Abstract
The Canadian Network for Mood and Anxiety Treatments (CANMAT) Guidelines for Perinatal Mood and Anxiety Disorders (PMADs) are a welcome addition to the existing resources in this field. There are several reasons why specific guidelines are needed. Firstly, clinicians working with pregnant and postpartum mothers are treating two (mother and the fetus or infant), and hence the focus is not only on effectiveness but also on safety. Secondly, there are several changes in women's metabolism during the perinatal period, needing attention to dosage and side effects of medications. Thirdly, health systems need to respond adequately to women with PMADs by ensuring early identification and well-defined care pathways as well as using a dyadic approach. Finally, mental health services need to ensure that all women in the reproductive age group with a preexisting mental health problem get proper preconception advice and support.
The development of the guidelines by a group of experienced perinatal psychiatrists in collaboration with other professionals as well as persons with a lived experience is reflected in the very practical way the guidance has been provided.
The first part of the guidelines describes the prevalence and risks related to the various PMADs and highlights the distinct clinical presentations of these disorders in the perinatal period. Perinatal anxiety may have unique features such as heightened anxiety about fetal well-being, fears about labour and concerns about one's own health. Intrusive thoughts are not uncommon during this period and even though they may not meet the criteria for diagnosable obsessive-compulsive disorder, can be very distressing and need attention. 1 The inclusion of postpartum psychosis (PPP) in the guidelines is important because of its similarity to bipolar disorder and the current understanding that most PPP may be bipolar disorders with some distinct clinical features. 2 The guidelines also recognize the limitations of the current diagnostic systems such as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition in the understanding of PMADs. The postpartum specifier code mentions that a condition should have an onset within 4 weeks of childbirth. This leads to most conditions being excluded, as a majority of them may occur after 4 weeks and often up to a year after childbirth.
The guidelines have been written in an easy-to-read, question-and-answer format and include recommendations for identification of PMADs, lifestyle interventions, preventive psychosocial interventions, psychological treatments, the use of complementary and alternative treatments, and managing high-risk clinical situations. In addition, there is a detailed description of medication use for each of the PMADs.
The guidelines focus on the challenges of screening and case identification, but emphasize that it is important to identify depression early with the advantages of identification overweighing any negative consequences. The importance of being sensitive to cultural aspects and stigma as well as ensuring care provision after screening is highlighted. Recognizing that women may hide information because of fear of social services is important and any case identification should be done in an environment of support and care, The guidelines, however, emphasize the need to develop more culturally sensitive and validated tools before using standard screening tools for depression and anxiety in non-Western populations. 3
Using evidence-based data to recommend medication use for PMADs both in pregnancy and lactation has several challenges as a balance has to be sought between efficacy and safety. The guidelines address these by assessing the level of evidence available for efficacy as well as safety and tolerability for each drug. A drug would be considered first-line if it has good evidence of efficacy as well as safety in the perinatal period as opposed to a drug that has good efficacy but not adequate safety data or has safety concerns in this population. As a result, some drugs such as Lurasidone and Cariprazine that have been mentioned in the CANMAT guidelines for bipolar disorders do not feature in the PMAD guidelines for the same condition due to inadequate evidence related to safety. A measured discussion regarding the use of electroconvulsive therapy and transcranial magnetic stimulation/transcranial direct current stimulation in pregnancy and postpartum is also available.
Social risk and protective factors become very important during the perinatal period and the guideline discusses the role of social interventions including assistance if there is food insecurity, financial and/or housing instability, or intimate partner violence.
Some practical and often overlooked areas while deciding medication use have been addressed including—the stage of pregnancy and age of the baby, pharmacokinetics in pregnancy and need for drug level monitoring, neonatal side effects, and the level of contact a woman may need with health services depending on the severity of her problems. In addition, the guidelines address discontinuation symptoms when a drug is stopped for safety reasons as well as a monitoring protocol for both gestational diabetes if on atypical antipsychotics and for lithium levels during labour. 4
The importance of sleep in the context of the perinatal period and its role in aggravating and preventing depression and psychosis cannot be emphasized enough. The guidelines highlight the need for sleep support as part of care and prevention. 5 Anyone who has worked in acute perinatal psychiatric services will acknowledge the role of a thorough risk assessment in this population, because of the risk of suicide and infant harm. The guidelines also discuss rapid tranquilization and safeguards needed with seclusion.
A large part of the guidelines is devoted to the planning and provision of health services. This includes the role of different health professionals in a team, the need for clear referral protocols and pathways to care, and the importance of specialized perinatal psychiatric services including inpatient mother–baby units.6,7 Such recommendations are important for professionals to advocate for patients and educate policymakers regarding funding of units that specialize in perinatal psychiatric care, develop collaborative care models, and integrate mental health into routine maternal and infant care. The guidelines also emphasize the importance of a sensitive systemic response, especially the role of trauma-informed care in this population at each stage of the assessment and treatment process. 8
It is evident from the guidelines that there are several gaps in research and more data is needed in this population. Some of these include—the need for head-to-head comparisons between different drugs and between drugs and psychological interventions on the maternal, infant, and childhood outcomes; the design and content of psychological interventions for perinatal anxiety and how psychosocial interventions should be adapted for this population in terms of dose, delivery, duration, and content; comparisons between different models of care (collaborative, integrated and stepped care); the effectiveness of sleep protection interventions in various patient groups, the importance of peer delivered support and self-help in prevention as well as ways in which we can make the screening and identification process more acceptable to women and less stigmatizing. There is a need to discuss perinatal mental health in the context of assisted reproduction including in vitro fertilization. Psychiatrists are often asked about the impact of psychotropic medications on embryos and we still don’t have enough answers.
Overall, the guidelines are an extensive and valuable resource for clinicians, covering the various situations encountered in perinatal mental health. It provides a comprehensive framework, discusses available evidence, and focuses on the entire journey of a woman's birth experience from preconception to postchildbirth at the same time focusing on service delivery and organizational issues.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
