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Focus on Women's Mental Health

Pregnancy and Psychiatric Disorders: Inherent Risks and Treatment Decisions

Pregnancy and Psychiatric Disorders: Inherent Risks and Treatment Decisions

Pregnancy is a risky endeavor. According to the Centers for Disease Control and Prevention, about 3% of pregnancies in the United States are complicated by birth defects, which is a substantial number per year (http://www.cdc.gov/NCBDDD/birthdefects/facts.html). The task of assessing the risks and benefits of antidepressant use for the treatment of depression during pregnancy is complicated. Psychiatric disorders are heterogeneous and affect many factors that may be integral in pregnancy health and outcomes. Antidepressant medications have received much study in pregnancy, with a preponderance of literature presenting reassuring findings, and more limited data raising concerns. The fact that clear patterns of negative outcomes are not demonstrated is in itself reassuring, as known teratogens carry risks of birth defects that are delineated in studies with consistently found and similar malformations. Depression represents a physiologically important exposure and may affect pregnancy outcomes. Depression also more indirectly may impact pregnancy outcomes by affecting core homeostatic systems (such as appetite and stress response) and lifestyle factors (such as substance use and engagement in prenatal care).

We are pleased to publish a collection of important new articles by Grigoriadis and colleagues that adds to the literature on the important topics of pregnancy, depression, and in utero antidepressant exposure. These 3 articles can be found online at PSYCHIATRIST.COM. They address major issues related to the treatment of depression during pregnancy, including the impact of maternal depression on pregnancy outcomes, the effect of prenatal antidepressant use on neonatal adaptation, and antidepressant use and congenital malformations. These articles all inform the field with systematic reviews and meta-analyses of key areas of clinical importance.

Also in this issue, Russell and colleagues report on the risk of obsessive-compulsive disorder (OCD) in perinatal women. They found that the rates of OCD in pregnant and postpartum women are higher than that in the general female population. Rates for the general population are around 1%, and rates in pregnant and postpartum women are 1.45 and 2.38%, respectively. Obsessive thoughts are even more common in pregnant and postpartum women. In clinical practice, OCD symptoms are often seen in postpartum women, and, not uncommonly, women may have disturbing obsessions such as thoughts about harming their babies. Due to the content of many obsessions reported during pregnancy and the postpartum, there must be careful differentiation between obsessions, which typically are experienced as distressing and illogical, compared with postpartum psychosis, in which reality testing and insight are impaired. Also, many women feel shame around obsessive thoughts and are reluctant to report them to clinicians. The authors’ discussion about screening is therefore an important one.

Another important topic for women’s mental health is that of infertility treatment. Bloch and colleagues provide data in the arena of psychiatric disorders and infertility treatment. In a sample of women undergoing in vitro fertilization (IVF), they compared a subset of women with lifetime depression or anxiety disorders to women without a history of psychiatric disorders. The authors prospectively assessed mood and anxiety symptoms, as well as plasma cortisol levels, across an IVF cycle. In consideration of the stressful context, they demonstrated that women with histories of depression or anxiety had symptomatic worsening during the IVF cycle. Although women with and without lifetime psychopathology had similar levels of symptom burden at the initiation of the cycle, women with histories of depression or anxiety had significantly elevated symptoms at follow-up time points during the cycle. The 2 groups with and without lifetime diagnoses of depression or anxiety also displayed different patterns of cortisol response. Both groups had a demonstrated elevation in cortisol levels across the cycle, but the levels of the group with a history of psychopathology were blunted in comparison to the more continuously elevated cortisol levels in women without such histories. The clinically important manifestations of illness in women at risk for psychiatric disorders and the biological differences in stress responses between groups are compelling, and more research in this area will be important.

In this issue, we are also pleased to present 2 important "negative" studies. Publication of negative studies has great impact on the field, as they inform evidence-based treatment and also may suggest future research directions. In the first such study, Spinelli and colleagues present research findings on psychotherapy for depression during pregnancy. Since psychotherapy is a mainstay for the treatment of depression, it is recommended as a primary treatment for mild-to-moderate depression during pregnancy. Evidence-based use of psychotherapy is a tenet in the care of pregnant women, as efficacious treatments that do not expose the fetus to medication are highly desirable. Spinelli and colleagues report findings from a 12-week interpersonal psychotherapy intervention during pregnancy in comparison to a parent education program. Interestingly, they found both psychotherapeutic interventions to be equally beneficial for women during pregnancy, without specific benefits demonstrated for interpersonal psychotherapy. These findings are of great consequence, because they suggest that aspects of psychotherapy are beneficial for depression during pregnancy and a better understanding of the beneficial components can yield treatments that can be implemented more broadly for a vulnerable population.

Also in this issue, White and Grilo report on a placebo-controlled trial of bupropion for binge-eating disorder. While bupropion was associated with short-term weight loss, it did not have a significant benefit compared to placebo for binge eating, food cravings, or other features of disordered eating. Systematic study of treatments for binge-eating disorder is important, as recognition of this disorder is increasing, and evidence-based guidelines will be of increasing importance.

As always, we thank the authors for their contributions to this issue of our Focus on Women’s Mental Health section. We also thank the reviewers of these articles for their very important contributions as well.

Marlene P. Freeman, MD

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