Psychiatric Disorders

Julio B. Delgado

Michael Frölich

Introduction

Diagnosis and treatment of psychiatric disorders during pregnancy and the postpartum period is a topic of significant relevance due to the high prevalence of these conditions and the multiple barriers to provide an appropriate diagnosis as well as effective and safe treatment. It is now more commonly acknowledged that new onset and exacerbation of psychiatric disorders during pregnancy and the postpartum period are frequent problems that may require a multidisciplinary approach to provide effective and timely diagnosis and treatment thereby minimizing the inherent risks secondary to treatment or lack of an early and effective intervention. Physicians who treat women during the childbearing years should be able to appropriately screen and provide guidance to effectively diagnose, refer, and treat patients who have a history of primary psychiatric disorders or exhibit symptoms which require a psychiatric evaluation. Empirical approaches to treatment are not ideal and consultation with psychiatry should be considered to provide safe and effective treatment minimizing morbidity to the mother and potential serious implications to the child. Pharmacologic treatment during pregnancy implies unique risks including neonatal exposure but untreated psychiatric illness can be more risky. The decision to treat includes many factors. A detailed history that addresses psychiatric issues and a careful assessment of the potential scenarios that affect the course of the specific condition during pregnancy and the postpartum period need to be carefully evaluated. In addition, consultation with psychiatry should be considered. In the absence of a thorough evaluation and planning, the consequences may be significant. The rationale to screen patients for psychiatric symptoms even before conception allows for better planning and better access to effective care.

Epidemiology

In general, psychiatric diseases affect both genders and all socioeconomic and ethnic groups. It is interesting to note that mental disease often affects highly functional and creative individuals. The association between mental illness and art is reflected in the painting Broken Lines by the German artist G. Schetelig (Fig. 39-1). The specific incidence and prevalence of most psychiatric disorders during pregnancy and the postpartum period has been described by Bijl (1,2). Therefore, there now exists a good understanding of the potential implications of having a primary psychiatric disorder prior to conception, the potential risks of developing a new condition, and the changes in the course of these illnesses during pregnancy and the postpartum period. According to Bijl’s findings, roughly 40% of the adult population under 65 years of age has experienced at least one Diagnostic & Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) disorder in their lifetime. Among them, 23% have experienced a disorder within the preceding year. No gender differences were found in overall morbidity, but there was certainly a gender difference in the disease incidence as shown in Table 39-1. Depression, anxiety, and alcohol abuse and dependence were most prevalent; there was a high degree of comorbidity between them.

Diagnosis and Initial Evaluation during Pregnancy

Psychiatric disorders are some of the most prevalent conditions in mankind and produce significant morbidity in the general population and in women during the reproductive years. Regardless of their high prevalence, they are frequently undiagnosed, untreated, or misdiagnosed. An appropriate evaluation and accurate diagnosis are critical components in the process of providing successful treatment. Many nonpsychiatric physicians feel uncomfortable approaching, diagnosing, and treating psychiatric disorders. The reasons are many including negative attitudes toward patients with psychiatric disease. Frequently, there is a basic lack of knowledge and understanding of the nature and relevance of diagnosing and treating primary disorders or psychiatric manifestations of other conditions. A systematic approach in the evaluation, diagnosis, and treatment is based on reliable evidence that allows a clear specific diagnosis and more effective treatments. The diagnostic criteria are based on the DSM-IV produced by the American Psychiatric Association (APA). This manual of mental disorders provides the basic parameters for diagnosing specific psychiatric syndromes and entities based on reliable evidence that allows a methodic approach to classifying and diagnosing specific conditions, which correlates well with specific therapeutic approaches. The DSM-IV should be consulted for the diagnostic parameters and classification of psychiatric disorders. This chapter will emphasize a diagnostic approach based on basic signs and symptoms to facilitate an efficient and practical way to assessing, diagnosing, and planning appropriate and timely interventions initiated and provided by the anesthesiologist. An accurate diagnosis is the main initial goal to provide effective treatment.

The initial approach should facilitate the patient’s description of her symptoms and concerns after the physician formulates open-ended questions to elicit general information to evaluate the presence of a primary psychiatric syndrome, to explore personality features, or to recognize the presence of a personality disorder. Such information may not be easily obtained if a structured set of concrete questions is the initial interaction. It is important to keep an open-minded approach exploring groups of signs and symptoms before diagnosing specific entities. Regardless of this initial flexibility, the anesthesiologist remains in control of the interviewing process by providing the necessary structure to the evaluation and
subsequently inquiring about the presence of specific symptoms but at the same time facilitating the description of the patient’s perceived problems to orient the diagnostic process and to make a preliminary impression. The rationale to consider obtaining a formal psychiatric consultation will depend on the patient’s history, severity of symptoms, and the patient’s and the physician’s preference. For patients who are actively suicidal, psychotic, manic, or where the diagnosis is completely unclear, a psychiatric consultation should be requested.

Figure 39-1 Creativity and Madness: Many psychiatrists have been intrigued by the definite link between creativity and madness. This female painter illustrates this concept by using broken (disconnected) lines that embody the madness of a painting that is in perfect harmony with color and shape. (Broken Lines by Gesine Schetelig, reprinted with permission.)

When the emotions, behavior, or thought processes of a patient appear unconventional or generate concern, a formal assessment should be initiated to rule out the possibility of a psychiatric disorder, a medical condition with psychiatric manifestations, or the consequences of substance abuse.

Specific Syndromes with Anesthetic Implications

Mood Disorders

Mood is the perception of the world through the patient’s eyes; it can be pathologically lowered, elevated, or it may excessively cycle between the two. True mood disorders are not the typical reactions to life stressors but prolonged and abnormal affective stages that require an appropriate evaluation.

Major Depression

As indicated above, the presence of depression during the childbearing years is 2 to 3 times more common in women (3,4) with the highest incidence in the age group from 25 to 44 and a lifetime risk of up to 25%. Depression is a recurrent disorder with a high risk of suicide and a progressively worsening course if it is not appropriately treated.

The problems of mental illness (in general) and depression (in particular) have long been misjudged. One in six persons in the United States will, at some point, deal with major depression. Depression is also a leading cause of medical disability in women in the United States (5). Recent studies suggest that 10% of gravid women meet criteria for major depression (6,7) and up to 18% show depressive symptoms during gestation (8). Variable prevalence rates noted within the scientific literature reflect the variety of methods for screening subjects, whether subjects report symptoms themselves or whether trained researchers collected the data.

Gender differences in the expression of affective disorders have been attributed to the impact of hormonal influence, socialization, and genetics. The negative influence of maternal depression on maternal and child health, psychological well-being and other possible outcomes are significant (9). Because women are more likely to experience first time depression beginning at puberty and because reproductive life transitions are associated with relapse and recurrent episodes, the urgency to treat depression as fully and as early as possible is of critical importance.

The main clinical manifestations consistent with the presence of clinically significant depression are feelings of sadness, guilt, inadequacy, hopelessness or helplessness, irritability, difficulty concentrating, low energy level, insomnia or hypersomnia, anorexia, decreased libido, social isolation, anhedonia, decreased psychomotor activity, and suicidal thoughts.

Patients who have five or more of the above symptoms for a time period greater than 2 weeks fulfill criteria for the diagnosis of major depression and require treatment. The precipitating causes are diverse and include genetic factors, environmental factors, or other medical conditions. It is important not to assume that the clinical syndrome is just a consequence of the specific stressors but instead it is a clinical condition that requires specific treatment. Appropriate treatment will allow the patient a much faster recovery and will improve her ability to deal effectively with the ongoing stressors that may have precipitated the episode. The magnitude of the symptoms and the presence of feelings of hopelessness, guilt, or suicidal ideation are significant parameters that clearly suggest the presence of major depression. The clinical course can be acute or chronic, but a major depressive episode without treatment can produce significant morbidity for several months or may precipitate suicide. Depression can be effectively treated with psychotherapy, electroconvulsive therapy (ECT), or pharmacologic interventions. Specific therapeutic approaches will be discussed later.

One of the most significant components of the assessment in the patient with depression is evaluating the potential for suicide. Women attempt suicide more frequently than men. A detailed approach to evaluating the potential risk factors includes:

The presence of a clinical syndrome consistent with major depression
History of previous suicide attempts, impulsive behavior, substance abuse
History of physical or sexual abuse or significant recent losses
Family history of suicide
A plan to commit suicide and access to the means to implement the plan
History of a severe personality disorder

A suicide risk assessment is an inherent component of every mental status examination and should be evaluated in more detail in patients with a history of previous suicide attempts, severe character pathology with impulsivity, and acts of self-destructive behavior. Passive suicidal thoughts should be differentiated from the true intentions of self-inflicting lethal harm. If the above assessment is consistent with a high risk of suicide,
psychiatry should always be consulted and the patient should be under constant supervision until the evaluation is complete.

Table 39-1 Incidence Rate of Psychiatric Diseases by Gender and Incidence Rate Ratio

	Women	95% CI	Men	95% CI	IRR (f/m)	95% CI	Wald χ²	p-value
Mood disorders	3.25	(2.48–4.02)	1.34	(0.89–1.79)	2.39	(1.55–3.68)	28	<0.000
Major depression	3.9	(3.06–4.69)	1.72	(1.23–2.24)	2.23	(1.53–3.26)	27.6	<0.000
Dysthymia	0.39	(0.14–0.60)	0.39	(0.17–0.63)	0.93	(0.39–2.22)	1309.6	0.869
Bipolar disorder	0.43	(0.19–0.68)	0.17	(0.02–0.33)	2.37	(0.75–7.54)	2805.7	0.143
Anxiety disorders	4.56	(3.62–5.46)	1.62	(1.13–2.13)	2.58	(1.73–3.86)	25.2	<0.000
Panic disorder	1.3	(0.88–1.75)	0.28	(0.09–0.49)	4.17	(1.98–8.77)	26.8	<0.000
Agoraphobia (without panic)	1.14	(0.75–1.56)	0.41	(0.18–0.65)	2.57	(1.23–5.35)	13.1	0.012
Simple phobia	3.17	(2.46–3.87)	1.34	(0.91–1.77)	2.41	(1.57–3.69)	23.3	<0.000
Social phobia	1.12	(0.72–1.54)	0.75	(0.43–1.07)	1.42	(0.77–2.60)	4.8	0.258
Generalized anxiety disorder	0.98	(0.61–1.37)	0.45	(0.22–0.72)	1.86	(0.95–3.66)	11.6	0.07
Obsessive-compulsive disorder	0.39	(0.15–0.60)	0.17	(0.03–0.33)	1.76	(0.52–5.99)	2708.2	0.366
Substance use disorders	0.99	(0.61–1.36)	2.96	(2.22–3.71)	0.27	(0.15–0.50)	53.7	<0.000
Alcohol abuse	0.91	(0.55–1.27)	4.09	(3.28–4.92)	0.2	(0.12–0.35)	57.5	<0.000
Alcohol dependence	0.18	(0.02–0.34)	0.82	(0.48–1.16)	0.2	(0.06–0.70)	12.7	0.012
Drug abuse	0.07	(-0.03–0.18)	0.48	(0.23–0.73)	0.05	(0.01–0.43)	2186.9	0.006
Drug dependence	0.32	(0.12–0.54)	0.21	(0.05–0.38)	1.42	(0.40–5.07)	2740.3	0.586
Schizophrenia	0.1	(-0.02–0.21)	—	—	—	—	—	—
Eating disorders	0.14	(0.00–0.28)	0.07	(-0.02–0.17)	1.91	(0.34–10.74)	1335.5	0.463
One or more DSM-III-R diagnoses	6.94	(5.65–8.19)	4.45	(3.44–5.47)	1.54	(1.12–2.14)	22.5	0.009
Adapted from: Bijl RV, De Graaf R, Ravelli A, et al.; Gender and age-specific first incidence of DSM-III-R psychiatric disorders in the general population. Results from the Netherlands Mental Health Survey and Incidence Study (NEMESIS). Soc Psychiatry Psychiatr Epidemiol 2002;37:372–379. IR, new cases per 100 person-years at risk; IRR, incidence rate ratio, the ratio between the IRs for women and for men (controlled for age). Rows with a light gray background represent psychiatric diagnoses with a higher female incidence; rows with a dark gray background represent psychiatric diagnoses with a higher male incidence.

Postpartum depression should be differentiated from the transitory and limited symptoms induced by changes in hormone levels (“baby blues”); such symptoms are more consistent with emotional lability rather than true depression. For patients with moderate to severe cases of depression, treatment with antidepressants or ECT may be necessary. ECT provides a very rapid and effective treatment that appears to be safe during or after pregnancy.

Numerous tools including the Edinburgh Postpartum Depression Scale can be used to screen for depression during pregnancy and postpartum. Common symptoms of depression (sleep, energy, and appetite change) may be misinterpreted as normative experiences of pregnancy. Other classical symptoms are continuous depressed mood, loss of interest in activities, irritability and restlessness, having unwarranted guilt feelings, excessive sleep, appetite disturbances, and concentration or memory difficulties. However, only a small number (18%) of women meet most criteria for major depressive disorder. Women typically do not seek treatment during pregnancy and postpartum but patients report that when providers speak to them about their depression, they are more likely to seek treatment (10). Some depressive disorders may be secondary to medical conditions or medications; the diagnosis will rest on physical signs and symptoms, medical history, and medication history. Laboratory testing (e.g., thyroid function tests, B₁₂, and folate levels) may aid in reaching an accurate diagnosis and uncovering medical problems partially or fully responsible for the psychiatric presentation.

Mania or Hypomania

Mania or hypomania are specific clinical syndromes which are most of the times the manifestation of manic depressive disorder but can also be induced by other medical conditions or substance abuse. Hypomania is characterized by increased energy and self-confidence but does not impair contact with reality unless it evolves into a true manic episode. The main clinical manifestations consistent with a manic syndrome are:

An expansive affect, a persistently elevated mood with frequent feelings of grandiosity with or without irritability
Increased physical activity, increased energy, decreased need for sleep and reckless behavior

Treatment is important as untreated depression during pregnancy may have unfavorable outcomes for both women
and children. Complications of pregnancy associated with depression include inadequate weight gain, underutilization of prenatal care, increased substance use, and premature birth. Human studies demonstrate that perceived life-event stress as well as depression and anxiety predicted lower birth weight, decreased Apgar scores, smaller head circumference, and small-for-gestational-age-babies. Because management of depressed pregnant women also includes care of a growing fetus, treatment may be complicated and primary care providers should consider a multidisciplinary approach including an obstetrician, psychiatrist, and pediatrician to provide optimal care (11).

Several antidepressants have been studied in the treatment of severe depression. Although onset of antidepressant efficacy may differ for individual patients, the onset may require 4 to 6 weeks of treatment with most agents, whereas full efficacy may require 8 to 12 weeks (12,13). Selective serotonin reuptake inhibitors (SSRIs) are often used as a first-line treatment of depressive disorders because of their specificity, therapeutic safety margin, and a favorable side-effect profile (14). They also effectively treat anxiety disorders and other psychiatric comorbidities frequently associated with depression (15,16). Serotonin–norepinephrine reuptake inhibitors (SNRIs) are also effective in treating depression and anxiety. They may be particularly helpful when other drugs show little effect and in specific chronic pain conditions (17). However, they tend to be more expensive. Tricyclic antidepressants (TCAs) are older, less expensive agents that act primarily by inhibiting serotonin and norepinephrine reuptake. They are effective as antidepressants and are also used to treat chronic pain (18). They interact with many other receptors and thereby produce side effects that may limit tolerability and compliance (19).

The major concern with drug therapy during pregnancy has been the question about teratologic drug effects. However, there appears to be no association of exposure to SSRIs during pregnancy and lactation and major fetal malformations. However, some minor perinatal complications have been reported. Prenatal antidepressant use was associated with lower gestational age at birth and an increased risk of preterm birth. Presence of depressive symptoms was not associated with this risk. These results suggest that medication status, rather than depression, is a predictor of gestational age at birth (20). With linked population health data and propensity score matching, prenatal SSRI exposure was associated with an increased risk of low birth weight and respiratory distress, even when maternal illness severity was accounted for (21). As for most drugs, data on the long-term developmental outcomes of children exposed to SSRIs in utero and during breastfeeding are limited (22).

Women with histories of depression who are euthymic in the context of ongoing antidepressant therapy should be aware of the association of depressive relapse during pregnancy with antidepressant discontinuation (23).

Anesthesia and Electroconvulsive Therapy in Pregnancy

In severe psychotic depression, severe melancholic depression, resistant depression, and in patients intolerant of antidepressant medications and those with medical illnesses which contraindicate the use of antidepressants (e.g., renal, cardiac, or hepatic disease), electroconvulsive therapy (ECT) may be indicated (24).

Maternal effects of ECT are caused by the cardiovascular responses consisting of generalized autonomic nervous system stimulation with initial parasympathetic outflow, followed immediately by a sympathetic response. The cerebrovascular system responds with a marked increase in cerebral blood flow in response to increased cerebral oxygen consumption that results in dramatic elevation of intracranial pressure. Methohexital (0.75 to 1.0 mg/kg intravenously) is the most frequently used agent for induction of anesthesia for ECT. Alternatively, propofol (1.5 to 2 mg/kg IV) can be used safely. Muscle relaxation is usually accomplished with succinylcholine (0.5 to 1.0 mg/kg IV) (25,26). The risk associated with ECT during pregnancy is that of inducing premature contractions that may be refractory to tocolytic therapy. Ishikawa et al., recommend the use of an inhalational technique to reduce uterine activity associated with ECT (27).

Anesthetic Considerations

There are few studies of perioperative outcomes in patients with serious mental illness. The available literature suggests that patients with schizophrenia, compared with those without mental illness, may have higher pain thresholds, higher rates of death and postoperative complications, and differential outcomes (e.g., confusion, ileus) by anesthetic technique (28). A small dose of ketamine improves postoperative depressive state and relieves postoperative pain in depressed patients and is a suitable anesthetic for depressed patients. NMDA receptor antagonists are reported to be effective for improving depression. It remains unclear whether ketamine, which is an NMDA receptor antagonist, postoperatively affects the psychological state in depressed patients (29). The incidence of postoperative confusion in depressed patients with fentanyl was significantly lower than that of depressed patients without fentanyl (30). As the anesthetic management of depressed patients is becoming increasingly more complex, anesthesiologists should be familiar with medical illness and abnormal response (31). Patients receiving serotonergic antidepressants show significantly higher, but clinically unimportant, intraoperative blood loss, without an increase in perioperative transfusion requirements (32). Recent evidence suggests that preoperative executive dysfunction and depression may predict postoperative delirium; however, the combined effect of these risk factors remains unknown. Preoperative executive dysfunction and depressive symptoms are predictive of postoperative delirium among noncardiac surgical patients. Executive tasks with greater complexity are more strongly associated with postoperative delirium relative to tests of basic sequencing (33). Research has established that antidepressants administered to depressed patients should be continued before anesthesia. Discontinuation of antidepressants did not increase the incidence of hypotension and arrhythmias during anesthesia but increased symptoms of depression and delirium or confusion (30).

Anesthetic Concerns (Major Depression)

Early detection of depression during pregnancy is critical because depression can adversely affect birth outcomes and neonatal health and, if left untreated, can persist after the birth.

Untreated postpartum depression can impair mother–infant attachments and have cognitive, emotional, and behavioral consequences for children (Ryan et al., 2005).

Patients treated by antidepressants may have high postoperative pain scores.

Patients treated by antidepressants may have a mildly increased bleeding risk.

Patients treated by antidepressants may be at higher risk for temporary postoperative cognitive dysfunction.

Antidepressant therapy should be continued; the risk of intraoperative arrhythmias does not appear to be increased.

Bipolar Disorders

The spectrum and diagnosis of bipolar disorder (BPD) is based on the predominance of manic (euphoric) and depressive episodes, including BPD I, BPD II, and BPD not otherwise specified (NOS). BPDs with predominantly depressive symptoms are thought to have a combined lifetime prevalence of 3.5% compared to a prevalence rate of 1.0% for BPD I, which consists of one or more manic episodes (34). Surprisingly little is known about the course and treatment of these disorders during pregnancy and the postpartum period. Brief hypomanic symptoms occur in the early puerperium in as many as 15% of women, and there is preliminary evidence that postpartum depression in some patients may be related to BPD II or BPD NOS, which have predominantly depressive episodes.

Unfortunately, there are no psychopharmacological studies on the acute or maintenance treatment of bipolar postpartum depression to guide clinical decision-making. Also, there is a lack of screening instruments designed specifically for use before or after delivery in women with suspected bipolar disorder. A prospective study of 89 pregnant women with BPD including 28 women with BPD II reported that the overall recurrence rate was two-fold greater (35) among women who discontinued versus continued mood stabilizers during pregnancy. Data on the effectiveness and safety of antidepressants are lacking since patients with BPD are routinely excluded from studies on the use of antidepressants during pregnancy or after delivery. Women who are on antidepressants should be carefully watched for cycle acceleration or a mood switch to hypomania or mania. There is increasing usage of neuroleptics for the depressive and maintenance phase of BPD but there are limited data on their use in pregnancy. In one study, placental passage, defined as the ratio of umbilical cord to maternal plasma concentrations, was highest for olanzapine followed by haloperidol, risperidone, and quetiapine (36). Due to reports of gestational diabetes, women on atypical neuroleptics need to be monitored closely (37,38,39). Exposure to atypical neuroleptics during pregnancy is also associated with increased infant birth weight and large for gestational age births (40). In general, patients suffering from BPD should be on antidepressants in combination with mood stabilizers. They need to be monitored closely for impending signs of mood instability.

Treatment of Bipolar Disorder during Pregnancy and the Postpartum Period

The priorities regarding the approach to treat BPD during pregnancy are: (1) The severity of the illness, (2) the clinical course with and without medications in the past, (3) the history of discontinuation attempts, and (4) the response to specific medication. Each phase during pregnancy and postpartum represents variable risk; the best therapeutic approach depends on the severity of the illness. Abrupt discontinuation of treatment is not the standard any longer due to the very high rates of relapse (41) mainly when cessation is done suddenly. This risk is significantly reduced by continued mood stabilizer treatment. Treatment planning for pregnant women with BPD should consider the significant morbidity associated with discontinuation of maintenance treatment. Patients with a history of multiple relapses represent the greater challenge and ideally should remain on a mood stabilizer before and during pregnancy. The teratogenic risk of using lithium during the first trimester is small comparing it with the potential implications of relapse during pregnancy. Relapse of BPD during pregnancy is particularly dangerous and requires aggressive medical treatment with exposure to multiple psychotropics at high dosages.

Treatment during the postpartum period is critical due to the very high risk of relapse; the ideal approach has been extensively documented and consists of prophylaxis with mood stabilizers or neuroleptics mainly for the patients who were not undergoing treatment during pregnancy (42). Treatment with lithium can be reintroduced within the first 48 hours postdelivery or can be initiated in the last 3 weeks prior to delivery. The rationale to decrease lithium dose before delivery is particularly risky because it is taking place at the time of greatest risk of relapse. A more reasonable option is to follow the patient closely by monitoring lithium levels during labor and delivery as well as during the first postpartum days to adjust the dose as necessary and to minimize the risk of relapse. Therapeutic drug monitoring plays an important role in psychiatric pharmacotherapy during pregnancy to ensure that an adequate dose is given to achieve a therapeutic effect while avoiding excessive fetal exposure (43). The use of anticonvulsants and antipsychotics during the postpartum period is an option when lithium treatment has not been effective or well tolerated.

Lithium has a low teratogenic risk of Ebstein’s anomaly following first trimester exposure (0.05 % to 0.1%). Additional risks of lithium exposure later in pregnancy include neonatal hypotonia and cyanosis; there are also sporadic cases of neonatal hypothyroidism.

Anticonvulsants including valproic acid have a much higher teratogenic risk including neural tube defects, cardiovascular malformations, craniofacial abnormalities, and other CNS structural abnormalities. Due to the inherent risks, therapeutic options should be discussed with the patient, her family, and other physicians involved in her care to facilitate the implementation of a safe and effective strategy.

Anesthetic Considerations

Some pregnant patients with a bipolar disorder may receive one or several mood stabilizers. It is important to realize that the therapeutic levels of these drugs may fluctuate, and the anesthesiologist should be aware of potential drug toxicity and drug interactions. Lithium may increase the effects of certain antiemetic agents (such as promethazine and prochlorperazine) and the neuroleptic drug haloperidol. Side effects of the latter are tremor and tardive dyskinesia. Lithium itself has a narrow therapeutic to toxic ratio. Plasma lithium concentrations should be maintained as 0.4 to 1.0 mmol/L. Levels greater than 2 mmol/L may result in toxic effects such as polyuria, polydipsia, cardiac rhythm disturbances, nausea, and vomiting. Severe toxic effects are renal failure, disorientation, convulsions, coma, and death. (44,45).

Anxiety Disorders

Anxiety is a sense of fear without a specific cause, which is usually associated to physical manifestations. It is a common human experience that becomes a pathologic condition when it induces disabling symptoms and interferes with the patient’s capacity to function and with her quality of life. As stated above, anxiety disorders are very prevalent conditions in mankind and some of them are more common in women. The primary anxiety disorders include panic disorder (PD) with or without agoraphobia, specific phobias, generalized anxiety disorder, post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD). The diagnostic approach should include a standard evaluation to rule out medical or toxic etiologies.

PD is a condition characterized by relapsing episodes of panic attacks, which can develop with or without specific precipitating factors; the onset of symptoms is more frequent in young adults and in the context of a recent traumatic event.
The presence of this condition without treatment significantly affects quality of life-inducing maladaptive behavioral changes. Panic attacks are frequently confused with symptoms of pulmonary, neurologic, or cardiac disease that generate additional anxiety and multiple unnecessary medical workups. A detailed history is frequently the best diagnostic instrument. Panic attacks consist of acute exacerbations of anxiety with sensation of impending doom with duration of up to 20 minutes. The main symptoms consist of shortness of breath, fear of dying or going crazy, chest pain, tremors, perspiration, feelings of detachment, lightheadedness, and paresthesias. The presence of agoraphobia, which can also be diagnosed independently of panic attacks, induces more avoidant behavior and increases the potential for disability. Agoraphobia is the fear and avoidance of situations where the patient may not be able to escape, and exposure to such conditions will typically generate great anxiety or will trigger a panic attack. PD with agoraphobia is 3 times more common in women and without agoraphobia is twice as common.

Specific phobias are characterized by the severe irrational fear of specific objects or situations that the patient most of the times knows represent no real threat. These conditions can generate disability because they induce avoidance and impair the patient’s ability to interact with others, to perform at work, or to carry out other activities of daily living. Specific phobias are probably more common in women and have a lifetime prevalence of up to 10%.

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is defined as excessive and uncontrollable worry and anxiety about everyday life situations. It is a chronic disorder, and is associated with substantial somatization, high rates of comorbid depression and other anxiety disorders, and significant disability (46).

There is now growing realization that many women suffer from new onset or worsening of anxiety disorders during pregnancy. Uguz et al. noted that the rate of any mood or anxiety disorder was 19.4% in the pregnant women. Major depression (5.5%) and obsessive-compulsive disorder (5.2%) were the most common diagnoses in the pregnant women. The results suggest that pregnancy is not a risk factor for the development of mood and anxiety disorders (47).

Generalized anxiety disorder is a condition characterized by an inherent inability to relax and an excessive tendency to worry in such a way that anxiety is consistently present in most aspects of the patient’s life. The main symptoms include excessive worrying, difficulty relaxing, concentration and working memory deficits, insomnia, irritability, and low energy level.

Anxiety disorders are common problems facing obstetricians and gynecologists. Women are at least twice as likely to present with most anxiety disorders. The anxiety disorders are PD (with and without agoraphobia), OCD, PTSD, social phobia, and generalized anxiety disorder (GAD). Approximately 30% of women experience some type of anxiety disorder during their lifetime. Women with these disorders may experience profound changes in their symptoms during pregnancy and the postpartum period.

Anxiety disorders are common during the perinatal period, with reported rates of obsessive-compulsive disorder and generalized anxiety disorder being higher in postpartum women than in the general population (48). In addition, some evidence exists that anxiety disorders can affect pregnancy outcomes (49). It appears that anxiety disorders are associated with increased preeclampsia risk (50).

The SSRIs are the first-line treatment for most anxiety disorders because of data supporting their efficacy, the minimal need for dosage titration, the overall favorable side-effect profile, and the length of available clinical experience (51).

Anxiety symptoms in pregnancy have been associated with adverse fetal and infant outcomes. Furthermore, having an anxiety disorder during pregnancy is one of the strongest risk factors for postnatal depression. Optimal control of the psychiatric disorder should be maintained during pregnancy, the postpartum period, and thereafter. All pregnancies wherein a mother has a serious psychiatric disorder should be considered high risk and the mother and the fetus must be carefully monitored (52).

Antianxiety medications such as benzodiazepines (BZDs) are frequently and appropriately used to ameliorate the anxiety symptoms of depression, dysthymic disorder, PD, agoraphobia, obsessive-compulsive disorder, generalized anxiety disorder, eating disorder, and many personality disorders. Pregnancy may be accompanied by anxiety necessitating therapeutic intervention by anxiolytic drugs like BZD (53). Anxiety and depression during pregnancy increase the risk for an adverse pregnancy outcome and neurodevelopmental problems in the child (54). The risk of teratogenicity with pharmacotherapy must be considered, but judicious tapering and cessation of medication during high-risk periods can minimize it (55). For these reasons, it has been recommended that nonpharmacologic treatment, such as cognitive-behavioral therapy, should be first-line treatment in pregnant women with GAD or PD (56).

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