Elsevier

Journal of Affective Disorders

Volume 190, 15 January 2016, Pages 543-550
Journal of Affective Disorders

Review
Clinical management of perinatal anxiety disorders: A systematic review

https://doi.org/10.1016/j.jad.2015.11.004Get rights and content

Highlights

  • AnxD are diagnosed in 4–39% of pregnant women and in up to 16% of women after delivery.

  • Selected studies supported the use of CBT for OCD, PD and specificphobia in pregnant and breast feeding women.

  • SSRIs can represent a treatment strategynotonly in AnxDrefractory to CBT.

Abstract

Background

In the last few decades, there has been a growing interest in anxiety disorders (AnxD) in the perinatal period. Although AnxD are diagnosed in 4–39% of pregnant women and in up to 16% of women after delivery, evidence on their clinical management is limited.

Methods

A systematic review was conducted on pharmacological and non-pharmacological treatment of AnxD in the perinatal period. Relevant papers published from January 1st 2015 were identified searching the electronic databases MEDLINE, Embase, PsycINFO and the Cochrane Library.

Results

18 articles met inclusion criteria. Selected studies supported the use of cognitive-behavioural therapy (CBT) for obsessive–compulsive disorder (OCD), panic disorder (PD) and specific phobia both in pregnancy and postpartum. Selective serotonin reuptake inhibitors (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 Yale–Brown Obsessive–Compulsive Scale (Y-BOCS). During pregnancy, SSRIs and tricyclic antidepressants (TCAs) led to remission of panic symptoms and healthy outcomes for the babies.

Limitations

Study design, mostly case reports, and enrolment of subjects mainly from outpatient specialty units might have limited community-wide generalisability.

Conclusions

Keeping in mind the scantiness and heterogeneity of the available literature, the best interpretation of the available evidence appears to be that CBT should be the first treatment offered to pregnant and breastfeeding women with AnxD. However SSRIs can represent a first line treatment strategy, and not exclusively in cases where AnxD is refractory to CBT.

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

References (52)

  • A. Wenzel et al.

    Anxiety symptoms and disorders at eight weeks postpartum

    J. Anxiety Disord.

    (2005)
  • American Psychiatric Association

    Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

    (2013)
  • American Psychiatric Association

    Practice guideline for the treatment of patients with obsessive-compulsive disorder

    (2007)
  • American Psychiatric Association

    Practice guideline for the treatment of patients with panic disorder

    (2009)
  • L.M. Arnold

    A Case Series of Women With Postpartum-Onset Obsessive–Compulsive Disorder

    J. Clin. Psychiatry

    (1999)
  • M.P. Austin et al.

    Depressive and anxiety disorders in the postpartum period: how prevalent are they and can we improve their detection?

    Arch. Women's Ment. Health

    (2010)
  • D. Chelmow et al.

    Pregnancy complicated by obsessive–compulsive disorder

    J. Matern. Fetal Med.

    (1997)
  • L.M. Christian et al.

    Cognitive behavioral treatment of postpartum onset: obsessive compulsive disorder with ag- gressive obsessions

    Clin. Case Stud.

    (2009)
  • S.H. Downs et al.

    The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions

    J. Epidemiol. Community Health

    (1998)
  • K. Furu et al.

    Selective serotonin reuptake inhibitors and venlafaxine in early pregnancy and risk of birth defects: population based cohort study and sibling design

    BMJ

    (2015)
  • S. Gentile

    Use of escitalopram during pregnancy: navigating towards international guidelines and the real world

    Clin. Drug. Investig.

    (2008)
  • C. Glasheen et al.

    A systematic review of the effects of postnatal maternal anxiety on children

    Arch. Women's Ment. Health

    (2010)
  • J.H. Goodman et al.

    Anxiety disorders during pregnancy: a systematic review

    J. Clin. Psychiatry

    (2014)
  • S. Grigoriadis et al.

    The effect of prenatal antidepressant exposure on neonatal adaptation: a systematic review and meta-analysis

    J. Clin. Psychiatry

    (2013)
  • S. Grigoriadis et al.

    Prenatal exposure to antidepressants and persistent pulmonary hypertension of the newborn: systematic review and meta-analysis

    BMJ

    (2014)
  • N.K. Grote et al.

    A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction

    Arch. Gen. Psychiatry

    (2010)
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