Conventional and Integrative Approaches to Treating Anxiety in Pregnancy

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CLINICAL

Anxiety is not unusual during pregnancy and postpartum for new mothers. However, for some women, anxiety symptoms are more severe, and cause distress, avoidance of activities, interfere with their ability to function at home or at work, or care for their children. One-third of women will suffer from an anxiety disorder in their lifetime.¹ Perinatal anxiety is common and often underreported, with the prevalence ranging from 4% to 33.4% (Figure 1, Figure 2).^2,3 Multiple factors may contribute to anxiety during the perinatal period, including rapid hormone fluctuations, biological predispositions, as well as psychosocial challenges that accompany the transition to parenthood.⁴

Figure 1. Symptom Changes in Pregnancy

The American College of Obstetrics and Gynecology (ACOG) recommends screening women for depression and anxiety at least once during the perinatal period followed by appropriate referral and treatment when necessary. Although common and impairing, much less attention has been focused on the treatment of perinatal anxiety, both in the literature and in the media. Untreated mood and anxiety disorders during pregnancy have been associated with multiple adverse outcomes for both the mother and baby, including a worsening of medical conditions, lack of medical care, substance use, smoking, suicide, and infanticide. Anxiety itself is a strong predictor of postpartum depression.⁵ Anxiety disorders have also been associated with negative birth outcomes such as preterm birth, lower birth weight, earlier gestational age, increased odds for being small for gestational age, and smaller head circumference.⁶

Figure 2. Prevalence of Anxiety Disorders in Pregnancy

Treatment

Current treatment recommendations for perinatal anxiety disorders include psychotherapy alone or in combination with pharmacotherapy. A variety of therapeutic modalities, such as cognitive behavioral therapy (CBT), have been shown to be both safe and effective for treating mild to moderate perinatal mood and anxiety disorders as an adjunctive measure or as monotherapy.⁷ Unfortunately, less resourced and geographically isolated communities may experience cultural, logistical, and financial barriers to accessing psychotherapy services.⁸

For women with moderate to severe anxiety disorders that do not respond to psychotherapy and/or that is impairing functioning, ACOG recommends considering the initiation or re-initiation of pharmacotherapy with a selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitor (SNRI).⁵ These medications are well studied and can be very helpful and, in some cases, necessary for managing symptoms.

The choice to use medications is very personal; the woman’s obstetrician and/or psychiatrist should discuss this option with her. The decision should be based on risks and benefits, weighing the risk of exposure to medication on the unborn baby against the severity and risk of untreated illness. The most common risks associated with antidepressant medications exposure are low birth weight, preterm birth, poor neonatal adaptation syndrome, and persistent pulmonary hypertension of the newborn (Table).⁷ Among women taking antidepressants, more than 50% will discontinue these medications during pregnancy.⁹ However, women should be encouraged to continue treatment during pregnancy and be provided with a variety of options, including non-pharmacological approaches.

Table. Sample Challenging Adverse Effects of Antidepressants During Pregnancy

An increasing number of women consider complementary and integrative approaches for alternatives or as adjunctives for treatment options during pregnancy. Complementary and integrative medicine emphasizes a holistic approach to health care and includes natural products and mind body approaches such as mindfulness training and yoga.¹⁰ Women utilize complementary medicine more frequently than men; data from the 2007 National Health Interview Survey found that 39.9% of pregnant and 28% of postpartum women reported using some form of complementary or alternative medicine in the past 12 months.¹¹ Additionally, pregnant women who participated in mind-body interventions, including mindfulness and yoga practice have reported an overall satisfaction with these interventions and described the practices as enjoyable, valuable, and beneficial.¹² Specifically, becoming aware of the causes of anxiety and the ability to reflect on thoughts and emotions were reported as beneficial by women across all categories of interventions.

Some of the most common forms of integrative practice are mindfulness-based interventions. Mindfulness-based stress reduction (MBSR) provides training in mindfulness meditation techniques as a self-regulation approach to stress reduction and emotion management. Mindfulness-based cognitive therapy is an adaptation of cognitive behavioral therapy with a focus on developing mindfulness skills learned in MBSR.¹³ The use of various forms of meditation such as those used in mindfulness-based interventions has increased more than three-fold in the past 5 years.¹⁴ Multiple studies of mindfulness-based interventions have demonstrated significant reductions on multiple measures (self-reported and interview screening scales) of anxiety in pregnant women.¹⁵

Yoga is a mind and body practice with origins in ancient Indian philosophy that combines postures, breathing, and meditation. Yoga has been associated with a reduction in sympathetic activity, balancing heart rate variability, normalizing HPA axis activity, and influencing monoamine changes.¹⁶ Over the past decade, yoga has become increasingly popular for promotion of fitness and relaxation, and prenatal yoga classes have become widely available both in studios and online.

The 2017 National Health Interview Survey (NHIS) found that yoga is the most common complementary practice used by US adults.¹⁶ Studies looking specifically at the practice of yoga in pregnant women have shown that anxiety symptoms (self-reported and interview screening scales) were significantly decreased in response to even a one-time 20-minute yoga session, and participants continued to show improvements in anxiety symptoms with ongoing, regular practice.¹⁷ An instructor registered and trained in prenatal yoga is necessary for practice during pregnancy, as certain positions and overheating, “Hot Yoga” should be avoided during pregnancy.

Regular physical activity has also been shown to be beneficial for pregnant and postpartum women for both physical and mental health. ACOG recommends that healthy pregnant women should aim to get at least 2.5 hours of moderate-intensity activity per week. Physical activity has been associated with reduction of pregnancy-related complications, including the risk of weight gain and gestational diabetes, as well as enhancing overall psychological well-being.¹⁸ During pregnancy, exercise may reduce the symptoms of anxiety as well as increase overall quality of life. Women who report exercising more frequently during pregnancy have lower than average anxiety symptoms (self-report measures).¹⁹ Findings indicate that exercise during pregnancy can be an important component of mental health treatment in addition to psychotherapy or medication management.²⁰

Conclusion

Anxiety is common during the perinatal period and can have negative effects on mother and neonate. Women should be provided with multiple options for treatment and encouraged and supported to engage in care during this critical period. The high prevalence of perinatal anxiety disorders indicates a need to broaden the evidence base for treatment interventions. Therapy and medications are evidence-based and effective options for treating anxiety disorders in pregnancy. However, it is important to take into account patient preferences regarding treatment during pregnancy, as well as access to care.

Complementary approaches are becoming increasingly used by women and may provide benefits for mental health treatment. Available evidence suggests that complementary approaches, specifically mindfulness-based interventions, yoga, and exercise have shown benefit for improving symptoms of perinatal anxiety disorders. Reductions in anxiety symptoms with mindfulness-based interventions, yoga, and exercise suggest an expanding and adjunctive role for complementary approaches to perinatal mental health treatment. More research is needed to systematically evaluate the use of nonpharmacological, integrative modalities for maternal mental health.

Dr Ballone is a Consultation-Liaison Psychiatry Fellow, The George Washington University Medical Center/Inova Fairfax Hospital Department of Psychiatry, Falls Church, VA; Ms Moffitt is an MD Candidate, Sidney Kimmel Medical College, Philadelphia; Dr Becker is Associate Professor and Director, Graduate Medical Education, Integrative Women’s Mental Health, Department of Integrative Medicine and Department of Psychiatry and Human Behavior, Thomas Jefferson University and Jefferson Health, Philadelphia, PA. The authors have nothing to disclose regarding the subject of this manuscript.

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