Gravedad específica

SSRIs and SNRIs (antidepressants) are first line treatment for women who require regular treatment for anxiety disorders.

Benzodiazepines may be useful on a PRN or regularly scheduled but time-limited basis. Long term use is discouraged as tolerance readily develops and withdrawal symptoms are common upon discontinuation. Benzodiazepines and other hypnotics (non-benzodiazepines) may be useful on a PRN basis for intermittent insomnia.

Quetiapine (Seroquel XR®_{), an atypical antipsychotic medication, may be considered for women with a severe}

anxiety disorder who have had only a partial response to antidepressants and benzodiazepines. This can be particularly helpful for women with severe obsessive compulsive disorder.

Key points and recommendations related to prescribing antidepressant medications in the perinatal period are provided in section 4.4.

Refer to Appendix 5 for current information (as of March 2013) about specific medications commonly used in the perinatal period for the treatment of anxiety disorders.

4.4 Key Points and Recommendations

Key points

⦁ Anxiety disorders and depression often co-exist. ⦁

⦁ Rates for anxiety disorders are higher in the perinatal population than non-perinatal population, both in terms of new onsets and worsening of existing symptoms. (see Section 2.1 on prevalence).

⦁

⦁ The most common types of anxiety disorders in the perinatal period are generalized anxiety disorder, obsessive compulsive disorder and panic disorder.

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⦁ Clinical features of anxiety disorders in perinatal women are similar to those in non-perinatal women (e.g., subjective experience of distress with accompanying disturbances of sleep, reduced concentration and lower levels of social and/or occupational functioning). In the perinatal period, women commonly present with excessive concerns about their pregnancy, fetus and/or baby.187

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⦁ Major risk factors for an anxiety disorder during the perinatal depression include: history of an anxiety disorder with a previous pregnancy, personal history of an anxiety disorder not related to the perinatal period, and family history of an anxiety disorder in the perinatal period.

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⦁ There is no evidence to support specific interventions for the prevention of anxiety disorders in the perinatal period.

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⦁ Unlike the EPDS for depression, there is no commonly accepted, validated self-report tool to screen for anxiety disorders.182

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⦁

⦁ The steps for diagnosing anxiety disorders are the same as for depression: diagnostic assessment interview and confirmation of the suspected diagnosis with the DSM-V criteria. Before diagnosing a mental health disorder, it is important to exclude medical conditions, including substance use, which might cause symptoms that mimic a mental health disorder.

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⦁ The treatments used for anxiety disorders in the perinatal period are similar to those used for depression. Mild to moderate anxiety disorders are often successfully treated with a combination of non-pharmacological treatments. Medications may also be required for women with moderate to severe anxiety disorders.

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⦁ Effective non-pharmacologic treatments include psychoeducation, self-care and psychotherapies (also called “talk therapies”). Of the psychotherapies, CBT has been studied the most in the treatment of anxiety disorders and shown to be effective. While the research is limited, IPT also shows promising results.211,212

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⦁ The evidence is currently stronger for CBT and IPT207,208 than for psychodynamic therapy. ⦁

⦁ There is little or no evidence to support the use of bright light therapy or ECT in the treatment of anxiety disorders.

Recommendations

1. Promote early identification and treatment of anxiety disorders in perinatal women by enquiring about risk factors (e.g., personal and/or family history of anxiety disorders) and/or direct observation (e.g., excessive concerns about fetus/pregnancy or baby).

2. Utilize the guidelines in Table 8 for the treatment of women with anxiety disorders:

Table 8: Guidelines for the Treatment of Anxiety Disorders during the Perinatal Period

Treatment approach

Pregnancy & Postpartum

Mild to Moderate Anxiety Disorder: Focus on psychoeducation, self-care &/or psychotherapies. Medications are usually not required.

Moderate to Severe Anxiety Disorder:

Medications are frequently required in addition to focusing on psychoeducation, self-care &/or psychotherapies.

Medication management

Pregnancy & Postpartum

SSRIs and SNRIs are first line treatment for women who require regular treatment for anxiety disorders (see section 3.5, table 6 for guidelines related to antidepressant use). Benzodiazepines may be useful on a PRN or regularly scheduled but time-limited basis. Long term use is discouraged as tolerance readily develops and withdrawal symptoms are common upon discontinuation.

Benzodiazepines and other hypnotics (non-benzodiazepines) may be useful on a PRN basis for intermittent insomnia.

Pregnancy Minimize the use of benzodiazepines and other hypnotics (non-benzodiazepines) close to delivery, if possible, to reduce the likelihood of NAS. Monitor baby for NAS.

Postpartum SSRIs and SNRIs are not contraindicated with breastfeeding.

If required, use short-acting benzodiazepines in divided doses during lactation. Monitor for adverse effects in the baby (e.g., sedation, poor feeding and irritability).

5.1 Education and Prevention

5.1.1 What is Bipolar Disorder?

Bipolar disorder is one of the most serious mental health disorders that affect women in the perinatal period. It is a mood disorder in which people experience disruptive mood swings which are so intense that they interfere with their daily life. Bipolar disorder usually lasts a lifetime. If not treated, bipolar disorder tends to worsen with more frequent and severe episodes. Proper treatment helps to reduce the frequency and severity of the episodes. Women with existing bipolar disorder are at risk of developing postpartum manic episodes, postpartum depressive episodes and postpartum mixed states and postpartum psychosis. Postpartum psychosis is a psychiatric and obstetric emergency, usually requiring hospitalization and intensive treatment. (See Section 6 for a discussion of postpartum psychosis and Section 7.0 for a discussion of Bipolar disorder, Psychosis and Suicide/Infanticide.)  A woman with no previous psychiatric history who develops a postpartum psychosis will require close follow up as she is at increased risk of developing further mood episodes during times of stress, including subsequent pregnancies. An eventual diagnosis of bipolar disorder may be made.

5.1.2 Signs and Symptoms

The two most common forms of bipolar disorder are: ⦁

⦁ Bipolar Disorder 1 (historically known as manic–depressive disorder or manic depression) ⦁

⦁ Bipolar Disorder 2

Bipolar Disorder 1 (DSM-V39_): ⦁

⦁ Disruptive mood swings characterized by episodes of either mania or hypomania which often (but may not) alternate with major depressive episodes (see below for definitions of mania, hypomania and depressive episodes). Episodes are intense and significantly interfere with daily functioning.

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⦁ If manic and depressive symptoms occur in the same episode, this is called a “mixed state”.

Bipolar Disorder 2 (DSM-V39_): ⦁

⦁ Characterized by at least one episode of hypomania and one major depressive episode. ⦁

⦁ Episodes of hypomania and depression frequently alternate and cause clinically significant distress and interfere with daily functioning.

Manic episode: ⦁

⦁ Distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least one week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

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⦁ Several of the following symptoms are usually present:

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◾ Inflated self-esteem or grandiosity. ⦁

◾ Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). ⦁

◾ Flight of ideas or subjective experience that thoughts are racing. ⦁

◾ More talkative than usual or pressure to keep talking. ⦁

◾ Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli). ⦁

◾ Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor

agitation (i.e., purposeless non-goal-directed activity).

⦁

◾ Excessive involvement in high-risk activities (e.g., engaging in unrestrained buying sprees, sexual

indiscretions, foolish or ill-advised business investments). ⦁

⦁ Mood disturbance is severe enough to significantly interfere with social or occupational functioning or to necessitate hospitalization to prevent harm to self or others.

⦁

⦁ Psychotic features may be present.