What is the recommended management approach for perinatal mood, anxiety, and related disorders?

Management of Perinatal Mood, Anxiety, and Related Disorders

Critical Note on Evidence Provided

The evidence provided focuses exclusively on ADHD in pregnancy and postpartum, not on the broader spectrum of perinatal mood and anxiety disorders (depression, anxiety, OCD, PTSD) that the question title suggests. I will address what the evidence actually contains—ADHD management—while noting this significant limitation.

Core Management Framework for Perinatal ADHD

For women with ADHD during the perinatal period, implement individualized treatment planning that includes psychoeducation and self-management strategies as foundational interventions, with pharmacotherapy considered for moderate-to-severe cases, as the available safety data for ADHD medications is largely reassuring. 1

Preconception and Early Pregnancy Planning

• Encourage pregnancy planning for all individuals with ADHD to optimize treatment strategies before conception 1
• Develop an individualized treatment plan that addresses mental health optimization, including education about signs of deteriorating mental health 1
• Prioritize sleep hygiene and regular nutrition, as sleep deprivation directly impairs executive function and irregular eating worsens ADHD symptoms 1, 2

Screening and Assessment

• Use the Adult ADHD Self-Report Scale (ASRS-V1.1) Part A as the first-line screening tool; a positive screen requires 4 or more items marked "often" or "very often" out of 6 questions 1
• Apply the Weiss Functional Impairment Rating Scale-Self (WFIRS-S) for comprehensive functional assessment 2
• Rule out mimicking conditions including perimenopausal depression, anxiety disorders, and sleep disorders before confirming ADHD diagnosis 2

Non-Pharmacologic Interventions (First-Line for Mild-Moderate ADHD)

Cognitive Behavioral Therapy (CBT) adapted for ADHD is the most extensively studied and effective psychotherapy, particularly when combined with medication, targeting executive functioning skills including time management, organization, planning, emotional self-regulation, and impulse control 1, 2

Additional evidence-based non-pharmacologic approaches include:

• Psychoeducation about ADHD symptoms and management strategies 1, 2
• Self-management strategies and coaching 1
• Mindfulness-based interventions (MBIs) 1
• Dialectical Behavior Therapy (DBT) 1

Important caveat: The evidence base for non-pharmacologic treatments is primarily from non-pregnant adults with ADHD; further research in the perinatal population is needed 1

Pharmacologic Management

Decision-Making Framework

When deciding on medication use, weigh the risks of ADHD medications against the risks of untreated or inadequately treated ADHD in pregnancy, recognizing that women who stopped psychostimulants during pregnancy experienced significant increases in depressive symptoms despite continuing antidepressants 1

Medication Considerations During Pregnancy

• For moderate-to-severe ADHD, pharmacotherapy is required even during pregnancy 1, 2
• Available safety data for ADHD medications in pregnancy is largely reassuring, though studies are limited particularly for non-stimulants 1
• Engage patients in risk-benefit discussions regarding continuing current well-tolerated, effective doses versus considering intermittent use or switching to non-stimulant options 1
• Consider the lowest effective dose or intermittent use strategies 1
• Monitor pregnancy carefully including fetal growth, blood pressure, and maternal weight gain 1

Lactation Management

For methylphenidate or bupropion: maintain therapeutic dose during breastfeeding 1

For amphetamine derivatives:

• Discuss breastfeeding safety concerns specifically 1
• Consider intermittent use and timing feeding or pumping to achieve lowest concentration in human milk 1
• Alternative feeding options may be discussed 1

Monitor infant development closely, ensuring appropriate weight gain and developmental milestone achievement 1

Comorbidity Management

Recognize that approximately 10% of adults with recurrent depression and/or anxiety disorders have comorbid ADHD, and treatment of depression/anxiety will likely be inadequate without addressing the underlying ADHD 1

• ADHD often co-exists with perinatal depression, anxiety, and other neurodevelopmental disorders 1
• ADHD must be adequately managed for greater chance of treating comorbid depression/anxiety to remission 1

Referral Criteria

Consider referral to general psychiatry or reproductive psychiatry if:

• Concerns exist about safety of ADHD medications in pregnancy or breastfeeding 1
• Support is needed for ongoing management of ADHD in the perinatal period 1

Special Populations and Considerations

• ADHD affects approximately 3.2% of adult women and 4.4% of gender-diverse adults assigned female at birth 1
• Use inclusive language regarding feeding preferences (breastfeeding, chestfeeding, nursing) based on patient preference 1
• Women with ADHD have increased vulnerability to mood disturbances during hormonal transitions including perimenopause 2
• Assess driving capability for women with severe or untreated ADHD, as stimulant treatment improves driving performance 2

Multidisciplinary Care Coordination

Develop a management plan involving the patient, family/support network, psychiatry, primary care, and gynecology with ongoing monitoring and medication adjustment throughout the perinatal transition 2

Critical Gap in Evidence

The provided evidence does NOT address the broader perinatal mood and anxiety disorders (major depression, generalized anxiety disorder, panic disorder, OCD, PTSD) that the question title suggests. The limited research evidence on general perinatal mood/anxiety disorder screening 3, 4, 5, 6 emphasizes systematic screening using tools like the Edinburgh Postnatal Depression Scale and Patient Health Questionnaire-9, but lacks specific treatment guidance beyond screening protocols.