Perinatal Mood Perinatal Mood and Anxiety and Anxiety DisordersDisorders

Cort A. Pedersen, M.D.Cort A. Pedersen, M.D.

UNC Department of UNC Department of PsychiatryPsychiatry

Prevalence of Perinatal Depressive Prevalence of Perinatal Depressive and Anxiety Disorders and Anxiety Disorders

DepressionDepression: approximately 14% within : approximately 14% within the first 2-3 months postpartum (similar the first 2-3 months postpartum (similar rate during pregnancy). Half meet DSM-rate during pregnancy). Half meet DSM-IV criteria, half RDC criteria.IV criteria, half RDC criteria.

AnxietyAnxiety: At least 14 % in postpartum : At least 14 % in postpartum period combining panic disorder, OCD period combining panic disorder, OCD and generalized anxiety disorder.and generalized anxiety disorder.

By far, the most common serious medical By far, the most common serious medical complications of the perinatal period. complications of the perinatal period.

Obstacles to Recognition and Treatment Obstacles to Recognition and Treatment of Perinatal Mood/Anxiety Disordersof Perinatal Mood/Anxiety Disorders

High expectations of joy & happiness with new High expectations of joy & happiness with new baby: cognitive dissonance if dysphoric symptoms baby: cognitive dissonance if dysphoric symptoms arise.arise.

Attribution of dysphoria to stress, not assessing Attribution of dysphoria to stress, not assessing hallmark symptoms.hallmark symptoms.

Self blame.Self blame. Lack of knowledge about mood and anxiety Lack of knowledge about mood and anxiety

disorders. disorders. Critical role of antenatal educationCritical role of antenatal education. .

Common Dysphoric Emotional Common Dysphoric Emotional Experiences in New MothersExperiences in New Mothers

Mood lability-blues and euphoria.Mood lability-blues and euphoria. Often unanticipated and sometimes Often unanticipated and sometimes

overwhelming stress of newborn care: loss overwhelming stress of newborn care: loss of control of one’s time, feeling trapped, of control of one’s time, feeling trapped, “Why did I do this?”“Why did I do this?”

Heightened anxiety due to hyper-vigilance Heightened anxiety due to hyper-vigilance about the baby’s welfare.about the baby’s welfare.

Delayed feelings of love for the baby.Delayed feelings of love for the baby.

DDiagnosing Perinatal Depression: iagnosing Perinatal Depression: Hallmark Psychological SymptomsHallmark Psychological Symptoms

Depressive mood, sadness, tearfulness.Depressive mood, sadness, tearfulness. Diminished interest or pleasure in most activities Diminished interest or pleasure in most activities

(especially in taking care of the baby).(especially in taking care of the baby). Feelings of worthlessness or inappropriate guilt Feelings of worthlessness or inappropriate guilt

(especially about being an inadequate mother).(especially about being an inadequate mother). Recurrent thoughts of death or suicide.Recurrent thoughts of death or suicide. Edinburgh Postnatal Depression Scale: Edinburgh Postnatal Depression Scale: Cox et al., Cox et al.,

1987, Br J Psychiatry 150: 782-6.1987, Br J Psychiatry 150: 782-6.

Ambiguous Symptoms Ambiguous Symptoms (often due to perinatal physiological changes, (often due to perinatal physiological changes,

demands of newborn, not depression)demands of newborn, not depression)

Changes in appetite or weightChanges in appetite or weight Sleep disruption (Sleep disruption (however, persistent however, persistent

inability to sleep when the baby is asleep is a inability to sleep when the baby is asleep is a common symptom in postpartum common symptom in postpartum depressiondepression).).

Persistent fatigue.Persistent fatigue. Psychomotor retardation or agitation.Psychomotor retardation or agitation. Diminished subjective perception of ability to Diminished subjective perception of ability to

think or concentrate.think or concentrate.

Biological Risk Factors for Biological Risk Factors for Postpartum DepressionPostpartum Depression

History of postpartum depression (up to History of postpartum depression (up to 50% risk).50% risk).

History of depression not associated with History of depression not associated with pregnancy (up to 25% risk). pregnancy (up to 25% risk).

Depressive symptoms during pregnancy. Depressive symptoms during pregnancy. Family history of depression. Family history of depression. History of premenstrual dysphoric disorder.History of premenstrual dysphoric disorder. Postpartum blues.Postpartum blues.

Do hormones play a role?Do hormones play a role?

Progesterone and estrogen levels drop precipitously Progesterone and estrogen levels drop precipitously postpartum. Cortisol, thyroid and other large postpartum. Cortisol, thyroid and other large hormonal shifts also occur . hormonal shifts also occur .

However, hormone levels and changes in levels do However, hormone levels and changes in levels do not correlate with mood symptoms. not correlate with mood symptoms.

But recent research indicates that women who get But recent research indicates that women who get peripartum depression are more sensitive to peripartum depression are more sensitive to hormone fluctuations (Bloch et al., 2000 Am J hormone fluctuations (Bloch et al., 2000 Am J Psychiatry 157: 924-930). Psychiatry 157: 924-930).

Psychosocial Risk Factors for Psychosocial Risk Factors for Perinatal DepressionPerinatal Depression

Lack of social support.Lack of social support. Poor relationship with the father of the baby. Poor relationship with the father of the baby. Stressful life events.Stressful life events. Primiparity.Primiparity. Adolescence.Adolescence. Postpartum Depression Predictors Postpartum Depression Predictors

Inventory-Inventory-Beck, 1998, JOGNN 27: 39-46.Beck, 1998, JOGNN 27: 39-46.

Postpartum Anxiety Disorders: Postpartum Anxiety Disorders: Clinical CharacteristicsClinical Characteristics

Panic disorder:Panic disorder:

Intense fear of harm/harming baby.Intense fear of harm/harming baby.

Palpitations, hyperventilation, sweating,etcPalpitations, hyperventilation, sweating,etc

Difficulty caring for, leaving baby. Difficulty caring for, leaving baby. OCD:OCD:

Intrusive thoughts/images of grievous harm to Intrusive thoughts/images of grievous harm to baby.baby.

Mother sometimes imagines herself inflicting Mother sometimes imagines herself inflicting harm. harm.

Effects of Pregnancy on the Natural Effects of Pregnancy on the Natural Course of Anxiety DisordersCourse of Anxiety Disorders

Panic disorderPanic disorder: : Increased risk of recurrence or Increased risk of recurrence or

intensification postpartum.intensification postpartum. Obsessive compulsive disorderObsessive compulsive disorder:: Many women with OCD (perhaps around Many women with OCD (perhaps around

40%) have initial onset of symptoms 40%) have initial onset of symptoms during pregnancy or the postpartum during pregnancy or the postpartum period. period.

Perinatal Depression and Anxiety: Perinatal Depression and Anxiety: Treatment and ProphylaxisTreatment and Prophylaxis

Stress reduction.Stress reduction. Support groups.Support groups. Psychotherapy: interpersonal, cognitive-Psychotherapy: interpersonal, cognitive-

behavioral, supportive. behavioral, supportive. O’Hara et al., 2000, Arch Gen O’Hara et al., 2000, Arch Gen

Psychiatry 57: 1039-1045.Psychiatry 57: 1039-1045. Medication: usual txs are generally very effective. Medication: usual txs are generally very effective.

SSRIs best for prophylaxis.SSRIs best for prophylaxis. Estrogen?Estrogen? Light therapyLight therapy

Pre & Postpartum Prevalence of Pre & Postpartum Prevalence of Psychiatric Admissions among WomenPsychiatric Admissions among Women

Postpartum Psychosis: Postpartum Psychosis: Clinical CharacteristicsClinical Characteristics

IncidenceIncidence: 1-2/1000, first few postnatal weeks.: 1-2/1000, first few postnatal weeks. 90%+ are psychotic mood disorders.90%+ are psychotic mood disorders. Mood symptomsMood symptoms: depression, mania, mixed, cycling. : depression, mania, mixed, cycling.

Suicidal impulses.Suicidal impulses. Psychotic symptomsPsychotic symptoms: hallucinations, delusions, thought : hallucinations, delusions, thought

disorder. Delusion-based homicidal/infanticidal disorder. Delusion-based homicidal/infanticidal impulses. impulses.

Symptoms of delirium often presentSymptoms of delirium often present: disturbances of : disturbances of consciousness, attention, cognition, perception, consciousness, attention, cognition, perception, fluctuation of symptoms. fluctuation of symptoms.

Risk Factors for Postpartum PsychosisRisk Factors for Postpartum Psychosis

History of bipolar or schizoaffective History of bipolar or schizoaffective disorder: risk increases with number of disorder: risk increases with number of prior episodes and prominence of prior episodes and prominence of psychotic symptoms (perhaps up to a 50% psychotic symptoms (perhaps up to a 50% risk). risk).

History of postpartum psychosis (50-75% History of postpartum psychosis (50-75% risk). risk).

Management and Treatment of Management and Treatment of Postpartum PsychosisPostpartum Psychosis

ManagementManagement: : Hospitalize immediately (psychiatric emergency!)Hospitalize immediately (psychiatric emergency!) Constant, close observationConstant, close observation Supervise visits with babySupervise visits with baby TreatmentTreatment:: Mood stabilizers (lithium, valproic acid)Mood stabilizers (lithium, valproic acid) AntipsychoticsAntipsychotics Antidepressants (if primarily depressed)Antidepressants (if primarily depressed) Benzodiazepines (agitation)Benzodiazepines (agitation) ECT ECT

Postpartum Psychosis ProphylaxisPostpartum Psychosis Prophylaxis

MedicationMedication: :

Start mood stabilizers immediately Start mood stabilizers immediately postpartum or even late in pregnancy. postpartum or even late in pregnancy. Estrogen?Estrogen?

GeneralGeneral::

Social support/help network in place.Social support/help network in place.

Patient/family education about symptoms.Patient/family education about symptoms.

Plan of action if symptoms develop.Plan of action if symptoms develop.

Assessing the Safety of Psychotropic Assessing the Safety of Psychotropic Medications in Pregnancy/LactationMedications in Pregnancy/Lactation

Prospective, double blind studies drug Prospective, double blind studies drug trials are unethicaltrials are unethical. Therefore, we are . Therefore, we are dependent on information from case dependent on information from case reports, retrospective chart reviews, reports, retrospective chart reviews, animal toxicology studies. animal toxicology studies.

Best summaries to date of this body of Best summaries to date of this body of evidence: Wisner et al., (2002) NEJM evidence: Wisner et al., (2002) NEJM 347: 194-199; Newport et al. (2004) 347: 194-199; Newport et al. (2004) The APA Textbook of The APA Textbook of Psychopharmacology, 3rd EditionPsychopharmacology, 3rd Edition

Assessing the Safety of Psychotropic Assessing the Safety of Psychotropic Medications in Pregnancy/Lactation-contMedications in Pregnancy/Lactation-cont

A considerable body of evidence accumulated over A considerable body of evidence accumulated over the last 2 decades indicates that fetal/newborn the last 2 decades indicates that fetal/newborn exposure to most classes of psychotropic exposure to most classes of psychotropic medication is relatively safe even during the first medication is relatively safe even during the first trimester.trimester.

Mounting evidence that stress during pregnancy, Mounting evidence that stress during pregnancy, including the stress of untreated severe psychiatric including the stress of untreated severe psychiatric illness, has adverse effects on fetal development. illness, has adverse effects on fetal development.

Potential Risks of Treatment with Potential Risks of Treatment with Psychiatric MedicationsPsychiatric Medications

Malformations.Malformations. Behavioral teratogenicity.Behavioral teratogenicity. Drug effects on the newborn- toxicity, Drug effects on the newborn- toxicity,

withdrawal.withdrawal. Blood volume changes: Drug levels shift Blood volume changes: Drug levels shift

into the sub-therapeutic range during into the sub-therapeutic range during pregnancy or toxic range postpartum.pregnancy or toxic range postpartum.

Potential Risks of Potential Risks of Not TreatingNot Treating With With Psychiatric MedicationsPsychiatric Medications

Depression, other untreated psychiatric disorders Depression, other untreated psychiatric disorders during pregnancy are associated with poor during pregnancy are associated with poor obstetric outcomes.obstetric outcomes.

In utero stress retards fetal growth, may disrupt In utero stress retards fetal growth, may disrupt normal behavioral development.normal behavioral development.

Children of mentally ill mothers have more Children of mentally ill mothers have more medical, psychological, and cognitive problems. medical, psychological, and cognitive problems.

Increased risk of recurrence and treatment Increased risk of recurrence and treatment resistance of illness. resistance of illness.

Antidepressants in Antidepressants in Pregnancy and LactationPregnancy and Lactation

SSRIs relatively safe even during 1SSRIs relatively safe even during 1stst trimester except trimester except paroxetine (increases birth defect rates). Worrisome paroxetine (increases birth defect rates). Worrisome recent reports that exposure during late pregnancy recent reports that exposure during late pregnancy more than doubles prevalence of pulmonary more than doubles prevalence of pulmonary hypertension in newborns.hypertension in newborns.

SSRIs (especially sertraline, citalopram, paroxetine) SSRIs (especially sertraline, citalopram, paroxetine) and TCAs (especially nortriptyline) relatively safe in and TCAs (especially nortriptyline) relatively safe in breast-feeding. Fluoxetine accumulation, TCA-induced breast-feeding. Fluoxetine accumulation, TCA-induced seizures. Venlafaxine accumulates in milk. Insufficient seizures. Venlafaxine accumulates in milk. Insufficient information about newer antidepressants, trazodone.information about newer antidepressants, trazodone.

Bupropion: FDA risk category B.Bupropion: FDA risk category B. MAOIs associated with growth retardation, congenital MAOIs associated with growth retardation, congenital

malformations. malformations.

Mood Stabilizers in Pregnancy and LactationMood Stabilizers in Pregnancy and Lactation

Lithium: First trimester exposure-0.1% risk of Ebstein’s Lithium: First trimester exposure-0.1% risk of Ebstein’s anomaly (10-20 x RR). Safer 2anomaly (10-20 x RR). Safer 2ndnd and 3 and 3rd rd trimesterstrimesters . . Increases birth weight. Newborn hypotonicity, arrhythmias, Increases birth weight. Newborn hypotonicity, arrhythmias, hypothyroidism, DI. Contraindicated during nursing. hypothyroidism, DI. Contraindicated during nursing.

Anticonvulsants: First trimester exposure-higher rates of Anticonvulsants: First trimester exposure-higher rates of miscarriage, birth defects (NTD, orofacial clefts), IUGR, miscarriage, birth defects (NTD, orofacial clefts), IUGR, neonate toxicity, cognitive impairment with VLP & CBZ neonate toxicity, cognitive impairment with VLP & CBZ (VLP > CBZ) but not with LTG (smaller database). Some (VLP > CBZ) but not with LTG (smaller database). Some evidence oxcarbazepine safer than VLP. Nursing-very low evidence oxcarbazepine safer than VLP. Nursing-very low VLP, CBZ breast milk concentrations. LTG? VLP, CBZ breast milk concentrations. LTG?

Anxiolytics During Pregnancy/LactationAnxiolytics During Pregnancy/Lactation Diazepam, other benzosDiazepam, other benzos: initial reports that 1: initial reports that 1stst trimester exposure to trimester exposure to

diazepam, other benzos increase risk of oral clefts not substantiated.diazepam, other benzos increase risk of oral clefts not substantiated. ClonazepamClonazepam: lowest teratogenicity of all benzos in animal studies. : lowest teratogenicity of all benzos in animal studies.

No clear teratogenicity when used in pregnant epileptics. No clear teratogenicity when used in pregnant epileptics. LorazepamLorazepam: safe track record. Limited milk penetration. Low-: safe track record. Limited milk penetration. Low-medium doses considered reasonably safe. medium doses considered reasonably safe.

RisksRisks: infant sedation, hypotonicity, postnatal withdrawal. : infant sedation, hypotonicity, postnatal withdrawal. AlprazolamAlprazolam: some evidence that exposure may increase oral cleft : some evidence that exposure may increase oral cleft

risk 12 times (0.06% to 0.7%).risk 12 times (0.06% to 0.7%). BuspironeBuspirone:?:?

Antipsychotics in Pregnancy/LactationAntipsychotics in Pregnancy/Lactation

Phenothiazines 1st trimester exposure may increase Phenothiazines 1st trimester exposure may increase malformation rate from 2.0% to 2.4%. Aliphatic > piperazine, malformation rate from 2.0% to 2.4%. Aliphatic > piperazine, piperidine. Haloperidol relatively safe. piperidine. Haloperidol relatively safe.

Infant toxicity: EPS, bowel obstruction (rare).Infant toxicity: EPS, bowel obstruction (rare). Atypicals: malformation, IUGR rates appear WNLs. Metabolic, Atypicals: malformation, IUGR rates appear WNLs. Metabolic,

neurodevelopmental effects, neonate toxicity, breast milk neurodevelopmental effects, neonate toxicity, breast milk concentrations unknown. concentrations unknown.

EPS treatments: Diphenhydramine is probably safest although EPS treatments: Diphenhydramine is probably safest although birth defects rate somewhat higher with 1st trimester exposure; birth defects rate somewhat higher with 1st trimester exposure; increased malformation rate with benztropine, trihexyphenidyl, increased malformation rate with benztropine, trihexyphenidyl, and especially amantadine. Propranolol is reasonably safe. and especially amantadine. Propranolol is reasonably safe.

Phenothiazines 1st trimester exposure may increase Phenothiazines 1st trimester exposure may increase malformation rate from 2.0% to 2.4%. Aliphatic > piperazine, malformation rate from 2.0% to 2.4%. Aliphatic > piperazine, piperidine. Haloperidol relatively safe. piperidine. Haloperidol relatively safe.

Infant toxicity: EPS, bowel obstruction (rare).Infant toxicity: EPS, bowel obstruction (rare). Atypicals: malformation, IUGR rates appear WNLs. Metabolic, Atypicals: malformation, IUGR rates appear WNLs. Metabolic,

neurodevelopmental effects, neonate toxicity, breast milk neurodevelopmental effects, neonate toxicity, breast milk concentrations unknown. concentrations unknown.

EPS treatments: Diphenhydramine is probably safest although EPS treatments: Diphenhydramine is probably safest although birth defects rate somewhat higher with 1st trimester exposure; birth defects rate somewhat higher with 1st trimester exposure; increased malformation rate with benztropine, trihexyphenidyl, increased malformation rate with benztropine, trihexyphenidyl, and especially amantadine. Propranolol is reasonably safe. and especially amantadine. Propranolol is reasonably safe.

Psychotropics in Pregnancy/Lactation: Psychotropics in Pregnancy/Lactation: General ConsiderationsGeneral Considerations

Explain risks and benefits of medication and Explain risks and benefits of medication and non-medication treatment approaches, respect non-medication treatment approaches, respect the mother’s wishes, document decision-the mother’s wishes, document decision-making. making.

Don’t use medication unless truly necessary, Don’t use medication unless truly necessary, especially during the first trimester. especially during the first trimester.

Dose medications to adequately treat disorders Dose medications to adequately treat disorders (i.e., don’t under-medicate to decrease drug (i.e., don’t under-medicate to decrease drug exposure). exposure).

Psychotropics in Pregnancy/Lactation: Psychotropics in Pregnancy/Lactation: General Considerations-cont.General Considerations-cont.

Adjust doses of some medications (mood Adjust doses of some medications (mood stabilizers, antidepressants) to compensate stabilizers, antidepressants) to compensate for changes in blood volume as pregnancy for changes in blood volume as pregnancy advances and postpartum. advances and postpartum.

Consider tapering dose or stopping some Consider tapering dose or stopping some medications pre-partum to diminish drug medications pre-partum to diminish drug effects on the newborn, especially if there effects on the newborn, especially if there are obstetric complications.are obstetric complications.

Guidelines for Treatment of Major Guidelines for Treatment of Major Depression During Pregnancy/LactationDepression During Pregnancy/Lactation

SSRIs (fluoxetine, sertraline) or secondary SSRIs (fluoxetine, sertraline) or secondary amine tricyclic antidepressants (desipramine, amine tricyclic antidepressants (desipramine, nortriptyline) during pregnancy or lactation. nortriptyline) during pregnancy or lactation. Buproprion is probably reasonably safe. Buproprion is probably reasonably safe.

Monitor TCA blood levels; increase dose as Monitor TCA blood levels; increase dose as necessary as pregnancy advances, cut back necessary as pregnancy advances, cut back dose at parturition.dose at parturition.

Guidelines for Treatment of Mania Guidelines for Treatment of Mania During Pregnancy/LactationDuring Pregnancy/Lactation

First trimester: Haloperidol for psychosis, First trimester: Haloperidol for psychosis, clonazepam for agitation; if mood stabilizer is clonazepam for agitation; if mood stabilizer is necessary, lithium may be first choice. ECT.necessary, lithium may be first choice. ECT.

Second/Third trimester/Postpartum: Lithium Second/Third trimester/Postpartum: Lithium or anticonvulsants, haloperidol and/or or anticonvulsants, haloperidol and/or clonazepam if truly needed. Continue clonazepam if truly needed. Continue treatment postpartum if no obstetric treatment postpartum if no obstetric complications. Follow breast-fed infants complications. Follow breast-fed infants closely.closely.

Guidelines for Treatment of Mania During Guidelines for Treatment of Mania During Pregnancy/Lactation-contPregnancy/Lactation-cont

Monitor blood levels of mood stabilizers as Monitor blood levels of mood stabilizers as pregnancy advances and increase doses to pregnancy advances and increase doses to maintain effective concentrations. maintain effective concentrations.

At parturition, decrease doses of mood stabilizers At parturition, decrease doses of mood stabilizers by approximately one third to prevent levels from by approximately one third to prevent levels from rising into the toxic range.rising into the toxic range.

Guidelines for Treatment of Anxiety Guidelines for Treatment of Anxiety Disorders During Pregnancy/LactationDisorders During Pregnancy/Lactation

Panic Disorder: SSRIs or secondary amine Panic Disorder: SSRIs or secondary amine TCAs. Clonazepam if a benzodiazepine is TCAs. Clonazepam if a benzodiazepine is necessary.necessary.

Obsessive-Compulsive Disorder: SSRIs or Obsessive-Compulsive Disorder: SSRIs or clomipramine if SSRIs are ineffective (risk clomipramine if SSRIs are ineffective (risk of hypotension during pregnancy, infant of hypotension during pregnancy, infant seizures). seizures).

Guidelines for Treatment of Psychosis Guidelines for Treatment of Psychosis During Pregnancy/LactationDuring Pregnancy/Lactation

Haloperidol would generally be the first Haloperidol would generally be the first choice although phenothiazines probably choice although phenothiazines probably increase risk minimally.increase risk minimally.

First choice for controlling EPS is First choice for controlling EPS is diphenhydramine. Try to avoid during first diphenhydramine. Try to avoid during first trimester.trimester.

Managing Pregnancy in Women Managing Pregnancy in Women Who Require Chronic Psychotropic Who Require Chronic Psychotropic

MedicationMedication

Emphasize the importance of birth control and Emphasize the importance of birth control and planning pregnancies. planning pregnancies.

Stop meds during 1Stop meds during 1stst trimester, if feasible. trimester, if feasible. Plan A: If possible, taper and stop medication prior Plan A: If possible, taper and stop medication prior

to attempts to conceive, e.g. at the beginning of a to attempts to conceive, e.g. at the beginning of a menstrual cycle. menstrual cycle.

Plan B: Detect pregnancy as early as possible (2 Plan B: Detect pregnancy as early as possible (2 wks with OTC pregnancy tests), then taper/stop wks with OTC pregnancy tests), then taper/stop medication. medication.

Managing Pregnancy in Women Who Managing Pregnancy in Women Who Require Chronic Psychotropics-contRequire Chronic Psychotropics-cont

If stability requires 1If stability requires 1stst trimester medication, trimester medication, consider switching to a less risky medication that consider switching to a less risky medication that could reasonably prevent relapse (e.g., from could reasonably prevent relapse (e.g., from anticonvulsant to lithium or haloperidol).anticonvulsant to lithium or haloperidol).

If a mood stabilizer or lithium is necessary during If a mood stabilizer or lithium is necessary during the 1the 1stst trimester, discuss ultrasound examination of trimester, discuss ultrasound examination of the fetus at 16-18 wks of pregnancy and how the fetus at 16-18 wks of pregnancy and how malformations might be handled (abortion?) malformations might be handled (abortion?) before conceptionbefore conception..

Managing Pregnancy in Women Who Managing Pregnancy in Women Who Require Chronic Psychotropics-contRequire Chronic Psychotropics-cont

To diminish the period off of or on less than To diminish the period off of or on less than optimal medication, resuming most optimal medication, resuming most psychotropics after the 1psychotropics after the 1stst trimester (lithium, trimester (lithium, some anticonvulsants?) is reasonably safe.some anticonvulsants?) is reasonably safe.

Risk of postpartum relapse in women with Risk of postpartum relapse in women with history of recurrent mood disorders is history of recurrent mood disorders is diminished by resuming medication immediately diminished by resuming medication immediately postpartum or even shortly prepartum. postpartum or even shortly prepartum.