Authored by Dr. Crystal Clark and Dr. Simone Vigod and reviewed by First Exposure Medical Review Team.
Dr. Crystal Clark, MD, MSc, a leading expert in mental health disorders during the reproductive period, is a scientist and the Associate Head of Research at Women’s College Hospital in the department of Psychiatry, as well as an Associate Professor of Psychiatry at the University of Toronto.
Dr. Simone Vigod, MD, MSc, FRCP, (Professor, University of Toronto), is Head of Psychiatry and the Shirley A. Brown Memorial Chair in Women’s Mental Health Research at Women’s College Hospital, as well as a leading expert in mental health disorders during the reproductive period.
This health topic is an expert opinion about Mental Health during pregnancy and postpartum.
* The information provided is the expert opinion of the First Exposure Medical Advisors. It is for informational purposes only and does not replace medical care and advice from a healthcare provider. Please contact your healthcare provider if you have any concerns or wish to discuss any questions that you believe may be relevant to you or your baby. In case of emergency, please go to the emergency room or call 911.
If you do not have a healthcare provider please go to: Finding a Healthcare Provider
Clinical scenario:
I have been dealing with mental health issues for several years. I am planning a pregnancy. What should I know about mental health and its treatment in pregnancy
Q. Are mental health problems common in pregnancy and postpartum?
A. Mental health issues may start before pregnancy, during pregnancy or in the early months after delivery (postpartum period):
- Common mental health issues such as depression, anxiety and related conditions such as post-traumatic stress disorder and obsessive-compulsive disorder are experienced by 1 out of 5 pregnant and postpartum individuals- these are some of the most common complications of pregnancy and the first year postpartum.
- More severe mental illnesses such as bipolar disorder and schizophrenia, which occur in 1-4% of the population, commonly affect people of reproductive age and may worsen in pregnancy.
- Postpartum psychosis is a serious but very rare condition that affects less than 1 in 1000 people, usually starting in the first few weeks postpartum. Postpartum psychosis often presents with severe confusion. Symptoms can also include hallucinations (seeing, hearing, smelling, touching, and/or tasting things that are not really there), cognitive changes, fixed false beliefs, and a high or irritable mood. It is considered a medical emergency.
Not every person with symptoms of depression and/or anxiety will be diagnosed with a mental health condition or disorder. A pregnancy may sometimes bring emotional changes. In the postpartum period, about 80 out of 100 (80%) people experience what is commonly known as “baby blues”. Symptoms may include tearfulness, mood changes and irritability that start within the first few days postpartum. The symptoms are not severe, and generally improve over the next few weeks without treatment.
If you are experiencing emotional changes in pregnancy and/or postpartum, speak to your health care provider to determine whether these emotional changes might benefit from treatment.
Q. Who is at risk for worsening mental health in pregnancy and postpartum?
A. The risk for mental health conditions starting during pregnancy is not higher than before becoming pregnant. However, the early months after delivery are a high-risk period for new-onset mental health conditions, or relapse of existing mental health conditions.
Mental health issues during pregnancy and the postpartum period affect people of all ages and backgrounds. However, people who are racialized, Indigenous, immigrant and/or from marginalized backgrounds may have a higher risk.
There are multiple factors that may increase the risk for mental health issues during pregnancy and postpartum; for example, a history of a mental health issue, a family history of a mental health condition, especially in a biological parent or sibling, age younger than 25, limited social support and life stressors, such as, difficult relationship with a partner, interpersonal violence, or a child who is ill.
Q. What are treatment options for mental health conditions in pregnancy and postpartum?
A. For common mental health conditions such as depression, anxiety and related conditions such as obsessive-compulsive disorder or post-traumatic stress disorder, there are many different treatment options in pregnancy and postpartum.
For example:
- For people with mild symptoms, treatments such as peer support, guided self-help (e.g. learning strategies independently with the help of a coach) or support from a healthcare provider such as a public health nurse, may be helpful.
- For people with moderate symptoms, a course of therapy with a healthcare provider might be needed. For example, therapies like cognitive behavioural therapy (CBT), interpersonal therapy (IPT) and behavioural activation (BA) may be effective.
- Medication might be needed in addition to these treatments, or may be a more effective treatment, for people who: (1) have more severe symptoms and need treatment quickly, (2) who do not feel better after trying the treatments mentioned above, or (3) have a history of needing to stay on medication to feel well.
- For people with mental health conditions such as bipolar disorder or schizophrenia, medication is usually needed during pregnancy and after birth.
Some types of medications that are used to treat mental health conditions include:
- Antidepressants (e.g. selective serotonin reuptake inhibitors [SSRI] or serotonin norepinephrine reuptake inhibitors [SNRI])
- Mood stabilizers (e.g. lithium, divalproex, carbamazepine)
- Antipsychotics (e.g. quetiapine, risperidone, olanzapine)
- Psychostimulants (e.g. methylphenidate)
- Benzodiazepines (e.g. lorazepam, clonazepam)
Q. Can people taking medications for mental health issues stay on them while pregnant or nursing?
A. Many of the medications used for mental health conditions have been studied and can be continued during pregnancy. Decisions about whether to start or continue a medication while pregnant or nursing need to be made together with a healthcare provider and involve weighing the potential benefits of the medication against any potential for adverse effects or risks.
Potential benefits of a medication include not only its effect on the well-being of the pregnant/postpartum individual but also on the well-being of the developing fetus or child. This is because untreated – or undertreated – mental health conditions, in some cases, negatively affect fetal or child well-being. Benefits of a medication(s) must also be carefully weighed against what is known about the safety of the medication(s) a person is taking or considering.
In general, suddenly stopping or reducing a medication that previously helped a person to feel well can result in problematic side effects (withdrawal like symptoms) or return of symptoms – so it is important for any decisions about changes in medication to be made with your prescribing health care provider.
Q. Where to get more information?
A. Stay Tuned
The goal of the information presented in First Exposure is to provide people and their health care providers up-to-date, evidence based/reliable information on the safety of medications in pregnancy so they can more confidently weigh the potential benefits of taking medication alongside potential risks and be comfortable that they are making the best possible decision for their individual circumstance.
Resources for patients:
Postpartum Support International
Postpartum Support International- International Resources
Mother Matters- Support forum for New Mothers
BounceBack® reclaim your health
Coping with depression during pregnancy and following the birth
Coping with anxiety during pregnancy and following the birth
Resources for Health Care Providers:
Links to treatment resources in Ontario for perinatal mental health conditions can be found here in the Ontario Provincial Council for Maternal and Child Health’s Care Pathway for the Management of Perinatal Mental Health.
Active U of T Affiliated Hospital Research Study
Key References
Statistics Canada. Maternal Mental Health in Canada. [September 16, 2023]. Available from: https://www150.statcan.gc.ca/n1/pub/11-627-m/11-627-m2019041-eng.htm
Fawcett EJ, Fairbrother N, Cox ML, White IR, Fawcett JM. The Prevalence of Anxiety Disorders During Pregnancy and the Postpartum Period: A Multivariate Bayesian Meta-Analysis. J Clin Psychiatry. 2019;80(4).[PMID: 31347796].
Werner E, Miller M, Osborne LM, Kuzava S, Monk C. Preventing postpartum depression: review and recommendations. Arch Womens Ment Health. 2015;18(1):41-60.[PMID: 25422150].
Daoud N, O’Brien K, O’Campo P, Harney S, Harney E, Bebee K, et al. Postpartum depression prevalence and risk factors among Indigenous, non-Indigenous and immigrant women in Canada. Can J Public Health. 2019;110(4):440-52.[PMID: 30767191].
Cannon C, Nasrallah HA. A focus on postpartum depression among African American women: A literature review. Ann Clin Psychiatry. 2019;31(2):138-43.[PMID: 31046035].
Yang K, Wu J, Chen X. Risk factors of perinatal depression in women: a systematic review and meta-analysis. BMC Psychiatry. 2022;22(1):63.[PMID: 35086502].
CAMH (Centre for Addiction and Mental Health). Perinatal Mood & Anxiety Disorders – Risk Factors Toronto, ON: CAMH; 2019 [cited 2023 September 16]. Adapted from Dalfen, Ariel K. Perinatal mood and anxiety disorders in Psychiatry in primary care]. Available from: https://www.camh.ca/en/professionals/treating-conditions-and-disorders/perinatal-mood-and-anxiety-disorders/perinatal-mood—risk-factors
Grigoriadis S, Graves L, Peer M, Mamisashvili L, Tomlinson G, Vigod SN, et al. A systematic review and meta-analysis of the effects of antenatal anxiety on postpartum outcomes. Arch Womens Ment Health. 2019;22(5):543-56.[PMID: 30523416].
Grigoriadis S, Graves L, Peer M, Mamisashvili L, Tomlinson G, Vigod SN, et al. Maternal Anxiety During Pregnancy and the Association With Adverse Perinatal Outcomes: Systematic Review and Meta-Analysis. J Clin Psychiatry. 2018;79(5).[PMID: 30192449].
Grigoriadis S, VonderPorten EH, Mamisashvili L, Tomlinson G, Dennis CL, Koren G, et al. The impact of maternal depression during pregnancy on perinatal outcomes: a systematic review and meta-analysis. J Clin Psychiatry. 2013;74(4):e321-41.[PMID: 23656857].
Stein A, Pearson RM, Goodman SH, Rapa E, Rahman A, McCallum M, et al. Effects of perinatal mental disorders on the fetus and child. Lancet. 2014;384(9956):1800-19.[PMID: 25455250].
Disclaimer
First Exposure does not offer health care treatment. If you have an urgent question about your pregnancy or your baby’s health, you should contact your health care provider directly. If you don’t have a health care provider and you live in Ontario, you have a variety of health care options. In the case of an emergency, visit a hospital emergency room or call 911.