Perinatal Generalized Anxiety Disorder: Assessment and Treatment

Abstract

Perinatal generalized anxiety disorder (GAD) has a high prevalence of 8.5%-10.5% during pregnancy and 4.4%-10.8% postpartum. Despite its attendant dysfunction in the patient, this potentially debilitating mental health condition is often underdiagnosed. This overview will provide guidance for clinicians in making timely diagnosis and managing symptoms appropriately. A significant barrier to the diagnosis of GAD in the perinatal population is difficulty in distinguishing normal versus pathological worry. Because a perinatal-specific screening tool for GAD is nonexistent, early identification, diagnosis and treatment is often compromised. The resultant maternal dysfunction can potentially impact mother-infant bonding and influence neurodevelopmental outcomes in the children. Comorbid occurrence of GAD and major depressive disorder changes the illness course and its treatment outcome. Psychoeducation is a key component in overcoming denial/stigma and facilitating successful intervention. Treatment strategies are contingent upon illness severity. Cognitive behavior therapy (CBT), relaxation, and mindfulness therapy are indicated for mild GAD. Moderate/severe illness requires pharmacotherapy and CBT, individually or in combination. No psychotropic medications are approved by the FDA or Health Canada in pregnancy or the postpartum; off-label pharmacological treatment is instituted only if the benefit of therapy outweighs its risk. SSRIs/SNRIs are the first-line treatment for anxiety disorders due to data supporting their efficacy and overall favorable side effect profile. Benzodiazepines are an option for short-term treatment. While research on atypical antipsychotics is evolving, some can be considered for severe manifestations where the response to antidepressants or benzodiazepines has been insufficient. A case example will illustrate the onset, clinical course, and treatment strategies of GAD through pregnancy and the postpartum.

Supporting women with postpartum anxiety: exploring views and experiences of specialist community public health nurses in the UK

“…The difficulty of distinguishing normal from pathological anxiety or worry as a barrier to identification and diagnosis in the postpartum population has previously been raised (Misri et al . ). It is therefore important to equip HVs or other healthcare professionals supporting postpartum women with appropriate screening tools for postpartum anxiety.…”

Anxiety Disorders Among Women: A Female Lifespan Approach

“…The literature on GAD during pregnancy and postpartum is much richer. Misri (39) and Goodman (27) both published recent reviews of perinatal GAD. Briefly, GAD is fairly prevalent perinatally (27), but symptoms can be difficult to discern from normal aspects of pregnancy and postpartum (e.g.…”

“…Briefly, GAD is fairly prevalent perinatally (27), but symptoms can be difficult to discern from normal aspects of pregnancy and postpartum (e.g. insomnia, fatigue, difficulty concentrating) (39). Women with a history of GAD are more likely to have a recurrence perinatally; in one study, women with four or more previous GAD episodes were significantly more likely to experience GAD in pregnancy (40).…”

“…insomnia, fatigue, difficulty concentrating) (39; 119). Thus, a careful diagnostic interview should be conducted.…”

Associations between poor subjective prenatal sleep quality and postnatal depression and anxiety symptoms

“…Symptoms of depression and anxiety during the peri-partum period are common, with a global prevalence of up to 26% (Gotlib et al, 1989;Norhayati et al, 2015) and 30% (Britton, 2008) respectively, while prevalence rates of diagnoses of postnatal depressive or anxiety disorders is, respectively up to 13% and 8-11% (Gavin et al, 2005;Misri et al, 2015;Reck et al, 2008). Importantly, these symptoms can have detrimental effects on neurodevelopment of the offspring, such as birth outcomes, and increased emotional and cognitive problems (Dunkel Schetter et al, 2012;Glover, 2014).…”