment strategies.

Also included is an article on the role of psychiatric care for patients living with cancer. 

 address some of the varied psychiatric issues that the consultant must take into account when caring for these patients. They discuss the importance of coordination of care, management of medications (including attention to pain control), and the involvement of a supportive care team.

 present a case, supplemented with a comprehensive discussion, of pediatric auto-immune neuropsychiatric disorder associated with streptococcal infection (PANDAS). The authors characterize the roles of infection, immune dysregulation, and inflammation in the development of this disorder. They also address psychiatric effects of the illness and of psychiatric treatments.

Finally, in this issue, Dr. Certa discusses the topic of determining where patients with both significant psychiatric symptoms and medical illness should be treated. There is little literature on this issue, but it remains a common challenge for both the hospitalist and the consulting psychiatrist. He discusses the evolution of the psychiatric hospital housed within the general hospital and some of the more common factors that might pose as barriers to the transfer of patients from the general to the psychiatric ward.

The authors and I hope that you find these articles useful and informative!

I am Director of the Psychiatric Hospital and Consultation Liaison Services at Thomas Jefferson University Hospital, a 965-bed academic general hospital in Center City, Philadelphia, Pa. In addition, I am the Program Director for the Psychosomatic Medicine Fellowship. As the medical student clerkship site director for the Consultation Liaison rotation, I’ve mentored and taught over 700 medical students in hospital psychiatry over the past 10 years.

My areas of clinical expertise are general hospital psychiatry and psychiatric treatment of women during the peripartum period. I’ve published on and lecture locally and nationally on women’s mental health. I am proud to serve as a council member for the Academy of Psychosomatic Medicine. I also chair their Fellowship Education Subcommittee, where I have the pleasure of working with some of the brightest and most talented psychosomatic medicine Program Directors from around the country.

Working in the field of consult psychiatry constantly reminds us that we must treat the whole patient, both in mind and body, and that these are not disparate. Entering the room as a psychiatric consultant, at a time when a patient is ill and most vulnerable, is the most rewarding work I do as a psychiatrist. The hospital is an ideal setting to teach future physicians. In this setting, it becomes most apparent that psychiatry is truly an essential specialty of medicine. Teaching psychiatry allows us to show trainees that psychiatric illness can be understandable and is treatable.

As an undergraduate at Drew University, I double majored in art and psychology. I worked as an art therapist for several years while in graduate school. I have two Masters Degrees-one in psychology from New York University and one in clinical health psychology from Albert Einstein College of Medicine; my medical degree is from Jefferson Medical College. I completed my residency in psychiatry at the University of Pennsylvania.

Even before medical school, I had been interested in integrative medicine and the integrative approach to patient care. I pursued multiple opportunities to increase my knowledge of the treatment of patients, including a fellowship at the Psychoanalytic Center of Philadelphia and also graduate training in Mindfulness Based Stress Reduction. Having skills in different modalities for treating patients is helpful for delivering care to a diverse patient population. It also helps me to keep an open mind when approaching each patient.

The study of traditional yoga has been one of my great interests as well. I have practiced regularly for the past 9 years and recently obtained yoga instructor certification after intensive training and study on weekends over the past 7 months. The foundations of yoga and meditation can help people control their breath, body, thoughts, and behavior. It provides people with insight into themselves and can help them be more attentive to their actions. I continue to paint and sketch when time allows. Last fall, I travelled to Sicily and found it to be the most peaceful and beautiful place that I have ever visited.

 This introduction to our Special Report on psychosomatic medicine should have run in the March issue with the bulk of the articles on that broad topic. We are grateful for the time and expertise Dr. Becker put into the articles of that Special Report, which you can find on our 

Dr. Becker is Director, Consultation-Liaison/Hospital Psychiatry and Program Director, Psychosomatic Medicine Fellowship, Thomas Jefferson University Hospital, Department of Psychiatry and Human Behavior, Philadelphia, PA.

American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill

. 2nd ed. Arlington, VA: American Psychiatric Association Publishing; 2011.

. 3rd ed. New York: Oxford University Press; 2015.

Psychogenic non-epileptic seizures: clinical issues for psychiatrists

Update on medical catatonia: highlights on delirium

Depression and anxiety disorders in patients with cancer.

Sudden onset of tics, tantrums, hyperactivity, and emotional lability: update on PANS and PANDAS

Psychosomatic medicine psychiatrists specialize in managing psychiatric effects of medical treatments and medications.

Madeleine A. Becker MD, FACLP

Articles

Conventional and Integrative Approaches to Treating Anxiety in Pregnancy

Challenging Consultations