Preconception Planning to Reduce the Risk of Perinatal Depression and Anxiety Disorders

Orit Avni-Barron; Kelly Hoagland; Christina Ford; Laura J Miller

Disclosures

Expert Rev of Obstet Gynecol. 2010;5(4):421-435. 

In This Article

Abstract and Introduction

Abstract

Women who have depressive and anxiety disorders are at a high risk for recurrence or exacerbation of their psychiatric symptoms during pregnancy and/or postpartum. This risk can be reduced by implementing preventive measures prior to conception. A systematic preconception clinical assessment can identify factors that may contribute to a woman's risk for developing perinatal depression and/or anxiety. Each of these factors is amenable to interventions that could strengthen a woman's resilience and reduce her likelihood of developing perinatal psychiatric complications. This article reviews the evidence base for specific risk factors that can be influenced by preventive interventions, and describes the components of effective preconception planning for women with depressive and anxiety disorders.

Introduction

Pregnancy and the postpartum period are times of high risk for psychiatric symptom recurrence in women with pre-existing major depression and anxiety disorders. In a prospective naturalistic study of over 200 women with pre-existing major depression, relapses of major depression occurred during pregnancy in 43% of the overall study participants and 68% of the women who had opted to discontinue antidepressant medication.[1] Similarly, high rates of perinatal exacerbation of anxiety disorders, including panic disorder,[2] obsessive–compulsive disorder[3] and post-traumatic stress disorder,[4] have been observed.

For women with a high risk of perinatal depression and/or anxiety disorders, preconception consultation may help identify ways to reduce the likelihood of psychiatric complications of pregnancy. Effective preconception planning includes:

  • Assessing the likelihood of perinatal symptom recurrence, and the risks of untreated symptoms during pregnancy and postpartum;

  • Identifying specific factors that increase a woman's vulnerability to symptom relapse;

  • Recommending and implementing preventive interventions that reduce or protect against these vulnerabilities;

  • Assessing a woman's treatment preferences and related values so recommended interventions are congruent with her preferences.

This article provides a framework to help women with depressive and anxiety disorders plan preventive strategies before becoming pregnant. The recommended strategies are based on direct evidence of preventive efficacy, when available. However, to date, few studies of preventive measures are sufficiently powered, and many have other methodologic limitations such as the use of symptom-rating scales rather than diagnoses of major depression.[5,6] A key limitation of many prevention studies performed to date is that they isolate a single intervention and attempt to test its impact, rather than stemming from a more viable conceptual framework of attempting to influence several interacting variables.[7] At present, therefore, the best available data to guide women and their clinicians are based on extrapolation from studies regarding modifiable, interacting factors that have been shown to correlate with the risk of exacerbation of perinatal depression and/or anxiety.

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