Psychiatry

Focusing on psychopathology associated with pregnancy and the postpartum period runs counter to our cultural belief, often embodied in religious imagery and political discourse, that pregnancy should be a natural, even sacred, state of well being. This appealing but naive view is slowly yielding to a more nuanced understanding that the various phases of reproductive life pose unique hormonal, psychological, and behavioral challenges to women’s mental health¹ and that a maternal psychiatric disorder may affect the developing fetus or newborn child.

Postpartum Support International has rallied around the slogan, “Depression is the number one complication of pregnancy,”² with good reason. While much of the medical literature divides mental illness during pregnancy from disorders arising postpartum, the continuity between these periods is striking in terms of epidemiology, symptomatology, and treatment response.^3,4

A woman receiving basic maternity care typically visits health care providers more than a dozen times between learning she is pregnant and her child’s 1-year check-up. This is a period of high risk for the development of a mood or anxiety disorder. Unfortunately, excessive fears of liability for complications of psychiatric treatment, administrative barriers to referral or collaboration, and the lack of ownership of the overall health of women by any specialty often leave troubled women wandering in a “no man’s land” between obstetrics, psychiatry, and pediatrics.

The developing field of perinatal psychiatry tries to bring these patients in from the cold by promoting understanding of maternal physiology and psychology, before, during, and after pregnancy, supplemented with knowledge about the risks (and possible benefits) to fetuses and nursing infants whose mothers require treatment, particularly treatment that includes psychotropic medication.

As part of our educational mission, the psychiatry department at The George Washington University has launched a “Five Trimesters Clinic.” This service accepts self-referred patients and those identified as being in need of psychiatric services during the course of infertility treatment, prenatal care, or early well-child visits. We provide evaluation, brief treatment, and referrals, along with feedback to referring providers through our electronic medical record. This issue of Psychiatric Annals explores a selection of the issues we have found relevant in developing this service.

Prior to conception, the desire to experience or avoid pregnancy may be a woman’s central psychological concern. In addition to exploring these issues in psychotherapy, psychiatrists who treat women who might become pregnant need to be aware of the effects of medication on fertility and early fetal development. Once pregnancy occurs, estrogen, progesterone, cortisol, and other hormones that sustain pregnancy all modulate central nervous system functioning, both directly and through regulation of monamine transmitter activity. Pregnancy may trigger the same mood, anxiety, and psychotic disorders that occur in the non-pregnant state through mechanisms that may illuminate the pathophysiology of common disorders in all women and even in men.

Treatment during pregnancy involves going well beyond the FDA classification of the teratogenicity of psychotropic medication to assessing risks of treatment or no treatment to both the mother and the fetus.^3,5 These calculations vary by trimester, with concerns about fetal morphology being high in the first 3 months and birth related complications and effects on the neonate requiring consideration in the last trimester.

The postpartum period requires all women to adapt to an astonishing degree of hormonal flux, concurrent with major psychological and behavioral realignments related to caring for a helpless infant. Disorders ranging from temporary maladjustment to major psychotic episodes may arise de novo or intensify in this period.

Three articles in this issue describe severe disorders that have both typical and unique qualities when they develop in relation to pregnancy. Placental hormone secretion may contribute to severe affective illness in genetically vulnerable women, as illustrated by Frank and Khin Khin’s article on melancholia in pregnancy. While “postpartum depression” has become a popularly accepted category of psychiatric disorder, three articles in this issue highlight the recognition and treatment of other postpartum psychiatric conditions: bipolar II disorder (Rasooly and Frank), psychosis (Dorfman, Meisner, and Frank), and obsessive-compulsive disorder (Flosnik and Khin Khin). The article by Newborn and Frank explores enhancing postpartum mental health by examining the impact of women’s return to work outside the home after childbirth.

Providing specialized psychiatric care to women who may be, are now, or have just been pregnant is challenging, rewarding, and a great spur to curiosity and further professional development. By communicating some of what we have learned so far in our newly established clinic, we hope to improve the capacity of our colleagues in psychiatry, pediatrics, and obstetrics/gynecology to recognize and treat the common, disabling, and distressing psychiatric complications of pregnancy.

Note, I owe unbounded thanks to Eindra Khin Khin, MD for her masterful scholarly and stylistic contributions to the manuscript. We are both grateful to Julie Noblick, whose good cheer, patience, and eye for detail has improved every page of every article that follows.