Perinatal psychiatric disorders: an overview

Review

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OBSTETRICS

Perinatal psychiatric disorders: an overview Elena Paschetta, MD; Giles Berrisford, MD; Floriana Coccia, MD; Jennifer Whitmore, MD; Amanda G. Wood, PhD; Sam Pretlove, MD; Khaled M. K. Ismail, PhD

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ver the past decade, Perinatal Mental Health (PNMH) has gained increased attention in policy documents, medical literature, and the media. This was particularly triggered by reports from the United Kingdom, demonstrating that PNMH was the leading cause of maternal mortality within the first year postpartum.1 Thus, health services in several countries are focused on implementing clinical management systems that ensure the delivery of high-quality services for this group of vulnerable women.2,3 These policies have reduced PNMH-related maternal mortality.4 However, the impact of these services on other maternal, fetal, and child outcomes is less clear. The recommendation for effective multidisciplinary PNMH services has not been complemented by clear guidance about

From the Birmingham Women’s National Health Service Foundation Trust (Drs Paschetta, Pretlove, and Ismail); Perinatal Mental Health Service, Birmingham and Solihull Mental Health Foundation Trust (Drs Berrisford, Coccia, and Whitmore); School of Psychology, College of Life and Environmental Sciences (Dr Wood), and School of Clinical and Experimental Medicine, College of Medical and Dental Sciences (Dr Ismail), University of Birmingham, Birmingham, UK. Received May 31, 2013; revised Oct. 2, 2013; accepted Oct. 4, 2013. There was no specific funding for this review. E.P. is a Clinical Research Fellow at Birmingham Women’s National Health Service Foundation Trust funded by the Department of Neuroscience, Postgraduate School of Psychiatry, Psychiatric Clinic, University of Turin (Italy). The authors report no conflict of interest. Reprints: Khaled M. K. Ismail, PhD, Academic Department, Birmingham Women’s National Health Service Foundation Trust, Edgbaston, Birmingham B15 2 TG, UK. [email protected]. 0002-9378/$36.00 ª 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2013.10.009

Perinatal mental illness has a significant implication on maternal health, birth outcomes, and the offspring’s development. Prevalence estimates of perinatal psychiatric illnesses range widely, with substantial heterogeneity in different population studies, with a lower prevalence rate in high- rather than low- or middle-income countries. Because of the potential negative impact on maternal and child outcomes and the potential lability of these disorders, the perinatal period is a critical time to identify psychiatric illnesses. Thus, obstetricians and midwives play a crucial role in assessing women’s mental health needs and to refer identified women promptly for multidisciplinary specialist assessment. However, there is still limited evidence on best practice assessment and management policies during pregnancy and postpartum. This review focuses on the prevalence of common perinatal mental disorders and antenatal screening policies to identify women at risk. The effect of these conditions and their management on pregnancy, fetal outcomes, and child development are discussed. Key words: childbirth, mental illness, offspring, postpartum, pregnancy service structure, and currently service delivery is highly variable.5 The purpose of this review is to summarize the current literature on perinatal psychiatric illness, focusing on the magnitude of the problem, and review current screening policies, examining risk factors and critically evaluating the impact of suggested evidence based managements on maternal, fetal, and child outcomes.

Classification Perinatal psychiatric disorders (Figure 1) are wide ranging and can arise for the first time during the perinatal period or may represent a relapse of a preexisting condition. In Western societies, estimates of mental health problems during the perinatal period range considerably, with substantial heterogeneity in different population studies.6-8 Mood and anxiety disorders are the most prevalent mental illnesses found during this period.7-12 Literature reports higher rates of perinatal psychiatric disorders in low- and lower-middle-income countries.13-15 Less than 8% of women suspected to have perinatal mental illnesses are currently receiving any type of mental health care in these countries.16

There is a well-documented variation in prevalence by ethnic origin.17,18 Mood disorders Mood disorders include perinatal depression and bipolar affective disorder (BPAD). Perinatal depression can occur either during pregnancy or within the first 12 months after delivery. This diagnosis is made if the woman suffers with consistently low mood along with a fixed number of biological or cognitive symptoms for at least 2 consecutive weeks. Epidemiological studies in Western societies reported rates of antenatal and postnatal depressive episodes ranging between 5%,12,19 33%,6,8,9,11,20-26 and 1015%,6,19,23,27-29 respectively. Higher prevalence rates seem to occur in low-income settings.30-34 It is imperative to differentiate postnatal depression from postnatal blues. The latter is regarded as a normal variation of emotional change occurring after childbirth35 in which as high as 50-85% of women can experience symptoms of mild depressive symptoms, anxiety, irritability, mood swings, and increased tearfulness. Postnatal blues typically peak on the fourth or fifth day postpartum and usually resolve spontaneously by day 10.36,37

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FIGURE 1

Classification of common perinatal mental disorders

This figure summarizes common perinatal psychiatric disorders that can occur during the perinatal period. GAD, generalized anxiety disorder; OCD, obsessive-compulsive disorder; PNMD, perinatal mental disorders; PTSD, posttraumatic stress disorder. Paschetta. Perinatal Mental Health. Am J Obstet Gynecol 2013.

BPAD is characterized by episodes of mania or hypomania, typically alternating with episodes of depression. Childbirth is often related to the initial onset of BPAD.38,39 Up to 50% of women with a history of BPAD have a risk of relapse perinatally,40,41 especially after childbirth, when this risk is higher for BPAD than any other form of mental illness.42 Studies indicate that the risk of relapse is highest in the first 2 weeks postpartum, typically commencing as early as between days 2 and 4.43 Anxiety disorders A wide range of anxiety disorders are seen perinatally; these include obsessive compulsive disorder (OCD), posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), panic disorder, and specific phobias.

Their reported prevalence rates range from 4.5%34 to 15%.20,22,31,44 Some authors suggest that following childbirth, an increasing proportion of women experience PTSD.45-48 However, other studies report higher rates of OCD and GAD in postpartum women compared with general population.49-52 Among specific phobias, tokophobia (a morbid fear of childbirth) is gaining increased attention in clinical practice, especially for the high perinatal comorbidity with mood and anxiety disorders53 and the frequent request of elective cesarean section. Preliminary reports have shown that treatment for tokophobia and comorbid psychiatric conditions53 during pregnancy can lead to a significant reduction of the fear of vaginal delivery with a withdrawal in request for cesarean sections.54-57

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Psychotic disorders The lifetime prevalence of schizophrenia is approximately 1-2%.58 Key manifestations of disease include psychotic symptoms such as hallucinations and delusions, affective disturbances such as emotional blunting, and significant occupational and social dysfunction. The risk of relapse during the first 3 months postpartum is approximately 24-25%,59,60 especially following treatment discontinuation.61,62 Puerperal psychosis This is reported to occur following 1-2 per 1000 births,29,63-65and has its onset commonly within the first 2 weeks postpartum.42,66 Women usually develop paranoid, grandiose, or bizarre delusions, mood lability, and perplexity. These features represent a dramatic

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www.AJOG.org change from previously perceived normal functioning.67 It is estimated that approximately two thirds of women suffering from a puerperal psychosis will experience a relapse after subsequent deliveries.68 Preexisting BPAD is one of the greatest risk factors.69 Substance-use disorders Alcohol and tobacco are the most prevalent substances consumed by childbearing-aged women, followed by various illicit drugs,70,71 especially methamphetamines.72 Alcohol use during pregnancy is one of the leading preventable causes of birth defects, intellectual disability, and neurodevelopmental disorders,73 whereas mothers using illicit drugs are at high risk of psychiatric comorbidity and poorer obstetric outcomes.74 Because of the paucity of research, further investigations into the magnitude and management of these conditions are required. Substance misuse as an isolated perinatal psychiatric disorder is beyond the scope of this review.

Prediction Antenatal screening for mental health issues and risk factors allows early diagnosis, appropriate liaison with relevant professionals, timely discussion regarding treatment, and finalizing management plans throughout the perinatal period. This can help reduce the negative impact of the mental illness on the woman, her child, and her extended family. Efficient strategy of screening relies on identifying clinically vulnerable subgroups. The Table summarizes the known risk factors of the common perinatal mental disorders (PNMDs). A past history of postpartum and nonperinatal depression75-77and psychosocial factors are the most important predictors of antenatal depression.78,79 Likewise, postpartum depression (PPD) is caused by a combination of biological80 and psychosocial determinants. There is preliminary evidence that genetic factors may contribute to as much as one third of its etiological variance.80 Hormones, such as estrogen and progesterone,81 as well as thyroid dysfunction have been suggested as

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TABLE

Risk factors for PNMDs PNMDs

Risk factors

AND

Previous PPD and nonperinatal depression75-77 Recent adverse life events27,76,77,101,102,105,107,235-241 Low socioeconomic status15,27,76,77,90,101,102,105,107,108,110-112,235-241 Insufficient emotional/social support26,105 Unplanned pregnancy76,77,79 Unfavorable obstetric79/pregnancy outcomes242-244 Chronic physical illness245 Previous miscarriages246 Domestic violence95

PPD

Past history of psychiatric disorders8,85,86 Depression/anxiety during current pregnancy87,88 Maternity blues247 Biological factors (genetic, hormonal, others)80-84 Recent adverse life events27,76,77,101,102,105,107,235-241 Low socioeconomic status15,27,76,77,90,101,102,105,107,108,110-112,235-241 Insufficient emotional/social support15,113,101,102,105,107,235-240 Poor marital relationship101,102,105,107,235-240 Unplanned pregnancy15,113 Immigration/premigration stress248,249 Personality traits90,101,102 Unfavorable obstetric/pregnancy outcomes8,83,105 Unfavorable neonatal outcomes250,251 Chronic/current physical illnesses113,252 History of PMS89,90 and PMDD91,92 History of physical/sexual abuse93,94,253,254 Multiple births255,256 Domestic violence15,95-100 Childcare stress/infant temperament90,101,102

PPs

Previous episodes of PPs114 Personal history of psychotic disorders and BPAD114 Family history of PPs and BPAD114 Insufficient emotional/social support115-117 Sleep disturbance119

PNADs

Personal history of ADs120,121 Insufficient emotional/social support 120,121 Previous miscarriages246 History of physical/sexual abuse120,121 Multiple births121,255,256 Unfavorable pregnancy243,244/neonatal250 outcomes Maternity blues247

PTSD

Unfavorable obstetric/pregnancy and neonatal outcomes123,124,251 Perinatal death123,124

AD, anxiety disorders; AND, antenatal depression; BPAD, bipolar affective disorder; NICU, neonatal intensive care unit; PMS, premenstrual syndrome; PMDD, premenstrual dysphoric disorder; PNAD, perinatal anxiety disorders; PNMD, perinatal mental disorders; PPs, puerperal psychosis; PPD, postpartum depression; PTSD, posttraumatic stress disorder. Paschetta. Perinatal Mental Health. Am J Obstet Gynecol 2013.

potential biological factors involved in its psychopathology.82 Recent researches have also focused on the role of omega-3 fatty acids83 and specific polymorphisms of serotonin metabolism enzymes84 in the development of PPD, but the findings thus far have been inconclusive. To date, the strongest predictors of PPD is a past history of psychopathology8,85,86

and depression or anxiety during the current pregnancy.87,88 Recent evidence also found other important predictors, such as a history of premenstrual syndrome89,90 and premenstrual dysphoric disorder,91,92 and a history of physical or sexual abuse93,94and domestic violence.95-100 The levels of childcare stress, infant

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temperament, and vulnerable maternal personality traits90,101,102 seem to be other important and stable determinants of PPD.103,104 Finally, small but significant predictors include obstetric and pregnancy complications,8,83,105 especially hyperemesis and premature contractions,106 and socioeconomic status,90,101,107-112 which conversely represents a strong predictor of PPD in the developing world.15,113 The disparity in the rates of perinatal mental disorders between women living in high- and low-income settings suggests social rather than biological determinants.113 Predictors of puerperal psychosis include previous episodes or family history; personal history of psychotic disorders, especially schizophrenia; personal or family history of BPAD114; medication nonadherence; poor social support115-117; younger age; and unplanned pregnancy.118 Sleep disturbances have also been found as an important risk factor for puerperal psychosis relapse in susceptible women.119 Considering anxiety disorders, previous lifetime episodes, low social support, a history of child abuse, and a perception of high peripartum stress are all risk factors for experiencing anxiety disorders during the perinatal period.120,121 Multiparity has also been identified as another potential contributor to generalized anxiety in pregnancy.121 With regard specifically to PTSD, during the postpartum period, PTSD has been found to be associated with behavioral health risks and PTSD at the onset of pregnancy.122 Other known risk factors of postpartum PTSD include younger age, severe preeclampsia, cesarean section, lower gestational age, lower birthweight, baby admitted to the neonatal intensive care unit, and perinatal death.123,124 Finally, women with a past or current psychiatric disorder, especially puerperal psychosis and severe depression,4 a substance-use disorder, and intimate partner problems have been found at increased risk of postpartum suicide attempt compared with controls.125,126 Inquiries about psychiatric symptoms should be made at the initial antenatal

www.AJOG.org visits. Attention should be paid to any sign of poor self-care and over- or underactivity. Particular care should be given to suicidal ideation or thoughts of harming the baby, substance abuse, and domestic violence. One of the most important risk factor is a previous personal or family history of psychopathology. It is essential to take a focused history on past or present severe mental illness, previous treatment by a psychiatrist or specialist mental health team, and any personal or family history of perinatal mental health problems. The literature shows a wide variability of antenatal screening tools for perinatal psychiatric disorders in different countries.127 The British National Institute for Health and Clinical Excellence guidelines2 specifically recommend the utilization of the Whooley questions128 to screen for antenatal depression. However, some authors127 highlighted a lack of evidence in its effectiveness and also a need for further research to identify universal screening tools. When these strategies are instigated, care must be taken to ensure that all women are screened and assessed because it has been recognized that in practice, implementation can be patchy.129 All pregnant women identified as high risk should have a shared multidisciplinary care plan for their late pregnancy and early postnatal management.117

Effects on short-term outcomes Mental illness in the perinatal period can have a significant impact on maternal health, birth outcomes, and fetal development. The British Confidential Enquiries into Maternal Deaths reported that psychiatric disorders contributed to 12% of all maternal deaths in 2002-2005.130 Currently, suicide is a leading cause of perinatal maternal deaths in industrialized countries, but there is still little research on its prevalence and correlates,131,132 especially in the developing world.133 Among female suicide victims of reproductive age, recent data show a high prevalence of an existing mental health diagnosis126,132,134 or a past

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history of serious affective disorder (59%), such as puerperal psychosis and severe depression4 ; substance use; and intimate partner problems.126,135 Furthermore, maternal suicide can be associated with a risk of infanticide.133,136 It is a rare event but can have tragic consequences, so it is important to highlight. Up to 50% of pregnancies in the general population are unplanned, and the rate is even higher in women suffering from mental illness.137 Among these women, the frequency of sexual activity may be normal, but contraceptive use may be lower and autonomous reproductive decision-making compromised.138 Women with mental illnesses often start their pregnancy without having their medications optimized and often stop taking them abruptly when they find out they are pregnant, which frequently leads to a relapse of their psychiatric symptoms.40,42,66,69,115,139 They are more likely to default antenatal care appointments, use substances, have a poor diet, and be overweight, all of which are lifestyle factors associated with poor obstetric outcomes.59,140-143 It is increasingly recognized that severe mental illnesses can be an underlying cause of pregnancy-related medical disorders and obstetric complications.83,144-159 It is suggested that one biological mechanism linking severe mental illnesses and some pregnancyrelated complications is a result of the promoting effect of these illnesses on the immune system that subsequently increases the levels of inflammatory markers and altering proinflammatory cytokines regulation.160 Another possible biological mechanism is represented by the overactivity of the maternal neuroendocrine system caused by maternal psychosocial stress and preexisting psychiatric symptoms.161,162 Several studies reported an association between maternal mental illness/stress and changes in the fetal heart rate and vascular distribution as well as negative fetal outcomes, including intrauterine growth retardation,83,154,161,163 lower Apgar scores,164,165 congenital malformations,143,151,154,165-168 and perinatal loss.146,154,165,168-171

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www.AJOG.org Women with mental disorders more frequently misuse substances.140 Prenatal exposure to cocaine and amphetamines is associated with several adverse outcomes, such as spontaneous abortion, preterm births, placental abruption, congenital abnormalities, neonatal poor feeding, lethargy, and seizures. Alcohol use is associated with spontaneous abortion, growth restriction, and birth defects; moreover, fetal alcohol syndrome is a common cause of long-term sequelae for the infant. Prenatal tobacco exposure can induce spontaneous abortion, ectopic pregnancy, placental insufficiency, low birthweight, fetal growth restriction, and preterm delivery, whereas marijuana use has been found related to fetal growth restriction.172,173 All these substances can also predispose to neonatal withdrawal syndrome, which, interestingly, increased in the past 25 years.174 Psychotropic medications may also have an impact on outcomes. Prenatal antidepressant use has been found associated with lower gestational age at birth, preterm birth,175 and small increased risk of persistent pulmonary hypertension of the newborn.176 Exposures of concern include that of untreated maternal illness as well as medication exposure.177,178 Conversely, no significant risk of stillbirth, neonatal mortality, postnatal mortality,179,180 and major congenital malformations181,182 has been found, apart from a slight increased risk of cardiac malformations associated with first-trimester paroxetine exposure.154,183,184 With regard to antipsychotics, there is no conclusive evidence of their structural teratogenicity.183,185 There are 2 case reports of pregnancy loss in women taking atypical antipsychotic aripiprazole,186 whereas other observational studies found no increased risk of stillbirth, gestational age at birth, and perinatal syndromes187,188 in pregnant women under antipsychotics. There have been reports of self-limiting extrapyramidal or possible withdrawal symptoms in neonates exposed to atypical agent risperidone in the third trimester.188 Transient complications

have been documented in neonates exposed to typical antipsychotics, including withdrawal symptoms, extrapyramidal signs, neonatal jaundice, and intestinal obstruction.183 Other authors found an association between low birthweight and the use of typical antipsychotics in pregnancy and large-forgestational-age babies and the use of atypical antipsychotics, especially olanzapine and clozapine.189 An increased risk of gestational diabetes has been found related to the use of olanzapine and clozapine.148,185 Prenatal exposure to lithium may be associated with a small increase in Ebstein’s anomaly (probably overvalued in the past),184 cardiac arrhythmias, hypoglycemia, nephrogenic diabetes insipidus, polyhydramnios, reversible changes in thyroid function, hyperparathyroidism,190 premature delivery, abnormally large infants, floppy infant syndrome, lethargy, and poor suck reflexes.154,183,184,191 Among other mood stabilizers, prenatal exposure to valproic acid (VPA) has been found related with neural tube defects, craniofacial, limb and cardiovascular anomalies, genitourinary malformations, low birthweight, neonatal hepatotoxicity, coagulopathies, hypoglycemia, and an increased risk of withdrawal symptoms and cognitive impairment.154,183,184,191 Carbamazepine has teratogenic risks similar to VPA but less frequent and severe,154,183,191 whereas fetal exposure to lamotrigine has not been found to be related to major anomalies, excluding an increased risk of midline facial clefts.154 Evidence from the treatment of epilepsy, however, suggests an increased risk of major congenital malformations following prenatal exposure to anticonvulsants,192,193 particularly at higher doses192 and in polytherapy.193 Lastly, benzodiazepine use during the first trimester may be associated with cleft lip and palate, skeletal abnormalities, and central nervous system dysfunction.194 Neonatal toxicity includes withdrawal symptoms and floppy infant syndrome.154,183,184,191 The contribution of various genetic factors in directing the variability of fetal

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drug exposure is still mostly unclear.195 The use of pharmacogenomics to predict maternal plasma drug concentrations and fetal drug exposure is expected to increase in the future, but there is still limited clinical use of currently available methods of therapeutic monitoring of drug concentrations in making treatment decisions.196

Long-term effects The multiple psychosocial difficulties experienced by women with mental disorders can have adverse effects on the development of mother-infant attachment197 and the child.198 Children of parents with psychiatric illnesses are at increased risk of neglect or inadequate care and the later development of psychopathology.199-204 Several studies have also shown a link between antenatal stress/anxiety and behavioral/emotional problems in the child.205-220 Mechanisms underlying these effects have only just been started to be studied in humans. Literature evidence supports a link between prenatal mood and the development of the fetal brain.221 One potential pathway to early deregulation is fetal programming of the hypothalamic-pituitary-adrenal axis.222,223 There is a strong correlation between maternal and fetal levels of cortisol,224 suggesting there is a passage of cortisol across the placenta. Recent findings show that cortisol and pregnancy-specific anxiety independently predicted child anxiety. Children exposed to elevated prenatal maternal cortisol and pregnancy-specific anxiety are at increased risk for developing anxiety problems during the preadolescent period.220 Fetal exposure to maternal mental illnesses and psychosocial stress result in subsequent risk for poor health outcomes171 and a wide spectrum of pediatric diseases in the offspring.225 Many studies to date have not taken in to account the impact of medication exposure in key gestational stages on longer-term outcomes in the child.226 It is critical to disambiguate the effects of medications used to manage these disorders from the maternal psychiatric illness itself.

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Management Multidisciplinary nonpharmacological interventions All current guidelines2,3 recommend obstetricians and hospital/community midwives identify women (preferably at their early pregnancy assessment) with past or present severe mental illness including schizophrenia and other psychoses, BPAD and moderate to severe depression, a previous psychiatric treatment, and a family history of perinatal psychiatric disorder. Women identified at risk need to be referred to specialist perinatal mental health professionals for further assessment, specific interventions, and the monitoring of their mental health both during pregnancy and postpartum. Some of these guidelines2 recognize the need for a written care plan for women so that information can be shared between obstetric and specialist perinatal mental health services and all professionals involved in their care. Conditions such as substance abuse and domestic violence should also be considered as risk factors for perinatal mental health morbidity and should be managed by specialist services. In women whose pregnancy or postpartum year is complicated by serious mental illness, apart from specific pharmacological interventions, the available guidelines2 recommend establishing specialized community perinatal teams to monitor their mental state during pregnancy and postpartum. Mother and baby units are used to treat acutely ill women who cannot be safely managed in the community within the last weeks of pregnancy or after childbirth.227 Women who develop a puerperal psychosis or who are at a very high risk of relapse227 should ideally be admitted with their baby to these specialized units. This enables mothers to remain with their baby in a safe supervised environment in which they can also be treated for their psychiatric illness. Women with a past personal or family history of severe mental illness should be carefully monitored by specialist mental health professionals throughout the perinatal period because of the higher

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FIGURE 2

Multidisciplinary models for managing PNMDs

This figure summarizes all the proposed multidisciplinary models for the management of perinatal mental disorders. CPN, community psychiatric nurse; PNMD, perinatal mental disorders; PNMH, perinatal mental health. Paschetta. Perinatal Mental Health. Am J Obstet Gynecol 2013.

risk of relapse. Based on individual need, these women may be advised to start prophylactic treatment during pregnancy or soon after delivery and may be referred to mother and baby units as a precaution should their mental health deteriorate. Nonpharmacological treatment such as cognitive behavioral therapy and interpersonal therapy228 may be of benefit, but evidence is limited for this except for the treatment of depression.2 The recommendations for screening at booking have been widely but not universally implemented. It is of huge concern that access to specialized perinatal mental health services is still not readily available in most countries.5,229 Figure 2 summarizes the proposed multidisciplinary models for managing perinatal mental disorders. Pharmacological interventions Selective serotonin reuptake inhibitors (SSRIs; with the exception of paroxetine)230 are advised as first-line treatment

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for depression in both antenatal and postnatal period.2,3 In pregnant women with recurrent depressive disorder, it is important to continue pharmacological treatment because moderate to severe depression is unlikely to respond to talking therapies. Moreover, discontinuation of antidepressants can often lead to relapse (75%) in the first trimester.139 Women with a previous history of puerperal psychosis and who are drug free during pregnancy should be advised to start an atypical antipsychotic and/or a mood stabilizer at 32 weeks’ gestation. Because of the higher risk of relapse after subsequent pregnancies,68 during which these women are reluctant to consider medication in pregnancy, it is recommended to commence treatment immediately after delivery, preferably before the discharge from hospital. This way therapeutic levels will be established when the woman enters the high-risk period in the first week postpartum.43 Puerperal psychosis is usually very responsive to treatment, but delays in

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www.AJOG.org starting medication result in longer, more severe, and more difficult-to-treat episodes.231 Management of women with BPAD during pregnancy should be tailored to their individual history and circumstances. For many women discontinuation of prophylactic medication poses too many risks. Those women on lithium who are keen to come off medication prior to pregnancy should have a slow reduction of lithium to reduce the risk of relapse.2,232 Other commonly used mood stabilizers such as carbamazepine and VPA are known to be teratogenic and should be avoided in pregnancy.2 Switching to an atypical antipsychotic is recommended in such women.2,233 For pregnant women with schizophrenia, it is often necessary to continue their antipsychotic medication because of the high risk of relapse.234 In these women the risk of untreated psychiatric illness outweighs any risk to the fetus from exposure to psychotropic medications.184 For perinatal anxiety disorders, SSRIs (excluding paroxetine)230 remain the first-line treatment for clinically significant symptoms both during pregnancy and postpartum.

Conclusion Perinatal psychiatric disorders can have a significant impact on maternal and child outcomes, carrying a high morbidity and mortality. The challenge for health professionals is to effectively identify women with perinatal mental health problems and to ensure they are given comprehensive management plans. This article has highlighted the advantages of an accurate antenatal assessment and multidisciplinary evidence-based models for improving patient care, treatment, and outcomes for both mother and infant in different settings. Note: The first 100 references associated with this article are available below in print. The complete reference list accompanying this article is available online only with the electronic version of the article. To access the remaining references, visit the online version of

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prevalence and risk factors in an Italian sample. Arch Womens Ment Health 2012;15:21-30. 27. Moses-Kolko EL, Roth EK. Antepartum and postpartum depression: healthy mom, healthy baby. J Am Med Womens Assoc 2004;59: 181-91. 28. Freeman MP, Wright R, Watchman M, et al. Postpartum depression assessments at well-baby visits: screening feasibility, prevalence, and risk factors. J Womens Health 2005;14:929-35. 29. Berle JO. Psychiatric conditions in pregnancy and postpartum. Acta Obstet Gynecol Scand 2012;91:38. 30. Da Silva RA, Jansen K, Souza LDDM, et al. Depression during pregnancy in the Brazilian public health care system. Rev Brasil Psiquiatr 2010;32:139-44. 31. Sawyer A, Ayers S, Smith H. Pre- and postnatal psychological wellbeing in Africa: a systematic review. J Affect Disord 2010;123: 17-29. 32. Nasreen HE, Kabir ZN, Forsell Y, Edhborg M. Prevalence and associated factors of depressive and anxiety symptoms during pregnancy: a population based study in rural Bangladesh. BMC Womens Health 2011;11:22. 33. Rochat TJ, Tomlinson M, Barnighausen T, Newell M-L, Stein A. The prevalence and clinical presentation of antenatal depression in rural South Africa. J Affect Disord 2011;135: 362-73. 34. Keleher V, Nyunt SZ, Broekman B, Chee C. Prevalence and risk factors for antenatal depression in pregnant women attending National University Hospital, Singapore. Eur Psychiatry 2012;27:1210. 35. Miller LJ, Ruckstalis M. Hypotheses about postpartum reactivity. In: Miller LJ, ed. Postpartum mood disorder. Washington, DC: American Psychiatric Press; 1999.p.262-5. 36. Pitt B. Maternity blues. Br J Psychiatry 1973;122:431-3. 37. Gold LH. Postpartum disorders in primary care: diagnosis and treatment. Prim Care 2002;29:27-41. 38. Terp IM, Mortensen PB. Post-partum psychoses: clinical diagnoses and relative risk of admission after parturition. Br J Psychiatry 1998;172:521-6. 39. Munk-Olsen T, Laursen TM, MeltzerBrody S, Mortensen PB, Jones I. Psychiatric disorders with postpartum onset: possible early manifestations of bipolar affective disorders. Arch Gen Psychiatry 2012;69:428-34. 40. Freeman MP, Smith KW, Freeman SA, et al. The impact of reproductive events on the course of bipolar disorder in women. J Clin Psychiatry 2002;63:284-7. 41. Di Florio A, Forty L, Gordon-Smith K, et al. Perinatal episodes across the mood disorder spectrum. JAMA Psychiatry 2013;70:168-75. 42. Kendell RE, Chalmers JC, Platz C. Epidemiology of puerperal psychosis. Br J Psychiatry 1987;150:662-73. 43. Heron J, Robertson Blackmore E, McGuinness M, Craddock N, Jones I. No ‘latent

www.AJOG.org period’ in the onset of bipolar affective puerperal psychosis. Arch Womens Ment Health 2007;10: 79-81. 44. Bixo M, Sundstrom-Poromaa I, Bjorn I, Astrom M. Patients with psychiatric disorders in gynecologic practice. Am J Obstet Gynecol 2001;185:396-402. 45. Soderquist J, Wijma K, Wijma B. Traumatic stress in late pregnancy. J Anxiety Disord 2004;18:127-42. 46. Ayers S, Joseph S, McKenzie-McHarg K, Slade P, Wijma K. Post-traumatic stress disorder following childbirth: current issues and recommendations for future research. J Psychosom Obstet Gynecol 2008;29:240-50. 47. Seng JS, Low LK, Sperlich M, Ronis DL, Liberzon I. Prevalence, trauma history, and risk for posttraumatic stress disorder among nulliparous women in maternity care. Obstet Gynecol 2009;114:839-47. 48. Zambaldi CF, Cantilino A, Sougey EB. Biosocio-demographic factors associated with post-traumatic stress disorder in a sample of postpartum Brazilian women. Arch Womens Ment Health 2011;14:435-9. 49. Wenzel A, Haugen EN, Jackson LC, Brendle JR. Anxiety symptoms and disorders at eight weeks postpartum. J Anxiety Disord 2005;19:295-311. 50. Ross LE, McLean LM. Anxiety disorders during pregnancy and the postpartum period: a systematic review. J Clin Psychiatry 2006;67: 1285-98. 51. Giardinelli L, Cecchelli C, Innocenti A. Psychiatric disorders in pregnancy. Ital J Psychopathol 2008;14:211-9. 52. Chaudron LH, Nirodi N. The obsessivecompulsive spectrum in the perinatal period: a prospective pilot study. Arch Womens Ment Health 2010;13:403-10. 53. Rouhe H, Salmela-Aro K, Gissler M, Halmesmaki E, Saisto T. Mental health problems common in women with fear of childbirth. BJOG 2011;118:1104-11. 54. Ryding EL. Investigation of 33 women who demanded a caesarean section for personal reasons. Acta Obstet Gynecol Scand 1993;72: 280-5. 55. Sjogren B, Thomassen P. Obstetric outcome in 100 women with severe anxiety over childbirth. Acta Obstet Gynecol Scand 1997;76:948-52. 56. Saisto T, Salmela-Aro K, Nurmi JE, Kononen T, Halmesmaki E. A randomized controlled trial of intervention in the fear of childbirth. Obstet Gynecol 2001;98:820-6. 57. Nerum H, Halvorsen L, Sorlie T, Oian P. Maternal request for caesarean section due to fear of birth: can it be changed through crisis-oriented counseling? Birth 2006;33: 221-8. 58. Einarson A, Boskovic R. Use and safety of antipsychotic drugs during pregnancy. J Psychiatr Pract 2009;15:183-92. 59. Seeman MV. Clinical interventions for women with schizophrenia: pregnancy. Clinical recommendation. Acta Psychiatr Scand 2012; 127:12-22.

8 American Journal of Obstetrics & Gynecology MONTH 2013

60. Robinson GE. Treatment of schizophrenia in pregnancy and postpartum. J Popul Ther Clin Pharmacol 2012;19:380-6. 61. Altshuler LL, Cohen L, Szuba MP, Burt VK, Gitlin M, Mintz J. Pharmacologic management of psychiatric illness during pregnancy: dilemmas and guidelines. Am J Psychiatry 1996;153: 592-606. 62. Trixler M, Gati A, Fekete S, Tenyi T. Use of antipsychotics in the management of schizophrenia during pregnancy. Drugs 2005;65: 1193-206. 63. Jones I, Lendon C, Coyle N, Robertson E, Brockington I, Craddock N. Molecular genetic approaches to puerperal psychosis. Prog Brain Res 2001;133:321-31. 64. Harlow BL, Vitonis AF, Sparen P, Cnattingius S, Joffe H, Hultman CM. Incidence of hospitalization for postpartum psychotic and bipolar episodes in women with and without prior pre-pregnancy or prenatal psychiatric hospitalizations. Arch Gen Psychiatry 2007;64: 42-8. 65. McCauley-Elsom K, Kulkarni J. Managing psychosis in pregnancy. Aust N Z J Psychiatry 2007;41:289-92. 66. Spinelli MG. Postpartum psychosis: detection of risk and management. Am J Psychiatry 2009;166:405-8. 67. Brockington IF. Puerperal psychosis. In: Brockington IF, ed. Motherhood and mental health. Oxford, UK: Oxford University Press; 1996:200-84. 68. Newport DJ, Hostetter A, Arnold A, Stowe ZN. The treatment of postpartum depression: minimizing infant exposures. J Clin Psychiatry 2002;63:31-44. 69. Chaudron LH, Pies RW. The relationship between postpartum psychosis and bipolar disorder: a review. J Clin Psychiatry 2003;64: 1284-92. 70. Havens JR, Simmons LA, Shannon LM, Hansen WF. Factors associated with substance use during pregnancy: results from a national sample. Drug Alcohol Depend 2009;99:89-95. 71. Albright BB, Rayburn WF. Substance abuse among reproductive age women. Obstet Gynecol Clin North Am 2009;36:891-906. 72. Terplan M, Smith EJ, Kozloski MJ, Pollack HA. Methamphetamine use among pregnant women. Obstet Gynecol 2009;113: 1285-91. 73. Kelly R, Zatzick D, Anders T. The detection and treatment of psychiatric disorders and substance use among pregnant women cared for in obstetrics. Am J Psychiatry 2001;158: 213-9. 74. Oei JL, Kingsbury A, Dhawan A, et al. Amphetamines, the pregnant woman and her children: a review. J Perinatol 2012;32: 737-47. 75. Freeman MP. Perinatal mental health: new data regarding risk factors and treatment considerations. J Clin Psychiatry 2009;70: 1289-90. 76. Lancaster CA, Gold KJ, Flynn HA, Yoo H, Marcus SM, Davis MM. Risk factors for

Obstetrics

www.AJOG.org depressive symptoms during pregnancy: a systematic review. Am J Obstet Gynecol 2010;202:5-14. 77. Stewart DE. Clinical practice: depression during pregnancy. N Engl J Med 2011;365: 1605-11. 78. Altemus M, Neeb CC, Davis A, Occhiogrosso M, Nguyen T, Bleiberg KL. Phenotypic differences between pregnancyonset and postpartum-onset major depressive disorder. J Clin Psychiatry 2012;73:1485-91. 79. Dudas RB, Csatordai S, Devosa I, et al. Obstetric and psychosocial risk factors for depressive symptoms during pregnancy. Psychiatr Res 2012;200:323-8. 80. Treloar SA, Martin NG, Bucholz KK, et al. Genetic influences on post-natal depressive symptoms: findings from an Australian twin sample. Psychol Med 1999;29:645-54. 81. Zonana J, Gorman JM. The neurobiology of postnatal depression. CNS Spectr 2005;10: 792-9, 805. 82. Harris B. Hormonal aspects of postnatal depression. Int Rev Psychiatry 1996;8:27-36. 83. Lee DTS, Chung TKH. Postnatal depression: an update. Best Pract Res Clin Obstet Gynaecol 2007;21:183-91. 84. Lin Y-MJ, Ko H-C, Chang F-M, Yeh T-L, Sun HS. Population-specific functional variant of the TPH2 gene 2755C. A polymorphism contributes risk association to major depression and anxiety in Chinese peripartum women. Arch Womens Ment Health 2009;12:401-8. 85. Banti S, Mauri M, Oppo A, et al. From the third month of pregnancy to 1 year postpartum. Prevalence, incidence, recurrence, and new

onset of depression. Results from the Perinatal Depression-Research and Screening Unit study. Compr Psychiatry 2011;52:343-51. 86. Witt WP, Wisk LE, Cheng ER, et al. Poor prepregnancy and antepartum mental health predicts postpartum mental health problems among US women: a nationally representative population-based study. Womens Health Issues 2011;21:304-13. 87. Matthey S, Barnett B, Howie P, Kavanagh DJ. Diagnosing postpartum depression in mothers and fathers: whatever happened to anxiety? J Affect Disord 2003;74:139-47. 88. Alipour Z, Lamyian M, Hajizadeh E. Anxiety and fear of childbirth as predictors of postnatal depression in nulliparous women. Women Birth 2012;25:37-43. 89. Garcia-Esteve L, Navarro P, Ascaso C, et al. Family caregiver role and premenstrual syndrome as associated factors for postnatal depression. Arch Womens Ment Health 2008;11:193-200. 90. Tian T, Xie D, Shen Y, et al. Clinical features and risk factors for post-partum depression in a large cohort of Chinese women with recurrent major depressive disorder. J Affect Disord 2012;136:983-7. 91. Buttner MM, Mott SL, Pearlstein T, Stuart S, Zlotnick C, O’Hara MW. Examination of premenstrual symptoms as a risk factor for depression in postpartum women. Arch Womens Ment Health 2013;16:219-25. 92. Sylvén SM, Ekselius L, SundströmPoromaa I, Skalkidou A. Premenstrual syndrome and dysphoric disorder as risk factors for postpartum depression. Acta Obstet Gynecol Scand 2013;92:178-84.

Review

93. Silverman ME, Loudon H. Antenatal reports of pre-pregnancy abuse is associated with symptoms of depression in the postpartum period. Arch Womens Mental Health 2010;13: 411-5. 94. Janssen PA, Heaman MI, Urquia ML, O’Campo PJ, Thiessen KR. Risk factors for postpartum depression among abused and non-abused women. Am J Obstet Gynecol 2012;207:489.e1-8. 95. Flach C, Leese M, Heron J, et al. Antenatal domestic violence, maternal mental health and subsequent child behaviour: a cohort study. BJOG 2011;118:1383-91. 96. Bacchus L, Mezey G, Bewley S. Domestic violence: prevalence in pregnant women and associations with physical and psychological health. Eur J Obstet Gynecol Reprod Biol 2004;113:6-11. 97. Varma D, Chandra PS, Thomas T, Carey MP. Intimate partner violence and sexual coercion among pregnant women in India: relationship with depression and post-traumatic stress disorder. J Affect Disord 2007;102:227-35. 98. Tiwari A, Chan KL, Fong D, et al. The impact of psychological abuse by an intimate partner on the mental health of pregnant women. BJOG 2008;115:377-84. 99. Gao W, Paterson J, Abbott M, Carter S, Iusitini L. Pacific Islands families study: intimate partner violence and postnatal depression. J Immigr Minor Health 2010;12:242-8. 100. Ola B, Crabb J, Tayo A, et al. Factors associated with antenatal mental disorder in West Africa: a cross-sectional survey. BMC Pregnancy Childbirth 2011;11:90.

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REFERENCES (ONLINE ONLY) 1. Confidential enquiry into maternal and child health. Why mothers die, 2000-2002. The Sixth Report of the Confidential Enquiries into Maternal Death in the United Kingdom. London, UK: RCOG Press; 2004. 2. National Institute for Health and Clinical Excellence (NICE). Antenatal and postnatal mental health: clinical management and service guidance. In: NICE Clinical Guidelines, no. 45. Leicester, UK: British Psychological Society; 2007. Available at: http://guidance.nice.org.uk/ cg45. Accessed March 12, 2013. 3. Austin MP, Middleton P, Reilly NM, Highet NJ. Detection and management of mood disorders in the maternity setting: the Australian Clinical Practice Guidelines. Women Birth 2013;26:2-9. 4. CMACE. Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. Br J Obstet Gynaecol 2011;118:1-203. 5. Kim JJ, La Porte LM, Corcoran M, Magasi S, Batza J, Silver RK. Barriers to mental health treatment among obstetric patients at risk for depression. Am J Obstet Gynecol 2010;202: 312.e1-5. 6. Gavin NI, Gaynes BN, Lohr KN, MeltzerBrody S, Gartlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol 2005;106(5 Pt 1):1071-83. 7. Witt WP, Deleire T, Hagen EW, et al. The prevalence and determinants of antepartum mental health problems among women in the USA: a nationally representative populationbased study. Arch Womens Mental Health 2010;13:425-37. 8. Le Strat Y, Dubertret C, Le Foll B. Prevalence and correlates of major depressive episode in pregnant and postpartum women in the United States. J Affect Disord 2011;135:128-38. 9. Nicholson WK, Setse R, Hill-Briggs F, Cooper LA, Strobino D, Powe NR. Depressive symptoms and health-related quality of life in early pregnancy. Obstet Gynecol 2006;107: 798-806. 10. Vesga-López O, Blanco C, Keyes K, Olfson M, Grant BF, Hasin DS. Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry 2008;65:805-15. 11. Melville JL, Gavin A, Guo Y, Fan M-Y, Katon WJ. Depressive disorders during pregnancy: prevalence and risk factors in a large urban sample. Obstet Gynecol 2010;116: 1064-70. 12. Uguz F, Gezginc K, Kayhan F, Sari S, Buyukoz D. Is pregnancy associated with mood and anxiety disorders? A cross-sectional study. Gen Hosp Psychiatry 2010;32:213-5. 13. Faisal-Cury A, Menezes P, Araya R, Zugaib M. Common mental disorders during pregnancy: prevalence and associated factors among low-income women in Sao Paulo, Brazil:

www.AJOG.org depression and anxiety during pregnancy. Arch Womens Ment Health 2009;12:335-43. 14. Cook CAL, Flick LH, Homan SM, Campbell C, McSweeney M, Gallagher ME. Psychiatric disorders and treatment in lowincome pregnant women. J Womens Health 2010;19:1251-62. 15. Fisher J, de Mello MC, Patel V, et al. Prevalence and determinants of common perinatal mental disorders in women in low-and lowermiddle-income countries: a systematic review. Bull World Health Organ 2012;90:139-49. 16. Price SK, Proctor EK. A rural perspective on perinatal depression: prevalence, correlates, and implications for help seeking among lowincome women. J Rural Health 2009;25:158-66. 17. Wei G, Greaver LB, Marson SM, Herndon CH, Rogers J. Postpartum depression: racial differences and ethnic disparities in a triracial and bi-ethnic population. Matern Child Health J 2008;12:699-707. 18. Gavin AR, Melville JL, Rue T, Guo Y, Dina KT, Katon WJ. Racial differences in the prevalence of antenatal depression. Gen Hosp Psychiatry 2011;33:87-93. 19. Ban L, Gibson JE, West J, Fiaschi L, Oates MR, Tata LJ. Impact of socioeconomic deprivation on maternal perinatal mental illnesses presenting to UK general practice. Br J Gen Pract 2012;62:671-8. 20. Andersson L, Sundstrom-Poromaa I, Bixo M, Wulff M, Bondestam K, Astrom M. Point prevalence of psychiatric disorders during the second trimester of pregnancy: a populationbased study. Am J Obstet Gynecol 2003;189: 148-54. 21. Lee DTS, Chan SSM, Sahota DS, Yip ASK, Tsui M, Chung TKH. A prevalence study of antenatal depression among Chinese women. J Affect Disord 2004;82:93-9. 22. Kim HG, Mandell M, Crandall C, Kuskowski MA, Dieperink B, Buchberger RL. Antenatal psychiatric illness and adequacy of prenatal care in an ethnically diverse inner-city obstetric population. Arch Womens Ment Health 2006;9:103-7. 23. Dietz PM, Williams SB, Callaghan WM, Bachman DJ, Whitlock EP, Hornbrook MC. Clinically identified maternal depression before, during, and after pregnancies ending in live births. Am J Psychiatry 2007;164:1515-20. 24. Bilszta JLC, Gu YZ, Meyer D, Buist AE. A geographic comparison of the prevalence and risk factors for postnatal depression in an Australian population. Aust N Z J Public Health 2008;32:424-30. 25. Senturk V, Abas M, Berksun O, Stewart R. Social support and antenatal depression in extended and nuclear family environments in Turkey: a cross-sectional survey. BMC Psychiatry 2011;11:48. 26. Giardinelli L, Innocenti A, Benni L, et al. Depression and anxiety in perinatal period: prevalence and risk factors in an Italian sample. Arch Womens Ment Health 2012;15:21-30. 27. Moses-Kolko EL, Roth EK. Antepartum and postpartum depression: healthy mom, healthy

9.e1 American Journal of Obstetrics & Gynecology MONTH 2013

baby. J Am Med Womens Assoc 2004;59: 181-91. 28. Freeman MP, Wright R, Watchman M, et al. Postpartum depression assessments at wellbaby visits: screening feasibility, prevalence, and risk factors. J Womens Health 2005;14: 929-35. 29. Berle JO. Psychiatric conditions in pregnancy and postpartum. Acta Obstet Gynecol Scand 2012;91:38. 30. Da Silva RA, Jansen K, Souza LDDM, et al. Depression during pregnancy in the Brazilian public health care system. Rev Brasil Psiquiatr 2010;32:139-44. 31. Sawyer A, Ayers S, Smith H. Pre- and postnatal psychological wellbeing in Africa: a systematic review. J Affect Disord 2010;123: 17-29. 32. Nasreen HE, Kabir ZN, Forsell Y, Edhborg M. Prevalence and associated factors of depressive and anxiety symptoms during pregnancy: a population based study in rural Bangladesh. BMC Womens Health 2011;11:22. 33. Rochat TJ, Tomlinson M, Barnighausen T, Newell M-L, Stein A. The prevalence and clinical presentation of antenatal depression in rural South Africa. J Affect Disord 2011;135:362-73. 34. Keleher V, Nyunt SZ, Broekman B, Chee C. Prevalence and risk factors for antenatal depression in pregnant women attending National University Hospital, Singapore. Eur Psychiatry 2012;27:1210. 35. Miller LJ, Ruckstalis M. Hypotheses about postpartum reactivity. In: Miller LJ, ed. Postpartum mood disorder. Washington, DC: American Psychiatric Press; 1999.p.262-5. 36. Pitt B. Maternity blues. Br J Psychiatry 1973;122:431-3. 37. Gold LH. Postpartum disorders in primary care: diagnosis and treatment. Prim Care 2002;29:27-41. 38. Terp IM, Mortensen PB. Post-partum psychoses: clinical diagnoses and relative risk of admission after parturition. Br J Psychiatry 1998;172:521-6. 39. Munk-Olsen T, Laursen TM, MeltzerBrody S, Mortensen PB, Jones I. Psychiatric disorders with postpartum onset: possible early manifestations of bipolar affective disorders. Arch Gen Psychiatry 2012;69:428-34. 40. Freeman MP, Smith KW, Freeman SA, et al. The impact of reproductive events on the course of bipolar disorder in women. J Clin Psychiatry 2002;63:284-7. 41. Di Florio A, Forty L, Gordon-Smith K, et al. Perinatal episodes across the mood disorder spectrum. JAMA Psychiatry 2013;70:168-75. 42. Kendell RE, Chalmers JC, Platz C. Epidemiology of puerperal psychosis. Br J Psychiatry 1987;150:662-73. 43. Heron J, Robertson Blackmore E, McGuinness M, Craddock N, Jones I. No ‘latent period’ in the onset of bipolar affective puerperal psychosis. Arch Womens Ment Health 2007;10: 79-81. 44. Bixo M, Sundstrom-Poromaa I, Bjorn I, Astrom M. Patients with psychiatric disorders in

Obstetrics

www.AJOG.org gynecologic practice. Am J Obstet Gynecol 2001;185:396-402. 45. Soderquist J, Wijma K, Wijma B. Traumatic stress in late pregnancy. J Anxiety Disord 2004;18:127-42. 46. Ayers S, Joseph S, McKenzie-McHarg K, Slade P, Wijma K. Post-traumatic stress disorder following childbirth: current issues and recommendations for future research. J Psychosom Obstet Gynecol 2008;29:240-50. 47. Seng JS, Low LK, Sperlich M, Ronis DL, Liberzon I. Prevalence, trauma history, and risk for posttraumatic stress disorder among nulliparous women in maternity care. Obstet Gynecol 2009;114:839-47. 48. Zambaldi CF, Cantilino A, Sougey EB. Bio-socio-demographic factors associated with post-traumatic stress disorder in a sample of postpartum Brazilian women. Arch Womens Ment Health 2011;14:435-9. 49. Wenzel A, Haugen EN, Jackson LC, Brendle JR. Anxiety symptoms and disorders at eight weeks postpartum. J Anxiety Disord 2005;19:295-311. 50. Ross LE, McLean LM. Anxiety disorders during pregnancy and the postpartum period: a systematic review. J Clin Psychiatry 2006;67: 1285-98. 51. Giardinelli L, Cecchelli C, Innocenti A. Psychiatric disorders in pregnancy. Ital J Psychopathol 2008;14:211-9. 52. Chaudron LH, Nirodi N. The obsessivecompulsive spectrum in the perinatal period: a prospective pilot study. Arch Womens Ment Health 2010;13:403-10. 53. Rouhe H, Salmela-Aro K, Gissler M, Halmesmaki E, Saisto T. Mental health problems common in women with fear of childbirth. BJOG 2011;118:1104-11. 54. Ryding EL. Investigation of 33 women who demanded a caesarean section for personal reasons. Acta Obstet Gynecol Scand 1993;72: 280-5. 55. Sjogren B, Thomassen P. Obstetric outcome in 100 women with severe anxiety over childbirth. Acta Obstet Gynecol Scand 1997;76: 948-52. 56. Saisto T, Salmela-Aro K, Nurmi JE, Kononen T, Halmesmaki E. A randomized controlled trial of intervention in the fear of childbirth. Obstet Gynecol 2001;98:820-6. 57. Nerum H, Halvorsen L, Sorlie T, Oian P. Maternal request for caesarean section due to fear of birth: can it be changed through crisisoriented counseling? Birth 2006;33:221-8. 58. Einarson A, Boskovic R. Use and safety of antipsychotic drugs during pregnancy. J Psychiatr Pract 2009;15:183-92. 59. Seeman MV. Clinical interventions for women with schizophrenia: pregnancy. Clinical recommendation. Acta Psychiatr Scand 2012;127:12-22. 60. Robinson GE. Treatment of schizophrenia in pregnancy and postpartum. J Popul Ther Clin Pharmacol 2012;19:380-6. 61. Altshuler LL, Cohen L, Szuba MP, Burt VK, Gitlin M, Mintz J. Pharmacologic management of

psychiatric illness during pregnancy: dilemmas and guidelines. Am J Psychiatry 1996;153: 592-606. 62. Trixler M, Gati A, Fekete S, Tenyi T. Use of antipsychotics in the management of schizophrenia during pregnancy. Drugs 2005;65: 1193-206. 63. Jones I, Lendon C, Coyle N, Robertson E, Brockington I, Craddock N. Molecular genetic approaches to puerperal psychosis. Prog Brain Res 2001;133:321-31. 64. Harlow BL, Vitonis AF, Sparen P, Cnattingius S, Joffe H, Hultman CM. Incidence of hospitalization for postpartum psychotic and bipolar episodes in women with and without prior pre-pregnancy or prenatal psychiatric hospitalizations. Arch Gen Psychiatry 2007;64:42-8. 65. McCauley-Elsom K, Kulkarni J. Managing psychosis in pregnancy. Aust N Z J Psychiatry 2007;41:289-92. 66. Spinelli MG. Postpartum psychosis: detection of risk and management. Am J Psychiatry 2009;166:405-8. 67. Brockington IF. Puerperal psychosis. In: Brockington IF, ed. Motherhood and mental health. Oxford, UK: Oxford University Press; 1996:200-84. 68. Newport DJ, Hostetter A, Arnold A, Stowe ZN. The treatment of postpartum depression: minimizing infant exposures. J Clin Psychiatry 2002;63:31-44. 69. Chaudron LH, Pies RW. The relationship between postpartum psychosis and bipolar disorder: a review. J Clin Psychiatry 2003;64: 1284-92. 70. Havens JR, Simmons LA, Shannon LM, Hansen WF. Factors associated with substance use during pregnancy: results from a national sample. Drug Alcohol Depend 2009;99:89-95. 71. Albright BB, Rayburn WF. Substance abuse among reproductive age women. Obstet Gynecol Clin North Am 2009;36:891-906. 72. Terplan M, Smith EJ, Kozloski MJ, Pollack HA. Methamphetamine use among pregnant women. Obstet Gynecol 2009;113: 1285-91. 73. Kelly R, Zatzick D, Anders T. The detection and treatment of psychiatric disorders and substance use among pregnant women cared for in obstetrics. Am J Psychiatry 2001;158: 213-9. 74. Oei JL, Kingsbury A, Dhawan A, et al. Amphetamines, the pregnant woman and her children: a review. J Perinatol 2012;32:737-47. 75. Freeman MP. Perinatal mental health: new data regarding risk factors and treatment considerations. J Clin Psychiatry 2009;70:1289-90. 76. Lancaster CA, Gold KJ, Flynn HA, Yoo H, Marcus SM, Davis MM. Risk factors for depressive symptoms during pregnancy: a systematic review. Am J Obstet Gynecol 2010;202:5-14. 77. Stewart DE. Clinical practice: depression during pregnancy. N Engl J Med 2011;365: 1605-11. 78. Altemus M, Neeb CC, Davis A, Occhiogrosso M, Nguyen T, Bleiberg KL.

Review

Phenotypic differences between pregnancyonset and postpartum-onset major depressive disorder. J Clin Psychiatry 2012;73: 1485-91. 79. Dudas RB, Csatordai S, Devosa I, et al. Obstetric and psychosocial risk factors for depressive symptoms during pregnancy. Psychiatr Res 2012;200:323-8. 80. Treloar SA, Martin NG, Bucholz KK, et al. Genetic influences on post-natal depressive symptoms: findings from an Australian twin sample. Psychol Med 1999;29:645-54. 81. Zonana J, Gorman JM. The neurobiology of postnatal depression. CNS Spectr 2005;10: 792-9, 805. 82. Harris B. Hormonal aspects of postnatal depression. Int Rev Psychiatry 1996;8:27-36. 83. Lee DTS, Chung TKH. Postnatal depression: an update. Best Pract Res Clin Obstet Gynaecol 2007;21:183-91. 84. Lin Y-MJ, Ko H-C, Chang F-M, Yeh T-L, Sun HS. Population-specific functional variant of the TPH2 gene 2755C. A polymorphism contributes risk association to major depression and anxiety in Chinese peripartum women. Arch Womens Ment Health 2009;12: 401-8. 85. Banti S, Mauri M, Oppo A, et al. From the third month of pregnancy to 1 year postpartum. Prevalence, incidence, recurrence, and new onset of depression. Results from the Perinatal Depression-Research and Screening Unit study. Compr Psychiatry 2011;52:343-51. 86. Witt WP, Wisk LE, Cheng ER, et al. Poor prepregnancy and antepartum mental health predicts postpartum mental health problems among US women: a nationally representative population-based study. Womens Health Issues 2011;21:304-13. 87. Matthey S, Barnett B, Howie P, Kavanagh DJ. Diagnosing postpartum depression in mothers and fathers: whatever happened to anxiety? J Affect Disord 2003;74:139-47. 88. Alipour Z, Lamyian M, Hajizadeh E. Anxiety and fear of childbirth as predictors of postnatal depression in nulliparous women. Women Birth 2012;25:37-43. 89. Garcia-Esteve L, Navarro P, Ascaso C, et al. Family caregiver role and premenstrual syndrome as associated factors for postnatal depression. Arch Womens Ment Health 2008;11:193-200. 90. Tian T, Xie D, Shen Y, et al. Clinical features and risk factors for post-partum depression in a large cohort of Chinese women with recurrent major depressive disorder. J Affect Disord 2012;136:983-7. 91. Buttner MM, Mott SL, Pearlstein T, Stuart S, Zlotnick C, O’Hara MW. Examination of premenstrual symptoms as a risk factor for depression in postpartum women. Arch Womens Ment Health 2013;16:219-25. 92. Sylvén SM, Ekselius L, SundströmPoromaa I, Skalkidou A. Premenstrual syndrome and dysphoric disorder as risk factors for postpartum depression. Acta Obstet Gynecol Scand 2013;92:178-84.

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