What are the recommended treatments for anxiety in pregnant women?

Treatment of Anxiety During Pregnancy

For pregnant women with anxiety, cognitive behavioral therapy (CBT) and mindfulness therapy are recommended as first-line treatments, with selective serotonin reuptake inhibitors (SSRIs) such as sertraline considered for moderate-to-severe cases when psychotherapy is insufficient. 1

Assessment and Screening

• Use validated screening tools to assess anxiety severity in pregnant women:
  • GAD-7
  • Edinburgh Postnatal Depression Scale
  • Patient Health Questionnaire (PHQ-9)
  • Hospital Anxiety and Depression Scale 1

Treatment Algorithm

First-Line Treatment: Non-Pharmacological Approaches

1. Cognitive Behavioral Therapy (CBT)

   • Recommended as initial treatment for pregnant women with anxiety
   • 8-12 sessions typically needed
   • No reported harms to mother or fetus 1
   • Significantly improves anxiety symptoms (SUCRA = 65%) 2

2. Mindfulness-Based Interventions

   • Most effective non-pharmacological treatment according to recent evidence
   • Highest SUCRA score (80%) for reducing anxiety symptoms 2
   • CALM Pregnancy (mindfulness-based cognitive therapy adaptation) shows significant improvements in anxiety, worry, and depression 3
   • Increases self-compassion and mindfulness 3

3. Additional Non-Pharmacological Options

   • Mind-body exercises (SUCRA = 67.43%) 2
   • Education therapy (SUCRA = 48%) 2
   • Relaxation techniques and sleep hygiene 1

Second-Line Treatment: Pharmacological Approaches

For moderate-to-severe anxiety or when psychotherapy is ineffective (reassess at 4-8 weeks):

1. Sertraline (Preferred SSRI)

   • Starting dose: 25-50mg daily
   • Maximum dose: 200mg daily
   • Continue psychotherapy concurrently 1

2. Alternative: Fluoxetine

   • Consider potential third-trimester complications:
     • Neonatal respiratory distress
     • Feeding difficulties
     • Irritability
   • Should be tapered to minimize discontinuation symptoms 1

Important Clinical Considerations

• Untreated anxiety risks:

  • Increased risk of spontaneous abortion and preterm birth
  • Negative impacts on maternal-infant bonding 1

• Medication management:

  • Abrupt discontinuation of previously effective medication can worsen symptoms
  • If medication was effective pre-pregnancy, continuing may be appropriate 1
  • Regular reassessment of treatment response is necessary

• Third trimester considerations:

  • Discuss potential tapering of medications to minimize neonatal effects
  • Balance risks of medication against risks of untreated anxiety 1

• Treatment monitoring:

  • Evaluate response at 4 weeks and 8 weeks after each treatment change
  • Use standardized instruments to assess both symptom relief and side effects 1

Evidence Quality and Limitations

The recommendations are primarily based on clinical guidelines from major medical organizations including the American College of Obstetricians and Gynecologists and the American Psychiatric Association 1. Recent research strongly supports mindfulness therapy as the most effective non-pharmacological intervention for anxiety during pregnancy 2, with CBT also showing significant benefits 1, 2.

While SSRIs and SNRIs are first-line pharmacological treatments for anxiety disorders in adults, pregnant women were not included in many clinical trials 4, though these medications are widely used in this population. The balance of evidence suggests that for moderate to severe anxiety, the benefits of appropriate treatment outweigh the risks of untreated anxiety during pregnancy.