What perinatal psychiatric evaluation and management is recommended for a 17‑year‑old pregnant adolescent with ADHD, generalized anxiety disorder, major depressive disorder, not seen in two years, currently taking escitalopram 20 mg daily and hydroxyzine 10 mg as needed?

Immediate Psychiatric Evaluation and Medication Management for a Pregnant 17‑Year‑Old with ADHD, GAD, and MDD

This pregnant adolescent requires urgent comprehensive psychiatric re‑evaluation with a multidisciplinary team involving psychiatry, obstetrics, and primary care to develop a perinatal management plan that addresses her ADHD, anxiety, depression, and the safety of her current medications during pregnancy. 1

Critical Initial Assessment

Conduct a thorough psychiatric assessment immediately to determine current symptom severity across all three diagnoses (ADHD, GAD, MDD), functional impairment, and suicide risk, as she has not been seen in two years and is now pregnant. 1

• Screen for worsening depression and suicidal ideation, particularly given the pregnancy and two‑year gap in care, as untreated perinatal depression poses significant risks to both mother and fetus. 1
• Use the Adult ADHD Self‑Report Scale (ASRS‑V1.1) Part A to formally assess current ADHD symptom severity; a positive screen requires 4 or more "often/very often" responses out of 6 questions. 1
• Evaluate how ADHD symptoms have changed during pregnancy, as the increased demands of pregnancy often make ADHD symptoms more challenging to manage. 1, 2
• Assess for comorbid conditions and functional impairment across multiple settings (home, school/work, relationships), as around 10% of adults with recurrent depression/anxiety have ADHD, and treating mood symptoms alone will be inadequate without addressing ADHD. 1, 2

Medication Safety Review During Pregnancy

Escitalopram 20 mg Daily

Continue escitalopram 20 mg daily throughout pregnancy, as SSRIs are the treatment of choice for depression and anxiety during pregnancy, and abrupt discontinuation poses greater risks than continuation. 3, 4

• Escitalopram has demonstrated efficacy in both GAD and MDD, with 10–20 mg daily being the established therapeutic range for anxiety disorders. 4
• Advise the patient that escitalopram use later in pregnancy may lead to increased risk for neonatal complications requiring prolonged hospitalization, respiratory support, tube feeding, and/or persistent pulmonary hypertension (PPHN), but these risks must be weighed against the dangers of untreated maternal depression. 3
• Monitor for worsening depression or anxiety symptoms throughout pregnancy, as hormonal changes and increased stress may require dose adjustment. 1

Hydroxyzine 10 mg PRN

Discontinue hydroxyzine immediately and replace with non‑pharmacologic anxiety management strategies or consider increasing escitalopram if anxiety is inadequately controlled. 5, 6

• While hydroxyzine has shown efficacy for GAD in non‑pregnant adults (NNT 5.15), there is insufficient safety data during pregnancy, and the Cochrane review noted high risk of bias in hydroxyzine studies. 5, 6
• The sedating properties of hydroxyzine may worsen pregnancy‑related fatigue and interfere with daily functioning. 6
• If anxiety remains at 7/10 or higher after discontinuing hydroxyzine, consider increasing escitalopram toward the maximum dose of 20 mg (already at target) or adding structured CBT for anxiety. 4, 7

ADHD Management During Pregnancy

Address the patient's ADHD directly, as untreated ADHD during pregnancy significantly increases depressive symptoms even when antidepressants are continued, and functional impairment from ADHD persists despite mood improvement. 1, 2

First‑Line Non‑Pharmacologic Interventions

Initiate psychoeducation, self‑management strategies, coaching, and ADHD‑specific cognitive behavioral therapy as first‑line interventions for mild to moderate ADHD during pregnancy. 1, 2

• Provide comprehensive psychoeducation covering ADHD symptoms, how pregnancy exacerbates executive dysfunction, treatment options, and the risks/benefits of medication during pregnancy. 1
• Teach specific executive functioning skills including time management, organization, planning, and emotional self‑regulation through targeted CBT, which has the strongest evidence among psychotherapies for ADHD. 1
• Implement mindfulness‑based interventions (MBCT or MBSR) to help with inattention symptoms, emotion regulation, and quality of life. 1
• Address modifiable factors that worsen ADHD functioning: ensure adequate nutrition (eating throughout the day), prioritize sleep hygiene, and develop stress‑management strategies. 1, 2

Pharmacotherapy Consideration for Moderate to Severe ADHD

If ADHD symptoms cause moderate to severe functional impairment despite non‑pharmacologic interventions, consider stimulant medication (methylphenidate or lisdexamfetamine) after thorough informed consent discussion. 1, 2

• Current evidence shows no association between methylphenidate or amphetamines and major congenital malformations or major adverse developmental outcomes. 1
• There is a modest increased risk of preterm birth (aRR 1.30) and preeclampsia (aRR 1.29) with stimulant use in the second half of pregnancy, which must be weighed against the risks of untreated ADHD. 1
• Individuals with ADHD who stopped psychostimulant medication during pregnancy had a significant increase in depressive symptoms despite remaining on antidepressant medication, indicating that mood stabilization requires concurrent treatment of both conditions. 1, 2
• The decision to use stimulants should balance the documented hazards of untreated ADHD (spontaneous abortion, preterm birth, overall functional impairment, increased accidents, substance use problems) against potential medication risks. 1
• If stimulants are initiated, start with long‑acting formulations (e.g., methylphenidate ER 18 mg daily or lisdexamfetamine 20–30 mg daily) and titrate weekly based on symptom response. 1

Multidisciplinary Care Plan

Develop a comprehensive management plan involving the patient, her family/support network, psychiatry, obstetrics, and primary care, with ongoing monitoring and medication adjustment throughout the perinatal period. 1, 2

• Schedule monthly psychiatric follow‑up visits during pregnancy to monitor ADHD, depression, and anxiety symptoms, with more frequent visits if symptoms worsen. 1
• Coordinate with obstetrics for close monitoring of pregnancy complications, particularly if stimulant medication is used. 1
• Develop a postpartum plan immediately, as the postpartum period carries significantly increased risk of relapse for all three conditions (ADHD, depression, anxiety), and parents with ADHD experience greater parental distress in the first year postpartum. 2
• Involve the patient's partner and family support system in the management plan, as this is crucial for pregnant individuals with ADHD. 2

Critical Safety Monitoring

• Monitor blood pressure and pulse at each visit if stimulant medication is initiated, as pregnancy itself increases cardiovascular demands. 1
• Screen systematically for suicidal ideation at every visit, particularly given the history of MDD and current pregnancy stress. 3
• Assess sleep quality, appetite, and weight gain throughout pregnancy, as both ADHD and medications can affect these parameters. 1
• Educate the patient to seek immediate help if ADHD symptoms worsen significantly during pregnancy, as this may trigger worsening depression. 1, 2

Common Pitfalls to Avoid

• Do not assume that treating depression and anxiety alone will restore optimal functioning—ADHD must be addressed directly, as 10% of adults with recurrent depression/anxiety have ADHD, and mood treatment alone is inadequate. 1, 2
• Do not abruptly discontinue escitalopram—this poses greater risks than continuation, including worsening maternal mental health that can adversely affect fetal development. 3
• Do not delay ADHD treatment until after delivery—untreated ADHD during pregnancy leads to increased depressive symptoms, functional impairment, and worse outcomes for both mother and baby. 1, 2
• Do not fail to plan for postpartum care—the risk of relapse is highest in the postpartum period, and planning must begin during pregnancy. 2
• Do not rely solely on PRN hydroxyzine for anxiety management—this is inadequate treatment for GAD and lacks pregnancy safety data; optimize escitalopram and add CBT instead. 5, 4