Management of Psychiatric Disorders during the Perinatal Period

Abstract

INTRODUCTION The psychiatrist working in a general hospital psychiatric unit has several opportunities for consultation-liaison work with the obstetrician. There is a bidirectional relationship between psychiatry and obstetrics. While on one hand, the improved management of psychiatric illness is helping many more women with mental illness embrace motherhood; on the other hand, psychiatrists often receive referrals for the evaluation of women undergoing treatment for infertility or Assisted Reproductive Techniques (ART) or antenatal and postnatal care. From the obstetrician’s point of view, the major contributors to maternal mortality in the past were obstetric complications such as hemorrhage and medical disorders complicating pregnancy such as diabetes mellitus and hypertension. However, with improved obstetric care protocols and a significant reduction of maternal mortality rates due to obstetric and medical diseases, maternal mental health has come to the fore as one of the major contributors to morbidity and mortality. A psychiatrist may receive a referral for consultation in three broad situations: Either as an out-patient referral from the antenatal or postnatal clinic of obstetrics; In the obstetric in-patient or labor room; or From the obstetric emergency services. This article is organized as follows: First, we would like to give a broad overview of the various conditions that may be seen in the context of the perinatal period, including the medical disorders that can lead to these presentations and the suggested investigations. Second, we present a format for clinical assessment. Third is a note on the general principles of management in the perinatal setting, including a note on the risk-benefit analysis of medications and management planning. Fourth is a section on the management of individual disorders in the perinatal period. Finally, we cover other conditions such as management of suicidal risk, agitation, the use of electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (RTMS), and the future role of mother–baby units (MBUs) in general hospital psychiatry. OVERVIEW OF PSYCHOLOGICAL CONDITIONS IN THE PERINATAL PERIOD Preconception In the preconception stage, there are broadly three groups of patients who may be referred for evaluation: (i) Patients undergoing treatment for infertility or ART who may be referred for psychological issues such as stress, anxiety, and depression; (ii) Patients with previous traumatic experiences during pregnancy and childbirth; (iii) those with preexisting psychiatric illness. Patients who are undergoing treatment for infertility and those with previous traumatic experiences during childbirth, such as injuries during labor, disrespectful care during labor, stillbirth, or requirement for emergency interventions including Caesarean section may be at risk for psychological morbidity such as depression and anxiety. Patients with preexisting psychiatric illnesses may need a review of their clinical condition and decision on continuation, modification, or discontinuation of medication will have to be taken. During pregnancy referrals may be received for women with new onset of a psychiatric condition, preexisting mental illness, or for psychological distress caused by psychosocial factors such as marital discord, domestic violence, or substance use in spouse. Events around childbirth, such as stillbirth can lead to grief. There may be psychological distress related to gender of the infant. Medical illness in the infant and separation of mother and infant due to NICU admission may also lead to psychological distress including anxiety, anticipatory grief. In the postpartum period, disorders of mother–infant bonding may be there. Mood-related changes may present as postpartum blues or postpartum depression (PPD). Postpartum psychosis (PPP) is a particularly severe form of behavioral disturbance that may be seen in the postpartum period. Tables 1 and 2 present an overview of the various conditions seen in the perinatal period.Table 1: Overview of perinatal psychiatric conditions for which consultation may be soughtTable 2: Overview of postpartum psychiatric conditionsOUTLINE OF CLINICAL ASSESSMENT OF PERINATAL PSYCHIATRIC CONDITIONS When the psychiatrist is called for the evaluation of the obstetric patient, the psychiatric evaluation may proceed along the following lines [outlined in Box 1].Box 1: Clinical assessment in perinatal psychiatry historyHistory includes a routine psychiatric history and in addition, specific history pertaining to the perinatal context is elicited. This includes a history of past pregnancies and their outcomes, including traumatic pregnancies, obstetric complications, and perinatal loss. Current pregnancy details including psychosocial context of pregnancy, support from spouse and family as well as a history of substance use and domestic violence is collected. Care is taken to ensure privacy to the woman and family members as they may not be forthcoming with a history of psychological symptoms in a crowded emergency room or in the obstetric ward. Physical examination should be conducted to rule out organic etiology of the psychiatric presentation. Some of the common etiological possibilities such as hypertension, anemia, jaundice, thyroid disorders, connective tissue disorders, movement disorders, cerebral and cerebrovascular disorders must be ruled out. In addition to clinical examination, certain investigations [Table 3] and referrals to other specialists may be advised to the obstetrician.Table 3: Suggested laboratory investigations for diagnosis of common medical conditions occurring in the perinatal periodMental status examination can be done using the routine format used for general psychiatric evaluation. Particular note must be made if the patient has confusion, perplexity, or even frank disorientation as these may alert us to a medical/neurological etiology. Attention is given to the presence of delusions related to the infant or the presence of hallucinations that refer to the infant. These may have a bearing on the risk assessment that is done. Cognitive functions can be assessed as part of the routine mental status examination and followed up with further structured cognitive assessments which can help us assess the possibility of an organic etiology. Risk assessment should include an assessment of risk of suicide, infanticidal risk, and risk of harm to others. In every case, a specific enquiry must be made about suicidal ideas, plans, or any recent attempts of suicide. We may also use structured tools for the assessment of suicide risk. This may include the IS PATH WARM? Signs[15] or any other structured tool for assessment of suicidal risk. Mothers with severe mental illness (SMI) in the postpartum period may have infanticidal ideas and risk for infant harm. The presence of a depressive disorder and suicidality as well as psychotic symptoms related to the infant can lead to risk of harm to the infant.[16] Mothers with postpartum mania may handle the infant in a rough manner leading to potential injuries to the infant. They may also be verbally or physically aggressive to the infant during the irritable phase. Table 4 lists some psychopathology specific to the perinatal period and its clinical implications.Table 4: Psychopathology related to the infant and its implicationsPsychometric tools [Table 5] are helpful in the objective assessment of the patient’s clinical condition and can help monitor the treatment outcomes. While some scales are useful for screening in the antenatal setting, others are useful in rating the severity of psychopathology. Finally, some scales are particularly designed for research purposes use in specialized in-patient peripartum psychiatry settings; they assess constructs such as maternal behavior and mother–infant bonding or have been adapted for the peripartum setting.Table 5: Psychometric tools that may be useful in perinatal psychiatryROUTINE SCREENING FOR DEPRESSION AND ANXIETY IN THE ANTENATAL AND POSTNATAL PERIOD While universal screening may tend to overestimate the prevalence of psychosocial disorders or even unduly raise the alarm in the case of false-positive screen (~35%–40%), the Marce International Society position paper recommends that a basic inquiry into current symptoms using the Whooley’s questions, Patient Health Questionnaire-9[4] or Edinburgh Postnatal Depression Scale[5] along with inquiry about past and family history of psychiatric disorders may be useful.[17] The Whooley’s questions[3] are the first two questions of PRIME-MD, namely: (1) In the past 1 month, have you felt down, depressed or hopeless? (2) In the past 1 month, have you been bothered by little interest or pleasure in things? The offer for screening must be backed up with adequate resources to provide timely and appropriate services required for the woman (including appropriate referrals to secondary or tertiary care centers). In larger centers with multi-disciplinary teams, this may be possible within the hospital, however, obstetricians working in smaller centers without in-house counselors or mental health professionals may refer the women appropriately. Psychometric tools specific for the peripartum setting such as specialized MBUs or research purposes include the NIMHANS Maternal Behaviour Scale for rating maternal behavior and the Postpartum Bonding Questionnaire which is helpful in screening for disorders of mother–infant bonding. The Stafford Interview is a detailed interview schedule useful in MBUs and for research purposes. Table 5 lists some psychometric tools that may be used in perinatal psychiatry. We also suggest the settings in which the scales may be used. GENERAL APPROACH TO THE PATIENT IN PERINATAL PSYCHIATRY If the woman consults during the preconception period, and the woman is still symptomatic, we may advise the couple to delay pregnancy. They can plan for pregnancy once the clinical condition stabilizes. In case the woman is on medications and is asymptomatic, a trial of discontinuation may be attempted for women who have a history of mild illness such as a mild depressive episode in the past. The risk of relapse and the need for early review in case of relapse has to be emphasized in such cases. It is beneficial if there is a supportive caregiver at home who can detect early signs of relapse and bring the patient for management in the event of relapse. In case of SMI, prophylactic medications are preferable even if the patient is presently asymptomatic. A medication which is relatively safe in pregnancy and lactation may be chosen. We may need to taper and discontinue medications that are adjunctive in nature and no longer required. This may include benzodiazepines, beta-blockers, and anticholinergic agents. The decision to change the medication to another one with greater safety data may not be required in every case unless the risks of continuing the current medication are high for the given patient. However, abrupt discontinuation of medications must be avoided. Folic acid 5 mg/day is prescribed in all women who are planning for pregnancy. When a woman presents for consultation during pregnancy, we must emphasize that early and regular antenatal check-up and planning childbirth at a hospital with adequate facilities for maternal and including care is preferable if the mother is on medications are advised to in early as well as at can also be done for who are on medications that may be with a risk of If is not a pregnancy and there were no opportunities to the medications in the preconception period, medications may be as new onset of psychiatric disorder during pregnancy, is for mild illness in the first However, in case of or symptoms and in women with severe of illness, medication may be pregnancy can the of there may be a need for A of and can delay the of to and changes in to greater of for that are due to in and 2 and that greater due to a These changes may the following [Table in a of in The medications which have infant are with the medications a a of there is no need for for a of is The infant should be for signs of such as or and for may have to be in case of any signs of and a review of medication done. In case of or or with medical or disorders, the of the or may be the safety of This is the of medications may be in with these conditions and they may be at greater risk of as to who are at and have of the with the use of medications has been a possible delay in infant However, the delay is mild and is with the infant up with the once the to medication such were more common in or or those to In of general must be given adequate stimulation of This would include that the mother or another caregiver is to provide adequate stimulation to the infant in the form of and and the a of and an to the infant in the mother has severe symptoms or due to The possible risks of this mild and delay the of medications for in the 1 the general to the woman on the context of The general for the at which the woman is seen and general in medical management are 1: to management in perinatal ASSESSMENT AND of the of medication use in perinatal psychiatry is the potential of medications on the pregnancy and and outcomes. There is often and other to medications during pregnancy. Some patients medications once they and risk a relapse of psychiatric illness and the at risk. A risk-benefit assessment with to the use of medications in the perinatal period along with planning of pregnancy to these The major of risks and to the mother and that need to be risks of maternal psychiatric (ii) of medication (iii) of adequate of maternal and risks of The risks of maternal depression or include the risk of to antenatal and of suicidal risk infanticidal risk, and Risk of domestic violence, substance and obstetric such as labor, and stillbirth in patients who are The risks of maternal illness are the risks include the potential of potential for maternal and outcomes. In this we some of these risks which can in The risk for medications were as and from to Some medications and their are in Table of safety and medication were for and They were by the new and from The new the risks into three risks are This includes any on risks to mother and or any required during pregnancy, maternal and on labor and includes details of the presence of and in of on the and of on on and for is also and of This section the for pregnancy use or during It also includes on the of the on These help us to on medication management for psychiatric illnesses in pregnancy and Some risks are to the woman and in of for major any risk of specific or maternal and these risks with the risk of in women who to discontinue medications during pregnancy. from has suggested that the risks of a may not be to the medication and may be due to the condition for which the medication is This is called as by Table lists the risks with some of the medications with risks which can in patient However, is to note that the in this is still and is to review the and the patient of risks with OF OF AND OF AND the clinical assessment is and a decision is made that the woman will have more risks of the following is suggested with the woman and family the medication 2 and 2: of medication risks and 2: risk to risks during OF PSYCHIATRIC IN THE PERINATAL PERIOD mental disorders include anxiety, depression and related disorders such as disorders are to in the and they are mild in the is to mild of these disorders with Cognitive behavior therapy may help in as well as may help in depression and and may be for treatment of If the or depressive symptoms are or are in or if there is to may be prescribed for the management of the illness. disorders Some women or related to infertility and treatment for previous pregnancy of during labor and about traumatic experiences during pregnancy. In such management supportive and by due antenatal In case these not more structured or medications may be as in the case of or are the medication of for the management of disorders in pregnancy. not have many to support the disorders In the case of depressive disorders, the risk-benefit assessment for medication has the following who have a mild episode of depression in the past may be given a trial of discontinuation of medications if they are for However, those who have a more severe illness such as or more of or have severe depression with psychotic or suicide attempts during the depressive episode or have required or for of depressive symptoms in the past will from continuing the The presence of domestic violence and previous traumatic experiences the risk and the presence of adequate support is a disorder mild severity of previous to with and of significant like depression may a trial of discontinuation of However, in more women with depression or suicidal risk, the risks of discontinuation of medication may the OF IN PERINATAL PERIOD to disorder and In the context of perinatal severe behavioral can also in as well as which is often of abrupt with severe psychotic and suicidal risk. The risk of relapse of disorder is as high as in women who discontinue as to about those who with are also advised to in the perinatal period. are for There is a risk of as well as diabetes with and women should be for and to a during disorder with is as In there may be a need to for a period in some Some women may the addition of a and are during pregnancy due to the risks of and However, may not be with risk of major and may be in women with depression the risks and in women who have required to may be with the woman and is not as and a is or may be as the clinical for disorder medication substance and of early signs of a with of with medication is for the management of are treatment has to be While or are not for treatment of during pregnancy. This is there is safety data these In case a woman is well on and a change of medications the risk of we may to the medications with the woman and In case a woman of treatment with the discontinuation may not the possibility of as the of these may While are with and have is in the management of severe postpartum psychiatric medications with lactation are within the first 4 following the risk period can be up to 2 In mild may be with In of psychotic an is also However, the disorder must be ruled out in women for illness, suicidal risk is may in-patient care to ensure safety of the patient, infant and others family with a previous episode of may be given prophylactic in the postpartum period. is an which as an of the is for to severe in a as follows: in first 4 followed by for at a of for and to for 4 and in the 4 The of the in an in-patient or are the major The by is to be in is a which has abrupt onset in the postpartum period within of It may present as any one of the following clinical and psychotic or psychotic The specific disorder must be out medical conditions that can In addition, is also often severe in with suicidal risk or risk of harm to the infant or others. This may often in-patient care for adequate management of The of management of is an which is with While may in case of psychotic psychotic depression may the addition of an In case of a may be is common in pregnancy and postpartum period. of women in the perinatal period as to about of to in-patient psychiatric The management of in pregnancy often presents with a in management the use of a for its However, the symptoms of and to can and The presence of or the risk of and during pregnancy. the of treatment with often the risks with its use for patients and management can be with of mg/day in of three or a In case of the first the may be to mg/day for maternal and and may be if the maternal is or is or is When is must be made to the and discontinue the medication for symptoms of relapse. medication must be to the is the other for the management of that not to Table the management for various psychiatric disorders on the clinical of the disorder in a given Overview of of management for psychiatric disorders in the perinatal OF to is with and such as and in the of use can be safe in pregnancy. must be about the risks of use and advised of may or however, those with or use may Mothers with who significant symptoms can be with a of or may be for in case of severe for relapse on and relapse There is not safety data to support the routine use of medications such as or They may be prescribed in women who have a high risk of relapse. is in pregnancy. OF IN AND use is with an risk of disorders, disorders, and in the use is with risk of and of and as well as risk of maternal during are for of There is not for the safety of therapy including and for the treatment of use that they may not the risk of The for the safety of these medications is not and treatment must be taken on an individual IN AND The risk of suicide women is in the childbirth any other in their to a domestic violence, depressive and a past history of suicidality suicidal risk. are also more to use more in the perinatal period. risk and infanticidal risk may and care may be along with the presence of family members and adequate support to ensure a the mother during the period of suicidal risk is Box interventions specific and appropriate for women with suicidal risk in the perinatal 3: interventions specific and appropriate for women with suicidal risk in the perinatal OF IN THE PERINATAL PSYCHIATRY in the peripartum setting can the mother and to risk of harm. must be done first followed by medication such as or or or In case medications are not of 2 or or with to or may be of and may be Care should be taken to ensure that patient is with to of to The use of during pregnancy may be in certain cases. Patients with or severe suicidal risk secondary to depression who not to medical management may be for Some taken during in pregnancy are in Box 4: of electroconvulsive therapy in The safety of during pregnancy has not been however, the that have been done in pregnancy have not any maternal or due to IN PSYCHIATRIC mother–infant will have been from other or may have in of a mental health in the are a risk for and in the and other in and should be to the assessment of bonding using the and a clinical If a bonding is interventions include about the in infant and in case of a severe mother–infant an caregiver such as a or is often OF PERINATAL AND THE The recommends the for patient care. care is in mild psychiatric illnesses or However, in severe illness or care may be required to ensure safety of mother and infant. When care is to a mother with risk of suicidal or infanticidal risk, of mother and of is as of the In case a decision to the mother and is made by the psychiatrist on the patient’s illness and an assessment of the patient’s clinical the decision must be every In case the separation must a period of the Health must be and for the MBUs are in-patient units with at in-patient which the of and their or the of and are by a multi-disciplinary of psychiatrists and health The of setting up an in have been by There may be a need to MBUs in the The role of a psychiatrist in the care of with mental illness broadly includes evaluation and management of with (i) psychological issues related to all of pregnancy and childbirth such as infertility and its traumatic experiences related to pregnancy and childbirth; (ii) management of psychiatric conditions in the perinatal and (iii) management of preexisting psychiatric illnesses in planning pregnancy. The major of treatment is taken on risk-benefit analysis of the treatment of the psychiatric condition the risks of psychiatric illness in the In the of for with the decision may need to be taken in The new the setting up of specialized MBUs for the admission of with their infant or the of support and of interest There are no of

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