Abstract
Plain Language Summary
Key points about the CANMAT perinatal guidelines are commented on. The process of developing the guidelines was robust and there can be a high level of confidence in their recommendations. An important aspect is that services for women with perinatal mood and anxiety disorders need to put in place so that the range on evidence based treatments can be implemented.
Providing high-quality evidence-based treatment to women with mood and anxiety disorders arising during pregnancy and the first postpartum year (the perinatal period) is of critical importance, not only to reduce the immediate impact of these disorders (distress, poor obstetric outcomes) but also for the well-being of the next generation. If untreated, perinatal mood and anxiety disorders can have an adverse effect on the health and well-being of the children of mothers affected by them. This makes these clinical practice guidelines welcome.
This clinical practice guideline for the management of perinatal mood, anxiety, and related disorders (PMADs) is the most recent clinical practice guideline to come from the Canadian Network for Mood and Anxiety Treatments (CANMAT), to accompany their high-quality depression 1 and bipolar guidelines. 2
While perinatal mood and anxiety disorders are recognized by clinicians and researchers, they are not officially recognized in DSM-5. The DSM-5 peripartum specifier only applies to mood disorders, and there are no formally recognized, distinct anxiety disorders, despite some being uniquely related to the perinatal period (such as fear of childbirth and childbirth-related Posttraumatic Stress Disorder [PTSD]). Given the prevalence of PMADs (up to 12.9% of women experience major depression and 20% clinically significant anxiety symptoms), and their importance from a public health perspective, 3 it is surely time for official recognition of these disorders. By the same token, the most severe perinatal mood disorder, postpartum psychosis (covered in this guideline), with its close temporal link to childbirth, unique clinical presentation, and outcome, has no official diagnostic status. 4 It is time for official recognition of this important variant of bipolar disorder.
The team producing this guideline is made up of highly credentialled experts in the field across the relevant professional groups of psychiatry, psychology, pediatrics, nursing, and public health, as well as women with lived experience. This core group met regularly while developing the guidelines, consulted with persons with lived experience, non-mental health professionals (midwifery, obstetrics and gynecology, pediatrics, and primary care), and perinatal mental health clinicians in order to make their recommendations. This rigorous process gives us confidence to know that their recommendations are supported by research evidence, clinical wisdom, and are acceptable to service providers and users.
The structure of the guideline follows that of the CANMAT depression guideline, with recommendations regarding the identification of PMADs and how services should be organized. This includes specific interventions for the disorders. There are also invaluable recommendations regarding high-risk clinical situations, covering the important issue of thoughts of harm to the infant and recommendations regarding the mental health of fathers and co-parents.
They use the same criteria for the level of evidence as in interventions in the previous guidelines, but with two important additions: they give ratings for those that are not effective (negative evidence), and most importantly, ratings of perinatal safety. The recommendations for first, second, and third lines of treatment are then based upon efficacy and clinical support for the intervention, based on the balance of efficacy, safety, tolerability, and feasibility of applying perinatally.
Women are excluded from clinical trials of pharmacological interventions over the perinatal period, meaning that there are no randomised controlled trials to draw on in evaluating the evidence for medications. Instead, efficacy has to be extrapolated from clinical trials in non-perinatal populations, but this has to be coupled with an evaluation of obstetric safety and safety to the developing fetus or nursing baby taken from observational studies, where available. The developers of these guidelines have been able to couple this with clinical experience to write the evidence and recommend first-, second-, and third-line treatments. A critical point here is that a medication may be the first-line treatment for a disorder, such as valproic acid, but because of the high rates of congenital malformations and its detrimental effect on neurodevelopment, it is not recommended for women of childbearing age. While most of the routinely used psychotropic medications are considered to be safe, there is insufficient information to state whether some of the newer medications, such as lurasidone or cariprazine, are safe during pregnancy or for breastfeeding. In general, the first-line pharmacological treatments are not very different from those in non-perinatal populations, and these guidelines will provide some reassurance to clinicians and women treated with them.
A key issue for the management of perinatal disorders is recognition. Many women miss out on treatment for their mood and anxiety disorders as their disorder is not recognized. Screening tools, such as the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire, are widely used to aid identification. Routine screening is recommended in many jurisdictions, 5 but not all. The Canadian Task Force on Preventative Health Care 6 recommends against routine screening because of concerns about false positives; false positives lead to increased costs, unnecessary treatment, and stress and stigma to the women so identified. Routine screening programs have to be backed up with clear treatment pathways, which are not in place in many jurisdictions. CANMAT supports the use of validated questionnaires to aid in case identification and, also, that clinicians should implement case identification into clinical practice throughout the perinatal period.
The CANMAT guidelines lay out a clear vision of what services should be for the prevention, recognition, and management of PMADs. They describe key elements for the design of care, the characteristics of healthcare providers, organizational, political, and societal factors that need to be considered in setting up perinatal mental health services. They recommend collaborative care, involving interdisciplinary contributions to systematize identification, assessment, triage, and referral for appropriate level of treatment. This means integration of primary care, obstetrics, nursing, midwifery, and mental health clinicians. A key aspect of the collaborative care model is that it encompasses population-based assessment and monitoring. Women with PMADs can then access appropriate interventions guided by the severity of their illness. Lifestyle interventions (exercise and bright light therapy) and psychosocial interventions, especially peer support are the first-line interventions for those with milder illnesses. The evidence-based psychological therapies and pharmacotherapy for those with moderate and more severe disorders.
CANMAT makes a case for the provision of mother-and-baby units where women with more severe illnesses, especially postpartum psychosis and bipolar relapse, can be admitted to a dedicated facility with their infant, allowing support for the mother–infant relationship. Establishing such units should be a priority in setting up appropriate services for women with perinatal mental health disorders.
The guidelines make clear recommendations for evidence-based treatments for depression, anxiety disorders, Obsessive Compulsive Disorder, and childbirth-related PTSD.
The recommendations on pharmacological treatments are an important reference for psychiatrists; the recommendations consider the safety concerns in pregnancy and breastfeeding.
These guidelines provide for all clinicians a well-considered template for what a clinical assessment should comprise, how services should be structured, recommendations regarding the prevention of PMADs (especially bipolar disorder, a disorder with the highest relapse rate), and the appropriate management for women affected by these disorders.
Footnotes
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.
