Anxiety Disorders and Pregnancy

For many women, pregnancy is a time of joy, excitement and anticipation. For most, it is also a time of some worry. Concerns about carrying a child to term, the health of the baby and the delivery process are common and quite natural. However, some women are plagued by persistent, excessive and irrational anxiety and worry during, and after, pregnancy. Some may have a previous history of such excessive anxiety, while others may be experiencing it for the first time. These women may be suffering from an anxiety disorder, a serious but treatable illness.

While much has been written on the "baby blues" and postpartum depression, anxiety disorders also affect many women before, during and after pregnancy. Read on to learn more about anxiety disorders during pregnancy and the postpartum period.

I thought women were supposed to be happy during pregnancy. Aren't there biological safeguards that protect pregnant women from anxiety and mood disorders?

No. Although pregnancy has typically been considered a time of emotional well being, studies suggest that up to 20 percent of women suffer from anxiety or mood disorders (such as depression or bipolar disorder) during pregnancy. In fact, the childbearing years are a time when many such disorders first emerge in women.

Is there a connection between pregnancy and anxiety disorders?

Although research is limited, studies have uncovered some interesting findings. For example, some women with panic disorder experience a reduction or complete eradication of their symptoms after becoming pregnant. Conversely, some women with obsessive-compulsive disorder (OCD) suffer more severe symptoms during pregnancy, or experience OCD symptoms for the first time after becoming pregnant.

Studies have found the postpartum period to be a time of increased vulnerability to reoccurring and first time panic disorder, OCD, generalized anxiety disorder (GAD) and other disorders such as hypochondria. Among women with pregnancy-related and postpartum OCD, it is not uncommon to suffer disturbing and intrusive thoughts about harming their newborns.

Why can pregnancy change the course of a woman's anxiety disorder as described above?

It is not fully clear why pregnancy can have these effects, and much more research is needed. One likely culprit is the steadily rising hormone levels during pregnancy. The reduction in panic symptoms during this time may occur because the hormone progesterone - which has a much greater presence during pregnancy - has breakdown products that have effects similar to benzodiazepine medications like clonazepam (Klonopin) and diazepam (Valium), which are often used to treat anxiety disorders.

The hormones oxytocin and prolactin have been shown to have anti-anxiety effects in animals and may also help reduce panic during pregnancy. However, other hormonal changes during pregnancy, e.g., possible increases in androgen hormones, may contribute to the worsening of OCD symptoms that some women experience.

Although these hormone changes occur gradually during pregnancy, they reverse very suddenly after delivery. This abrupt drop likely contributes to postpartum worsening of anxiety and depression in some women.

For more about the role of hormones on anxiety disorders during pregnancy (and throughout a woman's life), click here to read an article by Margaret Altemus, MD, Weill Medical College, Cornell University.

Can a mother's mental health during pregnancy affect her baby?

There is growing evidence that suggests an untreated anxiety disorder or depression during pregnancy may contribute to poor neonatal outcomes, including preterm labor, premature delivery, low birth weight, and childhood behavioral and cognitive problems. This makes it essential for a pregnant woman to seek treatment for an anxiety disorder or depression, not just for her own health but for her baby's health. While the issue of antidepressant use to treat anxiety disorders and depression during pregnancy is a complex one (more information on this below), women who do decide to discontinue antidepressants should work with their treatment provider to develop an alternative plan for mental health treatment during pregnancy to prevent a relapse, which, as noted above, can have its own consequences. Nonmedication treatments include cognitive-behavioral therapy (CBT) and other methods (described in more detail under, "What are nonmedication treatment approaches for an anxiety disorder?"). It is of the utmost importance for women with anxiety disorders or depression to receive some sort of treatment during this time.

Is it safe to take antidepressants during pregnancy?

The benefits of medication to the mother and risks to the baby and mother should be weighed carefully. Research on this issue is still evolving. Therefore, the decision to start, continue or stop any medication during pregnancy should be done only in consultation with your physician.

At this time, studies have found no significant difference in the rates of miscarriages and stillbirth between women who take SSRIs, a group of antidepressants used in the treatment of anxiety disorders that include Prozac (fluoxetine), Zoloft (sertraline), Luvox (fluvoxamine), Paxil (paroxetine), Celexa (citalopram) and Lexapro (escitalopram), and those who don't. The same is true for another group of medications called tricyclic antidepressants, which include Elavil (amitriptyline) and Tofranil (imipramine).

However, some recent research has raised a few other concerns. A study published in February 2006 in the New England Journal of Medicine found that the babies of mothers who took SSRIs in the second half of their pregnancy were six times more likely to be born with a rare but potentially serious breathing problem called pulmonary hypertension. Although there is an increased risk for this condition, it is highly uncommon among exposed infants. Another study published in February 2006 in the Archives of Pediatrics and Adolescent Medicine found nearly one-third of newborns whose mothers used SSRIs late in their pregnancy experienced withdrawal symptoms such as high-pitched crying, tremors, disturbed sleep and gastrointestinal problems (a condition known as neonatal abstinence syndrome). However, these symptoms only lasted one to four days after birth and did not require medical treatment. (More detailed information about both studies can be found here). Additionally, in 2005, the Food & Drug Administration put out a warning stating that infants exposed to Paxil during the first three months of pregnancy had an increased risk of birth defects. In 2006, a large study in the journal Epidemiology also found that infants exposed to SSRIs during the first trimester had an increased rate of birth defects, but the study did not determine whether some SSRIs posed more risk than others (more on this study here).

Antidepressants known as monoamine oxidase inhibitors (MAOIs) are generally not considered safe during pregnancy.

Because there is not a simple answer to this question, and because discontinuing treatment can have its own risks for mothers and their babies, working closely with your doctor is essential. For more information, read this article from the Harvard Mental Health Letter or read a summary on the Center for Women's Health at Massachusetts General Hospital's website by clicking here.

Is it safe to take medication while breast-feeding?

The nutritional, immunologic and psychological benefits of breastfeeding are well documented, making breast-feeding an attractive option for many women. Women who plan to breastfeed should know that medications, including antidepressants, are secreted into the breast milk (although concentrations in the breast milk seem to vary widely). The amount of medication to which an infant is exposed depends on several factors, including dosage of medication, rate of maternal and infant drug metabolism, and frequency and timing of feedings. Scheduling feedings during certain time periods, reducing medication dosage and using formula for some feedings can help reduce the infant's exposure to medication.

Over the past five years, data has accumulated regarding the use of antidepressants during breastfeeding. Available data on the tricyclic antidepressants, fluoxetine, paroxetine, and sertraline during breastfeeding have been encouraging and suggest that significant complications related to neonatal exposure to such drugs in breast milk appear to be rare. Less information is available on the other antidepressants at this time.

The potential benefits and risks of breastfeeding by a woman taking such medications should be discussed by the patient, her physician and her partner. Since small amounts of medication do pass into breast milk, it is important to weigh the pros and cons of each option.

For more information on breastfeeding and antidepressants, visit the Center for Women's Health at Massachusetts General Hospital here and scroll to Using Medications While Breatfeeding.

Is it true that breastfeeding can have beneficial effects on anxiety?

Breastfeeding may help prevent some of the sudden hormonal transitions that occur at the end of pregnancy, since the hormones oxytocin and prolactin continue to be released. If the frequency of breastfeeding decreases gradually over time, the drop in oxytocin and prolactin for the mother will also be more gradual.

Studies have shown that women who breastfeed have reduced hormonal and nervous system reactions to acute stress. There have also been reports that breastfeeding may reduce anxiety symptoms for some women, but clearly other women continue to have anxiety. High levels of anxiety postpartum can make breastfeeding difficult because anxiety and stress suppress the release of oxytocin, a hormone needed for milk release.

For more on this, click here.

Are there long term effects on a child whose mother took medication while pregnant?

Although research suggests some medications may be used safely during pregnancy, knowledge regarding the long-term effects on a child is incomplete. At this time, few studies have thoroughly examined the impact of exposure to antidepressants during pregnancy on a child's future development and behavior.

Of the two major studies, which both looked at exposure to either tricyclic antidepressants or Prozac (fluoxetine), both found no significant differences in IQ, temperament, behavior, reactivity, mood, distractibility or activity level between children who were and were not exposed. The authors concluded that fluoxetine and tricyclic antidepressants do not have a significant effect on cognitive development, language or behavior.

For more information, visit the Center for Women's Health at Massachusetts General Hospital here.

What are nonmedication treatment approaches for an anxiety disorder?

The following are some alternatives to medication that may be appropriate for some women.

• Behavior Therapy. The goal of behavior therapy is to modify and gain control over unwanted behavior. The individual learns to cope with difficult situations, often through controlled exposure to them.
  
• Cognitive Therapy. The goal of cognitive therapy is to identify, challenge, and change unwanted, unproductive thoughts, feelings and behaviors. The individual learns to separate unrealistic thoughts and feelings from realistic ones. As with behavior therapy, the individual is actively involved in his or her own recovery.
  
• Cognitive-Behavior Therapy (CBT). Many therapists use a combination of cognitive and behavior therapies. This is often referred to as CBT. With CBT, the patient learns recovery skills that are useful for a lifetime.
  
• Relaxation Techniques. Relaxation techniques help individuals develop the ability to more effectively cope with the stresses that contribute to anxiety, as well as with some of the physical symptoms of anxiety. The techniques taught include breathing re-training, progressive muscle relaxation and exercise.
  
• Self-Help Support Groups. Support groups can be an invaluable resource for recovery and empowerment. They involve people with similar needs or experiences, and are facilitated by a consumer, layperson or survivor. Self-help groups for anxiety disorders can be found here.

To learn more about treatment options, click here.

What steps should a woman with an anxiety disorder take before becoming pregnant, or after learning she is pregnant?

It is ideal for a woman who suffers from an anxiety disorder to discuss the potential of pregnancy with her doctors before becoming pregnant, or as soon as possible after learning she is pregnant. Considerations you and your doctor to keep in mind when determining your treatment include:

• Severity of your illness
  
• History of symptoms when not on medication
  
• Potential effects of medications on your child
  
• Availability of alternative approaches to medication
  
• Plans for breast feeding
  
• Presence of a stable support system
  
• Availability of child care support during postpartum period

What about postpartum depression?

Postpartum depression is a serious illness that typically emerges over the first two to three postpartum months but may occur at any point after delivery. Depression often co-occurs with an anxiety disorder. Any of these symptoms during and after pregnancy that last longer than two weeks are signs of depression and/or an anxiety disorder:

• Feeling restless or irritable
  
• Feeling sad, hopeless, and overwhelmed
  
• Crying a lot
  
• Having no energy or motivation
  
• Eating too little or too much
  
• Sleeping too little or too much
  
• Trouble focusing, remembering, or making decisions
  
• Feeling worthless and guilty
  
• Loss of interest or pleasure in activities
  
• Withdrawal from friends and family
  
• Having headaches, chest pains, heart palpitations (the heart beating fast and feeling like it is skipping beats), or hyperventilation (fast and shallow breathing)
  

After pregnancy, signs may also include being afraid of hurting the baby or oneself and not having any interest in the baby.

Leaving depression untreated during and after pregnancy can have serious consequences on the entire family. Women with any of the signs listed above should seek help immediately from a trained professional.

For more information about depression during and after pregnancy, including treatment options, click here.

References and Resources

Center for Women's Health at Massachusetts General Hospital

Department of Health & Human Services

Harvard Mental Health Letter

Hormones: How Do They Affect Anxiety in Women

MADI Resource Center at Massachusetts General Hospital

Parenting.com - When a Mom's Worry Goes Too Far

Psychiatric Times - Psychiatric Disorders During Pregnancy