ORIGINAL ARTICLE
Symptoms of the Anxiety Disorders in a Perinatal Psychiatric Sample A Chart Review Casey A. Schofield, PhD,* Cynthia L. Battle, PhD,Þþ§ Margaret Howard, PhD,Þ§ and Samia Ortiz-Hernandez, BA||
Abstract: Symptoms of anxiety are a central feature of perinatal mental health, yet the anxiety disorders have received considerably less attention than depression in both perinatal research and practice. The present investigation involved a retrospective review of the clinical records of 334 patients seen at a psychiatric day hospital program serving pregnant and postpartum women. We examined the frequency with which the patients in this setting reported symptoms of anxiety, clinical correlates of elevated anxiety, and patterns of diagnosis in the clinical record. The results suggest that anxiety symptoms are very common in this population and that the presence of anxiety is associated with a more severe clinical profile, including higher rates of suicidality and increased use of psychotropic medications during pregnancy and postpartum. Although anxiety symptom levels were markedly elevated in this sample, anxiety disorders were diagnosed at relatively low rates. Implications for clinical practice, including discharge and treatment planning, are discussed. Key Words: Pregnancy and postpartum, anxiety, depression, antidepressants (J Nerv Ment Dis 2014;202: 154Y160)
T
he anxiety disorders are the largest class of psychiatric illnesses (American Psychiatric Association [APA], 2000). These chronic disorders are associated with high levels of psychiatric comorbidity (Gorman, 1996; Merikangas et al., 1998) and impairment in daily functioning, including elevated rates of suicidality (Sareen et al., 2005). Rates of anxiety disorders are higher among women than men starting as early as the age of 6 years (Lewinsohn et al., 1998), and the typical age of onset of most of these disorders occurs sometime before or during the childbearing years (Coleman et al., 2006). This is of particular relevance given that the perinatal period may be a time of both heightened risk for psychiatric distress (Bennett et al., 2004) and increased functional demands. However, data suggest that detection of psychiatric distress during pregnancy remains alarmingly low (Goodman and Tyer-Viola, 2010). This represents a potential missed opportunity given that most pregnant and postpartum women interface with the medical system frequently, yet screening for psychiatric distress during these visits remains uncommon (Coleman et al., 2008). Given the low rates of screening, it is unsurprising that rates of recognition and treatment of psychiatric distress are similarly low for pregnant and postpartum women (Kelly et al., 2001; Marcus et al.,
*Department of Psychology, Skidmore College, Saratoga Springs, NY; †Department of Psychiatry and Human Behavior, Brown University Medical School, Providence, RI; ‡Butler Hospital, Providence, RI; §Women & Infants’ Hospital of Rhode Island, Providence, RI; and ||George Washington University, Washington, DC. Send reprint requests to Casey A. Schofield, PhD, Department of Psychology, Skidmore College, 815 North Broadway, Saratoga Springs, NY 12866. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20202Y0154 DOI: 10.1097/NMD.0000000000000086
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2003; Spitzer et al., 2000). Furthermore, when mental health screening is conducted, it has traditionally focused on the assessment of symptoms of depression (Ross and McLean, 2006), an approach that may overlook meaningful symptoms of anxiety (Muzik et al., 2000). Although anxiety presents as a comorbid problem along with depression in many instances, clinically impairing anxiety is not uncommon in the absence of depression in perinatal samples (Matthey et al., 2003). Therefore, screening exclusively for depression is likely to result in overlooking important psychiatric distress. The growing recognition of the risks associated with perinatal anxiety in combination with the comparatively low level of attention to screening, detection, and treatment of these disorders has prompted increasing interest in the clinical characterization of perinatal anxiety (Matthey, 2004; Ross and McLean, 2006; Vythilingum, 2008). The past decade has yielded a growing literature highlighting the importance of understanding the prevalence and the nature of perinatal anxiety. Several initial studies documented that anxiety is common during pregnancy and the postpartum period (Heron et al., 2004; Reck et al., 2008; Stuart et al., 1998; Wenzel et al., 2003). In fact, some evidence has suggested that childbearing is associated with the onset of certain anxiety disorders (e.g., obsessive-compulsive disorder [OCD]; Abramowitz et al., 2002; Forray et al., 2010). Importantly, antenatal anxiety and stress have been associated with a number of adverse fetal effects (Van den Bergh et al., 2005) including low infant birth weight (Field et al., 2003), preterm labor (Dayan et al., 2002), and elevated fetal heart rate patterns (Monk et al., 2000), although not all studies have found such associations between anxiety and adverse perinatal outcomes (Littleton et al., 2007). Further, the presence of prenatal anxiety significantly predicts both postnatal anxiety and mood symptoms, indicating that these clinical profiles remain relatively stable (Grant et al., 2008; Mauri et al., 2010; Milgrom et al., 2008). Lastly, studies of postpartum and maternal anxiety indicate that children of anxious mothers are at increased risk for experiencing significant behavioral problems (O’Connor et al., 2002), including attention deficit hyperactivity disorder and internalizing symptoms (Hudson, 2001; Turner et al., 2003; Van den Bergh and Marcoen, 2004). In short, there are clear public health ramifications associated with unidentified and untreated perinatal anxiety, highlighting the importance of drawing attention to this clinical phenomenon. To date, the bulk of the literature characterizing the presence of perinatal anxiety has focused on nonpsychiatric samples, such as a general population of women seeking prenatal care in obstetriciangynecologist settings. This previous work has been important in establishing the presence of anxiety symptoms in the general population of perinatal women but falls short in informing our understanding of the role anxiety symptoms play in perinatal women who are more significantly impaired by psychiatric distress. Importantly, there have been a few initial studies evaluating the presence of anxiety within psychiatric perinatal populations. A previous chart review study demonstrated very high rates of major depression as an assigned diagnosis in a treatment-seeking perinatal psychiatric
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sample (i.e., 86.7%) with comparatively low rates of anxiety disorder diagnoses assigned (e.g., 0.5%, generalized anxiety disorder [GAD], to 4%, panic disorder; Battle et al., 2006). This low rate of assigned anxiety diagnoses stands in contrast to data from one recent study in which most women who met criteria for major depression also had a comorbid anxiety disorder (most frequently GAD; Grigoriadis et al., 2011) and another investigation of a sample of women admitted to a specialized mother-baby inpatient unit who reported elevated scores on the anxiety-focused items of the Edinburgh Postnatal Depression Scale (EPDS; Fisher et al., 2002). Together, this work suggests that there may be a discrepancy between symptoms of anxiety and clinician-assigned diagnoses in perinatal psychiatric samples, although to our knowledge, no previous work has evaluated the presence of anxiety symptom self-report in comparison with clinical diagnoses in a psychiatric perinatal population. The goal of the current investigation was to add to this growing body of literature characterizing anxiety symptoms in a perinatal psychiatric sample compared with diagnostic profiles. Specifically, this study used retrospective chart review methodology to evaluate symptom self-report and to describe the diagnostic profile of a sample of women seeking care at the Women and Infants’ Hospital of Rhode Island Day Hospital (DH) program. The DH is a unique mother-baby day treatment facility that provides integrated psychiatric care for pregnant and postpartum women who present with psychiatric disorders during the perinatal period (Howard et al., 2006). The core of this program integrates group and individual psychotherapy with psychopharmacology and family support. The psychotherapy component is grounded in interpersonal psychotherapy and cognitive-behavioral therapy approaches, with an explicit focus on role transitions, interpersonal problems, emotion regulation/ skill development, and psychoeducation. Given the clinical relevance of perinatal anxiety disorders, this study sought to examine the frequency of self-reported symptoms of anxiety in comparison with clinician diagnoses of anxiety and relevant clinical correlates of perinatal anxiety symptoms such as rates of suicidality, functional impairment, and psychiatric medication use.
METHODS The current study was approved by the hospital’s institutional review board. Clinical records of 334 DH patients (110 pregnant and 224 postpartum) were retrospectively reviewed by trained research staff members. The DH program treats psychiatric conditions in perinatal patients within the context of a 7- to 10-day partial hospitalization program; patients are typically experiencing a level of symptom severity and functional impairment more severe than those managed on an outpatient basis yet less severe than patients requiring hospitalization on an inpatient unit. Patients admitted to the program between January 2005 and April 2007 were included in this study. A data abstraction form was created for this study that included variables to be obtained from both admission and discharge clinical records, including information regarding patient demographics, treatment history, gestational information, clinician-rated diagnosis, intake and discharge medications, and data obtained from two brief self-report questionnaires. Clinicians responsible for treating patients and documenting clinical care in the record were licensed clinicians who specialize in perinatal mental health, representing a range of disciplines (psychiatrists, psychologists, licensed social workers, and nurse specialists). Research staff were trained in chart abstraction procedures, and 10% (n = 27) of all charts were reviewed by multiple raters to examine interrater reliability. Reliability analyses on 11 dichotomous chart variables revealed that raters demonstrated good to very good agreement (mean J = 0.93). In terms of self-report measures, the EPDS (Cox et al., 1987) was administered at both intake and discharge to all DH patients. The * 2014 Lippincott Williams & Wilkins
Anxiety in a Perinatal Sample
EPDS is a widely used, 10-item self-report questionnaire that has been validated to assess the presence of symptoms of depression in prenatal and postpartum samples (Cox et al., 1987; Murray and Cox, 1990). Relevant to the current study, a three-item subscale of the EPDS has been recognized as a brief measure of anxiety symptoms in perinatal women (EPDS-A) and has been used to examine anxiety severity among both pregnant (Brouwers et al., 2001; Jomeen and Martin, 2005) and postpartum samples (Ross et al., 2003). In addition to the EPDS-A subscale, the women were also administered a standard DH intake screener that assesses the presence of symptoms indicative of the most common anxiety disorders. Although not identical, items on the self-report DH intake screener are comparable with verbally administered items included in the Anxiety Disorders Interview Schedule (DiNardo et al., 1994). The patients were asked to respond yes or no on a symptom screening questionnaire to the following questions related to anxiety: Have you repeatedly experienced a sudden rush of very intense fear, anxiety, or discomfort that came on from out of the blue for no reason? and Are there places you avoid because they make you too nervous? (panic attacks and agoraphobia); Have you been worrying too much and had difficulty controlling your worry in the past 6 months? (GAD); Have you been worrying that you might do or say something that would embarrass you in front of others? Or that other people might think badly of you? (social phobia); Are you frequently bothered by intrusive, silly, unpleasant, or horrible thoughts or images that seem unreasonable or do not make sense, but keep repeating over and over (e.g., getting contaminated by germs, doing something violent, etc.)? and Are you frequently bothered by having to do something over that you can’t resist (e.g., handwashing, cleaning, checking, etc.)? (OCD); and Have you felt a lot of distress (such as flashbacks, nightmares, etc.) since you experienced a very traumatic event? (posttraumatic stress disorder [PTSD]).
RESULTS Participant demographic information is presented in Table 1. This was the first baby for less than half of the sample (40.5%). The sample was ethnically diverse, with slightly more than half of the participants identifying their primary ethnicity as white (54.2%) and a significant proportion of women identifying as Hispanic/Latina (21.6%) or black/African-American (12.9%). Slightly more than half of the women (50.6%) reported being single at the time of admission to the program.
Treatment History For 16.8% of the sample, their admission to the DH program marked their first encounter with any form of psychiatric treatment. The charts revealed that a meaningful portion of the sample had a history of substance use problems (29%) and nearly half of the sample was taking psychiatric medication at the time of admission (42.5% of the total sample; 40% of the women who were pregnant at admission and 44.6% of the postpartum women). The most common types of psychiatric medication taken at DH intake were selective serotonin reuptake inhibitors (SSRIs; 31.4%) followed by anxiolytics (12.9%). Program enrollment lasted from 1 to 18 days, with a mean duration of 5.7 days.
Self-reported Symptoms and Diagnostic Assignment Regarding self-reported anxiety symptoms, the mean score on the EPDS-A was markedly high at the time of intake (mean, 7.1; SD, 1.6). Anxiety levels improved significantly from DH intake to discharge, to a mean EPDS-A discharge score of 4.7 (SD, 2.0), t(192) = 15.21, p G 0.001. Similarly, the mean overall EPDS scores improved from intake to discharge, t(195) = 22.57, p G 0.001 (intake mean, 20.1; SD, 4.6; discharge mean, 11.80; SD, 4.9). Of note, rates of all www.jonmd.com
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of obsessions (30.2%) and compulsions (24.6%) were also notable; however, a diagnosis of OCD was also assigned relatively rarely (3.9% of the patients). PTSD was diagnosed more frequently: 31.1% of the women self-reported persistent distress related to a traumatic experience, and 9.9% of the sample received a PTSD diagnosis. Of note, 6% of the sample was assigned a diagnosis of anxiety disorder not otherwise specified (NOS). In all, 32.3% of this sample received a diagnosis of an anxiety disorder.
TABLE 1. Participant Characteristics Mean (SD)
Age
27.9 (6.3) Frequency
Marital status Single Married/committed relationship Divorced/separated Not recorded Education Eighth grade Some HS Completed HS/GED Some college/AA degree Completed bachelor’s degree Completed graduate degree Not recorded Primary ethnicity American Indian/Alaska Native Asian Hawaiian/Pacific Islander Black/African-American White Hispanic/Latina Other (Cape Verdean, Dominican, Portuguese, Laotian, West African) Not recorded Perinatal status Currently pregnant Currently postpartum First pregnancy/first baby Medication status Taking Q1 psychotropic medication at intake Taking SSRI Taking anxiolytic Taking antipsychotic Taking mood stabilizer Taking SARI Other (TCA, NDRI, NASA)
50.6% 44.0% 4.8% 0.6%
Functional Impairment and Suicidality
2.1% 12.6% 23.4% 33.2% 11.1% 3.4% 14.4% 1.8% 0.3% 0.3% 12.9% 54.2% 21.6% 7.8% 1.2% 36.2% 63.8% 40.5% Intake
Discharge
42.5%
83.2%
31.4% 12.9% 4.8% 3.0% 3.0% 2.4%
65.0% 47.6% 13.5% 6.6% 6.3% 7.8%
In terms of functional impairment, the mean clinician-rated Global Assessment of Functioning (GAF) score for the entire sample at intake was 50.22, indicative of serious psychiatric symptoms and clinically significant functional impairment. Suicidality was assessed by clinician documentation of suicidal ideation at the time of DH admission and self-report of suicidality on the EPDS. At the time of admission, 44.6% of the women who completed the EPDS self-reported thoughts of harming themselves (Q1 on the EPDS suicidality item). Similarly, clinicians’ chart notes indicated that 44.9% of the women endorsed suicidal ideation at intake, with 29% endorsing suicidal behavior. To evaluate whether heightened functional impairment, psychotropic medication use, or suicidality varied as a function of symptoms of anxiety, the sample was divided into high- and low-anxiety groups on the basis of quartile scores on the EPDS-A. The patients who scored in the top 25% (EPDS-A Q 8, n = 130) composed the ‘‘elevated anxiety’’ group, and the participants who scored in the bottom 25% (EPDS-A e 6, n = 94) composed the ‘‘nonelevated anxiety’’ group. These groups did not differ from one another on the psychosocial variables of age, t(222) = 1.19, p = 0.24; education (no high school [HS] diploma, HS or some college, or completed college or higher), W2(1, N = 194) = 5.34, p = 0.07; ethnicity (white or nonwhite), W2(1, N = 220) = 2.22, p = 0.14; or marital status (single, married, or divorced/separated), W2(1, N = 223) = 4.75, p = 0.09. The results revealed that the patients with elevated anxiety symptoms were significantly more likely to endorse suicidality, both on a self-report scale (EPDS t[221] = 3.47, p = 0.001) and by verbal report to their DH clinician, W2(1, N = 221) = 5.63, p = 0.02 (see Fig. 1). Furthermore, the patients with high levels of anxiety symptoms were more likely to endorse a history of psychiatric medication use, W2(1, N = 216) = 4.74, p = 0.04, and were also more likely to be taking psychiatric medication at the time of both intake, W2(1, N = 221) = 7.82, p = 0.006, and discharge, W2(1, N = 222) = 9.69, p = 0.002 TABLE 2. Patients’ Responses to DH Screener Questionnaire and Assigned Chart Diagnoses
AA indicates Associate degree; GED, general educational development; NASA, norepinephrine antagonist serotonin antagonist; NDRI, norepinephrine dopamine reuptake inhibitor; SARI, serotonin antagonist and reuptake inhibitors; TCA, tricyclic antidepressants.
Disorder
categories of psychiatric medication increased from intake to discharge, with 83.2% of the sample prescribed at least one psychiatric medication at the time of discharge. Most women in our sample (84%) completed the DH intake screener. Rates of self-reported anxiety symptoms and rates of clinical diagnosis of the anxiety disorders are presented in Table 2. Analyses revealed a high level of anxiety symptoms. Specifically, of the women who completed the screener, more than half reported experiencing symptoms of the following major anxiety disorders: GAD (62.6%), panic attacks (58.1%), and agoraphobia (51.2%); nearly half of the women reported symptoms of social phobia (47.3%). These diagnoses were rarely assigned by clinicians at discharge from the DH program. Specifically, 0.6% of the sample was diagnosed with GAD; 4.2%, with panic disorder (with or without agoraphobia); and 1.5%, with social phobia. Self-reported symptoms 156
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Sad, blue, depressed Anhedonia GAD Social phobia PTSD Obsessions Compulsions Panic attack Agoraphobia Anxiety disorderYNOS
Patients Who Patients for Endorsed the DH Patients Assigned Whom This Is Intake Screener a Chart Diagnosis Primary Axis as Yes, % of the Disorder, % I Diagnosis, %
74.6 72.2 62.6 47.3 31.1 30.2 24.6 58.1 51.2 N/A
70.7 (MDD)
68.6
1.5 0.6 9.9 3.9 (OCD)
0.3 0 3.6 1.5
4.2 (panic disorder)
1.5
6.0
0
MDD indicates major depressive disorder; N/A, not applicable.
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FIGURE 1. Percentage of patients with low versus high anxiety using psychiatric medication and reporting suicidal ideation.
(see Fig. 1). Of note, the differences in psychiatric medication use between the patients with high and low anxiety seemed to be driven primarily by higher rates of SSRI prescriptions among the patients with elevated anxiety at both intake, W2(1, N = 139) = 5.88, p = 0.015, and discharge, W2(1, N = 192) = 4.27, p = 0.039. Rates of psychiatric medication use were not different between the groups for any other classes of medications at either intake or discharge (all p’s 9 0.05). Significant differences were not found on the clinician-rated GAF scale between the patients with elevated versus nonelevated anxiety, t(212) = 1.07, p = 0.29.
DISCUSSION There are three primary findings of this chart review investigation. First, consistent with other recent reports, symptoms of anxiety are markedly elevated among pregnant and postpartum women seeking psychiatric care. Second, patients with the most elevated selfreported anxiety have a more severe clinical profile, including higher levels of suicidality and more frequent perinatal psychotropic medication use. Finally, our data suggest that diagnosis of anxiety disorders in the clinical record occurs relatively infrequently in contrast to the high rate of anxiety based on patients’ responses on selfreport measures. Given that this study used a retrospective chart review methodology targeting patients who sought care at a single treatment facility, it cannot establish prevalence rates of perinatal anxiety disorders. Related, although an anxiety factor has been identified within the EPDS (Brouwers et al., 2001; Jomeen and Martin, 2005; Ross et al., 2003), this self-report measure is not a diagnostic instrument for the detection of perinatal anxiety disorders; rather, the measure reflects the presence of symptoms of perinatal anxiety. As such, the aim of this study was to characterize how commonly anxiety symptoms were reported in a psychiatric treatment-seeking sample and, related, how frequently clinicians documented anxiety disorder diagnoses in the clinical record. Thus, this approach is limited in that our results cannot speak directly to either the prevalence of anxiety disorders in this perinatal psychiatric sample or to true ‘‘missed’’ diagnoses within this clinical setting. That said, our findings suggest that there may be a discrepancy between the high levels of anxiety symptoms in comparison with the small proportion of women assigned an anxiety disorder diagnosis in their clinical chart. This potential disconnect may be explained in various ways. First, self-report screening measures (e.g., EPDS-A) are useful at noting patients’ experience of symptoms but in some cases may be capturing subthreshold cases of anxiety. As such, these measures may reflect symptom elevations but not anxiety occurring at a level at which a clinical diagnosis is appropriate. Related, the screening questions and symptom measure used are not able to capture the * 2014 Lippincott Williams & Wilkins
Anxiety in a Perinatal Sample
patients’ current level of functional impairment related to the symptom in question; this is relevant because functional impairment is a key factor in determining whether a clinical diagnosis of a disorder is warranted. Although some cases of patients reporting elevated symptoms of anxiety may not have reached the appropriate clinical threshold to warrant full diagnosis of a disorder, it is also possible that a number of cases did in fact reach the clinical threshold. In these cases, the anxiety disorder was either not detected during clinician interview or detected yet not noted in the clinical record as part of the discharge diagnosis. Of note, it will be important for future work to confirm this potential disconnect between the presence of clinical anxiety and assigned diagnoses using methods that establish the presence of anxiety disorder (i.e., diagnostic clinical interviewing) rather than assessment of symptoms of anxiety exclusively via selfreport measures. Measurement of anxiety disorders during the perinatal period has some unique challenges. In particular, there is some evidence to suggest that the presence of maternally focused worry often does not align with current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), anxiety disorder diagnoses but represents a similar clinical profile in terms of severity and impairment (Phillips et al., 2009). In fact, it may be that the experience of such maternal worry accounts in part for the elevated reports of symptoms of OCD and GAD, in particular, in the current sample. That is, concerns typical of maternally focused worry (e.g., frequent thoughts about body image, baby’s health, parenting abilities, and finances) could reasonably prompt a woman to endorse questions such as ‘‘Have you been worrying too much and had difficulty controlling your worry?’’ or ‘‘Have you been bothered by intrusive, silly, unpleasant, or horrible thoughts or images?’’ potentially accounting for an exaggeration of the presence of OCD and/or GAD by the intake screener. That said, maternal worry may be overlooked given that such concerns may be considered ‘‘normal’’ during this unique time in a woman’s life, yet this form of worry can be associated with impairment and distress consistent with DSM-IV anxiety disordersVeven when it does not align with a DSM-IV anxiety disorder diagnosis (Phillips et al., 2009). Despite low levels of assigned anxiety disorder diagnoses, mood disorders (in particular, major depressive disorder) were assigned to most of the patients enrolled in the DH program. A great deal of clinical and public health attention has been focused on perinatal depressionVrightfully so, given the impairment and distress experienced by women as well as the adverse effects on infant development and family functioning. However, it may be that this public health focus on perinatal depression has overlooked symptoms of perinatal anxiety in a way that undermines women’s recognition and help seeking in response to perinatal anxiety symptoms. For example, evidence suggests that women with anxiety symptoms in the absence of symptoms of depression are less likely to seek professional help than women with symptoms of depression alone (Woolhouse et al., 2009). Although concern regarding perinatal depression is well warranted, it is possible that a clinical focus on symptoms of depression may account in part for the rare assignment of anxiety disorder diagnoses. That is, in patients experiencing cooccurring mood and anxiety disorders, mood disorders may be perceived as most clinically relevant and leading to most clinical impairment at the time of program intake and discharge. This may be particularly true for the anxiety disorders GAD and social phobia, in which the frequency of diagnosis is well lower than the populationbased rates of these disorders (GAD population prevalence: È5% vs. GAD sample diagnosis: 1.5%; social phobia prevalence: È10% vs. social phobia sample diagnosis: 0.6%; APA, 2000). The potential underrecognition of anxiety disorders is not unique to the perinatal setting. In fact, despite the oft-reported evidence that depression is commonly comorbid with anxiety disorders www.jonmd.com
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(Fava et al., 2000; Zimmerman et al., 2000), evidence suggests that mental health professionals frequently overlook the presence of anxiety disorders in their patients (Zimmerman and Chelminski, 2003a). This is in contrast to evidence that patients overwhelmingly self-report that they are interested in treatment of the symptoms of anxiety disorder (Zimmerman and Chelminski, 2003a). We recognize that a comprehensive evaluation of the anxiety disorders is prohibitively time consuming within the bounds of many mental health settings, and, at this time, there are genuine limitations to the available self-report measures typically used to assess anxiety in perinatal populations (Meades and Ayers, 2011), a limitation that will be important to address in future work. That said, there is evidence (Meades and Ayers, 2011) to suggest that some brief screening questionnaires and symptom inventories can reliably and validly measure symptoms of the anxiety disorders in pregnant populations (e.g., the State Trait Anxiety Inventory [Spielberger, 1983], The Kessler 10 [Kessler et al., 2003]). Identifying and treating symptoms of anxiety are critical for clinical care. For one, the presence of anxiety disorders is relevant to the severity and the prognosis of major depression. That is, the severity of patients’ clinical profile in terms of functional impairment and suicidality is worse for depression with comorbid anxiety disorder (Goldberg and Fawcett, in press; Hegel et al., 2005; Kessler et al., 1994; Mittal et al., 2006; Rhebergen et al., 2011; Zimmerman and Chelminski, 2003b), and the prognosis of depression with comorbid anxiety disorder is demonstrably poorer than depression alone (Gaynes et al., 1999; Sherbourne and Wells, 1997). In the current sample, elevated levels of self-reported symptoms of anxiety were associated with higher levels of suicidality at intake and a more significant psychiatric history. Although the patients with high levels of anxiety were not assigned lower GAF scores, they were more likely to have a history of psychiatric medication use and were more likely to be on psychiatric medication at the time of hospital admission and discharge, while pregnant or postpartum. This replicates previous research demonstrating that more severe clinical profiles are associated with higher rates of antidepressant use in perinatal women (Battle et al., 2008). On the one hand, these findings are encouraging in that these suggest that women experiencing high levels of perinatal psychiatric distress are accessing and receiving psychiatric treatment. On the other hand, given the intensity of psychiatric symptoms captured in self-report measures in combination with elevated suicidality and high rates of psychiatric medications, it suggests that these symptoms may be insufficiently treated. This could potentially be explained by limited attention to the presence of anxiety disorders in treatment planning and underscores the importance of considering symptoms of anxiety in clinical evaluations and discharge for perinatal women. Treatment recommendations for depression versus depression with comorbid anxiety differ with regard to pharmacological treatment (APA, 2000; Baldwin et al., 2005), psychotherapeutic treatment, and their combination (Otto et al., 2005). Encouragingly, the anxiety disorders are responsive to appropriate psychotherapeutic and psychopharmacological treatment, and thus, discharge planning that incorporates consideration of anxiety symptoms is important. Further, the perinatal period may be particularly meaningful in terms of appropriate diagnostic and treatment planning given that, for many women, it represents their first-ever contact with the mental health care system (Battle et al., 2006). In fact, in the current sample, intake at a DH level of care during pregnancy was the very first contact women had with the mental health system for approximately 17% of the sample. As such, the perinatal period represents a potential opportunity to connect women with the appropriate careVthroughout the perinatal period and also beyond it.
CONCLUSIONS The current study contributes to the growing body of research highlighting the relevance of symptoms of anxiety disorders during 158
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the perinatal period. Given that the methods of the current study cannot speak to prevalence rates of anxiety disorders among perinatal psychiatric patients, future epidemiological work in this population will be important. To draw conclusions about whether diagnoses are being overlooked, a comprehensive structured diagnostic interview would need to be conducted and compared with diagnoses documented in clinical charts. Although the current study cannot establish detection rates of anxiety disorders, it demonstrates that symptoms of anxiety are remarkably common among perinatal patients with psychiatric distress. Further, the presence of anxiety is associated with a more severe clinical picture. Thus, it will be valuable for clinicians working with pregnant and postpartum women to broaden evaluations of perinatal mental health to consistently include evaluations of the anxiety symptoms. This point is particularly relevant within perinatal populations given the public health concern related to poor fetal and neonatal outcomes associated with untreated anxiety in pregnant women (Dayan et al., 2002; Field et al., 2003; Monk et al., 2000; Van den Bergh et al., 2005). Similarly, maternal outcomes are impacted by untreated anxiety, as demonstrated by a recent study indicating that antenatal anxiety disorders significantly predict rates of postpartum anxiety and depression (Grant et al., 2008; Mauri et al., 2010), findings that are consistent with previous research (Heron et al., 2004; Skouteris et al., 2009; Sutter-Dallay et al., 2004). The anxiety disorders are a clinically significantVyet treatableV cluster of psychiatric conditions because existing empirically supported treatments hold great potential for alleviating distress and improving functioning. However, without successful detection and treatment, anxiety disorders often represent a gateway to the subsequent development of added psychiatric distress, including both depression (Beesdo et al., 2007) and substance abuse (Merikangas et al., 1998). For these reasons, and given that growing evidence supports that anxiety is a common clinical presentation among perinatal women, greater attention to the presence of anxiety disorders in this population warrants ongoing empirical and clinical attention. DISCLOSURES The authors declare no conflict of interest.
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Milgrom J, Gemmill AW, Beliszta J, Hayes B, Barnett B, Brokks J, Ericksen J, Ellwood D, Buist A (2008) Antenatal risk factors for postnatal depression: A large prospective study. J Affect Disord. 108:147Y157. Mittal D, Fortney J, Pyne J, Edlund M, Wetherrell JL (2006) Impact of comorbid anxiety disorders on health-related quality of life among patients with major depressive disorder. Psychiatr Serv. 57:1731Y1737. Monk C, Fifer W, Myers M, Sloan RP, Trien L, Hurtado A (2000) Maternal stress responses and anxiety during pregnancy: Effects on fetal heart rate. Dev Psychobiol. 36:67Y77. Murray D, Cox JL, (1990) Screening for depression during pregnancy with the Edinburgh Depression Scale (EDDS). J Reproduct Infant Psychol. 8:99Y107. Muzik M, Klier C, Rosenblum K, Holzinger A, Umek W, Katschnig H (2000) Are commonly used self-report inventories suitable for screening postpartum depression and anxiety disorders? Acta Psychiatr Scand. 102:71Y73. O’Connor T, Heron J, Golding J, Beveridge M, Glover V (2002) Maternal antenatal anxiety and children’s behavioural/emotional problems at 4 years. Br J Psychiatry. 180:502Y508. Otto MW, Smits JAJ, Reese HE (2005) Combined psychotherapy and pharmacotherapy for mood and anxiety disorders in adults: Review and analysis. Clin Psychol. 12:72Y86. Phillips J, Sharpe L, Matthey S, Charles M (2009) Maternally focused worry. Arch Womens Ment Health. 12:409Y418. Reck C, Struben K, Backenstrass M, Stefenelli U, Reinig K, Fuchs T, Sohn C, Mundt C (2008) Prevalence, onset and comorbidity of postpartum anxiety and depressive disorders. Acta Psychiatr Scand. 118:459Y468. Rhebergen D, Batelaan N, de Graaf R (2011) The 7-year course of depression and anxiety in the general population. Acta Psychiatr Scand. 123:297Y306. Ross L, Evans S, Sellers E (2003) Measurement issues in postpartum depression part 1: Anxiety as a feature of postpartum depression. Arch Womens Ment Health. 6:51Y57. Ross LE, McLean LM (2006) Anxiety disorders during pregnancy and the postpartum period: A systematic review. J Clin Psychiatry. 67:1285Y1298. Sareen J, Cox B, Afifi T, de Graaf R, Asmundson GHG, ten Have M, Stein MB (2005) Anxiety disorders and risk for suicidal ideation and suicide attempts: A population-based longitudinal study of adults. Arch Gen Psychiatry. 62: 1249Y1257. Sherbourne CD, Wells KB (1997) Course of depression in patients with comorbid anxiety disorders. J Affect Disord. 43:1249Y1257. Skouteris H, Wertheim E, Rallis S, Milgrom J, Paxton SJ (2009) Depression and anxiety through pregnancy and the early postpartum: An examination of prospective relationships. J Affect Disord. 113:303Y308. Spielberger CD (1983) Manual for the State-Trait Anxiety Inventory STAI (Form Y). Palo Alto, CA: Consulting Psychologists Press. Spitzer RL, Williams JB, Kroenke K, Hornyak R, McMurray J (2000) Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic patients: The PRIME-MD Patient Health Questionnaire obstetrics-gynecology study. Am J Obstet Gynecol. 183:759Y769. Stuart S, Couser G, Schilder K, O’Hara MW, Gormon L (1998) Postpartum anxiety and depression: Onset and comorbidity in a community sample. J Nerv Ment Dis. 186:420Y424. Sutter-Dallay A, Giaconne-Marcesche V, Gatigny-Dallay E, Verdoux H (2004) Women with anxiety disorders during pregnancy are at increased risk of
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intense postnatal depressive symptoms: A prospective survey of the MATQUID cohort. Eur Psychiatry. 19:459Y463. Turner S, Beidel DC, Roberson-Nay R, Tervo K (2003) Parenting behaviors in parents with anxiety disorders. Behav Res Ther. 41:541Y554. Van den Bergh B, Mulder E, Mennes M, Glover V (2005) Antenatal maternal anxiety and stress and the neurobehavioural development of the fetus and child: Links and possible mechanisms. A review. Neurosci Biobehav Rev. 41:541Y554. Van den Bergh BRH, Marcoen A (2004) High antenatal maternal anxiety is related to ADHD symptoms, externalizing problems, and anxiety in 8- and 9-year-olds. Child Dev. 75:1085Y1097. Vythilingum B (2008) Anxiety disorders in pregnancy. Curr Psychiatry Rep. 10:331Y335.
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Wenzel A, Haugen E, Jackson L, Robinson K (2003) Prevalence of generalized anxiety at eight weeks postpartum. Arch Womens Ment Health. 6:43Y49. Woolhouse H, Brown S, Krastev A, Perlen S, Gunn J (2009) Seeking help for anxiety and depression after childbirth: Results of the Maternal Health Study. Arch Womens Ment Health. 12:75Y83. Zimmerman M, Chelminski I (2003a) Clinician recognition of anxiety disorders in depressed outpatients. J Psychiatr Res. 37:325Y333. Zimmerman M, Chelminski I (2003b) Generalized anxiety disorder in patients with major depression: Is DSM-IV’s hierarchy correct? Am J Psychiatry. 160:504Y512. Zimmerman M, McDermut W, Mattia JI (2000) Frequency of anxiety disorders in psychiatric outpatients with major depressive disorder. Am J Psychiatry. 157:1337Y1340.
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Symptoms of the Anxiety Disorders in a Perinatal Psychiatric Sample A Chart Review Casey A. Schofield, PhD,* Cynthia L. Battle, PhD,Þþ§ Margaret Howard, PhD,Þ§ and Samia Ortiz-Hernandez, BA||
Abstract: Symptoms of anxiety are a central feature of perinatal mental health, yet the anxiety disorders have received considerably less attention than depression in both perinatal research and practice. The present investigation involved a retrospective review of the clinical records of 334 patients seen at a psychiatric day hospital program serving pregnant and postpartum women. We examined the frequency with which the patients in this setting reported symptoms of anxiety, clinical correlates of elevated anxiety, and patterns of diagnosis in the clinical record. The results suggest that anxiety symptoms are very common in this population and that the presence of anxiety is associated with a more severe clinical profile, including higher rates of suicidality and increased use of psychotropic medications during pregnancy and postpartum. Although anxiety symptom levels were markedly elevated in this sample, anxiety disorders were diagnosed at relatively low rates. Implications for clinical practice, including discharge and treatment planning, are discussed. Key Words: Pregnancy and postpartum, anxiety, depression, antidepressants (J Nerv Ment Dis 2014;202: 154Y160)
T
he anxiety disorders are the largest class of psychiatric illnesses (American Psychiatric Association [APA], 2000). These chronic disorders are associated with high levels of psychiatric comorbidity (Gorman, 1996; Merikangas et al., 1998) and impairment in daily functioning, including elevated rates of suicidality (Sareen et al., 2005). Rates of anxiety disorders are higher among women than men starting as early as the age of 6 years (Lewinsohn et al., 1998), and the typical age of onset of most of these disorders occurs sometime before or during the childbearing years (Coleman et al., 2006). This is of particular relevance given that the perinatal period may be a time of both heightened risk for psychiatric distress (Bennett et al., 2004) and increased functional demands. However, data suggest that detection of psychiatric distress during pregnancy remains alarmingly low (Goodman and Tyer-Viola, 2010). This represents a potential missed opportunity given that most pregnant and postpartum women interface with the medical system frequently, yet screening for psychiatric distress during these visits remains uncommon (Coleman et al., 2008). Given the low rates of screening, it is unsurprising that rates of recognition and treatment of psychiatric distress are similarly low for pregnant and postpartum women (Kelly et al., 2001; Marcus et al.,
*Department of Psychology, Skidmore College, Saratoga Springs, NY; †Department of Psychiatry and Human Behavior, Brown University Medical School, Providence, RI; ‡Butler Hospital, Providence, RI; §Women & Infants’ Hospital of Rhode Island, Providence, RI; and ||George Washington University, Washington, DC. Send reprint requests to Casey A. Schofield, PhD, Department of Psychology, Skidmore College, 815 North Broadway, Saratoga Springs, NY 12866. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20202Y0154 DOI: 10.1097/NMD.0000000000000086
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2003; Spitzer et al., 2000). Furthermore, when mental health screening is conducted, it has traditionally focused on the assessment of symptoms of depression (Ross and McLean, 2006), an approach that may overlook meaningful symptoms of anxiety (Muzik et al., 2000). Although anxiety presents as a comorbid problem along with depression in many instances, clinically impairing anxiety is not uncommon in the absence of depression in perinatal samples (Matthey et al., 2003). Therefore, screening exclusively for depression is likely to result in overlooking important psychiatric distress. The growing recognition of the risks associated with perinatal anxiety in combination with the comparatively low level of attention to screening, detection, and treatment of these disorders has prompted increasing interest in the clinical characterization of perinatal anxiety (Matthey, 2004; Ross and McLean, 2006; Vythilingum, 2008). The past decade has yielded a growing literature highlighting the importance of understanding the prevalence and the nature of perinatal anxiety. Several initial studies documented that anxiety is common during pregnancy and the postpartum period (Heron et al., 2004; Reck et al., 2008; Stuart et al., 1998; Wenzel et al., 2003). In fact, some evidence has suggested that childbearing is associated with the onset of certain anxiety disorders (e.g., obsessive-compulsive disorder [OCD]; Abramowitz et al., 2002; Forray et al., 2010). Importantly, antenatal anxiety and stress have been associated with a number of adverse fetal effects (Van den Bergh et al., 2005) including low infant birth weight (Field et al., 2003), preterm labor (Dayan et al., 2002), and elevated fetal heart rate patterns (Monk et al., 2000), although not all studies have found such associations between anxiety and adverse perinatal outcomes (Littleton et al., 2007). Further, the presence of prenatal anxiety significantly predicts both postnatal anxiety and mood symptoms, indicating that these clinical profiles remain relatively stable (Grant et al., 2008; Mauri et al., 2010; Milgrom et al., 2008). Lastly, studies of postpartum and maternal anxiety indicate that children of anxious mothers are at increased risk for experiencing significant behavioral problems (O’Connor et al., 2002), including attention deficit hyperactivity disorder and internalizing symptoms (Hudson, 2001; Turner et al., 2003; Van den Bergh and Marcoen, 2004). In short, there are clear public health ramifications associated with unidentified and untreated perinatal anxiety, highlighting the importance of drawing attention to this clinical phenomenon. To date, the bulk of the literature characterizing the presence of perinatal anxiety has focused on nonpsychiatric samples, such as a general population of women seeking prenatal care in obstetriciangynecologist settings. This previous work has been important in establishing the presence of anxiety symptoms in the general population of perinatal women but falls short in informing our understanding of the role anxiety symptoms play in perinatal women who are more significantly impaired by psychiatric distress. Importantly, there have been a few initial studies evaluating the presence of anxiety within psychiatric perinatal populations. A previous chart review study demonstrated very high rates of major depression as an assigned diagnosis in a treatment-seeking perinatal psychiatric
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sample (i.e., 86.7%) with comparatively low rates of anxiety disorder diagnoses assigned (e.g., 0.5%, generalized anxiety disorder [GAD], to 4%, panic disorder; Battle et al., 2006). This low rate of assigned anxiety diagnoses stands in contrast to data from one recent study in which most women who met criteria for major depression also had a comorbid anxiety disorder (most frequently GAD; Grigoriadis et al., 2011) and another investigation of a sample of women admitted to a specialized mother-baby inpatient unit who reported elevated scores on the anxiety-focused items of the Edinburgh Postnatal Depression Scale (EPDS; Fisher et al., 2002). Together, this work suggests that there may be a discrepancy between symptoms of anxiety and clinician-assigned diagnoses in perinatal psychiatric samples, although to our knowledge, no previous work has evaluated the presence of anxiety symptom self-report in comparison with clinical diagnoses in a psychiatric perinatal population. The goal of the current investigation was to add to this growing body of literature characterizing anxiety symptoms in a perinatal psychiatric sample compared with diagnostic profiles. Specifically, this study used retrospective chart review methodology to evaluate symptom self-report and to describe the diagnostic profile of a sample of women seeking care at the Women and Infants’ Hospital of Rhode Island Day Hospital (DH) program. The DH is a unique mother-baby day treatment facility that provides integrated psychiatric care for pregnant and postpartum women who present with psychiatric disorders during the perinatal period (Howard et al., 2006). The core of this program integrates group and individual psychotherapy with psychopharmacology and family support. The psychotherapy component is grounded in interpersonal psychotherapy and cognitive-behavioral therapy approaches, with an explicit focus on role transitions, interpersonal problems, emotion regulation/ skill development, and psychoeducation. Given the clinical relevance of perinatal anxiety disorders, this study sought to examine the frequency of self-reported symptoms of anxiety in comparison with clinician diagnoses of anxiety and relevant clinical correlates of perinatal anxiety symptoms such as rates of suicidality, functional impairment, and psychiatric medication use.
METHODS The current study was approved by the hospital’s institutional review board. Clinical records of 334 DH patients (110 pregnant and 224 postpartum) were retrospectively reviewed by trained research staff members. The DH program treats psychiatric conditions in perinatal patients within the context of a 7- to 10-day partial hospitalization program; patients are typically experiencing a level of symptom severity and functional impairment more severe than those managed on an outpatient basis yet less severe than patients requiring hospitalization on an inpatient unit. Patients admitted to the program between January 2005 and April 2007 were included in this study. A data abstraction form was created for this study that included variables to be obtained from both admission and discharge clinical records, including information regarding patient demographics, treatment history, gestational information, clinician-rated diagnosis, intake and discharge medications, and data obtained from two brief self-report questionnaires. Clinicians responsible for treating patients and documenting clinical care in the record were licensed clinicians who specialize in perinatal mental health, representing a range of disciplines (psychiatrists, psychologists, licensed social workers, and nurse specialists). Research staff were trained in chart abstraction procedures, and 10% (n = 27) of all charts were reviewed by multiple raters to examine interrater reliability. Reliability analyses on 11 dichotomous chart variables revealed that raters demonstrated good to very good agreement (mean J = 0.93). In terms of self-report measures, the EPDS (Cox et al., 1987) was administered at both intake and discharge to all DH patients. The * 2014 Lippincott Williams & Wilkins
Anxiety in a Perinatal Sample
EPDS is a widely used, 10-item self-report questionnaire that has been validated to assess the presence of symptoms of depression in prenatal and postpartum samples (Cox et al., 1987; Murray and Cox, 1990). Relevant to the current study, a three-item subscale of the EPDS has been recognized as a brief measure of anxiety symptoms in perinatal women (EPDS-A) and has been used to examine anxiety severity among both pregnant (Brouwers et al., 2001; Jomeen and Martin, 2005) and postpartum samples (Ross et al., 2003). In addition to the EPDS-A subscale, the women were also administered a standard DH intake screener that assesses the presence of symptoms indicative of the most common anxiety disorders. Although not identical, items on the self-report DH intake screener are comparable with verbally administered items included in the Anxiety Disorders Interview Schedule (DiNardo et al., 1994). The patients were asked to respond yes or no on a symptom screening questionnaire to the following questions related to anxiety: Have you repeatedly experienced a sudden rush of very intense fear, anxiety, or discomfort that came on from out of the blue for no reason? and Are there places you avoid because they make you too nervous? (panic attacks and agoraphobia); Have you been worrying too much and had difficulty controlling your worry in the past 6 months? (GAD); Have you been worrying that you might do or say something that would embarrass you in front of others? Or that other people might think badly of you? (social phobia); Are you frequently bothered by intrusive, silly, unpleasant, or horrible thoughts or images that seem unreasonable or do not make sense, but keep repeating over and over (e.g., getting contaminated by germs, doing something violent, etc.)? and Are you frequently bothered by having to do something over that you can’t resist (e.g., handwashing, cleaning, checking, etc.)? (OCD); and Have you felt a lot of distress (such as flashbacks, nightmares, etc.) since you experienced a very traumatic event? (posttraumatic stress disorder [PTSD]).
RESULTS Participant demographic information is presented in Table 1. This was the first baby for less than half of the sample (40.5%). The sample was ethnically diverse, with slightly more than half of the participants identifying their primary ethnicity as white (54.2%) and a significant proportion of women identifying as Hispanic/Latina (21.6%) or black/African-American (12.9%). Slightly more than half of the women (50.6%) reported being single at the time of admission to the program.
Treatment History For 16.8% of the sample, their admission to the DH program marked their first encounter with any form of psychiatric treatment. The charts revealed that a meaningful portion of the sample had a history of substance use problems (29%) and nearly half of the sample was taking psychiatric medication at the time of admission (42.5% of the total sample; 40% of the women who were pregnant at admission and 44.6% of the postpartum women). The most common types of psychiatric medication taken at DH intake were selective serotonin reuptake inhibitors (SSRIs; 31.4%) followed by anxiolytics (12.9%). Program enrollment lasted from 1 to 18 days, with a mean duration of 5.7 days.
Self-reported Symptoms and Diagnostic Assignment Regarding self-reported anxiety symptoms, the mean score on the EPDS-A was markedly high at the time of intake (mean, 7.1; SD, 1.6). Anxiety levels improved significantly from DH intake to discharge, to a mean EPDS-A discharge score of 4.7 (SD, 2.0), t(192) = 15.21, p G 0.001. Similarly, the mean overall EPDS scores improved from intake to discharge, t(195) = 22.57, p G 0.001 (intake mean, 20.1; SD, 4.6; discharge mean, 11.80; SD, 4.9). Of note, rates of all www.jonmd.com
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of obsessions (30.2%) and compulsions (24.6%) were also notable; however, a diagnosis of OCD was also assigned relatively rarely (3.9% of the patients). PTSD was diagnosed more frequently: 31.1% of the women self-reported persistent distress related to a traumatic experience, and 9.9% of the sample received a PTSD diagnosis. Of note, 6% of the sample was assigned a diagnosis of anxiety disorder not otherwise specified (NOS). In all, 32.3% of this sample received a diagnosis of an anxiety disorder.
TABLE 1. Participant Characteristics Mean (SD)
Age
27.9 (6.3) Frequency
Marital status Single Married/committed relationship Divorced/separated Not recorded Education Eighth grade Some HS Completed HS/GED Some college/AA degree Completed bachelor’s degree Completed graduate degree Not recorded Primary ethnicity American Indian/Alaska Native Asian Hawaiian/Pacific Islander Black/African-American White Hispanic/Latina Other (Cape Verdean, Dominican, Portuguese, Laotian, West African) Not recorded Perinatal status Currently pregnant Currently postpartum First pregnancy/first baby Medication status Taking Q1 psychotropic medication at intake Taking SSRI Taking anxiolytic Taking antipsychotic Taking mood stabilizer Taking SARI Other (TCA, NDRI, NASA)
50.6% 44.0% 4.8% 0.6%
Functional Impairment and Suicidality
2.1% 12.6% 23.4% 33.2% 11.1% 3.4% 14.4% 1.8% 0.3% 0.3% 12.9% 54.2% 21.6% 7.8% 1.2% 36.2% 63.8% 40.5% Intake
Discharge
42.5%
83.2%
31.4% 12.9% 4.8% 3.0% 3.0% 2.4%
65.0% 47.6% 13.5% 6.6% 6.3% 7.8%
In terms of functional impairment, the mean clinician-rated Global Assessment of Functioning (GAF) score for the entire sample at intake was 50.22, indicative of serious psychiatric symptoms and clinically significant functional impairment. Suicidality was assessed by clinician documentation of suicidal ideation at the time of DH admission and self-report of suicidality on the EPDS. At the time of admission, 44.6% of the women who completed the EPDS self-reported thoughts of harming themselves (Q1 on the EPDS suicidality item). Similarly, clinicians’ chart notes indicated that 44.9% of the women endorsed suicidal ideation at intake, with 29% endorsing suicidal behavior. To evaluate whether heightened functional impairment, psychotropic medication use, or suicidality varied as a function of symptoms of anxiety, the sample was divided into high- and low-anxiety groups on the basis of quartile scores on the EPDS-A. The patients who scored in the top 25% (EPDS-A Q 8, n = 130) composed the ‘‘elevated anxiety’’ group, and the participants who scored in the bottom 25% (EPDS-A e 6, n = 94) composed the ‘‘nonelevated anxiety’’ group. These groups did not differ from one another on the psychosocial variables of age, t(222) = 1.19, p = 0.24; education (no high school [HS] diploma, HS or some college, or completed college or higher), W2(1, N = 194) = 5.34, p = 0.07; ethnicity (white or nonwhite), W2(1, N = 220) = 2.22, p = 0.14; or marital status (single, married, or divorced/separated), W2(1, N = 223) = 4.75, p = 0.09. The results revealed that the patients with elevated anxiety symptoms were significantly more likely to endorse suicidality, both on a self-report scale (EPDS t[221] = 3.47, p = 0.001) and by verbal report to their DH clinician, W2(1, N = 221) = 5.63, p = 0.02 (see Fig. 1). Furthermore, the patients with high levels of anxiety symptoms were more likely to endorse a history of psychiatric medication use, W2(1, N = 216) = 4.74, p = 0.04, and were also more likely to be taking psychiatric medication at the time of both intake, W2(1, N = 221) = 7.82, p = 0.006, and discharge, W2(1, N = 222) = 9.69, p = 0.002 TABLE 2. Patients’ Responses to DH Screener Questionnaire and Assigned Chart Diagnoses
AA indicates Associate degree; GED, general educational development; NASA, norepinephrine antagonist serotonin antagonist; NDRI, norepinephrine dopamine reuptake inhibitor; SARI, serotonin antagonist and reuptake inhibitors; TCA, tricyclic antidepressants.
Disorder
categories of psychiatric medication increased from intake to discharge, with 83.2% of the sample prescribed at least one psychiatric medication at the time of discharge. Most women in our sample (84%) completed the DH intake screener. Rates of self-reported anxiety symptoms and rates of clinical diagnosis of the anxiety disorders are presented in Table 2. Analyses revealed a high level of anxiety symptoms. Specifically, of the women who completed the screener, more than half reported experiencing symptoms of the following major anxiety disorders: GAD (62.6%), panic attacks (58.1%), and agoraphobia (51.2%); nearly half of the women reported symptoms of social phobia (47.3%). These diagnoses were rarely assigned by clinicians at discharge from the DH program. Specifically, 0.6% of the sample was diagnosed with GAD; 4.2%, with panic disorder (with or without agoraphobia); and 1.5%, with social phobia. Self-reported symptoms 156
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Sad, blue, depressed Anhedonia GAD Social phobia PTSD Obsessions Compulsions Panic attack Agoraphobia Anxiety disorderYNOS
Patients Who Patients for Endorsed the DH Patients Assigned Whom This Is Intake Screener a Chart Diagnosis Primary Axis as Yes, % of the Disorder, % I Diagnosis, %
74.6 72.2 62.6 47.3 31.1 30.2 24.6 58.1 51.2 N/A
70.7 (MDD)
68.6
1.5 0.6 9.9 3.9 (OCD)
0.3 0 3.6 1.5
4.2 (panic disorder)
1.5
6.0
0
MDD indicates major depressive disorder; N/A, not applicable.
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FIGURE 1. Percentage of patients with low versus high anxiety using psychiatric medication and reporting suicidal ideation.
(see Fig. 1). Of note, the differences in psychiatric medication use between the patients with high and low anxiety seemed to be driven primarily by higher rates of SSRI prescriptions among the patients with elevated anxiety at both intake, W2(1, N = 139) = 5.88, p = 0.015, and discharge, W2(1, N = 192) = 4.27, p = 0.039. Rates of psychiatric medication use were not different between the groups for any other classes of medications at either intake or discharge (all p’s 9 0.05). Significant differences were not found on the clinician-rated GAF scale between the patients with elevated versus nonelevated anxiety, t(212) = 1.07, p = 0.29.
DISCUSSION There are three primary findings of this chart review investigation. First, consistent with other recent reports, symptoms of anxiety are markedly elevated among pregnant and postpartum women seeking psychiatric care. Second, patients with the most elevated selfreported anxiety have a more severe clinical profile, including higher levels of suicidality and more frequent perinatal psychotropic medication use. Finally, our data suggest that diagnosis of anxiety disorders in the clinical record occurs relatively infrequently in contrast to the high rate of anxiety based on patients’ responses on selfreport measures. Given that this study used a retrospective chart review methodology targeting patients who sought care at a single treatment facility, it cannot establish prevalence rates of perinatal anxiety disorders. Related, although an anxiety factor has been identified within the EPDS (Brouwers et al., 2001; Jomeen and Martin, 2005; Ross et al., 2003), this self-report measure is not a diagnostic instrument for the detection of perinatal anxiety disorders; rather, the measure reflects the presence of symptoms of perinatal anxiety. As such, the aim of this study was to characterize how commonly anxiety symptoms were reported in a psychiatric treatment-seeking sample and, related, how frequently clinicians documented anxiety disorder diagnoses in the clinical record. Thus, this approach is limited in that our results cannot speak directly to either the prevalence of anxiety disorders in this perinatal psychiatric sample or to true ‘‘missed’’ diagnoses within this clinical setting. That said, our findings suggest that there may be a discrepancy between the high levels of anxiety symptoms in comparison with the small proportion of women assigned an anxiety disorder diagnosis in their clinical chart. This potential disconnect may be explained in various ways. First, self-report screening measures (e.g., EPDS-A) are useful at noting patients’ experience of symptoms but in some cases may be capturing subthreshold cases of anxiety. As such, these measures may reflect symptom elevations but not anxiety occurring at a level at which a clinical diagnosis is appropriate. Related, the screening questions and symptom measure used are not able to capture the * 2014 Lippincott Williams & Wilkins
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patients’ current level of functional impairment related to the symptom in question; this is relevant because functional impairment is a key factor in determining whether a clinical diagnosis of a disorder is warranted. Although some cases of patients reporting elevated symptoms of anxiety may not have reached the appropriate clinical threshold to warrant full diagnosis of a disorder, it is also possible that a number of cases did in fact reach the clinical threshold. In these cases, the anxiety disorder was either not detected during clinician interview or detected yet not noted in the clinical record as part of the discharge diagnosis. Of note, it will be important for future work to confirm this potential disconnect between the presence of clinical anxiety and assigned diagnoses using methods that establish the presence of anxiety disorder (i.e., diagnostic clinical interviewing) rather than assessment of symptoms of anxiety exclusively via selfreport measures. Measurement of anxiety disorders during the perinatal period has some unique challenges. In particular, there is some evidence to suggest that the presence of maternally focused worry often does not align with current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), anxiety disorder diagnoses but represents a similar clinical profile in terms of severity and impairment (Phillips et al., 2009). In fact, it may be that the experience of such maternal worry accounts in part for the elevated reports of symptoms of OCD and GAD, in particular, in the current sample. That is, concerns typical of maternally focused worry (e.g., frequent thoughts about body image, baby’s health, parenting abilities, and finances) could reasonably prompt a woman to endorse questions such as ‘‘Have you been worrying too much and had difficulty controlling your worry?’’ or ‘‘Have you been bothered by intrusive, silly, unpleasant, or horrible thoughts or images?’’ potentially accounting for an exaggeration of the presence of OCD and/or GAD by the intake screener. That said, maternal worry may be overlooked given that such concerns may be considered ‘‘normal’’ during this unique time in a woman’s life, yet this form of worry can be associated with impairment and distress consistent with DSM-IV anxiety disordersVeven when it does not align with a DSM-IV anxiety disorder diagnosis (Phillips et al., 2009). Despite low levels of assigned anxiety disorder diagnoses, mood disorders (in particular, major depressive disorder) were assigned to most of the patients enrolled in the DH program. A great deal of clinical and public health attention has been focused on perinatal depressionVrightfully so, given the impairment and distress experienced by women as well as the adverse effects on infant development and family functioning. However, it may be that this public health focus on perinatal depression has overlooked symptoms of perinatal anxiety in a way that undermines women’s recognition and help seeking in response to perinatal anxiety symptoms. For example, evidence suggests that women with anxiety symptoms in the absence of symptoms of depression are less likely to seek professional help than women with symptoms of depression alone (Woolhouse et al., 2009). Although concern regarding perinatal depression is well warranted, it is possible that a clinical focus on symptoms of depression may account in part for the rare assignment of anxiety disorder diagnoses. That is, in patients experiencing cooccurring mood and anxiety disorders, mood disorders may be perceived as most clinically relevant and leading to most clinical impairment at the time of program intake and discharge. This may be particularly true for the anxiety disorders GAD and social phobia, in which the frequency of diagnosis is well lower than the populationbased rates of these disorders (GAD population prevalence: È5% vs. GAD sample diagnosis: 1.5%; social phobia prevalence: È10% vs. social phobia sample diagnosis: 0.6%; APA, 2000). The potential underrecognition of anxiety disorders is not unique to the perinatal setting. In fact, despite the oft-reported evidence that depression is commonly comorbid with anxiety disorders www.jonmd.com
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(Fava et al., 2000; Zimmerman et al., 2000), evidence suggests that mental health professionals frequently overlook the presence of anxiety disorders in their patients (Zimmerman and Chelminski, 2003a). This is in contrast to evidence that patients overwhelmingly self-report that they are interested in treatment of the symptoms of anxiety disorder (Zimmerman and Chelminski, 2003a). We recognize that a comprehensive evaluation of the anxiety disorders is prohibitively time consuming within the bounds of many mental health settings, and, at this time, there are genuine limitations to the available self-report measures typically used to assess anxiety in perinatal populations (Meades and Ayers, 2011), a limitation that will be important to address in future work. That said, there is evidence (Meades and Ayers, 2011) to suggest that some brief screening questionnaires and symptom inventories can reliably and validly measure symptoms of the anxiety disorders in pregnant populations (e.g., the State Trait Anxiety Inventory [Spielberger, 1983], The Kessler 10 [Kessler et al., 2003]). Identifying and treating symptoms of anxiety are critical for clinical care. For one, the presence of anxiety disorders is relevant to the severity and the prognosis of major depression. That is, the severity of patients’ clinical profile in terms of functional impairment and suicidality is worse for depression with comorbid anxiety disorder (Goldberg and Fawcett, in press; Hegel et al., 2005; Kessler et al., 1994; Mittal et al., 2006; Rhebergen et al., 2011; Zimmerman and Chelminski, 2003b), and the prognosis of depression with comorbid anxiety disorder is demonstrably poorer than depression alone (Gaynes et al., 1999; Sherbourne and Wells, 1997). In the current sample, elevated levels of self-reported symptoms of anxiety were associated with higher levels of suicidality at intake and a more significant psychiatric history. Although the patients with high levels of anxiety were not assigned lower GAF scores, they were more likely to have a history of psychiatric medication use and were more likely to be on psychiatric medication at the time of hospital admission and discharge, while pregnant or postpartum. This replicates previous research demonstrating that more severe clinical profiles are associated with higher rates of antidepressant use in perinatal women (Battle et al., 2008). On the one hand, these findings are encouraging in that these suggest that women experiencing high levels of perinatal psychiatric distress are accessing and receiving psychiatric treatment. On the other hand, given the intensity of psychiatric symptoms captured in self-report measures in combination with elevated suicidality and high rates of psychiatric medications, it suggests that these symptoms may be insufficiently treated. This could potentially be explained by limited attention to the presence of anxiety disorders in treatment planning and underscores the importance of considering symptoms of anxiety in clinical evaluations and discharge for perinatal women. Treatment recommendations for depression versus depression with comorbid anxiety differ with regard to pharmacological treatment (APA, 2000; Baldwin et al., 2005), psychotherapeutic treatment, and their combination (Otto et al., 2005). Encouragingly, the anxiety disorders are responsive to appropriate psychotherapeutic and psychopharmacological treatment, and thus, discharge planning that incorporates consideration of anxiety symptoms is important. Further, the perinatal period may be particularly meaningful in terms of appropriate diagnostic and treatment planning given that, for many women, it represents their first-ever contact with the mental health care system (Battle et al., 2006). In fact, in the current sample, intake at a DH level of care during pregnancy was the very first contact women had with the mental health system for approximately 17% of the sample. As such, the perinatal period represents a potential opportunity to connect women with the appropriate careVthroughout the perinatal period and also beyond it.
CONCLUSIONS The current study contributes to the growing body of research highlighting the relevance of symptoms of anxiety disorders during 158
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the perinatal period. Given that the methods of the current study cannot speak to prevalence rates of anxiety disorders among perinatal psychiatric patients, future epidemiological work in this population will be important. To draw conclusions about whether diagnoses are being overlooked, a comprehensive structured diagnostic interview would need to be conducted and compared with diagnoses documented in clinical charts. Although the current study cannot establish detection rates of anxiety disorders, it demonstrates that symptoms of anxiety are remarkably common among perinatal patients with psychiatric distress. Further, the presence of anxiety is associated with a more severe clinical picture. Thus, it will be valuable for clinicians working with pregnant and postpartum women to broaden evaluations of perinatal mental health to consistently include evaluations of the anxiety symptoms. This point is particularly relevant within perinatal populations given the public health concern related to poor fetal and neonatal outcomes associated with untreated anxiety in pregnant women (Dayan et al., 2002; Field et al., 2003; Monk et al., 2000; Van den Bergh et al., 2005). Similarly, maternal outcomes are impacted by untreated anxiety, as demonstrated by a recent study indicating that antenatal anxiety disorders significantly predict rates of postpartum anxiety and depression (Grant et al., 2008; Mauri et al., 2010), findings that are consistent with previous research (Heron et al., 2004; Skouteris et al., 2009; Sutter-Dallay et al., 2004). The anxiety disorders are a clinically significantVyet treatableV cluster of psychiatric conditions because existing empirically supported treatments hold great potential for alleviating distress and improving functioning. However, without successful detection and treatment, anxiety disorders often represent a gateway to the subsequent development of added psychiatric distress, including both depression (Beesdo et al., 2007) and substance abuse (Merikangas et al., 1998). For these reasons, and given that growing evidence supports that anxiety is a common clinical presentation among perinatal women, greater attention to the presence of anxiety disorders in this population warrants ongoing empirical and clinical attention. DISCLOSURES The authors declare no conflict of interest.
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