Critical Issues in Perinatal Psychiatric Emergency Care

May 1, 2006

The perinatal period is a high-risk time for some women to experience a new onset or exacerbation of a mood disorder that may require emergency psychiatric care.

Over the past decade, there has been increasing attention to the identification and management of mood and anxiety disorders related to childbearing. Emergency physicians, including psychiatrists, primary care providers, obstetricians, gynecologists, and pediatricians, encounter women who are struggling with mental health issues in the context of reproductive events, such as pregnancy, pregnancy loss, and the postpartum adjustment period.

In some cases, the reproductive event may precipitate a mental health crisis. In others, it may exacerbate an underlying mental health condition that, in turn, may need to be managed differently because of issues related to pregnancy or breast-feeding.

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. 3,4Symptoms 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.8Many 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 riskbenefit 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.

• Antiepileptic Drug Pregnancy Registry:
• Depression After Delivery, Inc:
• Massachusetts General Hospital (MGH) Center for Women’s Mental Health Perinatal Information Resource Center:
• Motherisk Helpline:
• National Institute of Mental Health:
• National Women’s Health Information Center:
• Postpartum Support International:
• The Marcé Society:
• Women’s Behavioral HealthCARE:
 RisksTreatment options
• Untreated mental illness• No treatment • Psychotherapy • Prescription medication • Combination psychotherapy and medication • Hospitalization-inpatient or partial • Electroconvulsive therapy • Alternative treatments, such as light therapy, omega-3 fatty acids

What affects and guides the decisions?
• Patient’s wishes and fears
• Severity of current illness
• Medication(s) needed

Monotherapy versus polytherapy

POSTPARTUM PSYCHIATRIC DISORDERS

Postpartum psychiatric disorders arecommonly categorized as postpartumblues, postpartum depression, or postpartumpsychosis. The DSM-IV-TRdoes not classify postpartum psychiatricdisorders in any such categories.The DSM-IV-TR allows the specifier"postpartum onset" to be applied tomajor depressive disorder, bipolardisorder (types I and II), and briefpsychotic disorder if the onset of symptomsoccurs within 4 weeks after childbirth.31 Many consider this brief timeframe for the onset of postpartum symptomsto be too restrictive. Some believe"postpartum" should be considered upto 3 or 4 months after childbirth, whileothers argue for a year. Regardless, formany women, the postpartum periodis a high-risk time for the evolution ofa new mood disorder or an exacerbationor recurrence of a preexisting mooddisorder.

Postpartum blues

"The blues" is the most prevalent postpartumaffective experience, affectingup to 75% of all women after childbirth.It is a self-limited condition thattypically begins within the first 2 to 5days and resolves by the second weekafter delivery. Women who experiencethe blues often do not report feelingdepressed; rather, they describe heightenedemotional sensitivity, increasedlabile mood, crying, and irritability.32No treatment is necessary for postpartumblues except support, education, andencouragement of attention to self-care,such as sleep and good nutrition. Norisk factors have been identified.

Women who have a history of depressionor mood instability may be fearfulthat the blues they experience areheralding the onset of a recurrence oftheir mood disorder. These women maybenefit from additional support andguidance and should be monitoredclosely to make sure they are not experiencingthe beginning of a postpartumdepression or psychosis.

Depression

Postpartum depression affects approximately10% to 15% of new mothers2,33but affects certain groups of women athigher rates (such as teenaged mothersand women in lower socioeconomicgroups). Despite considerable debateabout whether postpartum depressionis a distinct disorder from major depressionexperienced at other times inwomen's lives, the symptom profile isthe same (depressed mood, anhedonia,sleep and appetite disturbances, fatigue,poor concentration, feelings of guilt, suicidal ideation). One of the differencesin symptom presentation is that womenreport more anxiety (often related toinfant health, care, and well-being),feelings of maternal inadequacy andguilt, irritability, somatic complaints,and ruminative or obsessive thoughts.

As in pregnancy, many women havedifficulty in distinguishing these symptomsas part of a depression versus"normal" adjustment to a new infant.Some women have intrusive recurrentthoughts of harming their infants andare frightened by these thoughts. Thesewomen are often hesitant to disclosesuch thoughts to medical practitionersfor fear that they will be considered"crazy" or that their children will betaken from them. Women with postpartumdepression rarely act on thesethoughts but often will do things to avoidthe frightening obsession (eg, will notbathe the baby for fear of thinking aboutdrowning the baby). Acknowledgmentby the clinician that these thoughts arecommon and frightening may encouragedisclosure. Clinicians must alsoassess the level of apathy and irritability,because very depressed women maybe at risk for either neglecting theirinfants or acting out toward them.

Risk factors for postpartum depressionare similar to those for depressionduring pregnancy and include a personalor family history of depression or postpartumdepression, psychosocial stressors,adverse life events, and maritaldiscord.3,4,33 The relationship betweendepression during pregnancy and postpartumdepression has also been documented.About half of women whoexperience a depressive episode in thepostpartum period experienced depression or depressive symptoms duringtheir pregnancy.34Thus, many depressedwomen who may not present until 3months postpartum have been sufferingfor months. Depression during thepostpartum period must be thoroughlyevaluated, because it may representeither a unipolar depression or a bipolardepressive episode. This distinctionis important, because each disorder hasdifferent prognostic risks and treatmentchoices.

Bipolar disorder

Women with bipolar disorder are at thehighest risk for recurrence of an affectiveepisode when untreated in the postpartumperiod.8Viguera and colleagues11found that women with bipolar disorderwho discontinued their medicationhad a risk of experiencing an affectiveepisode in the postpartum period almost3 times as high as nonchildbearingwomen with bipolar disorder. Fortunately,data suggest that recurrentbipolar episodes may be prevented withprophylactic mood stabilizers, such aslithium.35,36

Treatment of postpartum mood disordersInterpersonal psychotherapy37 andcognitive behavioral therapy38 have bothbeen found to be effective for postpartumdepression in controlled studies.Medication trials are limited to openlabeltrials with small sample sizes39,40and one randomized controlled trial.38In all these studies, medications wereeffective in managing postpartum depression. However, the limitations ofopen-label trials must be considered.

Treatment of women with bipolardisorder in the postpartum period hasnot been systematically evaluated. Inclinical practice, the approach to bipolardisorder in the postpartum periodhas been to reinitiate the mood stabilizerthat was most effective for themother in an effort to prevent a recurrentepisode. Clinicians must take intoaccount the special needs of nursingmothers. If an episode occurs, rapidtreatment with a mood stabilizer issuggested because of the high risk ofpostpartum psychosis (see below). Ifrequired, caution should be used whenprescribing antidepressants in the postpartumperiod for women with bipolardisorder because of the possibility oftriggering a manic or mixed episode.

Postpartum anxiety disordersAnxiety disorders have not typicallybeen considered as among the postpartumdisorders. However, in the clinicalsituation, comorbid anxiety disordersor severe anxiety symptoms often gohand in hand with mood disorders. Inaddition, the obsessive thinking andcompulsive behaviors often experiencedby women in the postpartum periodmandate clinicians to consider anxietydisorders, including obsessive-compulsivedisorder (OCD), generalized anxietydisorder, and panic disorder.

Women may experience either a newonset or exacerbation of an anxietydisorder in the postpartum period.41-43For some women who have OCD or a spectrum of OCD symptoms, the introductionof a new infant who requiresthe mother to be increasingly flexiblecan be very distressing. It is importantto inquire about everyday cleaning andorderliness habits, because these can bea clue to the difficulty that some womenmay experience when a new infantinterrupts their rituals or schedules.While there are no treatment studiesspecific to OCD during the perinatalperiod, the established approach ofcognitive behavioral therapy, as wellas use of an SSRI, is recommended.The same issues exist for the use ofSSRIs for postpartum anxiety disordersas with postpartum depression.

Postpartum psychosis

Psychosis that occurs postpartum is arare but serious psychiatric illness thatusually requires urgent attention andoften psychiatric hospitalization.Postpartum psychosis occurs in 1 to 2per 1000 births in the general population,44 but its rate skyrockets amongwomen with bipolar disorder to 260 per1000.45 The symptoms start abruptly,often within 3 days of birth but almostalways within 3 weeks. Symptomsinclude confusion, hallucinations,delusions, labile mood, and often mixedaffective states.

Women with postpartum psychosismay complain of anxiety, obsessionalthoughts, and severely disturbed sleep.They may experience suicidal and/orhomicidal thoughts, many timesdirected toward their infants in thecontext of a delusion. They may be athigh risk for harming themselves and/ortheir infants.

Postpartum psychosis is most intimatelyassociated with bipolar disorder.46However, women who experiencepsychosis may not have a history ofbipolar disorder, and the psychosis maybe its initial presentation. It is importantto distinguish what may be a mixedaffective episode from a unipolar depressiveor anxiety disorder, because thetreatment of postpartum depression mayexacerbate the symptoms of postpartumpsychosis.

Because of the close relationshipbetween postpartum psychosis andbipolar disorder, in patients without ahistory of another psychiatric disorderfor which the psychosis may representan exacerbation (such as schizophreniaor psychotic depression), the approachto treating postpartum psychosisincludes hospitalization for safety andrapid medication stabilization, a medicationregimen of a mood stabilizer andan antipsychotic agent, and familyinvolvement to support and plan for thepatient's and infant's care during thetreatment and recovery phases. In addition,if the patient is severely depressedand an antidepressant is required, thesame caution regarding the use of antidepressantsmust be taken as in otherpatients with bipolar disorder. Electroconvulsivetherapy may also be aconsideration for the management ofpostpartum psychosis.

MEDICAL EVALUATION

With any new or exacerbated mood oranxiety symptoms, a thorough medicalworkup is required to rule out an organiccause. Thyroid dysregulation, tumors,HIV infection, syphilis, cerebral embolism,seizures, electrolyte disturbances,diabetes, vitamin deficiencies(particularly vitamin B12), anoxia, toxicor drug exposures, and head injuriesmust be considered.

SPECIAL CONSIDERATIONS IN BREAST-FEEDING MOTHERS

If mothers are breast-feeding, a riskbenefitassessment similar to the oneconducted during pregnancy must beconducted (Table 3).47 The benefits ofbreast-feeding for both mothers andinfants are clearly established andshould be reviewed with the patient.48-51For mothers with psychiatric illnesses,however, the benefits must be weighedagainst the risks.

 NeurobiologicConsiderations of medication exposurethrough breast milkWhat affects and guides the decisions?
• Untreated mental illness –Safety of the mother (self-harm,suicidality) –Safety of infant (homicide, neglect, abuse) –Long-term effects on the infant: bonding difficulties, depression, cognitive delays, behavioral problems –Increased risk of recurrent mental illness –Drug and alcohol use –Over-the-counter/herbal self-treatment • Medication–Infant is exposed to a medication (levels differ, depending on the medication)• Breast-feeding –Dependence on mother –Sleep disruption –Guilt if using a medication• Choice of medication (low amounts of SSRIs, valproate, and carbamazepine in breast milk, but high amount of lithium) • Monotherapy versus polytherapy • Age of infant • Infant's health and ability to metabolize the medication • Medication dose • Medication half-life • Timing of feedings • Adverse-effect profile • Data available in the literature • Total breast-fed versus combined breast-fed and formula• Patient's wishes and fears • Severity of current illness • Patient's psychiatric history–Severity –Recurrences when untreated –Treatment response• Patient's triggers • Family, partner support/opinions about treatment • Ob/gyn, pediatrician opinions about treatment

Risks to the infant include the risk of untreated mood and anxiety disorders. Postpartum depression has beenclearly associated with both long- andshort-term effects on the infant, includingcognitive, social, and behavioraldisturbances.52-56 Many mothers feelinadequate or do not experience theanticipated bonding with their infant.Women who are severely depressedmay be unable to care appropriately fortheir infants and, in severe cases, mayneglect or harm them.56 Women withpostpartum psychosis often requirehospitalization because of the severityof their symptoms and risk of harm totheir infants. Therefore, the length oftime mothers are away from their newinfants can be a source of guilt and difficultyin bonding once mothers returnhome. The mother may also be atincreased risk for an exacerbation ofher disorder because of the reliance onher for all feedings if she is nursingexclusively. Sleep disruption must beconsidered, because it can trigger arecurrence for some women, particularlythose with bipolar disorder.

The risks of infant exposure tomedication must also be considered. Thepotential risk is related to a number offactors, including the pharmacokineticsof the specific medication, theamount of medication in breast milk,the age and health of the infant, theinfant's ability to metabolize the medication,the maternal dose, and timing ofmedication and nursing. While formulafeeding may seem the easiest answer,many women wish to nurse their infants.These women need to make an informeddecision based on the known andunknown risks and benefits.

In general, data on the use of medicationduring breast-feeding are limitedto individual case reports or case series,either published or through casesreported to pharmaceutical companies.There are few data on breast milk levelsof antidepressants or mood stabilizers.Even less is known about infant serumlevels.47,57 Mothers and clinicians mustmake decisions based on very limitedinformation. If mothers choose to breastfeed,they may lessen infant exposureby supplementing with formula, waitinguntil the infant is a little older, andpumping and dumping during peakbreast milk levels. Some mothers maynot wish to nurse but need support andapproval from clinicians for this decision.Pediatricians, obstetricians, andpsychiatrists can all assist and supportmothers in this difficult decision.

CONCLUSION

Reproductive events can be a high-risktime for some women to experience anew onset or exacerbation of a mooddisorder. Emergency department (ED)clinicians can best serve their patients bybeing aware of the extent of mood andanxiety disorders that can occur duringpregnancy, following pregnancy loss, andpostpartum. Effective treatments exist, buta thorough assessment of the existing riskand benefits of available treatments mustbe conducted. In the ED setting, decisionsregarding initiation of medicationare often made. ED providers must beaware of these risks and benefits anddiscuss them with patients.

Dr Chaudron is assistant professor of psychiatryat the University of Rochester MedicalCenter in Rochester, New York.Dr Chaudron has received research fundingfrom Forest Laboratories, Inc. and is on thespeaker's bureau for Wyeth Pharmaceuticals.

This article first appeared in Psychiatric Issuesin Emergency Care Settings. 2005;4(4):11-18.

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