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.Background
- Mental health conditions are common in women of reproductive age. The prevalence for selected diseases is as follows (Kaiser Family Foundation, Women’s Health Care Chartbook, 2011 http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8164.pdf): (Kessler et al. Arch Gen Psych. 2005)
- Depression and Anxiety—26%
- Mental Health Issues—35%
- Saw a mental health professional in past year–12% (by self-report).
- 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;
- Treatment options to minimize risks;
- Signs and symptoms of disease progression;
- The severe 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.
- Women with mental health disorders can have healthy pregnancies and healthy infants but the likelihood is greatly increased by good pre-pregnancy disease control with the fewest and safest medicines possible.
- 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 stopping their method of contraception.
- 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:
- Women with mental health disorders are at high risk for unintended pregnancies.
- 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 the woman’s 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.
- Women at risk for an unintended pregnancy should be aware of the following:
- Depression in pregnant women is associated with 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
- An important strategy to minimize the risks of poor pregnancy outcomes is actively planning if and when to become pregnant.
Medication Issues:
- As many as 68% of women who stop their antidepressants will experience a relapse of major depression.
- SSRIs are considered first line treatment for depression in most patients, pregnant and nonpregnant.
- 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
- For women who could become pregnant, avoid prescribing Paroxetine as it 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)
- Strongly encourage highly effective contraception such as one of the LARCs and assure access to method.
- Encourage woman (and partner) to actively consider their reproductive life plan for both the short and long term.
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 risk for unintended pregnancies and risky sexual behavior, especially during periods of mania
- 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).
- An important strategy to minimize the risks of poor pregnancy outcomes is actively planning if and when to become pregnant.
- Patients need to be closely monitored and cared for by a multidisciplinary team before, between and beyond pregnancy.
Medication Issues:
- Patients should receive education that:
- Bipolar conditions can be severe and highly recurrent in pregnancy.
- 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%.
- 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%).
- Folic acid supplementation (4 mg) is recommended to prevent neural tube defects (starting one month prior to attempts to become pregnant and continued through the first trimester)
- Discussing risks and best medication choices with woman’s psychiatric provider is important to achieve coordinated care and to avoid mixed messages.
- Stress that she should NOT discontinue any of her medications without medical supervision, even if she thinks she may have become pregnant.
Family Planning (timing of conception):
- Strongly encourage highly effective contraception such as one of the LARCs and assure access to method.
- Encourage woman (and partner) to actively consider their reproductive life plan for both the short and long term.
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.
- Schizophrenia associated with higher prevalence of cigarette smoking, alcohol use, illicit drug use, interpersonal violence and risky sexual behaviors all of which should be assessed and addressed in woman’s care
- 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.
- Women at risk for an unintended pregnancy should know that pregnancy is associated with increased maternal and neonatal morbidity especially LBW, SGA and prematurity.
- An important strategy to minimize the risks of poor pregnancy outcomes is actively planning if and when to become pregnant.
Medication Issues:
- High risk for relapse when not on medications.
- Stress that the woman should NOT discontinue any of her medications without medical supervision, even if she thinks she may have become pregnant.
- 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.
Family Planning (timing of conception):
- Strongly encourage highly effective contraception such as one of the LARCs and assure access to method.
- Encourage woman (and partner) to actively consider their reproductive life plan for both the short and long term.
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 PDQ-9 screen is an example of an efficient, self-administered tool—for information on the PDQ-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://ask.hrsa.gov/detail_materials.cfm?ProdID=3924
Reproductive life plan tools:
http://www.cdc.gov/preconception/reproductiveplan.html
[/symple_toggle][symple_toggle title="Bipolar Disorder" state="closed"]Up To Date (paid service): Bipolar Disorder in Women: Preconception and prenatal maintenance pharmacotherapy.
Up To Date (paid service): Bipolar disorder in women: Indications for preconception and prenatal maintenance pharmacotherapy.
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
Major Depression During Conception and Pregnancy: A Guide for Patients and Families.
http://womensmentalhealth.org/wp-content/uploads/2008/04/mdd_guide.pdf
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
Reproductive life plan tools:
http://www.cdc.gov/preconception/reproductiveplan.html
[/symple_toggle][symple_toggle title="Schizophrenia" state="closed"]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:
- https://play.google.com/store/apps/details?id=gov.nih.nlm.sis.lactmed
- https://itunes.apple.com/us/app/lactmed/id441969514?mt=8
Reproductive life plan tools:
[/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.
