Psychiatric Disorders
Warwick D. Ngan Kee BHB, MBChB, MD, FANZCA, FHKCA, FHKAM
Chapter Outline
Psychiatric disorders occur commonly during pregnancy, but their prevalence is often underestimated and underappreciated. Women have higher rates than men of many psychiatric disorders, such as anxiety, feeding and eating disorders, and depression; the reproductive years coincide with the greatest period of risk.1 Management can be difficult and may be complicated by variable presentation of symptoms, social stigmas, confusion with normal symptoms of pregnancy, and inconsistent published treatment recommendations. Further, pregnant women with psychiatric disorders may resist drug treatment because of their desire to avoid fetal harm. Psychiatric disorders during pregnancy may be associated with other aspects of poor maternal health and deficient prenatal care, which may have an impact on anesthesia care.2 Women with a history of previous psychiatric hospitalization or an identified mental illness are at increased risk for cesarean delivery.3
Classification
Internationally, psychiatric disorders are most commonly classified according to the International Statistical Classification of Diseases and Related Health Problems (ICD), produced by the World Health Organization; the current version is ICD-10 and is available on the Internet.* In the United States, a clinical modification of ICD is used; the latest version, ICD-10-CM, is due for implementation on October 1, 2014, and is also available on the Internet.† Although in the United States ICD is the official diagnostic system for mental disorders, the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA), is widely used; the current version is DSM-5.4 These classification systems provide standardized language and criteria for diagnosis and classification of mental disorders, but it should be noted that definitions may not have precise boundaries and may not cover all situations, and there may be considerable overlap between “mental” and “physical” disorders.4
Epidemiology
Estimates of the prevalence of psychiatric disease in pregnancy vary. It has been estimated that more than 500,000 pregnancies each year in the United States involve women who have a psychiatric illness that either predates or emerges during pregnancy1 and that 14% to 23% of pregnant women will experience a depressive disorder during pregnancy.5 Importantly, data from the Confidential Enquiries into Maternal Deaths in the United Kingdom6 have consistently highlighted suicide as a major indirect cause of maternal death.
Pregnancy is widely considered a time of increased vulnerability to psychiatric disorders. However, a large national epidemiologic survey in the United States found that although the prevalence of disorders was high among pregnant women, pregnancy itself was not associated with an increased risk; the results were thought to reflect a general increase in risk for psychiatric disorders in women during the childbearing years.2 A conspicuous exception was the risk for major depressive disorder, which appears to be increased during the postpartum period. Identified risk factors for developing psychiatric disorders during pregnancy include younger age, unmarried status, exposure to traumatic or stressful life events, pregnancy complications, and poor overall health. The survey also noted that treatment rates among pregnant women with psychiatric disorders were very low.
Mood Disorders
Mood disorders include depressive disorders and bipolar disorders (“manic-depressive disorders”).4
Major Depressive Disorder
Box 51-1 includes diagnostic criteria for major depressive disorder. Although depression is recognized as being relatively common during pregnancy, many of its symptoms (e.g., weight gain, appetite changes, sleep disturbances, fatigue) must be differentiated from symptoms that may occur during normal pregnancy. Risk factors for depression during pregnancy include a history of depression or bipolar disorder, childhood mistreatment, being a single mother or having more than three children, marital problems, unwanted pregnancy, smoking, low income, age younger than 20 years, poor social support, and domestic violence.7,8 The risk for major depressive illness is increased in women who have a miscarriage (i.e., spontaneous abortion); this most frequently occurs in the first month after miscarriage and is more likely to occur in women who are childless or who have a prior history of major depressive disorder.9 Depression during pregnancy is associated with an increased risk for poor obstetric outcomes such as miscarriage, preterm birth, and low birth weight.10
Bipolar (Manic-Depressive) Disorder
Patients with bipolar disorder (BPD) have episodes of major depression with other distinct periods of mania or hypomania. A strong familial association exists. Diagnostic criteria for mania are summarized in Box 51-2. BPD in pregnancy is particularly important because there is a strong link between discontinuation of medication and relapse of BPD and a relatively high suicide rate among patients. Treatment of BPD typically consists of mood stabilizer and antipsychotic medication, with psychotherapy as an adjunct.11 Electroconvulsive therapy (ECT) is very effective for patients with BPD and severe depression.
Postpartum Depression
Postpartum depression describes a major depressive episode that occurs in the first 4 to 6 weeks after birth. Symptoms do not differ from those of depression occurring at other times. There may be accompanying psychotic features, which are thought to be more common in nulliparous women,4,12 and there is a high risk for recurrence in subsequent pregnancies. It is important to differentiate postpartum depression from the “baby blues,” which affects up to 70% of women in the first 10 days after delivery and is transient without functional impairment. It is also important to differentiate postpartum depression from delirium that arises from physical causes.4 In a systematic review, Robertson et al.13 showed that the strongest predictors of postpartum depression were (1) depression, anxiety, or stressful life events occurring during pregnancy or the early puerperium; (2) low levels of social support; and (3) previous history of depression. Biologic effects such as hormonal changes and psychologic and social role changes that occur with childbirth may increase the risk for postpartum depression.14
Postpartum Psychosis
Postpartum psychosis occurs within 2 weeks of approximately 1 to 2 per 1000 live births; a relatively high risk continues for the first 3 months postpartum.15 The risk is higher in patients with a history of BPD or a history of previous postpartum psychosis,16 as well as in women with major depression and schizophrenia. Typical features include prominence of cognitive symptoms such as disorganization, confusion, impaired sensorium, disorientation, and distractibility.15 Infanticide may be associated with command hallucinations to kill the infant or delusions that the infant is possessed.12
Anxiety Disorders
Anxiety disorders affect women twice as often as men and are the most common psychiatric disorders during pregnancy and the postpartum period.17 There is a wide range of anxiety disorders, including panic disorder, separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder, agoraphobia, generalized anxiety disorder, substance /medication-induced anxiety disorder, anxiety disorder due to another medical condition, other specified anxiety disorder, and unspecified anxiety disorder. Closely related to anxiety disorders are trauma- and stressor-related disorders, which includes post-traumatic stress disorder, and obsessive-compulsive disorder.4 Clinical features of anxiety disorders in pregnant women are similar to those in nonpregnant women, but concern about the pregnancy and the fetus may be the predominant feature.18
Panic Disorder
Panic disorder is characterized by the occurrence of recurrent, unexpected panic attacks. Affected women experience discrete episodes of intense fear or discomfort in the absence of a true danger; these episodes are accompanied by somatic or cognitive symptoms such as palpitations, sweating, shaking, dyspnea, choking, chest pain, nausea, paresthesias, chills, and/or flushes. Typically there is a rapid onset and peak of symptoms that may be accompanied by an urge to escape.4 It is important to be aware of the possibility that panic attacks may occur during preparation of a patient for cesarean delivery. Panic attacks with hyperventilation may mimic systemic local anesthetic toxicity.19 A possible role of lactated Ringer’s solution as a trigger has been refuted.20 Patients with panic disorder often have co-morbid major depression.17
Post-traumatic Stress Disorder
Post-traumatic stress disorder (PTSD) occurs after the experience of a traumatic event that evokes intense fear or helplessness.1 Pregnancy and childbirth may exacerbate symptoms of PTSD. Symptoms of PTSD are more common after emergency cesarean delivery than after other modes of delivery,21 and PTSD has resulted from (1) awareness during general anesthesia,22 (2) inadequate regional anesthesia for cesarean delivery,23 and (3) inadequate pain control during vaginal delivery.23
