Mental Illness and Pregnancy (FL INITIAL Autonomous Practice- Pharmacology)

Patients with depression may experience (American Psychological Association [APA], 2022; Rothschild, 2024):

• Low, depressed mood
• Loss of interest in most activities (anhedonia)
• Change in appetite (eating more or eating less than usual)
• Insomnia or hypersomnia
• Agitation
• Guilt
• Low energy
• Poor concentration
• Recurrent thoughts of death

There are risks of depression impacting the mother and the fetus, for a woman who experiences depression and does not receive treatment (Khanghah et al., 2020).

These may include (Khanghah et al., 2020):

• Preeclampsia
• Premature membrane rupture
• Need for cesarean section delivery
• Fetal growth restriction
• Fetal death

For mothers, suicide, psychosis, catatonia, and substance use or abuse may be associated with depression (Khanghah et al., 2020).

First-line treatment for depression often involves therapy, such as Cognitive Behavioral Therapy (CBT). CBT is evidence-based and one of the most widely used forms of therapy (Psychology Today, 2022). It is a form of psychotherapy that works on identifying negative or maladaptive thoughts, bringing awareness to those thoughts, learning to challenge them, and ultimately working to change thinking patterns to be more realistic, positive, and adaptive to your life situations (Psychology Today, 2022). CBT is the evidence-based treatment recommendation for depression (Psychology Today, 2022).

Another form of therapy that is often utilized for depression is interpersonal psychotherapy (IPT). IPT is another form of evidence-based talk therapy that focuses on improving interpersonal relationships in order to improve overall mood and mental health (Cleveland Clinic, 2024a). Other than therapy or even in addition to therapy, psychotropic medications can be very helpful in treatment (National Institute of Health [NIH], 2023).

Although generally considered safe to take during pregnancy, selective serotonin reuptake inhibitors (SSRIs) have been previously associated with transient neonatal complications when taken late in pregnancy (University of California San Francisco [UCSF] Department of Pediatrics, 2024). Newer research from the Department of Pediatrics at University of California San Francisco (UCSF) showed that SSRI use during late pregnancy (after 20 weeks gestation) does double the risk of delayed neonatal adaptation (Cornet et al., 2024; UCSF Department of Pediatrics, 2024). Delayed neonatal adaptation is when the neonate might require additional intervention or support, such as respiratory support during the initial transitioning process for the newborn as they adapt from intrauterine to extrauterine life (UCSF Department of Pediatrics, 2024). More “typical” symptoms, if they do occur, include irritability, poor feeding, and jitteriness, that resolves within a few days but can last for up to two weeks (Mayo Clinic, 2024). The UCSF study also found no association with more severe outcomes including pulmonary hypertension (PPHN), seizures, or brain injury with SSRI use that had been previously noted in other studies (Cornet et al., 2024; UCSF Department of Pediatrics, 2024). SSRIs do not increase baseline risk for congenital anomalies or increase the risk of miscarriage or stillbirth (PSI, 2025).

The minor potential risks associated with SSRI use must be weighed against the risk of relapse if treatment is discontinued and the risk of not treating depression in the mother (UCSF Department of Pediatrics, 2024; Postpartum Support International [PSI], 2025). Suffering from depression during pregnancy can increase the risk for premature birth, intrauterine growth restriction, as well as low birth weight for the infant (Mayo Clinic, 2023). The potential benefits of depression treatment for both the mother and the child might significantly outweigh the less likely risks. During pregnancy, treatment with SSRIs should be individualized and should ideally be discussed before pregnancy.

During the postpartum period, brexanolone has been used inpatient to treat postpartum depression (PPD) via intravenous route over a period of 60 hours (Mayo Clinic, 2025). An oral medication, zuranolone, was approved by the Food and Drug Administration (FDA) in 2023 as the first oral medication to treat PPD (U.S. Food & Drug Administration [FDA], 2023; NIH, 2023; PSI, 2025). Zuranolone is ideally taken within the first four weeks of delivery, and the daily recommended dosage is 50 mg, taken once every day for two weeks, in the evening, along with a fatty meal (FDA, 2023; PSI, 2025).

For those suffering with anxiety, this worry and fear is often accompanied by physical signs and symptoms that include (APA, 2022):

• Restlessness
• Difficulty concentrating
• Feeling on edge
• Feeling easily fatigued
• Muscle tension
• Issues sleeping

Panic attacks can occur as a result of a trigger or can be completely random (APA, 2022). Signs and symptoms of panic attacks, more commonly known as panic disorder can include (APA, 2022):

• Trembling
• Shaking
• Nausea
• Stomach pains
• Chills or hot flashes
• Numbness or tingling
• Sweating
• Chest pain
• Feeling dizzy or light-headed
• Sensation of being choked
• Palpitations
• Rapid heart rate
• Feeling of detachment from reality
• Feeling of impending doom

Because the signs and symptoms of the panic level of anxiety can be so severe, many individuals feel as if they are having a heart attack or that they might die (APA, 2022). Therefore, it is common for these patients to come to the emergency department to be assessed.

Although a direct causal relationship has not been established, anxiety and stress during pregnancy have been associated with (Children’s National, 2020; Mayo Clinic, 2018; Grigoriadis, 2019):

• Spontaneous abortion
• Preterm delivery
• Spontaneous preterm birth
• Low birth weight
• Earlier gestational age
• Small for gestational age (SGA) infant
• Delivery complications
• Smaller head circumference

A 2020 study by Children’s National Hospital looked at maternal anxiety and neurodevelopmental disorders in their children (Children’s National, 2020). It featured postnatal imaging that suggests that differences in brain anatomy may originate during pregnancy (Children’s National, 2020). This study reviewed resting-state functional magnetic resonance imaging (rs-fMRI) to examine developing neural circuitry in fetuses at different stages of their development while in utero in the late second and third trimesters (Children’s National, 2020). The analysis concluded that pregnant women who had higher screening scores for anxiety were more likely to carry fetuses with stronger connections between the brainstem and sensorimotor areas, which are essential areas for arousal and sensory skills, and weaker connections between the parieto-frontal and occipital cortices, which are areas involved in executive and higher level cognitive functions than women with lower anxiety scores (Children’s National, 2020). What this study is pointing to is the likelihood that anxiety can have an impact on fetal brain development. Further studies are needed to assess if anxiety during pregnancy is the sole influence over these effects or if subpar postnatal care and anxiety management might also be to blame (Children’s National, 2020).

It is important to note that anxiety during pregnancy is associated with several adverse perinatal outcomes and is not benign (Grigoriadis et al., 2019).

CBT is the gold standard for psychotherapy treatment for anxiety disorders, just as it is for depression (APA, 2022). Again, the goal is to question those maladaptive thoughts and emotions and reframe thinking to help turn off the spiraling thoughts and harness more control over the physical symptoms of anxiety, starting with the thoughts that elicit these symptoms (APA, 2022; Collier, 2021).

Another one of the modalities for anxiety treatment is the teaching of and use of breath work (Expecting and Empowered, 2019; Children’s Hospital Colorado, 2020). Breathing dysfunction is something that can occur due to stress and anxiety (Expecting and Empowered, 2019). With stress comes the inability to be fully aware of one’s breath work, potentially breath holding or short, shallow breathing, leading people to default to “chest breathing”, utilizing smaller muscles in the neck and shoulders, which often does not optimally oxygenate the blood, causing potential build-up of tension and pain in the upper part of the body (Expecting and Empowered, 2019). What is preferred is what is known as “diaphragmatic breathing”, where the deeper, more thorough work of the diaphragm in conjunction with the pelvic floor, allows for deeper breaths that allow for better oxygenation of the blood and more optimized lymphatic drainage to remove toxins from the body (Expecting and Empowered, 2019). Diaphragmatic breathing can be specifically adapted to pregnancy, given the diaphragm becomes squished, contributing to more laborious efforts to breathe (Expecting and Empowered, 2019).

There is a reason why breathing techniques and pregnancy have long been associated. Breath work is well known to help with stress and anxiety. It has been studied in research and shown to activate mental processes in the brain, stimulating the release of endorphins, which we know are hormones providing natural pain relief (Expecting and Empowered, 2019). Breath work also helps the blood vessels to dilate, which causes a decrease in blood pressure and increase blood oxygen levels (Expecting and Empowered, 2019). With slower, deeper, more controlled breaths, and bringing attention to intentionally do this, the autonomic nervous system is calmed, sending the message to the brain that it can relax (Expecting and Empowered, 2019; Children’s Hospital Colorado, 2020).

Some studies have also shown that yoga may improve depression or anxiety during pregnancy (Lin et al., 2022). Also, massage during pregnancy has also proven to be effective as a nonpharmacological method to reduce anxiety (Aswitami et al., 2022).

Additional nonpharmacological methods of mitigating anxiety include engaging in regular physical activity, as long as the pregnant individual is able to without pregnancy risk and complications, getting enough sleep, journaling worries and concerns to give them a safe home for thought and consideration without them overwhelming the mind, meditation, and practicing mindfulness to focus on the here and now (Collier, 2021).

In terms of pharmacological treatment for anxiety, as mentioned above when discussing the treatment of depression, SSRIs are also indicated for the treatment of anxiety disorders (SSRIs). The above information is still relevant regarding the risks and benefits.

The use of benzodiazepines in women with anxiety disorders has long been a controversial topic (Collier, 2021). However, according to a 2019 in-depth systematic review and meta-analysis of studies looking at the effects of benzodiazepine use during pregnancy, it concluded that exposure does not appear to carry an increased significant teratogenic risk, specifically of congenital malformations or cardiac malformations, but that use of benzodiazepines in addition to antidepressants might have an increased risk (Grigoriadis, 2019). Benzodiazepines have been associated with a risk of preterm birth, however (PSI, 2025). It is important to note that long term use of benzodiazepines can cause withdrawal symptoms in the newborn (ACOG, 2008). Benzodiazepines should not be used for longer than two weeks near term.

Bipolar disorder, regardless of type, is known as a condition that causes extreme mood swings (Mayo Clinic, 2024). While we have discussed the signs and symptoms of someone who is suffering from depression, we will now outline the signs and symptoms of mania and hypomania so they can be understood and distinguished.

Mania and hypomania can be very similar, but they do have a few distinct differences. Mania is more than just having lots of energy. It is an actual mood disturbance that is both physically and mentally energizing (Pietrangelo, 2023). Signs and symptoms of mania can include (Pietrangelo, 2023; Hendrick, 2024a; APA, 2022):

• Sudden change in behavior to involve an extreme increase in energy that lasts a week or more
• Feeling “detached” from reality
• Exaggerated/grandiose sense of self
• Insomnia or sleeping very little over the course of a week or more
• Pressured speech (rapid)
• Racing thoughts
• Easily distracted
• Extreme focus on a specific goal
• Irrational engagement in risky activities (gambling, reckless driving, financial investments, sexual promiscuity)
• Impairment in daily life functioning
• Delusions and hallucinations that can lead to psychosis (what often requires hospitalization for stabilization)

Hypomania is a less severe type of mania (Pietrangelo, 2023; APA, 2022). Signs and symptoms of hypomania can include (Pietrangelo, 2023; Hendrick, 2024a; APA, 2022):

• Sudden change in behavior to involve an extreme increase in energy that lasts at least 4 days but less than one week
• Exaggerated/grandiose sense of self
• Insomnia or sleeping very little over the course of the week or more
• Pressured speech (rapid)
• Racing thoughts
• Easily distracted
• Extreme focus on a specific goal
• Making poor decisions with risky activities (gambling, reckless driving, financial investments, sexual promiscuity)
• Judgment and decisions are altered but usually normal in daily life functioning

The major differences, as you will see as you compare and contrast these lists of signs and symptoms, is that mania is associated with irrational decision-making that ultimately impacts daily functioning and the existence of delusions and hallucinations that likely result in hospitalization (Pietrangelo, 2023; Hendrick, 2024a; APA, 2022). Hypomania does not include these severe features (Pietrangelo, 2023; Hendrick, 2024a; APA, 2022). In addition, the extreme high energy associated with mania lasts at least a week or more whereas hypomanic individuals experience these symptoms for at least 4 days but no longer than one week (Pietrangelo, 2023; Hendrick, 2024a; APA, 2022).

Unmanaged or untreated bipolar disorder can be very dangerous for both mom and baby. Patients with bipolar disorder are at risk for (Hendrick, 2024a):

• Suicidal ideation
• Homicidal ideation
• Aggressive behavior
• Psychotic features (delusions, hallucinations)
• Poor judgment
• Impaired social functioning

Because the pregnant mother with bipolar disorder often does not know she is in the midst of a manic or major depressive episode, the lack of sleep, disordered eating, use of substances, potential delusions and hallucinations, poor judgment, and reckless behavior puts them at high risk for harming themselves or their child (Hendrick, 2024b).

Bipolar disorder contributes to increased risk of some maternal and fetal complications during pregnancy and birth that include (Mohamed, 2023; Rejnö, 2023):

• Preterm birth
• Gestational hypertension
• Microcephaly
• Instrumental delivery (forceps or vacuum extraction)
• Low birth weight
• Small for gestational age (SGA) infant (less than 10th percentile)
• Congenital malformations
• Central nervous system defects
• Neonatal intensive care unit (NICU) admission

Bipolar is a serious disorder that can cause harm to the mother or fetus; this requires close supervision and possible hospitalization (Hendrick, 2024a).

To treat hypomania and mania, psychotherapy is very highly recommended (Pietrangelo, 2023; Hendrick, 2024b). It is possible that hypomania can be managed without medication. Instead of medication and in addition to therapy, good lifestyle habits that are recommended as nonpharmacological treatment include (Pietrangelo, 2023):

• Getting physical activity daily
• Maintaining a regular sleep schedule
• Prioritizing rest when needed
• Eating a well-balanced, nutritious diet
• Keeping a log/diary with notes documenting mood changes that are personally noticed or pointed out by family or friends

Mania, on the other hand, necessitates pharmacological intervention (Pietrangelo, 2023; Hendrick, 2024a). Medication types that are often included in the treatment of bipolar disorder are mood stabilizers and antipsychotics (Pietrangelo, 2023; Hendrick, 2024a).

When treating pregnant patients with bipolar disorder, it is important to use only what medications are necessary, drugs with fewer known risks of teratogenic effects, and the lowest possible dosage that achieves remission of symptoms (Hendrick, 2024a). First-line drug therapy for pregnant patients with bipolar disorder is first-generation antipsychotics such as haloperidol or chlorpromazine (Hendrick, 2024a). For pregnant patients who are not responsive to or cannot tolerate first-generation antipsychotics, risperidone, a second-generation antipsychotic is often recommended (Hendrick, 2024a).

If this or another second-generation antipsychotic such as olanzapine are not effective, the mood stabilizer that is often tried is lithium (Hendrick, 2024a). Lithium is one of the best medications for relapse prevention in patients with bipolar disorder (Wittström et al., 2024). Taking lithium during pregnancy has been associated, in the past, with congenital cardiac malformations, specifically Ebstein’s anomaly (Wittström et al., 2024; Patorno et al., 2017). However, there have been studies such as the 2018 international meta-analysis conducted in Denmark, Sweden, and Canada, that concluded that there was no significant difference in major cardiac malformations between the reference group of pregnant women and their children and the group exposed to lithium during pregnancy (Massachusetts General Hospital Center for Women’s Mental Health [MGH Center for Women’s Mental Health], 2018). In addition, another 2017 study involving over 1.3 million pregnant women over a period of ten years, the magnitude of the effect of lithium use in the first trimester leading to these potential cardiac malformations was found to be smaller than previously thought (Patorno et al., 2017). Lithium use has not been associated with low birth weight, miscarriage, preterm birth, nor neurodevelopmental problems in infants (PSI, 2025).

Women with particular struggles in treating their bipolar disorder or with personal histories of positive response to treatment with lithium may, under supervision of their provider, consider the use of lithium during pregnancy given the about 50-year accumulation of data of its general reproductive safety, especially in comparison to mood stabilizers with confirmed teratogenicity (sodium valproate) (MGH Center for Women’s Mental Health, 2018). The decision to discontinue lithium therapy during pregnancy because of potential fetal risks that have come up in studies in the past should be weighed against the maternal risks of the illness (Wittström et al., 2024; Patorno et al., 2017). It is often decided that the benefit of maintaining mom on her bipolar treatment regimen that is working for her to prevent relapsing of symptoms outweighs the small, potential risk to the baby (Wittström et al., 2024; Patorno et al., 2017). It is important to note that the physiologic changes of pregnancy may affect the absorption, distribution, metabolism, and elimination of lithium, and close monitoring of lithium therapy is recommended (Wittström et al., 2024; Patorno et al., 2017).

Some antiepileptic drugs might also be used in the treatment of bipolar disorder, including valproic acid (Depakene®), carbamazepine (Tegretol®), and lamotrigine (Lamictal®). Depakene® and Tegretol® have been shown to cause birth defects. Lamictal® is generally considered safe (ACOG, 2008).

Schizophrenia features a wide range of symptoms that change how a person looks at the world, how they think, and how they behave. These symptoms are described as either positive or negative symptoms (Ellis, 2024; APA, 2022). Positive symptoms are those that “add” to someone’s life, but not in a “positive” way, but in a way that is a supplement to what “normal” things happen in everyday life. Negative symptoms are those that remove something from the person’s life, often making it much harder to function normally.

Positive symptoms of schizophrenia often include (Mayo Clinic, 2024; Ellis, 2024):

• Delusions (false beliefs that are based in fear that someone is trying to harm you)
• Hallucinations (most commonly auditory or visual; hearing and seeing things that are not actually there)
• Disorganized thinking process leads to disorganized speech (not making sense, saying words together that do not mean anything, explaining in great detail and goes off on tangents; overall speech is difficult to follow)
• Abnormal movements (moving repetitively, abnormal postures, agitation)

Negative symptoms of schizophrenia often include (Mayo Clinic, 2024; Ellis, 2024):

• Diminished emotions/ flat affect
• Anhedonia (inability to experience pleasure)
• Apathy (do not care)
• Avolition (lack of motivation)
• Alogia (decrease in talking)
• Lethargy

Untreated schizophrenia can lead to severe problems in a person’s life. These complications can include (Mayo Clinic, 2024):

• Thoughts of suicide/suicide attempt
• Anxiety disorders
• Social isolation
• Depression
• Use or even misuse of drugs and/or alcohol
• Financial problems
• Homelessness
• Medical problems
• Struggle with or inability to hold a job or attend school

Schizophrenia affects the person’s ability to concentrate, their attention, contributes to easy distractibility, impairs memory, causes issues with making decisions, impairs judgment, and can severely impact relationships due to paranoia, withdrawal, and inappropriate social behavior (APA, 2022; Mayo Clinic, 2024; Ellis, 2024). Therefore, pregnant patients with schizophrenia require treatment and close management to ensure both mom and baby are appropriately cared for.

Potential risks for women and their babies with schizophrenia during pregnancy include (Morgan, 2024; Fabre, 2021):

• Preterm delivery
• Intrauterine growth restriction (IUGR)
• Low birth weight
• Placental abnormalities
• Gestational diabetes
• Infections (genitourinary)
• High blood pressure/preecclampsia
• Caesarean sections
• Stillbirths

If left untreated during pregnancy, schizophrenia can have devastating effects on both mom and baby.

Patients with schizophrenia require lifelong treatment. This treatment requires medication, psychotherapy, and general assistance in learning how to manage their everyday life (Mayo Clinic, 2024).

Atypical antipsychotics (second and third-generation antipsychotics) are the first-line therapy for schizophrenia, recommended over typical antipsychotics (first-generation) because these drugs are generally better tolerated, have less extrapyramidal symptoms (EPS) such as tardive dyskinesia and dystonia, and are thought to be more effective in managing both the positive and negative symptoms of schizophrenia (ANA, 2022; ACOG, 2008). Most antipsychotics are considered to be reasonably safe to take during pregnancy (Morgan, 2024). Because antipsychotic medications cross the placenta, the risks to the fetus must be carefully weighed against the need for medication during pregnancy (Edinoff et al., 2022). It is possible that medications can be switched to those with less risk, or a lower dose can be tried (Morgan, 2024). These are good conversations to have prior to pregnancy. Generally, the risk of psychotic symptoms during pregnancy as a result of stopping antipsychotic treatment are considered to be more dangerous to both mom and baby than the potential risk of the drug to the fetus (Edinoff et al., 2022). Either way, these patients need to be closely monitored by a healthcare professional.

Anorexia is known for involving obsessive dieting to control weight (American Pregnancy Association, 2024). Bulimia is a focus on binge eating and purging episodes, to include either vomiting or the use of laxatives, to remove excess calories from the body (American Pregnancy Association, 2024). While there are several other types of eating disorders, we will primarily focus on these most common disorders in this course.

Signs and symptoms of eating disorders will vary based on the specific type, however, in general, these signs and symptoms can include (Cleveland Clinic, 2024b):

• Restrictive eating
• Frequent bathroom breaks after meals
• Eating a lot of food or calories in a short period of time
• Forced vomiting after meals
• Excessive exercise
• Unexplained or drastic weight loss
• Fatigue
• Mood swings
• Thinning hair/hair loss
• Withdrawing from friends or social activities

Anorexia and bulimia, the two most common eating disorders, most often emerge during adolescence or early adulthood (American Pregnancy Association, 2024). When they continue into a woman’s reproductive years, they can negatively impact both her health and the health of her baby (American Pregnancy Association, 2024).

Patients with eating disorders have negative feelings about food and calories. Thoughts that are similar and experienced among those who suffer with eating disorders can include (Cleveland Clinic, 2024b):

• “Food is the enemy”
• “I am not the correct weight or body size”
• “I am failing if I do not maintain a certain weight”
• “What I eat and how I eat it is the only thing in my life in my control”

Pregnancy requires proper nourishment from the mother’s body in order for the baby to grow and develop normally (National Eating Disorders Association [NEDA], 2024). While gaining weight is developmentally appropriate and necessary for a healthy pregnancy, for mothers with eating disorders, having to consume food and calories to gain that weight can be a frightening, anxiety-producing situation (NEDA, 2024).

Eating disorders during pregnancy can cause serious complications for the mother, including (NEDA, 2024; American Pregnancy Association, 2024):

• Dehydration
• Gestational diabetes
• Poor nutrition
• Cardiac irregularities
• Severe depression in pregnancy
• Postpartum depression
• Premature birth
• Labor complications
• Breastfeeding difficulties
• Preeclampsia
• Premature labor
• Increased risk for cesarean birth

The fetus also has serious risks, including (NEDA, 2024):

• Premature birth
• Low birth weight
• Feeding difficulties
• Poor growth and development
• Respiratory distress
• Miscarriage/stillbirth

Mothers suffering with an eating disorder must see a specialist to help manage an eating disorder during pregnancy. Often times, working with a specialist can help reduce some of the risks through nutritional education, counseling, and striving for healthy and appropriate weight gain and nutritional intake (American Pregnancy Association, 2024). For pregnant women struggling with disordered eating, the following is recommended for management and treatment (NEDA, 2024; American Pregnancy Association, 2024):

• Psychotherapy/support groups before, during, and after pregnancy to help learn coping mechanisms with fears regarding food, weight gain, and body image. CBT is often recommended
• Consultation with a nutritionist who has expertise in eating disorders before or immediately after becoming pregnant to help create a healthy eating plan
• Eating a well-balanced meal with all the proper nutrients
• Avoid purging and excessive exercise
• Close follow-up with providers to track growth and development of the baby that includes mother’s weight (face scale backwards so patient does not see it)
• Because anxiety and depression are often comorbid with eating disorders, antidepressants like SSRIs are often recommended to treat these conditions that may help improve the eating disorder as well