ReviewClinical management of perinatal anxiety disorders: A systematic review
Introduction
Even though pregnancy is a period of emotional well-being for most women, one fourth of pregnant women are affected by a mental disorder, with one-twelfth experiencing one of these disorders for the first time (Vesga-Lopez et al., 2008). Over the last few decades, more attention has been focused on anxiety disorders (AnxD), which were more extensively investigated in antenatal period (Goodman and Chenausky, 2014) than in post-partum.
AnxD are diagnosed in 4–39% of pregnant women (Goodman and Chenausky, 2014) and prevalence rates are even higher if comorbid disorders are also considered (Marchesi et al., 2014).
Although prenatal AnxD increase the risk of post-partum depression (Goodman and Chenausky, 2014), their effects on obstetric outcomes are debated. Regarding neonatal/infant outcomes, a low brain-derived neurotrophic factor (BDNF) level in the blood cord; no heart rate response to the mother anxiety; increase cortisol reactivity to stress (not replicated in other two studies) and early attention dysfunction, were found in infants of mothers with prenatal AnxD (Goodman and Chenausky, 2014).
With regard to the post-partum period, AnxD are diagnosed in 16% of women (Vesga-Lopez et al., 2008, Austin et al., 2010, Wenzel et al., 2005, Reck et al., 2008) and up to 50% if comorbid major depression is also taken into account (Austin et al., 2010, Wenzel et al., 2005).
Untreated AnxD increase the risk of postpartum depression (Prenoveau et al., 2013) and have been associated with maternal low self-confidence (Zietlow et al., 2014); early complications in the offspring (e.g. behavioural inhibition, mother–infant interaction problems, insecure attachment), and later adverse child development (Glasheen et al., 2010).
Recent reviews have mostly focused on prevalence rates and clinical presentation of AnxD in pregnant and postpartum women (Goodman et al., 2014, Ross and McLean, 2006). This is the first systematic review on pharmacological and non-pharmacological treatment approaches of perinatal AnxD.
We systematically reviewed the available literature on the treatment of perinatal AnxD and we provide recommendations for clinical management and future research.
Section snippets
Materials and methods
We conducted this review according to the methods recommended by the Cochrane Collaboration and documented the process and results in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Liberati et al., 2009, Higgins and Green, 2011).
Results
One thousand two hundred potential studies were identified from searching the selected databases and listing references of relevant articles. After removing duplicates, 756 articles were retrieved. Studies were screened and selected on the basis of pre-specified inclusion and exclusion criteria (Fig. 1). The search identified 18 articles that were included in the systematic review.
Fifteen of the 18 studies (83%) were case reports/case series, and three (17%) open label trials. The study
Discussion
Studies included in this review supported the use of CBT for OCD, PD and specific phobia both in pregnancy and postpartum. SSRIs led to significant OCD and PD improvement both in pregnancy and postpartum with no side effects for the babies. In the largest clinical sample to date, 65% of postpartum patients who entered the open-label trial of fluvoxamine (up to 300 mg/day) experienced a 30% or greater decrease in the total score of the Y-BOCS. During pregnancy, SSRIs and TCAs led to remission of
Limitations
The main limitation of included studies is sample size, as documented by the quality assessment scores. Only four studies (22%) were assigned a score equal or greater than 20/31 on the Downs and Black quality scale (Downs and Black, 1998) (Table 1). The majority of the selected studies are case reports (83%, 15/18) with only three clinical trials (17%). Study design and enrolment of subjects mainly from outpatient specialty units might have limited community-wide generalisability.
Another
Competing interests
Dr. Marchesi, Dr. Ossola, Dr. Amerio, Dr. Daniel, Dr. Tonna, and Dr. De Panfilis report no conflicts of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Contributors
Authors CM, PO, AA, and BDD designed the study and wrote the protocol. Studies were identified and independently reviewed for eligibility by two authors (AA, PO) in a two-step based process. Data were extracted by two authors (AA, PO) and supervised by a third author (CM) using an ad-hoc developed data extraction spreadsheet. The same authors who performed data extraction (AA, PO) independently assessed the quality of selected studies using the checklist developed by Downs and Black both for
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