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Perinatal Psychiatry: An Emerging Specialty

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Perinatal Psychiatry: An Emerging Specialty

As our field has seen a growing amount of evidence-based publications on topics within perinatal psychiatry, it is both easier to offer treatment to women who are pregnant, planning pregnancy, or postpartum and at the same time more difficult to keep up with the amassing literature. Within perinatal psychiatry, there is the dilemma of the need for an adequate number of multidisciplinary health care providers to deliver treatment, while the individual risk/benefit analyses and treatments are complex and, it could be argued, require the expertise and time of a clinician well versed in perinatal psychiatry. Has the time come for a recognized specialty in Perinatal Psychiatry? Or is the information available adequately disseminated and understood to support the treatment of perinatal women more broadly? At JCP, we hope that the publication of these papers in Perinatal Psychiatry adds to the knowledge base for specialized Perinatal Psychiatrists, as well as those with an interest in these topics.

This month’s Focus on Women’s Mental Health section includes an important, cutting-edge systematic review of the infant and childhood outcomes of antenatal depression and antidepressant exposure. Suri and colleagues separate their summaries of prospective studies into those assessing short-term outcomes (within the first 2 weeks of infant age) and those assessing longer-term outcomes (6 months to 18 years). Their review addresses a complex literature in which human studies are mired by confounding variables. However, they succinctly summarize the prospective studies in this area and discuss their clinical relevance. The text and tables summarizing the studies will most certainly be a rich resource for clinicians who are interested in the risks and benefits of antidepressant treatment during pregnancy.

As Suri et al provide the review of the literature to date, Santucci and colleagues add a valuable contribution to the original research in this area. They prospectively assessed infant outcomes in 3 maternal groups: (1) those with major depressive disorder (MDD) and serotonin reuptake inhibitor (SRI) exposure, (2) those with MDD but no SRI exposure, and (3) healthy controls. Assessments began during pregnancy and occurred up to 78 weeks postpartum. The primary outcomes were the Bayley Scales of Infant Development, which included psychomotor, cognitive, and behavioral components. Neither MDD nor antidepressant exposure appeared to significantly impact any of the subscales of the Bayley Scales. The authors did, however, demonstrate time interactions on the psychomotor subscale for infants of mothers with both SRI exposure and MDD, compared to mothers with MDD and no antidepressant exposure and controls. The difference was significant at 26 and 52 weeks, but transient, as it was not different at 78 weeks, suggesting a lack of longer-term effects. Santucci et al wisely discuss that prospective studies with multiple assessments of infant outcomes over time are needed. While the authors acknowledge as a limitation the relatively small number of participants, this study represents a relatively large number of mother-infant dyads considering the relative paucity of data in this critical area. The study also included assessment of infant outcomes after antidepressant exposure in utero, with a meaningful control group of women with depression but not medication exposure. Inclusion of this group is crucial, as studies of medication exposure are usually confounded by potential effects of the underlying illness.

Kapfhammer and colleagues report findings regarding the course of postpartum psychosis. In a retrospective study, they assessed course and risk factors of postpartum psychosis in a relatively large sample in a disorder that remains understudied. Their sample consisted of 90 women who had an onset of postpartum psychosis within 4 weeks of delivery and were hospitalized. Notably, in assessing the eligibility of cases, there were 6 patients who had committed suicide and therefore were not included, a sobering reminder of the potential lethality of this condition. The episode of postpartum psychosis represented new-onset psychosis in 55 of the 90 women. Diagnosis at onset was largely represented by bipolar disorder, as well as diagnoses further out during the course of illness, consistent with the body of evidence on postpartum psychosis. The investigators found a high risk of relapse for psychotic episodes during the years after the index episode, both in general and following subsequent pregnancies. In the majority of patients, the onset of psychosis was swift after delivery, with onset and hospitalization occurring within 1 week. This finding has important clinical significance. First, it makes clear the need to educate multidisciplinary health care providers about the presentation of postpartum psychosis and its potentially lethal consequences. Second, the finding raises the question of when pharmacologic prophylaxis should start for subsequent deliveries, as the illness onset may be so early that starting an antipsychotic or mood stabilizer after delivery may in fact be too late for women who are at high risk for recurrence. Since the onset can be so rapid, an educated public is also important, as family and friends may be the ones who are best able to detect this serious condition. Underscoring the severity of postpartum psychosis is the reality that the majority of women represented in this study elected not to have more children.

Finally, our group (Goodman et al) presents a systematic review of anxiety disorders during pregnancy. As the study of depression during pregnancy still leaves us with many unknowns that apply to the clinical care of women, there is a much greater paucity of data for anxiety disorders during pregnancy. Most of the available literature on anxiety during pregnancy pertains to prevalence and course; clinical studies are much needed in this area. Importantly, anxiety during pregnancy must be addressed with respect to its heterogeneity in terms of disorders and severity, and there is a substantial need for treatment research.

We thank the authors of these articles for their valuable contributions to the field of women’s mental health, and specifically perinatal psychiatry.

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J Clin Psychiatry 2014;75(10):1086-1087

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