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Mental Disorders during Pregnancy
Essentials
- Various mental disorders are common during pregnancy.
- The most common ones are depression, various anxiety disorders and sleep disturbances.
- Early detection and active support and treatment often give good results.
- Psychosocial forms of treatment are always the primary choice during pregnancy.
Epidemiology
- Depression is one of the most common mental disorders in people of any age. In the general population, its prevalence is about 5-7%; it is 1.5-2 times more common in women than in men. About 8% of pregnant women suffer from depression. Depression during pregnancy is estimated to be perhaps even more common than postnatal depression.
- The symptoms of depression during pregnancy do not differ from those at other stages of life.
- 8-12% of women have some anxiety disorder during pregnancy.
- 10-20% of women suffer from sleep problems at some stage during pregnancy, typically difficulty falling asleep and waking up in the early hours. Predisposing factors during pregnancy, particularly towards the end of pregnancy, include many physiological factors that make sleeping more difficult.
- Sleep problems are also common in the general population: in the course of a year, 30-35% of adults have temporary insomnia, and one in ten meet the diagnostic criteria for insomnia.
Depression
- Factors predisposing to depression during pregnancy may include changes in social relationships and roles and possibly also physiological changes brought on by pregnancy. Significant changes in pregnancy hormone levels may also have effects, as pregnancy hormones are known to be involved in mood regulation, too.
- The symptoms are the same as outside of pregnancy Recognition and Diagnostics of Depression.
- The main symptoms are depressed and low mood and loss of pleasure and interest.
- Constant exhaustion or being exhausted by the slightest effort
- Feelings of guilt and worthlessness, excessive self-criticism, having no vision for the future, and hopelessness
- Sleep disturbances are common; typically waking up in the early hours and difficulty falling asleep, but there may also be hypersomnia.
- The patient's appetite may be poor enough to delay weight increase during pregnancy. In some cases, there may be an increased appetite with considerable weight gain.
- Self-destructive thoughts
- The most typical cognitive symptoms are concentration problems and working memory problems.
- In differential diagnosis, hypothyroidism Hypothyroidism, anaemia Assessment of Anaemia in Adults and sometimes vitamin B12 or folate deficiency should be considered.
- Tests most commonly used for differential diagnosis: basic blood count with platelet count, serum TCII-bound vitamin B12 and fasting folate, plasma TSH and free T4
- In psychiatric differential diagnosis, bipolar disorder Bipolar Disorder, in particular, should be considered, using MDQ screening http://www.ncbi.nlm.nih.gov/pmc/articles/PMC314375/, for example.
- It is always useful to ask directly about mood, and screening forms, such as the Edinburgh Postnatal Depression Scale (EPDS Edinburgh Postnatal Depression Scale (Epds)) can be used, as necessary. It is also useful to ask directly about any self-destructive thoughts; asking does not increase the risk of suicide.
Treatment
- Treatment normally consists of psychosocial treatment with or without medication.
- During pregnancy, particular emphasis is placed on psychosocial forms of treatment.
- A child welfare clinic psychologist, depression nurse specialist or other professional trained to treat depression should always be involved.
- Brief psychotherapy has proved effective.
- Medication should be considered in patients with moderately severe to severe depression. When considering medication, the advantages and disadvantages of treatment often need to be weighed. See also Use of Medication during Pregnancy.
- A pregnant woman with severe depression or depression resistant to appropriate treatment should be referred for assessment in specialized care.
- Pregnancy justifies more urgent referral.
- Self-destructiveness should always be taken seriously, and assessment in specialized care is often warranted.
Anxiety
- Anxiety is an emotion that is part of normal life. If it starts to interfere with normal life, i.e. appears inappropriately often or is inappropriately severe, interferes with everyday life or starts to control what the patient can or cannot do, for example, we speak about an anxiety disorder. See also Anxiety Disorder.
- Anxiety during pregnancy may be either a recurrence of a previous anxiety disorder or anxiety becoming more severe in the new life situation or emergence of a completely new disorder.
- Symptoms
- Autonomic nervous system symptoms, such as palpitations, hand tremor, sweating or dyspnoea are typical.
- During a panic attack, fear of loss of control or losing one's mind and fear of death may occur.
- In generalised anxiety disorder, constant, gnawing worry and fear related to many even mundane issues is typical.
- In social phobia, activation of symptoms in association with social interaction plays a central role.
- Social phobia and panic disorder may involve even severe avoidance behaviour.
- In obsessive-compulsive disorder, anxiety-provoking thoughts arise that the patient cannot stop even though she knows the thoughts are irrational. Ritualistic compulsive behaviours to lessen the anxiety (such as constant hand washing in fear of contamination) may sometimes be involved.
- The Generalized Anxiety Disorder Screener (GAD-7 http://www.mdcalc.com/gad-7-general-anxiety-disorder-7), for example, can be used to identify the disorder.
- Various personality disorders and depression Recognition and Diagnostics of Depression and, of somatic disorders, hyperthyroidism Hyperthyroidism and substance abuse Pregnant Substance Abuser can be considered in the differential diagnosis.
- Workup
- Patients with anxiety disorder should be asked about the symptoms (what kind of symptoms does the patient experience?), factors triggering or worsening the symptoms and the effect of the symptoms on their functional capacity. In particular, they should be asked specifically about any avoidance behaviour.
- Patients with panic disorder should be asked about the occurrence and duration of typical panic attacks and the frequency of such attacks.
- Patients with generalised anxiety disorder should be asked about the duration of the disorder and the level of disturbance caused.
- Patients with obsessive-compulsive disorder should be asked about the occurrence of obsessive thoughts and compulsive behaviours, each separately. Pregnant women may have obsessive thoughts of the foetus being injured, which may be extremely anxiety provoking.
- Traumatic experiences and the experience of traumatic childbirth, in particular, may be activated during pregnancy; should this occur, do not hesitate to contact the maternity hospital's fear of childbirth outpatient clinic Antenatal Clinics and Specialist Care: Consultations, Referrals, Treatment Guidelines.
Treatment
- In the treatment of any anxiety disorder during pregnancy, just as in depression, emphasis is placed on psychosocial forms of treatment.
- For troublesome symptoms, SSRIs, such as citalopram 20 mg or escitalopram 10 mg, can be considered, as necessary, weighing the advantages and disadvantages carefully Use of Medication during Pregnancy.
- Benzodiazepines should be avoided, particularly during pregnancy.
- Even just a few sessions with a psychologist or psychotherapist may help the patient to strengthen her means of controlling anxiety.
- For worries and fears associated with childbirth, cooperation with the maternity hospital's fear of childbirth outpatient clinic is recommended Antenatal Clinics and Specialist Care: Consultations, Referrals, Treatment Guidelines.
- If the patient's functional ability is severely impaired or if suspicion of a psychotic disorder, for example, arises, she should be referred to specialized care.
Sleeping problems
- Sleeping problems most commonly involve difficulty falling asleep or waking up in the early hours.
- The objectively assessed quality of sleep often gets worse towards the end of pregnancy. Sleeping often becomes more difficult due to the growing uterus. Breathing symptoms during sleep (snoring and sleep apnoea) may increase, as may the incidence of restless legs syndrome.
- All sleep disorders are associated with impaired performance during the daytime, and for diagnosis symptoms should have occurred on at least 3 nights a week for one month. Any transient sleeping problem that does not affect coping with everyday life does not meet the criteria of a sleep disorder. See also Insomnia.
- Difficulty falling asleep is a disorder resulting in an insufficient duration of sleep. A vicious circle typically arises where fear of difficulty falling asleep leads to increased worrying, which in turn makes falling asleep more difficult.
- Sleep apnoea Sleep Apnoea in the Adult often, though not always, involves snoring and breathing pauses during sleep, as well as severe fatigue during daytime.
- Restless legs syndrome Restless Legs and Akathisia involves a compulsive need to move the limbs, which often disturbs sleeping and falling asleep.
- Worsening limb symptoms may sometimes be due to iron deficiency.
- Differential diagnostic alternatives
Treatment
- The emphasis in treatment should be on supporting the patient, treating appropriately any underlying issues maintaining or triggering the condition, and providing guidance on good sleep hygiene.
- As there is plenty of evidence for the effect of cognitive methods in the treatment of insomnia, the patient should be referred to a professional with expertise in sleep, particularly if the situation is longstanding.
- As there is insufficient data about the use of dopamine agonists during pregnancy, they should be avoided in the treatment of restless legs syndrome and periodic limb movement disorders.
- Hypnotics, including melatonin, are not recommended during pregnancy.
- Low-dose oxazepam (7.5-15 mg) Use of Medication during Pregnancy has been used for extremely severe acute sleeping problems for a few nights but it cannot be recommended for more extended use.
- Should suspicion of sleep apnoea arise, the patient should be urgently referred for further examination in specialized care. CPAP treatment for sleep apnoea is safe during pregnancy.
References
- Depression. Current Care Guideline. Working group appointed by the Finnish Medical Society Duodecim, the Finnish Psychiatric Association, 2020. http://www.kaypahoito.fi/en/ccs00062
- Sleep apnoea syndrome. Current Care Guideline. Working group appointed by the Finnish Medical Society Duodecim and the Finnish Respiratory Society, 2017. http://www.kaypahoito.fi/en/ccs00083
- Grigoriadis S, VonderPorten EH, Mamisashvili L et al. The impact of maternal depression during pregnancy on perinatal outcomes: a systematic review and meta-analysis. J Clin Psychiatry 2013;74(4):e321-41. [PubMed]