Arch Womens Ment Health DOI 10.1007/s00737-015-0514-3
LETTER TO THE EDITOR
Treatment of anxiety during pregnancy: room to grow Elizabeth L. Lemon & Rachel Vanderkruik & Sona Dimidjian
Received: 22 January 2015 / Accepted: 8 February 2015 # Springer-Verlag Wien 2015
Dear Editors: Anxiety in pregnancy is common and, left untreated, is associated with poor maternal, obstetric, and neonatal outcomes (see Goodman et al. 2014a for a review). Despite this, little attention has been devoted to this important mental health concern, resulting in a paucity of research that has left women with few evidence-based treatment options. Given that many women prefer non-pharmacologic options to manage anxiety during pregnancy (Arch 2014), the recent development of a psychotherapeutic treatment by Goodman et al. (2014) is timely and encouraging. The intervention, an adaptation of Mindfulness Based Cognitive Therapy (MBCT) for the treatment of generalized anxiety disorder (GAD) during pregnancy, resulted in a significant reduction in symptoms, and was regarded very positively by participants. Based on the evidence for the feasibility and acceptability of the intervention, Goodman et al. (2014) highlight the need for additional research examining this novel therapy. We concur, however, and add that the field also requires studies of standard cognitive behavioral therapy (CBT) for anxiety during pregnancy. CBT is considered the gold-standard in treating anxiety disorders in the general population, but there is a surprising lack of research on the use of CBT for anxiety during pregnancy. Pregnant women report a willingness to try CBT and, after reading a detailed description of the therapy, expressed only minimal concerns about the possible effects of treatment (Arch 2014). Yet, to our knowledge, only one small study using CBT exists: a pilot study treating blood and injection E. L. Lemon (*) : R. Vanderkruik : S. Dimidjian Department of Psychology and Neuroscience, University of Colorado Boulder, 345 UCB Muenzinger, Boulder, CO 80309, USA e-mail: [email protected]
phobia in pregnant women, which showed significant reduction in phobia symptoms post-treatment and through 3months postpartum (Lilliecreutz et al. 2010). Such a dearth of studies of CBT may be due to apprehension about potential risks associated with the exposure component of CBT for anxiety, given that antenatal physiological stress reactivity is associated with adverse birth outcomes, such as prematurity and low birth weight, and increased emotional and behavioral problems in the developing offspring (de Weerth and Buitelaar 2005). As such, the idea of electively inducing this state in pregnancy seems intuitively contraindicated. However, in a review by Arch et al. (2012), the authors conclude that it would be possible to reduce the treatment-associated stress to within pregnancy-safe limits by modifying standard exposure techniques. Furthermore, the authors hypothesize that exposure-based therapies may pose less risk to mother and fetus than untreated anxiety or psychotropic medication use, and they call for more research addressing these important questions. It is important to advance several future research directions in order to provide the data needed to guide women’s decision-making regarding the treatment of anxiety during pregnancy. First, to help contextualize women’s treatment choices, the field requires greater consensus regarding the short- and long-term effects of neonatal exposure to physiological and psychological stress, as well as the relative magnitude and impact of stress conferred by exposure-based procedures within standard CBT to pharmacological management and untreated anxiety. Pregnant women and their care providers require a solid evidence base with clear information about the relative risks and benefits of an array of treatment options for antenatal anxiety, including standard CBT. Second, systematic data describing the course, predictors, and unique clinical features of perinatal anxiety are necessary to inform the dissemination and implementation of evidence-
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based treatments. Third, it is necessary to examine potential differences among the anxiety disorders among pregnant women with respect to psychopathology and treatment considerations. The scant data available are not adequate to guide the range of clinical decisions that pregnant women and their care providers face. Goodman et al. (2014) have made a substantial contribution to the perinatal anxiety literature, but there is significant room to grow.
References Arch JJ (2014) Cognitive behavioral therapy and pharmacotherapy for anxiety: treatment preferences and credibility among pregnant and non-pregnant women. Behav Res Ther 52:53–60. doi:10.1016/j. brat.2013.11.003
Arch JJ, Dimidjian S, Chessick C (2012) Are exposure-based cognitive behavioral therapies safe during pregnancy? Arch Womens Ment Health 15(6):445–457. doi:10.1007/s00737012-0308-9 de Weerth C, Buitelaar JK (2005) Physiological stress reactivity in human pregnancy—a review. Neurosci Biobehav Rev 29(2):295–312. doi: 10.1016/j.neubiorev.2004.10.005 Goodman JH, Chenausky KL, Freeman MP (2014a) Anxiety disorders during pregnancy: a systematic review. J Clin Psychiatry 75(10): e1153–e1184. doi:10.4088/JCP.14r09035 Goodman JH, Guarino A, Chenausky KL, Klein L, Prager J, Petersen R, Freeman MP (2014b) CALM Pregnancy: results of a pilot study of mindfulness-based cognitive therapy for perinatal anxiety. Arch Womens Ment Health 17(5):373–387. doi:10.1007/s00737-0130402-7 Lilliecreutz C, Josefsson A, Sydsjo G (2010) An open trial with cognitive behavioral therapy for blood- and injection phobia in pregnant women-a group intervention program. Arch Womens Ment Health 13(3):259–265. doi:10.1007/s00737-009-0126-x