JOGNN AW H O N N P O S I T I O N S TAT E M E N T
Mood and Anxiety Disorders in
Pregnant and Postpartum Women
An official position
statement of the
Position
ll pregnant and postpartum women should
Association of Women’s
Health, Obstetric and
Neonatal Nurses
A be screened for mood and anxiety disorders.
Nurses are in key positions to screen women, pro-
Approved by the vide education regarding perinatal mood and anx-
AWHONN Board of iety disorders to pregnant and postpartum women
Directors, 1999; revised
and reaffirmed, June 2008. and their families, and ensure appropriate treat-
ment referrals.
Revised, re-titled, and
approved June 2015.
To effectively address perinatal mood and anxiety
AWHONN 2000 L Street,
NW, Suite 740, disorders, health care facilities that serve pregnant
Washington, DC 20036 women, new mothers, and newborns should have
(800) 673-8499
policies and protocols that address screening and
education for women and mechanisms for staff
training regarding these disorders.
Background
Perinatal mood disorders include depression dur-
ing pregnancy, postpartum depression, bipolar
disorder, and postpartum psychosis. Perinatal
anxiety disorders include generalized anxiety dis-
order, panic disorder, obsessive-compulsive dis-
order, social anxiety disorder, specific phobias,
and posttraumatic stress disorder (PTSD).
An estimated 10%–20% of women experience de-
pression or anxiety during pregnancy or in the
postpartum period. As a result, these conditions
are the most common complications of childbirth
(Josefsson, Berg, Nordin, & Sydsjö, 2001; O’Hara
& Swain, 1996). Much attention has been given
to postpartum depression; however, the preva-
lence of depression during pregnancy may be
even greater than in the postpartum period. Peri-
natal anxiety disorders are likewise quite common
(Goodman, Chenauskey, & Freeman, 2014). Co-
morbidity between perinatal anxiety and depres-
sion is also common, since many women suffer
concurrently from major depression and one or
more anxiety disorder (Grigoriadis et al., 2011;
Wisner et al., 2013).
PTSD due to traumatic childbirth is not uncom-
mon, and reported prevalence rates range from
1.5% (Ayers & Pickering, 2001) to 5.6% (Creedy,
Shochet, & Horsfall, 2000). Risk factors for PTSD
include perinatal depression or anxiety, a history of
http://jognn.awhonn.org 
C 2015 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
prior trauma, and a history of mental health prob-
lems (Beck, 2014). Women at risk to experience
trauma during childbirth had high levels of medical
intervention during labor, long and painful labors,
or a perceived lack of support (Beck, 2014).
Perinatal mood disorders occur on a continuum.
Extreme manifestations are life threatening for
women and newborns. Even in their more com-
mon manifestations, perinatal mood and anxiety
disorders can affect the woman’s health, her abil-
ity to connect with her child, her relationship with
her partner, and her child’s long-term health and
development. For example, women with untreated
depression during pregnancy are more likely to
have trouble sleeping; poor nutrition and inad-
equate weight gain; missed prenatal visits; and
greater use of harmful substances like tobacco,
alcohol, or illegal drugs. They are also less likely
to follow a health care provider’s advice (Wom-
enshealth.gov, 2012). For her child, a woman’s
depression during pregnancy is associated with
preterm birth, low birth weight, developmental and
cognitive delays, increased crying, and problems
with bonding (Beck, 2014; Steer, Scholl, Hediger,
& Fischer, 1992). The short- and long-term effects
of perinatal mood and anxiety disorders will con-
tinue to be discovered as nurses and other scien-
tists conduct research in this area.
Screening and Treatment
Systematic screening in pregnancy and the post-
partum period can help detect early symptoms
of perinatal psychiatric distress. Early detection
can lead to better management of perinatal mood
and anxiety disorders, which helps promote the
health and well-being of women and their children
(O’Hara & Wisner, 2014). Screening for perinatal
mood and anxiety disorders should be available
in all facilities that provide care for new mothers,
including obstetric, neonatal, and pediatric set-
tings. Because perinatal mood disorders occur
on a continuum, the importance of appropriate
screening and early intervention strategies can-
not be overstated. If a woman is contemplating
suicide or contemplating harming her infant, emer-
gency mental health interventions are necessary.
687
AW H O N N P O S I T I O N S TAT E M E N T
A variety of effective treatment options exist for
women with perinatal mood and anxiety disorders
(Sockol, Epperson, & Barber, 2011). Most of the re-
searchers studying treatment have focused on de-
pression, especially postpartum depression. Psy-
chotherapy, particularly cognitive-behavioral and
interpersonal psychotherapy, and antidepressant
medication have all been shown to be effective
in the treatment of postpartum depression (Sockol
et al., 2011; Stuart and Koleva, 2014). Psychoso-
cial interventions such as peer support and non-
directive counseling have also been shown to be
beneficial in decreasing depression symptoms in
postpartum women (Dennis & Hodnett, 2007; Mor-
rell et al., 2009). Whereas antidepressant treat-
ment may be indicated and most effective for
severe depression, psychosocial and/or psycho-
logical therapies may be a preferable option for
mild to moderate depression (Brandon & Free-
man, 2011; Yonkers, Vigod, & Ross, 2011). Psy-
chotherapy combined with medication may be the
treatment of choice for some women.
Research is limited regarding treatment for perina-
tal mood disorders other than depression. Psycho-
logical therapies, particularly cognitive behavioral
therapy, have been shown to effectively reduce
anxiety among the general population of patients
with anxiety disorders (Otte, 2011). However, re-
search regarding treatment of perinatal anxiety
disorders is in its beginning stages, and only a
handful of pilot studies are in existence. As a re-
sult, clinicians often extrapolate from the existing
evidence base regarding treatment of psychiatric
disorders at other times in women’s lives in or-
der to inform clinical management in the perinatal
period.
Women’s reluctance to take medication when
pregnant or during the postpartum period,
even if they are not breastfeeding (Goodman,
2009), along with potential concerns about fe-
tal and infant health outcomes, makes non-
pharmacological treatment options such as
psychotherapy particularly important in the peri-
natal period (Battle, Salisbury, Schofield, & Ortiz-
Hernandez, 2013; Goodman, 2009).
The Role of the Nurse
Given the potential negative effects of perina-
tal mood and anxiety disorders on the develop-
ing fetus, the mother-infant relationship, and early
parenting, registered nurses should be alert for
symptoms of depression and anxiety in the peri-
natal period. Further, nurses working with preg-
688 JOGNN, 44, 687-689; 2015. DOI: 10.1111/1552-6909.12734
nant women and new mothers are well-positioned
to perform routine screenings to identify at-risk
women, initiate effective interventions to ensure
the safety of the woman and newborn, and im-
prove access to community-based, perinatal men-
tal health providers and support groups. Nurses
can optimize the level of care they provide in the
following ways:
r Encourage women and new mothers to share
negative emotions they may experience.
r Assess all women for risk factors during the
perinatal period.
r Implement screening programs and perform
screening for perinatal mood and anxiety dis-
orders at various points during pregnancy
and in the postpartum period.
r Take careful histories when women come in
for their birth admission about their fears
related to childbirth, and, for multiparous
women, ask about past birth trauma.
r Prepare pregnant women and new mothers
for self-monitoring for symptoms of perina-
tal mood and anxiety disorders and advise
women of the steps they need to take if they
experience such symptoms.
r Refer women, as appropriate, for follow up
evaluation, diagnosis, and treatment with
mental health provider.
r Stay current with evidence about medication
safety and use during pregnancy and lacta-
tion.
r Develop and maintain a current list of com-
munity resources for treating perinatal mood
and anxiety disorders and make women and
their families aware of these resources.
r Serve as a champion for change to support
delivery of high quality, evidence-based care
for women experiencing perinatal mood and
anxiety disorders.
r Advocate for the expansion of treatment re-
sources in their communities.
r Encourage women to consult with their care
providers before discontinuing medications
due to pregnancy.
Recommendations
AWHONN supports the implementation of legisla-
tion, policies, and public health initiatives that help
raise awareness, remove stigma, reduce barriers
to treatment, and expand research related to peri-
natal mood and anxiety disorders. Such initiatives
include
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r Culturally specific public health campaigns
that help women and their families better un-
derstand perinatal mood and anxiety disor-
ders and where to seek treatment, if needed.
r Increased access to perinatal mental health
interventions, including psychotherapy, that
are high-quality, affordable, and logistically
feasible, including in the home or integrated
into the obstetric setting.
r Insurance coverage in public and private
plans for perinatal mood and anxiety disor-
der screening and for the full range of effec-
tive treatment options.
r
Establishment of community support net-
works and community-based partnerships in-
tended to support pregnant and postpartum
women.
r Further research to discern more accurately
the prevalence and course of anxiety over the
perinatal period.
r
Promotion of continuing education and train-
ing for nurses and other health care profes-
sionals.
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