Treating postpartum mood and anxiety disorders in primary care pediatrics

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Postpartum psychiatric disorders represent a significant public health problem that has not been readily addressed, particularly in the primary care setting. As maternal mood and anxiety difficulties are associated with a number of adverse outcomes for the mother, her offspring and the family system, addressing these concerns during the perinatal period is of critical importance. Although researchers and clinicians have become increasingly aware of the problem, postpartum mood and anxiety disorders (PMADs) remain widely unrecognized and poorly understood by both patients and providers. As pediatric primary care providers encounter mothers repeatedly throughout the postpartum period, the pediatric clinician has the unique opportunity to intervene with mothers suffering from mental illness. Given the potentially devastating impact of PMADs across multiple domains, the purpose of this article is to provide guidelines for pediatric clinicians to better manage maternal mental illness within the primary care pediatric setting. As such, we review the categories and prevalence of PMADs and provide strategies for responding to a positive PMADs screen or concerns raised during surveillance of the mother–infant-dyad. In addition, we offer a summary of the literature on evidence-based treatments for PMADs to allow pediatricians to guide the parents of their patients towards the most effective interventions. Finally, we provide an overview of alternative treatment models that can facilitate the screening and treatment of behavioral health concerns within the primary care setting.

Section snippets

Categories and Prevalence of Postpartum Mood and Anxiety Disorders

Postpartum is the term used to refer to the time following childbirth, while perinatal refers to the time before, during, and after a women gives birth. According to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Health Disorders-V (DSM-V), the term “peripartum” is used to describe onset of symptoms during pregnancy or in the first month following delivery. Importantly, although the DSM-V does not apply the same terminology to specifically address peripartum or

Screening and Surveillance of Mother–Infant Dyad

The US preventive services task force (USPSTF) recommends physicians screen for depression in the general adult population, including pregnant and postpartum women.8 USPSTF advises screening to be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.8 Additionally, The American College of Obstetricians and Gynecologists (ACOG) recommends that patients be screened at least once during the perinatal period for depression and

Offering Guidance to Parents Regarding Evidenced-based Treatment for PMADs

Women and their health care providers face challenging clinical decisions in the management of depression, as they weigh the potential costs and benefits of various treatment options.40 Parents’ understanding of perinatal mood and anxiety disorders and their treatment is fragmented due to societal misrepresentations, stigma around mental illness, and a general lack of consensus of the information shared by the scientific community.41, 42 Further compounding the problem is the absence of

Evidence-based Options for Treating PPD

It is important that parents have an understanding of their diagnosis, and the associated evidence-based treatment options so they can make informed decisions about their treatment. While describing the options available to parents, pediatricians are encouraged to frame this information with a universal message mentioned earlier in this article: You are not alone. You are not to blame. You will get better.36 The majority of the research on PMADs has focused on addressing treatments for

Evidence-based Options for Treating Post-partum Anxiety Disorders

Despite the limited literature on the effectiveness of treatment for perinatal anxiety disorders, there are several evidence-based treatments that can be used to inform professionals on how best to address specific postpartum diagnoses including anxiety disorders. CBT is accepted as the predominant form of treatment for maternal anxiety and should be used as the first line offered to pregnant and breastfeeding women with anxiety disorder.14 An adaptation of mindfulness-based CBT, called Coping

Evidence-based Options for Treating Post-Traumatic Stress Disorder

The postpartum period is a particularly vulnerable time for women and symptoms of post-traumatic stress disorder (PTSD) may present, especially in women with childhood maltreatment histories.65 An effective form of treatment for women experiencing postpartum PTSD is trauma-focused psychotherapy.48 Trauma-focused therapy provides an opportunity for women to adapt to the role of motherhood and explore the influences of early trauma including maladaptive cognitive schemas and biological stress

Evidence-based Options for Treating Post-partum Psychosis

Postpartum psychosis (PPP) is rare and is always considered a medical emergency; mothers who screen positive for PPP should be hospitalized immediately for treatment.9 Medication is most commonly administered for PPP treatment in the form of antipsychotics including Haldol, Zyprexa, Clozaril, and Risperidone.9 In many cases, antipsychotic medication is only needed in short term and it is common that after the initial psychosis lifts underlying depression will need treatment.9 It is important

General guidelines

Pharmacotherapy is a widely used treatment option for depressed women. Current estimates indicate over 7% of pregnant women use antidepressant medication67 and at least 75% of women identified before, during or after pregnancy as depressed are referred for pharmacotherapy.66 Furthermore, there is evidence to suggest that medication and psychotherapy are equally effective in reducing postpartum depression symptoms.68 Despite its frequent use and effectiveness, antidepressant medication continues

References (88)

  • H. Rowe et al.

    Maternal medication, drug use, and breastfeeding

    Child Adolesc Psychiatr Clin North Am

    (2015)
  • C. Bellantuono et al.

    Benzodiazepine exposure in pregnancy and risk of major malformations: a critical overview

    Gen Hosp Psychiatry

    (2013)
  • J. Knitzer et al.

    Reducing Maternal Depression and Its Impact on Young Children: Toward a Responsive Early Childhood Policy Framework

    (2008)
  • E.M. Cummings et al.

    Maternal depression and child development

    J Child Psychol Psychiatry

    (1994)
  • T. Field

    Infants of depressed mothers

    Dev Psychopathol

    (1992)
  • S.H. Goodman et al.

    Risk for psychopathology in the children of depressed mothers: a developmental model for understanding mechanisms of transmission

    Psychol Rev

    (1999)
  • M.J. England et al.

    Depression in Parents, Parenting, and Children: Opportunities to Improve Identification, Treatment, and Prevention

    (2009)
  • M. Silverstein et al.

    Maternal depression and violence exposure: double jeopardy for child school functioning

    Pediatrics

    (2006)
  • N.M. Talge et al.

    Antenatal maternal stress and long-term effects on child neurodevelopment: how and why?

    J Child Psychol Psychiatry

    (2007)
  • A.L. Siu et al.

    Screening for depression in adults: US Preventive Services Task Force recommendation statement

    J Am Med Assoc

    (2016)
  • S. Bennett

    More than depression: differences among postpartum psychosis, postpartum depression, and postpartum obsessive–compulsive disorder

  • Diagnostic and Statistical Manual of Mental Disorders (DSM-5®)

    (2013)
  • A.C. Viguera et al.

    Episodes of mood disorders in 2,252 pregnancies and postpartum periods

    Am J Psychiatry

    (2011)
  • M.-P.V. Austin et al.

    Depressive and anxiety disorders in the postpartum period: how prevalent are they and can we improve their detection?

    Arch Women’s Ment Health

    (2010)
  • E.J. Russell et al.

    Risk of obsessive–compulsive disorder in pregnant and postpartum women

    J Clin Psychiatry

    (2013)
  • C. Glasheen et al.

    A systematic review of the effects of postnatal maternal anxiety on children

    Arch Women’s Ment Health

    (2010)
  • S. Ayers

    Delivery as a traumatic event: prevalence, risk factors, and treatment for postnatal posttraumatic stress disorder

    Clin Obstet Gynecol

    (2004)
  • W. Schwab et al.

    Post-traumatic stress disorder post partum

    Geburtshilfe Frauenheilkunde

    (2012)
  • D. Bailham et al.

    Post-traumatic stress following childbirth: a review of the emerging literature and directions for research and practice

    Psychol Health Med

    (2003)
  • V. Bergink et al.

    Treatment of psychosis and mania in the postpartum period

    Am J Psychiatry

    (2015)
  • I.F. Brockington

    Puerperal Psychosis: Motherhood and Mental Health

    (1996)

  • Obstet Gynecol

    (2015)
  • S. Kurtz et al.

    Ask the question: screening for postpartum mood and anxiety disorders in pediatric primary care

    Curr Probl Pediatr Adolesc Health Care

    (2017)
  • D. Davies

    Child Development: A Practitioner’s Guide

    (2010)
  • J.P. Shonkoff et al.

    From Neurons to Neighborhoods: the Science of Early Childhood Development

    (2000)
  • J.F. Cohn et al.

    Infant response in the still-face paradigm at 6 months predicts avoidant and secure attachment at 12 months

    Dev Psychopathol

    (1991)
  • K.M. Robson et al.

    Delayed onset of maternal affection after childbirth

    Br J Psychiatry

    (1980)
  • S.K. Dørheim et al.

    Sleep and depression in postpartum women: a population-based study

    Sleep

    (2009)
  • D. Goyal et al.

    Fragmented maternal sleep is more strongly correlated with depressive symptoms than infant temperament at three months postpartum

    Arch Women’s Ment Health

    (2009)
  • P. Leahy-Warren et al.

    First-time mothers: social support, maternal parental self-efficacy and postnatal depression

    J Clin Nursing

    (2012)
  • D.M. Teti et al.

    Parenting sensitivity, parental depression and child health: the mediational role of parental self‐efficacy

    Early Dev Parent

    (1996)
  • D.M. Haslam et al.

    Social support and postpartum depressive symptomatology: the mediating role of maternal self-efficacy

    Infant Ment Health J

    (2006)
  • L.H. Chaudron et al.

    Detection of postpartum depressive symptoms by screening at well-child visits

    Pediatrics

    (2004)
  • Earls MF, The Committee On Psychosocial Aspects Of Child And Family Health. Clinical Report-Incorporating Recognition...

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