All women and men of reproductive age will achieve optimal health and wellness, fostering a healthy life course for them and any children they may have.- Mental health conditions are common in women of reproductive age. The 2014 Health Center Patient Survey revealed that among a nationally representative sample of female patients of reproductive age at federally-funded health centers across the US (Lin et al., 2020):
- 40.8% of patients reported depression
- 28.8% of patients reported generalized anxiety
- 15.2% met criteria for serious psychological distress
- Mental health conditions affecting women include:
- Anxiety disorders
- Attention deficit hyperactivity disorders,
- Bipolar disorder
- Borderline personality disorder
- Depression (and postpartum depression)
- Eating disorders
- Schizophrenia
- Posttraumatic stress disorder
- Psychiatric disorders in pregnancy are associated with poor obstetric outcomes, higher risk of postpartum psychiatric illnesses, increased rates of substance abuse, lower participation in prenatal care and adverse infant outcomes (Frieder et al., 2008).
- Pregnancy planning is important in patients with comorbid mental health conditions and should ideally focus on stabilizing the condition prior to conception.
- Aim for the safest, effective medication regimens with the lowest teratogenic potential prior to conception and during pregnancy.
A thorough history to identify mental health conditions and current therapies is appropriate for all women of childbearing age.
- Screen by asking about:
- Family history of mental health conditions (i.e. psychosis, depression, psychotic or affective disorders).
- Personal history of mood disorders, former and current depression (other psychiatric conditions, former and current intimate partner violence).
- History of postpartum depression or psychosis.
- History of military-service
- If a woman has served in the military, she may have experienced military sexual trauma (MST) or exposure to combat, both of which are associated with increased likelihood of a mental health condition (e.g. Post-Traumatic Stress Disorder).
- Women (and their partners) should be aware of the following before pregnancy:
- Risks to the woman and to their future children should pregnancy occur
- Benefits of planned conception
- Treatment options that offer the greatest benefit and minimize risks (may include medication and/ or psychotherapy)
- Signs and symptoms of disease progression
- The danger of stopping treatment regimens without medical supervision
- If pregnancy is desired, the optimal timing based on patient’s disease status, treatment modalities, and age.
- Preconception care should be provided collaboratively with the mental health provider, primary care provider, and obstetric provider.
- Attention to mental health is an important component of overall health and wellness, whether a woman later becomes pregnant or not.
- It is especially important for women with mental health disorders to plan their pregnancies and to work with their providers to achieve the highest level of wellness possible before trying to conceive.
- Patients with mental health disorders can have healthy pregnancies and healthy infants with appropriate support from healthcare professionals.
- For the best chance of a healthy outcome if pregnancy does occur, aim for control of the mental health disorder(s) with the fewest and safest medications possible.
- A woman with a mental health disorder should be specifically cautioned never to stop a prescription medicine without medical consultation—even if she thinks she has become pregnant.
- Screening for mental health disorders should be performed as a routine component of primary care and preconception care
- All women should be assessed for depression at least once a year (an assessment tool such as the PHQ-9 screen can be used).
- Consider screening for anxiety as well.
- In addition, a thorough mental health history should include:
- Asking about any history of mental health challenges, including postpartum depression, mood disorders, and behavioral changes
- History of suicidal ideation or homicidal ideation
- Alcohol and substance use history and screening
- Psychosocial stressors (intimate partner violence, social support, financial problems)
- Stability of illness
- Current symptoms
- Current medications and assessment of drug safety (See Medications section)
- If prior military service, screening for military sexual trauma (MST) includes the following questions:
- While you were in the military, did you receive uninvited and unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or verbal remarks?
- While you were in the military, did someone ever use force or threat of force you to have sexual contact against your will?
- If yes to either question, ask about formal psychiatric evaluation in the past and offer mental health referral if desired.
- Provide patient education about managing the mental health condition(s) for her own wellness and for optimizing the chance of a healthy pregnancy if one were to occur:
- Discuss the potential impact of a pregnancy on her own mental health condition and on pregnancy outcomes.
- Counsel her about the potential for exacerbations or recurrences during and following pregnancy (See Consideration for Specific Disorders below). It will be important to work with mental health specialists to identify and manage such occurrences.
- Discuss importance of planning pregnancy when mental health conditions are stable on the fewest, safest medications.
- Underscore that women with mental health conditions can have healthy pregnancies and healthy infants with appropriate medical intervention and support.
- Stress that the woman should NOT discontinue any of her medications without medical supervision, even if she thinks she may have become pregnant.
Considerations for Specific Mental Health Disorders
- Depression or Anxiety — Counsel patients diagnosed with depression or anxiety about the risk of these conditions potentially worsening during pregnancy or postpartum. Discuss the risks and benefits of treatment as well as the risks of untreated depression and anxiety on pregnancy, maternal, and infant outcomes (e.g., maternal self-harm, impaired maternal-infant bonding) (ACOG CO 762, 2019).
- Bipolar disorder — The risk of relapse for bipolar disorder is higher in pregnancy. For patients who desire pregnancy, proactively establish a plan to manage relapse in collaboration with the patient’s mental health specialist (Jones et al., 2014).
- Schizophrenia — Counsel patients on the risks of this disorder on pregnancy, and the risks of pregnancy on management of the disorder (Vigod et al, 2020). When trying to conceive, proactively establish a plan for managing schizophrenia during pregnancy in collaboration with the patient’s mental health specialist.
- Note that antidepressants and antipsychotics can have a negative impact on ovulation and fertility (Casilla-Lennon et al., 2016, Grigg et al., 2017) ). If patients who are clinical stable on these medications are having difficulty conceiving naturally, offer referral to reproductive health specialists.
Recommendations from the Women’s Preventive Services Initiative suggest using validated instruments for simultaneous depression and anxiety screening:
- EPDS specifically for pregnant and postpartum women — although not originally designed to screen for anxiety, the EPDS-3A subscale can be used (Smith-Nielsen et al., 2021)
- PHQ-4
- HADS in adult women
- Bright Futures Y-PSC in adolescents and young women
Additional depression screening tools include:
Additional anxiety screening tools include:
For general information about mental health and wellbeing, mental health quiz, and tips for coping with stress, see the CDC Mental Health website (CDC Mental Health).
For information on optimizing preconception health, including mental health, see the CDC website on Preconception Health and Health Care: Planning for Pregnancy (Planning for Pregnancy | Preconception Care | CDC).
ACOG Committee Opinion No. 762: Prepregnancy Counseling. Obstet Gynecol. 2019;133(1):e78-e89. doi:10.1097/AOG.0000000000003013
Casilla-Lennon MM, Meltzer-Brody S, Steiner AZ. The effect of antidepressants on fertility. Am J Obstet Gynecol. 2016;215(3):314.e1-5. doi:10.1016/j.ajog.2016.01.170
Frieder A, Dunlop AL, Culpepper L, Bernstein PS. The clinical content of preconception care: women with psychiatric conditions. Am J Obstet Gynecol. 2008;199(6 Suppl 2):S328-332. doi:10.1016/j.ajog.2008.09.001
Grigg J, Worsley R, Thew C, Gurvich C, Thomas N, Kulkarni J. Antipsychotic-induced hyperprolactinemia: synthesis of world-wide guidelines and integrated recommendations for assessment, management and future research. Psychopharmacology (Berl). 2017;234(22):3279-3297. doi:10.1007/s00213-017-4730-6
Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet. 2014;384(9956):1789-1799. doi:10.1016/S0140-6736(14)61278-2
Kimerling R, Gima K, Smith MW, Street A, Frayne S. The Veterans Health Administration and military sexual trauma. Am J Public Health. 2007;97(12):2160-2166. doi:10.2105/AJPH.2006.092999
Lin SC, Tyus N, Maloney M, Ohri B, Sripipatana A. (2020). Mental health status among women of reproductive age from underserved communities in the United States and the associations between depression and physical health. A cross-sectional study. PLoS One. 2020;15(4):e0231243. doi:10.1371/journal.pone.0231243
Vigod SN, Fung K, Amartey A, et al. Maternal schizophrenia and adverse birth outcomes: what mediates the risk? Soc Psychiatry Psychiatr Epidemiol. 2020;55(5):561-570. doi:10.1007/s00127-019-01814-7
Background
- Mental health conditions are common in women of reproductive age. The 2014 Health Center Patient Survey of patients revealed that among 2,061 female patients of reproductive age from federally funded health centers (Lin et al., 2020):
- 41% of patients reported depression
- 29% reported generalized anxiety
- Mental health conditions affecting women include:
- Anxiety disorders
- Attention deficit hyperactivity disorders,
- Bipolar disorder
- Borderline personality disorder
- Depression (and postpartum depression)
- Eating disorders
- Schizophrenia
- Psychiatric disorders in pregnancy are associated with poor obstetric outcomes, higher risk of postpartum psychiatric illnesses, increased rates of substance abuse, lower participation in prenatal care and adverse infant outcomes (Frieder et al).
- Reproductive life planning is important in women with comorbid mental health conditions. Pregnancy planning should ideally focus on effective contraception and stabilization of the condition.
- A balance between the risks and benefits of specific medication regimens against the risks and benefits to maternal and fetal well-being needs to be considered and discussed in advance of conception.
- Specific treatments in and around pregnancy should reflect a determination that the risk to the mother and fetus from the disorder outweighs the risk of the treatment.
A thorough history to identify mental health conditions and current therapies is appropriate for all women of childbearing age.
- Screen by asking about:
- Family history of mental health conditions (i.e. psychosis, depression, psychotic or affective disorders).
- Personal history of mood disorders, former and current depression (other psychiatric conditions, former and current intimate partner violence).
- History of postpartum depression or psychosis.
- History of military-service
- If a woman has served in the military she may have experienced military sexual trauma (MST) or exposure to combat, both of which are associated with increased likelihood of a mental health condition (e.g. Post-Traumatic Stress Disorder).
- Women (and their partners) should be aware of the following before pregnancy:
- Risks to the woman and to their future children should pregnancy occur;
- Benefits of planned conception;
- Safest treatment options to both manage the condition(s) and minimize pregnancy risks;
- Signs and symptoms of disease progression;
- The risks of stopping treatment regimens without medical supervision.
- If pregnancy is desired, the optimal timing based on patient’s disease status, treatment modalities and age.
- Preconception care should be provided collaboratively with the mental health provider, primary care provider and obstetric provider.
- Treatment strategies may include concomitant psychotherapy.
- Optimizing mental health is an important component of quality health care whether a woman later becomes pregnant or not.
- It is especially important for women with mental health disorders to plan their pregnancies and to work with their primary care and mental health providers to achieve the highest level of wellness possible before trying to conceive.
- Women with mental health disorders can have healthy pregnancies and healthy infants.
- The best chance of maintaining stable health during pregnancy is to stabilize mental health before pregnancy on the safest and fewest medications.
- A woman with a mental illness should be specifically cautioned to never stop a prescription medicine without medical consultation—even if she thinks she has become pregnant.
Clinical Guidance
Key Points:
- Screening for mental health disorders should be performed as a routine component of primary care. A mental health history should include:
- Alcohol and substance abuse history and screening
- Psychosocial stressors (intimate partner violence, social support, financial problems)
- Past history of mental illness
- Concurrent illnesses
- History of mood disorders, suicidal ideation, homicidal ideation behavioral changes
- Stability of illness
- Current symptoms
- Current medications
- Documentation of psychiatric illness during prior pregnancies
- If a woman has served in the military screening for military sexual trauma (MST) by asking:
- While you were in the military, did you receive uninvited and unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or verbal remarks?
- While you were in the military, did someone ever use force or threat of force you to have sexual contact against your will?
- If yes to either question- the woman should receive a formal psychiatric evaluation.
- Provide education about the potential impact of a pregnancy on her own mental health condition and on pregnancy outcomes.
- Discuss importance of planning pregnancies for all women with history of mental health conditions.
- Underscore that women with mental health conditions can have healthy pregnancies and healthy infants but the likelihood is increased by good pre-pregnancy disease management including efforts to manage the condition with the fewest and safest medications possible.
- Stress that the woman should NOT discontinue any of her medications without medical supervision, even if she thinks she may have become pregnant.
- See following information relative to specific diagnoses.
Prevalence:
- 26% of women suffer from depression or anxiety.
- More than 60% of women experience depression symptoms during pregnancy
- In all age groups, depression is more common among women than men
Key Points:
- Providers must screen for depression and anxiety disorders in women of childbearing age.
- Available screening tools are the PHQ-9, QIDS, GAD-7, Beck Depression Inventory and the Hamilton Rating Scale, among others.
- Depression in a previous pregnancy is a strong predictor of postpartum depression.
- Depression in pregnant women can result in increased rates of preterm birth and low birth weight and adverse effects of on the mother-infant relationship, infants and families.
- Anxiety disorders during pregnancy and postpartum have been associated with poor neonatal outcome, obstetric complications, childhood behavioral problems, and avoidance of the child by the mother
Medication Issues:
- As many as 68% of women who stop their antidepressants will experience a relapse of major depression.
- Multidisciplinary management involving the maternity care provider, mental health provider, and primary care provider is important for a coordinated approach to preconception care.
- A single medication at a higher dose is preferred over multiple medications for treatment.
- Medication selection should minimize the risk of illness and should be based on the following:
- Efficacy of medication
- Woman’s personal response to drug
- Available reproductive safety information
- If patient and providers agree to continue antidepressants (after discussing risks and benefits), the best option is usually the medication that has proven most effective in treating the patient’s depression in the past.
- SSRIs are considered the first line treatment for depression in most patients, pregnant and nonpregnant.
- Note: paroxetine use during the first trimester is associated with about a 2-fold increased risk for cardiac malformations (e.g. ventricular septal defects, right ventricular outflow tract obstruction).
- Psychotherapy, cognitive behavioral therapy, interpersonal psychotherapy can be beneficial in all women including women with mild depression who prefer to avoid antidepressant medication.
- Stress that the woman should NOT discontinue any of her medications without medical supervision, even if she thinks she may have become pregnant.
Family Planning (timing of conception)
- If alterations in the treatment regimen are indicated, the woman should understand the specific goals for treatment changes and be encouraged to identify and use a method of contraception until depression is well controlled under new drug(s).
Prevalence:
- Bipolar disorder affects approximately 2.6% of the U.S. population > 18 years old. (National Institute of Mental Health)
- The median age of onset for bipolar disorder is 25 years (National Institute of Mental Health)
- An equal number of men and women are afflicted.
Key Points:
- Characterized as a mood disorder with episodes of mania, hypomania and depression.
- Onset of bipolar disorder typically occurs in the reproductive years.
- There is a strong familial pattern with 10% of first degree relatives affected
- Screen by asking about family history of mood disorders and personal history of depression, psychosis or mania.
- If screens positive needs a formal psychiatric assessment.
- Women are at high risk of relapse during pregnancy and postpartum with a 10-20% prevalence of postpartum psychosis (associated with high rates of suicide and infanticide).
- Patients need to be closely monitored and cared for by a multidisciplinary team before, between and beyond pregnancy.
Medication Issues:
- Can be severe and highly recurrent in pregnancy.
- Some studies indicate high relapse rate if medications are discontinued.
- Pharmacotherapy choices in preconception/prenatal period should be based on:
- Prior response to various medications
- Illness severity
- Duration of euthymia while on medication
- Time of relapse after medication discontinuation
- Time to recover with reintroduction of pharmocotherapy
- Teratogenicity/fetal safety of drug
- When planning pregnancy- maintenance pharmacologic therapy is generally indicated.
- First trimester exposure to lithium increases the risk of cardiac malformation (Epstein’s anomaly) to levels 10-20 times greater than the general population. However, the absolute risk is low: 0.05-0.1%.
- The risks-benefits of discontinuation need to be explored with the patient before a woman/couple put themselves at risk for conception
- Anticonvulsants (valproic acid and carbamazepine) are also used for treatment of bipolar disorders; their use is associated with an increased risk of neural tube defects (1-7%).
- If on these medications, high dose folic acid supplementation (4 mg) is recommended starting one month before attempted pregnancy through the first trimester to prevent neural tube defects.
- Discussing risks and best medication choices with a woman’s psychiatric provider is important to achieve coordinated care and to avoid mixed messages.
Family Planning (timing of conception):
- Woman (and partner) need to appreciate risk of untreated disease versus risk of the treatment regimen and decide which risks they are willing to accept.
- If uncertain, continued contraception is highly recommended.
- Continued use of a contraceptive method is recommended until patient’s condition is well controlled on the safest possible medication regimen.
- If woman’s desires about pregnancy change, she should be encouraged to contact your office for additional contraceptive care.
Prevalence:
- Affects approximately 1% of the US population
- Affects men and women with equal frequency
- Average age of onset in women is between 25-35.
Key Points:
- Women should be screened by asking about family history of psychotic and affective disorders and personal history of psychosis
- Pregnancy is associated with increased maternal and neonatal morbidity especially LBW, SGA and prematurity.
- Women with schizophrenia have higher prevalence rates of cigarette smoking, alcohol use, illicit drug use and low socioeconomic status which are associated with compromised pregnancy outcomes.
- Some antipsychotics (e.g. clozapine and olanzapine) are associated with increased risk of Type 2 diabetes mellitus; women taking these drugs should be monitored for this risk.
Medication Issues:
- High risk for relapse when not on medications.
- To date, no teratogenicity from antipsychotics frequently used for the treatment of schizophrenia has been confirmed; studies have been small and include many confounding variables.
- Any alterations to medication regimens must be coordinated with the woman’s mental health provider.
- If benefits of continued treatment in preconception and prenatal period outweigh risks of disease relapse, then treatment should continue.
Family Planning (timing of conception):
- Woman (and partner) need to appreciate risk of untreated disease versus risk of the treatment regimen and decide which risks they are willing to accept.
- If uncertain, continued contraception is highly recommended.
- Contraception should be encouraged while woman is helped to address any substance use/abuse and chronic disease issues.
- The preconception period should be used to connect woman with community resources to enhance
- Psychiatric stability, access to early and continuous prenatal care, and support for parenting.
Clinical Tools
The PHQ-9 screen is an example of an efficient, self-administered tool—for information on the PHQ-9 and how to incorporate it into your practice go to http://impact-uw.org/tools/phq9.html.
LactMed provides a quick resource for accessing product safety information and is available as both an android and an Apple download:
Patient Resources
Preconception Health and Health Care. Health Promotion.
http://www.cdc.gov/preconception/careformen/promotion.html
MGH Center for Women’s Mental Health
Centers for Disease Control and Prevention. Preconception Health and Health Care: Women (2013). Offers content on a number of chronic diseases and on preconception health, in general, for men and women.
http://www.cdc.gov/preconception/women.html
Women and Mental Health
http://www.nimh.nih.gov/health/topics/women-and-mental-health/index.shtml
[/symple_toggle][symple_toggle title="Depression" state="closed"]The PHQ-9 screen is an example of an efficient, self-administered tool—for information on the PHQ-9 and how to incorporate it into your practice go to http://impact-uw.org/tools/phq9.html.
MGH Center for Women’s Mental Health
Major Depression During Conception and Pregnancy: A Guide for Patients and Families.
http://womensmentalhealth.org/wp-content/uploads/2008/04/mdd_guide.pdf
Depression During and After Pregnancy: A Resource for Women, Their Families, and Friends (HRSA).
http://mchb.hrsa.gov/pregnancyandbeyond/depression/index.html
LactMed provides a quick resource for accessing product safety information and is available as both an android and an Apple download:
- https://play.google.com/store/apps/details?id=gov.nih.nlm.sis.lactmed
- https://itunes.apple.com/us/app/lactmed/id441969514?mt=8
The National Institute of Mental Health (NIMH) booklet “Bipolar Disorder”
http://www.nimh.nih.gov/health/publications/bipolar-disorder/complete-index.shtml
MGH Center for Women’s Mental Health
http://womensmentalhealth.org/
LactMed provides a quick resource for accessing product safety information and is available as both an android and an Apple download:
- https://play.google.com/store/apps/details?id=gov.nih.nlm.sis.lactmed
- https://itunes.apple.com/us/app/lactmed/id441969514?mt=8
What is Schizophrenia?
http://www.nami.org/Template.cfm?Section=schizophrenia9
LactMed provides a quick resource for accessing product safety information and is available as both an android and an Apple download:
[/symple_toggle]References
ACOG. Use of psychiatric medications during pregnancy and lactation. ACOG Practice Bulletin No 92. Obstet Gynecol 2008; 111:1001-20.
Centers for Disease Control and Prevention. Preconception Health and Health Care: Women (2013). Offers content on a number of chronic diseases and on preconception health, in general, for men and women. http://www.cdc.gov/preconception/women.html.
Farr, S et al. Mental health and access to services among US women of reproductive age. Am J of Obstet Gynecol. 2010; 203(6):542e1-542e9.
Frieder A, Dunlop A., Culpepper L, Bernstein , PS. The clinical content of preconception care: women with psychiatric conditions. Am J Obstet Gynecol 2008; 199 [6 Suppl 2]: S328-32.
Kimberling R, Gima K, Smith MW, Street A, Frayne S. The Veterans Health Administration and military sexual trauma. Am J Public Health 2007; 97:2160–6.
Patton SW, Misri S, Corral MR, Perry KF, Kaun AJ. Antipsychotic medication during pregnancy and lactation in women with schizophrenia: Evaluating the risk. Can J Psychiatry 2002; 47:959-965.
Yonkers KA, Wisner KL, Stowe Z, Leibenluft E, Cohen L, et al. Management of bipolar disorder during pregnancy and the postpartum period. Am J Psychiatry 2004; 161:608-620.)
Yonkers KA, Wisner KL, Stewart DE, Oberlander TF, Dell DL, Stotland N et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol. 2009; 114(3):703-713.
Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602.
