Perinatal Mood and Anxiety Disorders (PMADs)

Perinatal mood and anxiety disorders (PMAD) encompass a range of mental health conditions, including depression, anxiety, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and psychosis [6]. These conditions are relatively common, affecting 15-21% of pregnant and postpartum women either during pregnancy or within the first year after childbirth [13,4].

Perinatal depression affects one in seven individuals, while perinatal and postpartum anxiety disorders affect 13-21% of pregnant and postpartum women [4]. The term prenatal refers to the period before childbirth, while postpartum refers to the time after birth. PMAD can affect women during pregnancy or after delivery.

Signs and Symptoms

Emotional challenges during pregnancy and the postpartum period manifest as a range of symptoms within perinatal mood and anxiety disorders (PMAD). Recognizing these signs is pivotal for early intervention and support [8, 13].

Signs of PMAD may include one or more of the following [8,13]:

• Mood destabilization: Significant mood swings, ranging from intense sadness to irritability.
• Sleep disturbances: Disruptions in sleep patterns, including insomnia or excessive sleep.
• Changes in appetite: Shifts in appetite, such as losing interest in eating or overeating.
• Difficulty concentrating: Struggles with focus and concentration, impacting daily activities.
• Persistent anxiety: Heightened and persistent feelings of worry, fear, or anxiety symptoms.

 Not every parent with PMAD experiences the same symptoms, but some symptoms may include [13]:

• Depressive symptoms: Feelings of sadness, hopelessness, and a loss of interest in previously enjoyed activities.
• Anxious thoughts: Intrusive and distressing thoughts about the baby’s well-being or oneself.
• Changes in physical activity level or movement speed: Observable changes in physical activity, such as restlessness or slowed movements.
• Fatigue: Persistent feelings of exhaustion beyond what is expected in the postpartum period.
• Intrusive thoughts: Disturbing and unwanted thoughts, often related to harm coming to the baby or oneself.

Understanding these signs and symptoms is critical for the timely identification of PMAD and facilitating effective intervention and support. If you or someone you know exhibits these signs or symptoms, seeking professional help is crucial for your well-being.

Causes and Risk Factors

A combination of biological, psychological, and social factors can cause perinatal mood and anxiety disorders (PMADs). Biological factors involve hormonal fluctuations during pregnancy and postpartum [13]. Women with pre-existing mental health conditions are at a higher risk of developing PMADs during the perinatal period. 60% of women are diagnosed with depressive disorders during this period, and 80% of those diagnosed also have anxiety disorders [4].

Risk factors that increase the likelihood of developing PMADs include [11]:

• History of psychiatric illness: Individuals with a history of depression, anxiety, bipolar disorder, or another mood disorder are at an increased risk.
• Depression and anxiety during pregnancy: Experiencing depression or anxiety during pregnancy is identified as a risk factor.
• Neuroticism and low self-esteem: Psychological factors such as neuroticism and low self-esteem are associated with an elevated risk.
• Postpartum blues: Experiencing postpartum blues and mild mood changes are considered risk factors for developing more severe perinatal mood disorders. However, not all “baby blues” lead to PMADs.
• Stressful life events: High levels of stress, primarily related to life events, contribute to the risk of perinatal mental health issues.
• Poor marital relationship: Difficulties in marital relationships are identified as a risk factor.
• Poor social support: Lack of adequate social support, both practical and emotional, is highlighted as a risk factor.
• Low socioeconomic status and being single: These socioeconomic factors are associated with an increased risk.
• Unwanted pregnancy: Women with unwanted pregnancies may face an elevated risk.
• Obstetrical stressors and difficult infant temperament: Stressful events during pregnancy and challenges related to the infant’s temperament are mentioned as additional risk factors.
• Traumatic or frightening childbirth: Birth complications can have a significant emotional, mental, and physical toll on new mothers, increasing the potential of perinatal mental health challenges.

Risks of Untreated Depression/Anxiety

When perinatal mood and anxiety disorders (PMADs) go untreated, it can have significant effects on both mothers and infants [1]. This means there’s a higher chance of giving birth prematurely, having a baby with low birth weight, and facing challenges in forming a solid connection between the mother and the baby [1].

If left unaddressed, anxiety disorders, perinatal mood disorders, and other challenges during pregnancy may lead to severe outcomes for both women and their children [5]. This includes neglecting medical care, making existing health issues worse, experiencing a decline in support from family, smoking or using substances, and developing postpartum psychosis that could induce self-harming behaviors or harm to the child [5]. It’s crucial to seek help to avoid these potential challenges.

Treatments

During the perinatal period, managing moderate to severe symptoms typically requires a blend of psychiatric medication and psychotherapy [14]. Antidepressants, specifically from the selective serotonin reuptake inhibitor (SSRI) class, are frequently prescribed as first-line treatments for depression and anxiety disorders [14].

Common SSRIs Include:

• Citalopram (Celexa)
• Escitalopram (Lexapro)
• Fluoxetine (Prozac)
• Paroxetine (Paxil)
• Sertraline (Zoloft)

Other types of antidepressants may be used as well and may include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs). The choice of medication depends on the individual’s specific symptoms and medical history.

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs):

• Desvenlafaxine (Pristiq)
• Duloxetine (Cymbalta)
• Venlafaxine XR (Effexor XR)

Other Antidepressants:

• Bupropion (Wellbutrin)
• Trazodone
• Mirtazapine (Remeron)

Anxiolytic or Sleep Aid:

• Lorazepam
• Clonazepam
• Zopiclone (Imovane)

Considerations

When addressing perinatal mental health, choosing the appropriate medication involves careful consideration of various factors to ensure both the mother’s well-being and the safety of the baby [14]. This decision-making process hinges on thoroughly evaluating numerous factors and prioritizing personalized care to navigate the complexities of individual circumstances.

Factors for consideration include [14]:

• Medication choice is guided by safety profile, past response, side-effect tolerance, and existing medical conditions.
• There is no specific preferred antidepressant; the selection is tailored to individual circumstances.
• Adjustments to antidepressant doses may be necessary during pregnancy due to physiological changes.
• Treatment guidelines recommend continuing medication for at least six to 12 months after symptom remission, with gradual tapering based on individual needs.
• Antidepressant use during nursing is generally considered safe, with exposure to breast milk significantly lower than in utero exposure.

 Psychotherapy

Psychotherapy offers various approaches tailored to individuals’ needs, and each method addresses mental health challenges differently, two effective forms of psychotherapy that are commonly used to treat patients with PMAD include CBT and IPT.

Cognitive-behavioral therapy (CBT)

Cognitive-behavioral therapy (CBT) is a structured and practical form of psychotherapy designed to address and manage mental health issues effectively [14]. This short-term approach, typically spanning 6-20 sessions, is goal-oriented and focuses on the immediate problems individuals encounter in their day-to-day lives [14]. CBT aids individuals in developing skills to recognize, question, and modify thoughts, attitudes, and beliefs that contribute to emotional and behavioral challenges [14].

CBT operates on the premise that monitoring and recording thoughts during challenging situations can reveal how thought processes influence emotional problems such as depression and anxiety [14]. The therapy teaches individuals to identify distortions in thinking, view thoughts as ideas rather than facts, and consider situations from different perspectives [14].

CBT has demonstrated efficacy in treating various mental health issues, particularly anxiety and depression, and has been adapted for conditions such as bipolar disorder, eating disorders, generalized anxiety disorder, and posttraumatic stress disorder [14]. Self-help resources based on CBT principles, including computer-based CBT and professionally supported self-management, are available and show increased effectiveness when combined with therapist support [14].

Interpersonal Psychotherapy (IPT)

Interpersonal Psychotherapy (IPT) is a structured form of psychotherapy designed to alleviate symptoms by enhancing interpersonal functioning [14]. Unlike delving into childhood or developmental issues, IPT concentrates on current problems and relationships, offering active, non-neutral, supportive, and hopeful therapist interactions [14]. This time-limited approach typically spans 12–16 weeks, emphasizing interpersonal relationships, communication, and improving social support [14].

The central concept of IPT is that psychological symptoms result from current difficulties in everyday relationships [14]. Four primary focus areas include relationship conflict, life changes affecting self-perception, grief, loss, and challenges initiating or sustaining relationships [14]. Effective strategies for handling these relationship problems often lead to symptom improvement [14].

Complementary and Alternative Medicine

Complementary and Alternative Medicine introduces additional strategies that can complement traditional therapeutic interventions. These alternative treatments include Omega-3 Fatty Acids, Folate, Bright Light Therapy, Exercise, Massage Therapy, and Acupuncture. While these approaches may provide valuable support, it’s important to note that their effectiveness can vary, and individuals should consult with healthcare professionals to determine the most suitable combination for their specific circumstances.

• Omega-3 Fatty Acids [3]: Omega-3 fatty acids, specifically eicosatetraenoic acid (EPA) and docosahexaenoic acid (DHA), have shown promise as complementary treatments for perinatal depression. Studies suggest a significant antidepressant benefit in mood disorders, mainly when used as an augmentation treatment. The recommended dosage is 1 gram EPA + DHA daily for perinatal patients with depression. However, caution is advised, especially when exceeding 3 grams daily, due to potential bleeding risks.
• Folate [3]: Folate, available in various forms, such as folic acid and L-methylfolate, has been studied for its potential role in alleviating depressive symptoms. While studies have shown associations between low folate levels and an increased risk of depression, the evidence for its efficacy in perinatal depression is limited. Nevertheless, folate is recommended as an adjunctive strategy for perinatal unipolar depression, especially for women with low serum folate levels.
• Bright Light Therapy [3]: Bright light therapy has demonstrated efficacy in treating seasonal and non-seasonal major depressive disorder. Recommended as a first-line treatment, the therapy involves exposure to bright light for specific durations. While studies suggest its effectiveness in perinatal depression, careful monitoring is advised, as it may induce mania in individuals with bipolar disorder.
• Exercise [3]: Regular exercise is integral to overall health, and studies have suggested its association with decreased risk of depressive symptoms. Regular aerobic and strength-conditioning exercise during the perinatal period is recommended for pregnant women without medical contraindications. Despite limited evidence for its effectiveness in treating perinatal depression, exercise remains crucial for general health.
• Massage Therapy [3]: Massage therapy, encompassing various techniques, has been studied for its potential health benefits, including reducing depressive symptoms. For perinatal women with mild depression symptomatology, weekly sessions of 20 minutes of massage therapy may be a reasonable consideration. The treatment has shown efficacy in both non-perinatal and perinatal populations, with associated neuroendocrine effects.
• Acupuncture [3]: Acupuncture, a longstanding component of Asian medicine, has shown inconsistent results regarding its efficacy in treating depression. While some studies suggest positive outcomes, particularly in perinatal depression, the evidence is not yet conclusive. Acupuncture may be considered as part of a treatment plan for perinatal depression. Still, it is premature to recommend it as a first-line treatment due to limited safety and efficacy data.

 Transcranial Magnetic Stimulation (TMS)

Transcranial Magnetic Stimulation (TMS) is an innovative and non-invasive treatment that has shown promise in treating various conditions, including Generalized Anxiety Disorder (GAD) and Posttraumatic Stress Disorder (PTSD) [2]. It may also be an effective treatment option for addressing perinatal mood and anxiety disorders.

TMS uses magnetic fields to target specific brain regions and has shown promise as an effective and generally safe treatment that is well-tolerated by patients [2]. Early research suggests that it could be an alternative to conventional medications for addressing Postpartum Depression (PPD) in women [7].

Studies conducted by the Massachusetts General Hospital (MGH) highlight the efficacy of repetitive Transcranial Magnetic Stimulation (rTMS) in gradually alleviating depressive symptoms in women with PPD, presenting it as a potential treatment option [7]. However, ongoing research is exploring its effectiveness in severe or treatment-resistant depression and considering alternative interventions such as Electroconvulsive Therapy (ECT) [7].

Several studies indicate favorable outcomes of rTMS in perinatal depression, especially during the postpartum period. Importantly, minimal side effects were observed for mothers, with no adverse effects on newborns, even during breastfeeding [12]. While generally considered safe and well-tolerated, rTMS may involve mild and short-term side effects like discomfort at the application site, muscle contractions, tingling sensations, headaches, and occasional lightheadedness [10].

A systematic review affirms the safety, feasibility, and well-tolerance of TMS in women with peripartum depression, including its impact on the developing fetus [9]. This evidence contributes to understanding TMS as a potential treatment modality for perinatal mood and anxiety disorders [9].

 Seek Help for PMADs

Understanding and addressing PMADs is vital for the well-being of mothers and infants. Early recognition, practical insights, and a range of treatment options empower individuals to navigate this complex aspect of perinatal mental health. Whether opting for traditional therapies or exploring innovative alternatives, the key lies in informed decisions and timely intervention.

If you or a loved one is navigating the complexities of perinatal mood and anxiety disorders, remember that support is available. Contact Neuro Wellness Spa today for compassionate and personalized assistance. Our dedicated team is here to provide understanding, guidance, and practical solutions tailored to your unique needs. Take the first step towards a healthier and happier journey through perinatal mental health. Reach out to Neuro Wellness Spa to learn more about our psychiatry and medication management or TMS therapy – because your well-being matters.

References

1. Ayala, N. K., Lewkowitz, A. K., Whelan, A. R., & Miller, E. S. (2023). Perinatal Mental Health Disorders: A Review of Lessons Learned from Obstetric Care Settings. Neuropsychiatric disease and treatment, 19, 427–432. https://doi.org/10.2147/NDT.S292734
2. Cirillo, P., Gold, A. K., Nardi, A. E., Ornelas, A. C., Nierenberg, A. A., Camprodon, J., & Kinrys, G. (2019). Transcranial magnetic stimulation in anxiety and trauma-related disorders: A systematic review and meta-analysis. Brain and behavior, 9(6), e01284. https://doi.org/10.1002/brb3.1284
3. Deligiannidis, K. M., & Freeman, M. P. (2014). Complementary and alternative medicine therapies for perinatal depression. Best practice & research. Clinical obstetrics & gynaecology, 28(1), 85–95. https://doi.org/10.1016/j.bpobgyn.2013.08.007
4. Hernandez, N. D., Francis, S., Allen, M., Bellamy, E., Sims, O. T., Oh, H., Guillaume, D., Parker, A., & Chandler, R. (2022). Prevalence and predictors of symptoms of Perinatal Mood and Anxiety Disorders among a sample of Urban Black Women in the South. Maternal and Child Health Journal, 26(4), 770–777. https://doi.org/10.1007/s10995-022-03425-2
5. Kendig, S., Keats, J. P., Hoffman, M. C., Kay, L. B., Miller, E. S., Moore Simas, T. A., Frieder, A., Hackley, B., Indman, P., Raines, C., Semenuk, K., Wisner, K. L., & Lemieux, L. A. (2017). Consensus Bundle on Maternal Mental Health: Perinatal Depression and Anxiety. Obstetrics and gynecology, 129(3), 422–430. https://doi.org/10.1097/AOG.0000000000001902
6. McKee, K., Admon, L. K., Winkelman, T. N. A., Muzik, M., Hall, S., Dalton, V. K., & Zivin, K. (2020). Perinatal mood and anxiety disorders, serious mental illness, and delivery-related health outcomes, United States, 2006-2015. BMC women’s health, 20(1), 150. https://doi.org/10.1186/s12905-020-00996-6
7. MGH Center for Women’s Health (2020, March 18). Is Transcranial Magnetic Stimulation Effective for Postpartum Depression? https://womensmentalhealth.org/posts/tms-for-ppd/
8. Misri, S., Abizadeh, J., Sanders, S., & Swift, E. (2015). Perinatal Generalized Anxiety Disorder: Assessment and Treatment. Journal of women’s health (2002), 24(9), 762–770. https://doi.org/10.1089/jwh.2014.5150
9. Miuli, A., Pettorruso, M., Stefanelli, G., Giovannetti, G., Cavallotto, C., Susini, O., Pasino, A., Bubbico, G., De Risio, L., Petta, G. D., Sensi, S. L., D’Antonio, F., & Martinotti, G. (2023). Beyond the efficacy of transcranial magnetic stimulation in peripartum depression: A systematic review exploring perinatal safety for newborns. Psychiatry Research, 326, 115251. https://doi.org/10.1016/j.psychres.2023.115251
10. National Institute of Mental Health (n.d.). Perinatal Depression. https://www.nimh.nih.gov/health/publications/perinatal-depression
11. O’Hara, M. W., & Wisner, K. L. (2014). Perinatal mental illness: definition, description, and aetiology. Best practice & research. Clinical obstetrics & gynaecology, 28(1), 3–12. https://doi.org/10.1016/j.bpobgyn.2013.09.002
12. Pacheco, F., Guiomar, R., Brunoni, A. R., Buhagiar, R., Evagorou, O., Roca-Lecumberri, A., Poleszczyk, A., Lambregtse-van den Berg, M., Caparros-Gonzalez, R. A., Fonseca, A., Osório, A., Soliman, M., & Ganho-Ávila, A. (2021). Efficacy of non-invasive brain stimulation in decreasing depression symptoms during the peripartum period: A systematic review. Journal of psychiatric research, 140, 443–460. https://doi.org/10.1016/j.jpsychires.2021.06.005
13. Robakis, T., Jernick, E., & Williams, K. (2017). Recent advances in understanding maternal perinatal mood disorders. F1000Research, 6, F1000 Faculty Rev-916. https://doi.org/10.12688/f1000research.10560.1
14. The Centre for Addiction and Mental Health (n.d.). Perinatal Mood and Anxiety Disorders. https://www.camh.ca/en/professionals/treating-conditions-and-disorders/perinatal-mood-and-anxiety-disorders