Perinatal depression and anxiety: Clinical sciences

Perinatal depression and anxiety are conditions that affect many pregnant and postpartum patients up to a year after childbirth. Depression can range from mild perinatal depression or “postpartum blues” to severe conditions with suicidal or infanticidal ideations, such as postpartum psychosis. Perinatal anxiety is often seen in combination with perinatal depression.

Keep in mind that, prior to making the diagnosis of a perinatal mental health condition, it’s important to consider and evaluate other medical conditions that could cause similar symptoms. These include thyroid dysfunction, severe anemia, medication side effects, and substance use. Screening for, diagnosing, and treating perinatal anxiety and depression is essential, as they’re associated with adverse maternal and fetal outcomes.

Your first step is to perform a safety assessment. Let’s first see what to do when there are safety concerns.

Start by asking your patient about symptoms of depression and anxiety.
You should also determine whether they have intrusive thoughts of harming themself or their baby, to the point where they’re comforted by those thoughts or feel as if acting on these thoughts will help the infant or society in general. Additional safety concerns include a lack of insight into whether their intrusive thoughts are based on reality; and if they have auditory or visual hallucinations or other bizarre beliefs that aren’t based on reality. If you notice any of these findings, the patient is considered unsafe.
This is an emergency and may indicate postpartum psychosis.

Start with acute management right away. Be sure not to alarm your patient, but don’t leave them or their baby alone while seeking help. Admit them to the hospital and seek emergent psychiatric consultation. Continue one-on-one monitoring to reduce the risk of suicide or infanticide.

Once you, your patient, and their baby are in a safe place, obtain a focused history and physical examination, which includes a mental status exam. Next, obtain labs to evaluate for conditions that can mimic postpartum psychosis. These include CBC, BMP, TSH, ammonia, and a toxicology screen to assess for alcohol, benzodiazepines, cocaine, or cannabis intoxication. You might also need to perform a lumbar puncture for CSF analysis. Additional testing might include brain imaging with an MRI, and an electroencephalogram or EEG.

Postpartum psychosis is rare but quite serious. History might reveal a sudden onset in the first 3 to 10 days postpartum, but it may present up to 4 weeks after delivery, or even longer. The biggest risk factors are having bipolar disorder or having had a previous history of postpartum psychosis or mania, but keep in mind that most patients with postpartum psychosis don’t have a significant mental health history.

On mental status exam, they may appear agitated and experience delusions, disorganized thoughts, or bizarre behavior. They may also experience auditory or visual hallucinations and have intrusive thoughts of suicide or infanticide. Finally, they’ll have limited or no insight into these symptoms, which are typically very different from their usual level of function.

If you see these findings in the setting of normal labs, imaging, and EEG, diagnose postpartum psychosis. Treatment requires psychiatric hospitalization, along with a multidisciplinary approach to care. Sleep preservation is important, so the patient might need to stop overnight breastfeeding. Most patients will require pharmacotherapy in the form of antipsychotics or benzodiazepines. You might also need to consider electroconvulsive therapy.

Keep in mind that these patients need continuous observation and psychiatric care. If treatment is initiated quickly and appropriately, full remission can be seen within 2 months.

Now let's go all the way back to our safety assessment. Patients who don’t present with concerns on safety assessment are considered safe. In this case, start with a focused history and physical examination, which includes a mental status exam. You’ll also need to use a validated tool to screen for depression, anxiety, and bipolar disorder. These include the Edinburgh Postnatal Depression Scale, or EPDS; the Patient Health Questionnaire 9, or PHQ-9; the General Anxiety Disorder-7, or GAD-7; and the Composite International Diagnostic Interview, or CIDI. The EPDS is most often used during pregnancy and postpartum because it screens for both depression and anxiety and includes a question about self-harm.

Time for a couple of clinical pearls! Perinatal depression and anxiety are common, so you should screen for these conditions periodically starting at the first prenatal visit, during the third trimester, and again postpartum. Screening for bipolar disorder only needs to occur once perinatally, and should also be done before starting medication for perinatal depression.

Additionally, if at any point, your patient has a positive response to a self-harm question during screening, provide appropriate mental health referrals. If the patient endorses suicidal ideation with intent and/or plan, immediately transfer them for an emergency psychiatric evaluation.

If your patient has a negative screen for depression, anxiety, and bipolar disorder, consider an alternative diagnosis.

On the flip side, if the EPDS or PHQ-9 screen is positive, suspect perinatal depression.

This condition typically occurs within the first 2 days up to 2 weeks after delivery. On the mental status exam, your patient may report a dysphoric mood, crying, mood lability, anxiety, sleeplessness, loss of appetite, or irritability. With these findings, diagnose mild perinatal depression, also known as “postpartum blues” or “baby blues”.

Symptoms generally resolve on their own without treatment, so management is focused on supportive care and close follow-up to ensure the symptoms have resolved. If symptoms persist for more than 1 to 2 weeks, or become worse and interfere with daily activities, you’ll need to evaluate for further mental health conditions.

Now let’s move on to perinatal depression.
In this case, your patient will present either during pregnancy or within the first 12 months after delivery. They’ll have at least 2 weeks of depressed mood or loss of interest, and four or more additional symptoms including weight gain or loss, insomnia or hypersomnia, psychomotor agitation, fatigue, feelings of worthlessness or guilt, concentration issues, or suicidal ideation.