Postpartum onset of obsessive-compulsive disorder

Gender-related romantic attachment and serum oxytocin level difference in adult patients with obsessive compulsive disorder

Background

Given the scarcity of data on gender-related romantic attachment changes and the potential role of oxytocin (OT) in the pathophysiology of obsessive-compulsive illness (OCD), the current study aimed to assess gender-related differences in romantic attachment characteristics and their relationship to serum oxytocin in a set of forty OCD cases compared with a similar group of healthy controls .Simultaneously examining the gender differences in serum oxytocin levels in OCD patients, the diagnosis of OCD patients was determined using DSM-5 criteria, and the severity of OCD was determined using the Y-BOCS rating scale. All of the patients were drug-free and not depressed. The romantic attachment was assessed using the “Experiences in Close Relationship” Questionnaire. Standard ELISA kits were used to assess plasma OT levels.

Results

Regarding romantic attachments, patients with obsessive compulsive disorder scored higher on the anxiety and avoidance domains than controls with no significant gender difference. Serum oxytocin was higher in patients with OCD than in healthy controls, indicating a possible underlying pathophysiology of the illness. Also, there was a significant gender difference, with female patients having higher serum oxytocin and symptoms severity being negatively associated.

Conclusions

Taken together, these findings propose that OT may play a role in OCD pathophysiology with gender specificity. Also, OCD associated with insecure romantic attachment.

Mothers' experiences of perinatal obsessive-compulsive disorder

INTRODUCTION

Perinatal obsessive-compulsive disorder (POCD) is characterised by the presence of intrusive thoughts resulting in significant distress and urges to execute repeated behaviours occurring in the perinatal period. POCD is largely understudied and existing literature has mostly studied POCD quantitatively.

OBJECTIVE

This qualitative study explores the experiences of 10 mothers randomly selected from a larger sample (N = 251; 86.8% White) who met high risk criteria based on the Postnatal Obsessive-Compulsive Scale (POCS≥16). These mothers were interviewed about their experiences with POCD retrospectively.

RESULTS

Qualitative analysis of the interviews (n = 10) revealed three main themes regarding women's experiences with POCD: 1) obsessions (i.e. safety, cleanliness), 2) compulsions (i.e. excessive checking for safety, excessive cleaning, researching information online), and 3) other emotional experiences (i.e. fear, panic, anxiety, suicidal ideation, guilt, shame, irritability/anger).

CONCLUSION

Mothers at high risk for POCD report obsessions and compulsions as well as other emotional experiences that are distressing, demonstrating the enduring impact of POCD beyond the perinatal period.

Anxiety disorders in postpartum women: A systematic review and meta-analysis

BACKGROUND

Evidence suggests that postpartum anxiety is relatively common among postpartum women. Anxiety meeting diagnostic criteria for a disorder represents anxiety at its most severe, distressing, and persistent, and thus it is most important to identify, understand, and treat. This paper describes a comprehensive systematic review of anxiety disorders among postpartum women, along with meta-analysis of prevalence.

METHODS

Findings are based on a thorough search of the literature, strict inclusion of only studies which utilized the gold standard of diagnostic interviews for anxiety disorder determination, and critical appraisal and review of included studies. A random effects meta-analysis was used to determine prevalence.

RESULTS

Fifty-eight studies were included in the review: 13 addressed prevalence, 5 incidence, 14 onset, 16 course, 13 correlates and risk factors, 15 outcomes, and 2 treatments for postpartum anxiety disorders. An estimated 8.5% of postpartum mothers experience one or more anxiety disorders.

LIMITATIONS

Many limitations relate to the state of the current literature, including a small number of studies to answer specific research questions for each disorder, methodological limitations, and considerable heterogeneity across studies.

CONCLUSIONS

Anxiety disorders are common among postpartum women. The review summarizes the current status of research on postpartum anxiety disorders and underscores the need for increased research to more accurately determine prevalence, understand course, identify risk factors and outcomes, and determine effective treatments. Greater clinical attention to these disorders is warranted to ameliorate the negative consequences of postpartum anxiety disorders on women and families.

Stress response in postpartum women with and without obsessive-compulsive symptoms: an fMRI study

BACKGROUND

During the postpartum period, some women might be under a considerable amount of stress and at increased risk for on-set or exacerbation of obsessive-compulsive disorder (OCD). Little is known about the stress response correlates during the postpartum period and in patients with OCD. This study aimed to examine the cerebral, psychologic and endocrine correlates of the stress response in patients with OCD and during the postpartum period.

METHODS

Women with postpartum OCD, healthy postpartum women and healthy mothers past the postpartum period underwent functional magnetic resonance imaging while facing a reliable psychosocial stressor (the Montreal Imaging Stress Task). Stress-related psychologic and endocrine responses (i.e., cortisol) were obtained.

RESULTS

We enrolled 12 women with postpartum OCD, 16 healthy postpartum women and 11 healthy mothers past the postpartum period in our study. Compared with healthy postpartum counterparts, postpartum women with OCD had a heightened self-reported and endocrine stress response associated with a distinct brain activation pattern in response to psychosocial stress involving the orbitofrontal and temporal cortices. Moreover, compared with mothers assessed in a period of time beyond the postpartum period, healthy postpartum women did not differ in psychologic and cortisol response to stress, but recruited different brain regions, such as the dorsolateral prefrontal cortex and the anterior cingulate cortex, during exposure to stress.

LIMITATIONS

Potential confounding factors, such as medication use, breastfeeding, parity and personality factors, may have modulated the stress-related endocrine response and could not be assessed in this study.

CONCLUSION

Obsessive-compulsive disorder and the postpartum period differentially influence the brain circuitry underlying psychosocial stress as well as the psychologic and endocrine responses.

Piloting the perinatal obsessive-compulsive scale (POCS): development and validation

Onset/worsening of obsessive-compulsive disorder (OCD) during the perinatal period are frequently seen clinically. No specific tool assessing the unique content, context, severity, and onset of perinatal OCD exists. A self-report scale of perinatal obsessions and compulsions, the Perinatal Obsessive-Compulsive Scale (POCS), was developed and validated. A total of 162 women (67 pregnant, 95 postpartum) participated in this pilot study. They completed the POCS as well as the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). The POCS has good construct validity, reflected by representative items, high internal consistency, good concurrent validity and discriminative capacity. The most common obsessions were fear of having an unhealthy baby at birth, contamination, the baby being taken away, and infant death. Behavioral compulsions such as repeating rituals, asking for reassurance, checking, and cleaning mirrored these obsessions. The POCS helps clinicians detect perinatal OCD while giving perinatal women an opportunity to openly discuss socially sensitive issues.

The nature and correlates of avoidance in obsessive-compulsive disorder

OBJECTIVES

Avoidance in obsessive-compulsive disorder (OCD) has been neglected by research. This study aimed (i) to collect information on the nature and frequency of avoidance in people with OCD and ascertain the types of obsessions related to avoidance; (ii) compare OCD individuals with and without avoidance, and (iii) determine predictors of avoidance in people with OCD.

METHOD

A total of 124 OCD adults underwent a comprehensive assessment. Participants were asked whether they engaged in any avoidance behaviour because of their OCD, and the nature and number of instances of such avoidance were recorded. The instances of avoidance were grouped according to the type of obsession and compulsion that they were related to.

RESULTS

A total of 74 (59.7%) participants reported OCD-related avoidance. Avoidance was most commonly related to contamination obsessions. Almost 80% of all contamination obsessions and more than 50% of all aggressive obsessions were associated with avoidance, and contamination obsessions were significantly more common among the participants with avoidance. In contrast, very few obsessions about a need to collect and keep objects and obsessions about a need for ordering, arranging and doing things right or in an exact way were associated with avoidance; these types of obsessions were also significantly more common among the participants without avoidance. The strongest predictor of avoidance was the presence of contamination obsessions. Participants with avoidance had a significantly more severe OCD than those without avoidance.

CONCLUSIONS

Avoidance is common in OCD, and it is particularly frequently associated with contamination obsessions. There is a weak link between avoidance and hoarding and between avoidance and ordering/arranging/symmetry obsessions and compulsions. These results, along with the finding that OCD with avoidance is a more severe illness, have implications for the future diagnostic criteria, description, subtyping and treatment of OCD and for its relationship with other anxiety disorders.

OCD in the Perinatal Period: Is Postpartum OCD (ppOCD) a Distinct Subtype? A Review of the Literature

Background: It has been suggested that the perinatal period is a period of increased risk for the development and/or exacerbation of OCD and that postpartum OCD (ppOCD) presents a distinct clinical picture. This raises the possibility that ppOCD might be a distinct subtype of OCD. This review examines this contention. Method: A search using Ovid (Medline, PsycINFO and Embase), EBSCO, Cochrane Library, Web of Science (ISI), Pubmed databases and Google Scholar was carried out using the key words: “obsessive compulsive disorder” (and derivatives), “perinatal”, “pregnancy”, “postnatal”, “postpartum”, “mothers” (and derivatives), “anxiety disorders” and “subtypes.” These articles and their references were reviewed. Results: The majority of studies reviewed were retrospective, which makes it impossible to infer causality. Two prospective studies found a higher incidence of OCD in the postpartum period. These were carried out in Turkey and Brazil and, as such, may be limited in their applicability to other cultural groups. Conclusion: The concept of ppOCD as a specific subtype has not been robustly demonstrated. The evidence that OCD is more prevalent in the postpartum period is mixed. The evidence that OCD in the postpartum period presents a distinctive clinical picture with specific symptomatology and course is more compelling. In view of the impact of culture and religion on the expression of OCD, collaborative, international, prospective studies that take into account the methodological and definitional issues raised in this review are necessary to provide clarification.

Onset and exacerbation of obsessive-compulsive disorder in pregnancy and the postpartum period

BACKGROUND

The primary goal of this study was to examine the impact of pregnancy, childbirth, and menstruation on the onset of obsessive-compulsive disorder (OCD) and/or exacerbation of OCD symptoms.

METHOD

One hundred twenty-six women aged between 18 and 69 years attending a university-based OCD clinic who met DSM-IV criteria for OCD according to the Structured Clinical Interview for DSM-IV Disorders were interviewed retrospectively to assess OCD onset and symptom exacerbation in relationship to reproductive events. Women were placed into 2 groups: those who had ever been pregnant (ever pregnant group) and those who had never been pregnant. The ever pregnant group was further subdivided into those who reported onset of OCD in the perinatal period (perinatal-related group) and those who denied onset related to pregnancy (nonperinatal-related group). Between-group comparisons were done using a Student t test for continuous measures, and categorical variables were assessed using the χ² test.

RESULTS

Of the 78 women in the ever pregnant group, 32.1% (n = 24) had OCD onset in the perinatal period (perinatal-related group), 15.4% in pregnancy, 14.1% at postpartum, and 1.3% after miscarriage. Of 132 total pregnancies, 34.1% involved an exacerbation of symptoms, 22.0% involved an improvement in OCD symptoms, and 43.9% did not change symptom severity in women with preexisting illness. Women in the perinatal-related group and women with perinatal worsening of preexisting OCD were more likely to have premenstrual worsening of OCD symptoms compared to women in the nonperinatal-related group (66% vs 39%, P = .047).

CONCLUSIONS

Findings from this study provide additional evidence that pregnancy and childbirth are frequently associated with the onset of OCD or worsening of symptoms in those with preexisting disorder. In addition, there appears to be continuity between OCD onset and/or exacerbation across the reproductive life cycle, at least with menstruation and pregnancy.

Treatment of mood disorders during pregnancy and postpartum

Studies suggest that pregnancy does not protect women from the emergence or persistence of mood disorders. Mood and anxiety disorders are prevalent in women during the childbearing years and, for many women, these mood disorders are chronic or recurrent. Maintenance antidepressant therapy is often indicated during the reproductive years and women face difficult treatment decisions regarding psychotropic medications and pregnancy. Treatment of psychiatric disorders during pregnancy involves a thoughtful weighing of the risks and benefits of proposed interventions and the documented and theoretical risks associated with untreated psychiatric disorders such as depression. Collaborative decision-making that incorporates patient treatment preferences is optimal for women trying to conceive or who are pregnant. This article reviews the diagnosis and treatment guidelines of mood disorders during pregnancy and postpartum, with specific reference to the use of psychotropic medications during this critical time.

Childbirth and mental disorders

This review approaches the topic of childbirth and mental illness using a model of perinatal health which takes into consideration the multiple determinants of health, approached from a lifespan perspective. The paper seeks to answer four broad questions using this model and available literature: (1) What is the relationship between childbirth and mental disorders? (2) How common are mental disorders during childbearing, and what is the perinatal course of illness? (3) What are the effects of mental illness during childbearing on foetal and infant developmental outcomes? (4) How do you approach the detection and treatment of mental disorders during the perinatal period?

New parenthood as a risk factor for the development of obsessional problems

Research on emotional disturbance during pregnancy and the postpartum period has focused primarily on mood disorders and psychosis, yet preliminary evidence suggests that early parenthood is also associated with an increased risk for the development and exacerbation of obsessional problems. In this article we describe the nature of "postpartum obsessive-compulsive disorder" (ppOCD) and present a cognitive-behavioural model to account for these signs and symptoms. The model outlines features of early parenthood that might increase vulnerability to ppOCD and proposes a conceptual framework similar to that described in cognitive-behavioural models of OCD in general. The empirical status of the model described herein is discussed, along with suggestions for future research and implications for treatment.

Pregnancy-induced obsessive compulsive disorder: a case report

Pregnancy is a well-recognised risk factor in precipitating obsessive-compulsive disorder. We present and discuss a case with the onset of obsessive-compulsive disorder in the fourth month of gestation, which fully recovered two weeks after delivery. The phenomenology of the observed disorder was similar to earlier reports of obsessive-compulsive disorder in pregnancy, i.e. the obsessions and compulsions were predominantly related to the concern of contaminating the foetus resulting in washing compulsions. Despite the initial success with anti-obsessional drugs, the patient stopped the medication in the last month of gestation. Nevertheless, she fully recovered two weeks after the delivery without any psychiatric intervention. There were no obsessive-compulsive symptoms at one-year follow up. The possible mechanisms involved in the aetiology of this case, and future research directions in understanding the role of pregnancy in OCD are discussed.

Recognizing Women’s Common Mental Health Problems: The Earthquake Assessment Model

Women's reproductive events may coincide with the onset of a mood or anxiety disorder or the exacerbation of a previously existing one due to the interconnection of neurotransmitters, stress, and reproductive hormones. The women's health nurse plays a critical role in the identification of mood and anxiety disorders during a woman's life span. This article provides nurses with a mental health assessment model, describes the common mood and anxiety disorders, and discusses simple management and referral strategies.

Obsessive-compulsive disorder in the postpartum: open-label trial of quetiapine augmentation

OBJECTIVE

Postpartum nonpsychotic conditions are routinely treated with antidepressant therapy. However, a subset of this population with comorbid obsessive-compulsive disorder (OCD) is treatment-resistant. Optimal response is obtained by augmentation therapy with novel antipsychotics. The objective of this open-label study was to evaluate clinical response to quetiapine augmentation of SSRIs or SNRIs in treatment-resistant OCD in the postpartum.

METHODS

Twenty-two postpartum women diagnosed with OCD as per DSM-IV criteria, who did not respond to at least 8 weeks of SSRI or SNRI monotherapy, were offered a trial of quetiapine augmentation for 12 weeks. Response (defined as >50% reduction in scores) was assessed using the Yale Brown Obsessive-Compulsive Scale (YBOCS) and Clinical Global Impressions scale (CGI).

RESULTS

Seventeen patients agreed to a trial of quetiapine augmentation. Three withdrew early due to side effects, and 14 completed the 12-week trial. Of these, 11 responded to treatment within 12 weeks, with a mean (SD) response time of 5.9 (2.6) weeks. The mean (SD) baseline YBOCS score of 24.7 (6.8) dropped to a mean of 10.3 (9.0), with a mean reduction of 59.6%. Mean CGI scores at outcome were 1.9 (1.2). The average dose of response was 112.5 mg (76.4 mg). Sedation was the most commonly reported side effect.

CONCLUSIONS

Although limited by lack of controls, this is the first study in a postpartum population where the addition of quetiapine to antidepressant therapy has been shown to be effective for treatment-refractory OCD. Quetiapine deserves further controlled study in this context.

Obsessive-compulsive symptoms in pregnancy and the puerperium: a review of the literature

In this article, we review the available research on postpartum obsessive-compulsive disorder (OCD). Most studies are retrospective in nature, thus not answering questions as to overall prevalence of such symptoms. However, there are consistent findings with regard to symptom profile: obsessional thoughts in postpartum OCD tend to concern fears of harm to the infant. We discuss distinctions between postpartum OCD symptoms and postpartum depression and psychosis. Although preliminary, research on treatments for postpartum OCD indicates the effectiveness of medications and cognitive-behavioral therapy. We explore the relationship between OCD symptoms and postpartum depression and offer possible directions for future study. We also consider the proposed etiological models and offer a fresh conceptualization of this condition.

Anxiety disorders in women

Women have higher overall prevalence rates for anxiety disorders than men. Women are also much more likely than men to meet lifetime criteria for each of the specific anxiety disorders: generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), social anxiety disorder (SAD), posttraumatic stress disorder (PTSD), simple phobia, panic disorder, and agoraphobia. Considerable evidence suggests that anxiety disorders remain underrecognized and undertreated despite their association with increased morbidity and severe functional impairment. Increasing evidence suggests that the onset, presentation, clinical course, and treatment response of anxiety disorders in women are often distinct from that associated with men. In addition, female reproductive hormone cycle events appear to have a significant influence on anxiety disorder onset, course, and risk of comorbid conditions throughout a woman's life. Further investigations concerning the unique features present in women with anxiety disorders are needed and may represent the best strategy to increase identification and optimize treatment interventions for women afflicted with these long-neglected psychiatric disorders.

Diagnosing postpartum depression in mothers and fathers: whatever happened to anxiety?

BACKGROUND

Although anxiety disorders are documented in the literature for new mothers (but less so for fathers), rates of postpartum caseness tend to include only those with depression when diagnostic interviews or self-report measures validated on such interviews are used. This methodology therefore underestimates the true percentage of women and men who experience significant psychological difficulties postpartum. This has implications for assessment, treatment and screening for postnatal mood disorders.

METHOD

Two studies were conducted on a total of 408 women and 356 men expecting their first child. They were recruited antenatally, and interviewed at 6 weeks postpartum using the Diagnostic Interview Schedule. DSM-IV criteria were applied to determine the presence since birth of depression (major or minor), panic disorder, acute adjustment disorder with anxiety (meeting the criteria for generalised anxiety disorder except for the duration criterion), and phobia.

RESULTS

The inclusion of diagnostic assessment for panic disorder and acute adjustment disorder with anxiety increased the rates of caseness by between 57 and 100% for mothers, and 31-130% for fathers, over the rates for major or minor depression. Inclusion of assessment for phobia further increased the rates of disorder in both samples. Couple concordance rates were between 6.6 and 11.1%, with no significant difference between rates for depressive or depressive and anxious caseness. For women, a previous history of an anxiety disorder appears to be a greater risk factor for a postnatal mood disorder (i.e. depression or anxiety) than a history of a depressive disorder.

CONCLUSIONS

These results clearly show the need to assess for both depression and anxiety in new and expectant parents, and we believe the term 'postnatal mood disorder' (PMD), rather than postnatal depression, more accurately reflects significant adjustment difficulties in new parents.

Postpartum disorders in primary care: diagnosis and treatment

Postpartum psychiatric illness consists of a highly prevalent group of disorders, which can result in serious dysfunction and require treatment. Patients are more likely to seek help for these disorders from their primary care physicians rather than mental health professionals. While severe postpartum depression and psychoses are easily recognized, milder or more insidious forms of depressive illness frequently are missed. Heightened sensitivity to and screening for the presence of these prevalent psychiatric disorders facilitates and enhances recognition of postpartum disorders and leads to more expeditious treatment.

The course of postpartum psychiatric disorders in women and their partners

This study examined the course of postpartum psychiatric disorders in a community sample of mothers and their partners to determine whether sociodemographic variables, life stress, and psychiatric history were related to persistence of mental health problems. At 6 months postpartum, 48 index couples where the wife had a psychiatric disorder at 2 months postpartum and 50 control couples with no such diagnosis underwent diagnostic interviews and completed questionnaires on psychological symptoms, life stress, and treatment history. The results indicate that at follow-up, 54% of the index mothers still had a psychiatric diagnosis, as did 60% of their partners who had had a psychiatric diagnosis at 2 months postpartum. Socioeconomic status, country of origin, and life stress were related to persistence, as were diagnosis and timing of onset of the disorder. About a third of the parents were referred for treatment. It is concluded that for many families, postpartum psychiatric disorders are not a transient phenomenon.

Acute onset of obsessive-compulsive disorder in males following childbirth

Research on postpartum onset obsessive-compulsive disorder (OCD) has focused exclusively on females. However, the authors present four cases of males with OCD onset that coincide with a spouse's pregnancy or delivery. The rapid onset and content of obsessions and compulsions are remarkably similar to those reported in previous studies of postpartum OCD in females. Each patient also responded to cognitive-behavioral therapy using exposure procedures. The implications of these cases for etiological models of postpartum OCD and future research directions are discussed.

The role of recent life events in the onset of obsessive-compulsive disorder

Although many investigations into the onset of obsessive-compulsive disorder (OCD) suggest the occurrence of potential life events as triggering factors, such an association has not been well studied to date. The purpose of the present paper is to review the literature on OCD onset in order to determine whether OCD is triggered by recent life events, what specific events may serve as triggers, and the clinical and research implications of these factors. Overall, the available studies do not consistently support the theory that OCD is triggered by specific antecedent life events. However, there is a body of evidence to support the theory that the specific life events of pregnancy and birth of a child can trigger OCD. This apparent association has led to the investigation of certain neurohormonal factors, including changes in estrogen or oxytocin levels, that may be of etiopathogenetic significance in OCD. Confirming such associations may allow clinicians to provide more targeted preventive and therapeutic interventions.

The impact of partner support in the treatment of postpartum depression

OBJECTIVE

To determine the impact of partner support in the treatment of mothers suffering from postpartum depression (PPD).

METHOD

Patients underwent a comprehensive psychiatric assessment and were enrolled in the study only if they met the DSM-IV criteria for major depressive disorder with postpartum onset. Patients with PPD (n = 29) were assigned randomly to 2 treatment groups: group 1 (control group) consisted of patients only (n = 13), while group 2 (support group) consisted of patients (n = 16) and their partners. The patients in both groups were seen for 7 psychoeducational visits each. In group 2, partners participated in 4 of the 7 visits. Patients in both groups were administered a set of questionnaires that included the Edinburgh Postnatal Depression Scale (EPDS), the Kellner Symptom Questionnaire, the Dyadic Adjustment Scale (DAS), and the Parental Bonding Instrument (PBI). In addition, during visits 1 and 7, all patients underwent assessment using the Mini International Neuropsychiatric Instrument (MINI), section A (major depressive episode). The partners in both groups completed the DAS and the General Health Questionnaire (GHQ).

RESULTS

Relative to the control-group patients, the support-group patients displayed a significant decrease in depressive symptoms and other psychiatric conditions. Relative to the support group, the general health of the partners in the control group deteriorated.

CONCLUSION

Partner support has a measurable effect on women experiencing PPD.

Characteristics and treatment of women with antenatal and postpartum depression

OBJECTIVE

Investigations of the efficacy of treatment for non-psychotic pregnancy-related mood disorders are scarce. Thus, a prospective, longitudinal study of six months duration, involving ninety-six index cases and forty-five healthy women as a reference group, was implemented to determine the response of mood, parenting stress and dyadic adjustment to an eclectic management.

METHOD

In this naturalistic study, the index cases were offered treatment consistent with their symptoms, context, and level of compliance. All women received individual psychotherapy combining strategies from Interpersonal and Cognitive Behavioral Psychotherapy and/or Marital Interventions and Pharmacology. Rating scales (Dyadic Adjustment Scale, Hamilton Rating Scale for Depression, Edinburgh Postnatal Depression Scale, Child Stress Inventory) scored monthly, were used to measure the response to treatment over time.

RESULTS

Depressive symptoms are generally alleviated by the second to third month of treatment. Dyadic discord accentuated by traditional sex role expectations and child care stress exacerbated by low self-esteem persisted throughout the trial at levels significantly different from the untreated reference group.

CONCLUSIONS

Short-term interventions are cost-effective for the relief of mood disorders. However, creative solutions, during an era of economic restraints, are required to extend treatment sufficiently to address couple conflicts and facilitate the transition to parenthood for index cases.

Treatment issues during pregnancy and lactation

The lifetime incidence of mood disorders is twice as great in women compared with men, with the highest risk occurring during the childbearing years. The management of mental illness during pregnancy and lactation is a particularly complex clinical situation. The cornerstone of such a clinical decision is a completion of an assessment of the risks of the illness vs the risks of treatment. The following article reviews the factors influencing infant outcome and outlines the essential elements of the process of determining risk for the use of psychotropics in women during pregnancy and lactation. As the available data rapidly change, the facets of the risk benefit assessment are consistent and often the issue of specific medication is decided by prior history and exposure.

A Case Series of Women With Postpartum-Onset Obsessive-Compulsive Disorder

BACKGROUND: There is emerging evidence that postpartum women are at risk for the development or worsening of obsessive-compulsive disorder. The purpose of this study was to provide data regarding the demographics, phenomenology, associated psychiatric comorbidity, family history, and response to open treatment with fluvoxamine in subjects with postpartum-onset obsessive-compulsive disorder. METHOD: Seven consecutive subjects were recruited from an outpatient obstetrical practice and by advertisement. Subjects completed the Structured Clinical Interview for DSM-IV, the Yale-Brown Obsessive Compulsive Scale, and a semistructured interview for family history, demographic data, and clinical features. Three of the 7 subjects participated in a 12-week, open-label trial of fluvoxamine treatment of postpartum-onset DSM-IV obsessive-compulsive disorder. RESULTS: The women described a mean age at onset of 28 years, and 4 subjects had a chronic course. Six subjects reported onset after the birth of their first child, and the mean time to onset was 3.7 weeks postpartum. All subjects experienced both obsessions and compulsions and reported aggressive obsessions that involved their children. None of the subjects acted on their obsessions to harm the children, but 5 reported dysfunctional mother-child behavior. All 7 subjects met criteria for at least 1 comorbid psychiatric disorder, with a mood disorder the most common. Family histories were notable for high rates of mood disorders and psychoactive substance use disorders in first-degree relatives. Two of the 3 subjects who entered the open-label trial of fluvoxamine experienced a positive response, defined as a 30% or greater decrease in the total score of the Yale-Brown Obsessive Compulsive Scale. CONCLUSION: Obsessive-compulsive disorder may present in the postpartum period and become chronic. Symptoms of the disorder may adversely affect the mother-child relationship, and it is important to assess for obsessions and compulsions in postpartum women who present with anxiety and/or depression. Fluvoxamine may be effective in reducing the symptoms of postpartum-onset obsessive-compulsive disorder. Controlled studies are needed to confirm these findings.