From the Guidelines
To manage postpartum anxiety and restlessness in a patient with polysubstance use disorder, a comprehensive approach combining medication, therapy, and support is recommended, prioritizing medication-assisted treatment (MAT) for opioid use disorder and cognitive-behavioral therapy (CBT) for substance use and anxiety management, as supported by the most recent evidence from 2022 1.
Medication
- Consider prescribing an SSRI like sertraline (Zoloft) starting at 25-50 mg daily, increasing to 50-200 mg daily as needed, while ensuring safety for breastfeeding mothers.
- For acute anxiety, use short-term benzodiazepines cautiously, such as lorazepam 0.5-1 mg as needed, for no more than 2-4 weeks, due to the risk of dependence and potential for misuse.
Therapy
- Refer for cognitive-behavioral therapy (CBT) focused on anxiety management and substance use, as CBT has been shown to be effective in managing substance use disorders and anxiety in combination with pharmacotherapy 1.
- Recommend attending support groups like Narcotics Anonymous or SMART Recovery to provide peer support and coping strategies.
Lifestyle Interventions
- Encourage regular exercise, such as 30 minutes of walking daily, to help manage anxiety and improve overall well-being.
- Promote good sleep hygiene and relaxation techniques like deep breathing or meditation to reduce anxiety and improve sleep quality.
Substance Use Management
- Implement a substance use treatment plan, potentially including medication-assisted treatment for opioid use disorder if applicable, as MAT has been shown to be effective in managing opioid use disorder 1.
- Regular drug screening to monitor adherence and progress, and to adjust the treatment plan as needed.
Support System
- Involve partner or family members in the treatment plan to provide emotional support and help monitor progress.
- Connect with a social worker for additional resources and support, including access to community services and counseling.
Postpartum Care
- Ensure regular follow-ups with an OB/GYN for postpartum care to monitor physical and mental health.
- Screen for postpartum depression at each visit, as the risk of postpartum depression is higher in patients with substance use disorders.
This comprehensive approach addresses both the anxiety and substance use issues while considering the unique needs of the postpartum period, and is supported by the most recent evidence from 2022 1.
From the Research
Strategies for Managing Postpartum Anxiety and Restlessness
- Cognitive behavior therapy (CBT), relaxation, and mindfulness therapy are indicated for mild generalized anxiety disorder (GAD) 2
- Moderate/severe illness requires pharmacotherapy and CBT, individually or in combination 2
- Selective serotonin reuptake inhibitors (SSRIs)/serotonin-norepinephrine reuptake inhibitors (SNRIs) are the first-line treatment for anxiety disorders due to data supporting their efficacy and overall favorable side effect profile 2
- Benzodiazepines are an option for short-term treatment 2
- Mindfulness-based cognitive therapy (MBCT) has potential as an adjunctive, non-pharmacological treatment for postpartum depression/anxiety that does not wholly remit with pharmacotherapy 3
- Paroxetine may be beneficial for postpartum women with GAD, with response and remission rates of 78.8 and 63.6%, respectively 4
Considerations for Patients with Polysubstance Use Disorder (PSUD)
- Comorbid occurrence of GAD and major depressive disorder changes the illness course and its treatment outcome 2
- Psychoeducation is a key component in overcoming denial/stigma and facilitating successful intervention 2
- Treatment strategies are contingent upon illness severity 2
- Anxiety disorders are common during the perinatal period, with reported rates of obsessive-compulsive disorder and generalized anxiety disorder being higher in postpartum women than in the general population 5
- Perinatal mood and anxiety disorders (PMADs) are associated with worse obstetric outcomes and suicide risk, highlighting the need for evidence-based screening, assessment, and management 6