Anxiety disorders among pregnant and postpartum women

Nichole Fairbrother PhD (biography and disclosures) Disclosures: Dr. Nichole Fairbrother is a registered psychologist and the director of the UBC Perinatal Anxiety Research Lab (PARLab) where the team is currently developing two trials of CBT for perinatal AD and has an application for funding under review with the Canadian Institutes of Health Research for a study of perinatal anxiety screening tools. Mitigating potential bias: Only published trial data is presented. Recommendations are consistent with current practice patterns.

What I have noticed

The anxiety and their related disorders (AD) include the core anxiety disorders (panic disorder, agoraphobia, generalized anxiety disorders, social anxiety disorders, and specific phobia) as well as obsessive-compulsive disorder and post-traumatic stress disorder.¹ The ADs are the most prevalent of all psychiatric conditions.² Nearly one-third (28.8%) of the adult population will suffer from an AD at some time in their life.² This is significantly greater than the prevalence of the mood disorders (i.e., depressive and bipolar disorders) at 20.8%.² Women are also 1.6 times as likely as are men to suffer from an AD.²

A recent meta-analysis places the prevalence of perinatal AD at 20.7%. This is significantly more common than postpartum depression at approximately 13% (this includes both minor and major depressive disorder combined).³ This is important because, with justification, much attention has been given to perinatal depression, but despite being more common, very little attention has been given to perinatal AD. This is problematic for the reasons outlined below.

Data that answers these questions

ADs are associated with substantial indirect costs related to functional impairment (e.g., diminished work capacity, unemployment).^4,5 People with AD are significantly more impaired with respect to social, emotional and physical functioning compared with non-anxious individuals.⁶ In Canada, ADs are associated with high levels of health care service utilization.^7-10 Maternal prenatal anxiety is also strongly associated with adverse pregnancy outcomes such as miscarriage, preeclampsia, preterm delivery, and low birth weight.^11-13 Children of mothers high in antenatal anxiety have twice the risk for attention-deficit/hyperactivity disorder (ADHD).^14,15 Prenatal anxiety is a strong predictor of postpartum depression, even after controlling for prenatal depression.^16-18 Prenatally anxious women interact less skillfully and communicate less with their infants, and have children more likely to be behaviourally inhibited and insecurely attached.^19,20 Postpartum maternal anxiety is associated with impaired adaptability, negative mood and soothing difficulty in the infant.²¹

Obsessive-compulsive disorder (OCD) is the only AD for which there is compelling evidence of an increase in the onset and exacerbation of the disorder among pregnant and postpartum women. This effect is the strongest in the postpartum period^23-26. In a recent meta-analysis, the prevalence of maternal pp OCD was reported to be 2.5%, significantly higher than the 12-month prevalence rate of OCD among adult women, estimated at 1.6%²⁷.

Postpartum OCD is characterized by rapid onset and the content of obsessions occurring in pp OCD most often revolves around fears of harming, or of harm coming to one’s infant (images of smothering one’s infant, throwing the infant off the balcony, and touching the infant in a sexual way).²⁸  This is a potentially debilitating disorder and the types of obsessions are extremely distressing to the parent. There is also evidence that perinatal OCD negatively affects parenting and consequently the developing infant²⁹. Further, anecdotal reports of new mothers who reported harm obsessions indicate that, in some instances, women were monitored, as if they were at high risk of child abuse, with some having had their children removed from their care.

Unwanted, intrusive thoughts of accidental harm to one’s infant are reported by 100% of new mothers, and unwanted, intrusive thoughts of intentionally harming one’s infant are reported by 50% of new mothers.³⁰ These thoughts occur among women who have no history of violence or instability, and who hold a deep desire to protect and care for their infant.^31-35 Examples include: “What if I throw her overboard on the ferry?” and “I had a horrible image of me flushing the baby down the toilet.” These thoughts can be extremely upsetting to the parents who experience them.^31-34 Thoughts of intentional harm, compared with thoughts of accidental harm, have been found to be less frequent and less time-consuming, but more distressing.

Protection of the infant is paramount in all cases. If intrusive thoughts of harm are predictable harbingers of violence, then acting to protect the infant is appropriate and necessary. However, postpartum harm thoughts are actually a common and normative postpartum experience that does not signal potential danger to the infant,^32-34. Taking dramatic steps (e.g., intense monitoring of the mother or removal of the infant) is unnecessary and may result in serious negative consequences for the mother’s mental health, as well as the mother-infant relationship. Specifically, if a new mother becomes unnecessarily anxious and worried that she is a threat to her infant, her worry about her own thoughts may lead to the development of obsessive-compulsive disorder (OCD).^22,36 To date, there is no evidence of a relationship between unwanted, intrusive thoughts of infant-related harm and child abuse.

To date, no effective, evidence-based, screening measures for perinatal AD have been identified.³⁷ In general, studies of perinatal anxiety screening tools have been poorly conducted.³⁷ Although the Edinburgh Postnatal Depression Scale (EPDS) and the Generalized Anxiety Disorder 7 (GAD-7) and its briefer GAD-2 are commonly used to screen for perinatal AD, current evidence does not support their use as effective screening tools for these disorders.³⁷

What I recommend (practice tip)

The following approaches to perinatal AD screening may be effective: (a) ask specifically about each disorder (i.e., panic disorder, generalized anxiety disorder, etc.), and (b) include questions about perinatal specific symptoms (e.g., fear of childbirth, harming obsessions, birth trauma, pregnancy-specific worries).

Cognitive behaviour therapy (CBT) has been shown to be equally if not more effective than medication at posttreatment and follow up, and the kinds of medications most often prescribed for AD (e.g., selective serotonin reuptake inhibitors [SSRIs] and norepinephrine reuptake inhibitors [SNRIs]) are associated with possible negative outcomes for the infant.^38-40 Although these outcomes are typically mild and short term, CBT offers significant protection against relapse and women generally prefer talk therapy to medication treatment. At present, very few trials of CBT for perinatal AD have been conducted. Exceptions include fear of childbirth and OCD.²⁹ A pilot trial of CBT for postnatal OCD has been found to be effective.

To better serve pregnant and postpartum women who suffer from one or more perinatal AD, I recommend the following:

• Until an effective screening instrument is identified, ask pregnant and postpartum women directly about the kinds of fears common to this population (e.g., excessive worry about the pregnancy/infant, fear of childbirth, thoughts of harm, and birth trauma) and follow up with a complete mental health assessment as needed.
• Educate pregnant women about postpartum intrusions of harm. This education has been shown to reduce the intensity of postpartum symptoms of OCD.
• Ask specifically about unwanted, intrusive thoughts of infant-related harm. As women are often reluctant to disclose these types of thoughts out of fear that their infant may be removed from their care, I suggest the following approach:
  • Normalize the occurrence of the thoughts. The authors of this practice tip typically share their own unwanted, intrusive postpartum thoughts of infant-related harm to reassure patients that these kinds of thoughts are a normal postpartum experience.
  • Reassure women that, in the absence of any additional risk factors for child abuse, disclosure of these thoughts will not result in any action on the part of the care provider / physician.
• In optimal circumstances women should be offered the choice between CBT or medication or both and provided with sufficient information about the pros and cons of each to make this decision. However, CBT is frequently not publicly funded and many women are unable to afford the out of pocket costs. These pragmatic considerations should be taken into account when advising women.

Resources

1. Anxiety Canada https://www.anxietycanada.com/parents
2. Antenatal and postnatal mental health: clinical management and service guidance https://www.nice.org.uk/guidance/cg192/chapter/1-recommendations
3. Reproductive Mental Health Canadahttps://reproductivementalhealth.ca
4. Risk factors of child abuse http://www.childmatters.org.nz/57/learn-about-child-abuse/risk-factors

References

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