416-813-6780 (Toronto and GTA)
Alcohol and Substance
Pregnancy & Breastfeeding Resources
Read more in our News Archive
Safety of treatment of obsessive compulsive disorder in pregnancy and puerperium
Shirin Namouz-Haddad, MD and Irena Nulman, MD
My patient is 3 weeks postpartum and has experienced repetitive checking and washing of her newborn as a result of obsessive concerns with the newborn's safety. Should I refer her for a psychiatric assessment to rule out obsessive compulsive disorder (OCD) or should I reassure her that her behaviour is normal?
Current data suggest that pregnancy and the postpartum period are times of high risk of OCD onset and exacerbation. The presenting symptoms of OCD overlap with normal concerns and behaviour during the perinatal period; however, an undiagnosed or untreated disorder could have adverse consequences for both the mother and her newborn. Therefore, it is strongly recommended that this patient undergo screening and psychiatric assessment in order to be appropriately managed.
Sécurité du traitement du trouble obsessionnel compulsif durant la grossesse et le puerpériumMa patiente a accouché il y a 3 semaines; elle me dit qu'elle vérifie et lave à répétition son nouveau-né, s'inquiétant de la sécurité du bébé. Devrais-je demander une évaluation psychiatrique pour écarter la possibilité d'un trouble obsessif compulsif (TOC) ou devrais-je la rassurer que son comportement est normal?
Les données actuelles font valoir que la grossesse et la période postpartum sont des moments où le risque d'apparition et d'exacerbation du TOC est élevé. Les symptômes du TOC chevauchent des préoccupations et des comportements habituels durant la période périnatale; cependant, un trouble non diagnostiqué ou non traité pourrait avoir des conséquences indésirables tant pour la mère que pour son nouveau-né. Il est donc fortement recommandé que cette patiente fasse l'objet d'un dépistage et d'une évaluation psychiatrique afin d'être prise en charge de manière appropriée.
Obsessive compulsive disorder (OCD) is relatively common. According to criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, it is characterized by recurrent and persistent thoughts; impulses, images (obsessions), or repetitive behaviour; or mental acts in response to an obsession (compulsions). 1 These obsessions and compulsions cause distress or substantially interfere with a person's normal, everyday life. Pregnancy and puerperium have a crucial role in the onset and course of the disorder, as they could affect the severity of pre-existing OCD or even trigger OCD onset. 2 Diagnosis and treatment of OCD during and following pregnancy are of utmost importance not only because it generally has a chronic course that might affect quality of life 3 but also because obsessions and compulsions in the perinatal period most often focus on the infant and could have persisting negative consequences for the development of the mother-infant relationship and bonding. 4-6
Prevalence in the perinatal period
Current data suggest that the perinatal period is a time of high risk of OCD onset. 7 This is consistent with a mean age between 23 and 35 years of OCD onset in the general population. 4 A systematic review of retrospective uncontrolled studies indicates that up to 40% of childbearing OCD outpatients experience onset of the disorder during pregnancy and 30% during puerperium. 8 A recent meta-analysis found higher prevalence of OCD during pregnancy (2.07%) and the postpartum period (2.43%) compared with in the general population (1.08%). 9 Fathers have seldom been reported to develop postpartum OCD. 10
Causes of OCD
Several theories have been proposed, but the cause of OCD is still unknown. One theory expands on the "serotonin hypothesis" of OCD, proposing that serotonergic dysfunction leading to OCD symptoms is caused by fluctuations in estrogen and progesterone during pregnancy and puerperium. 10,11 Another theory suggests that a rapid increase in oxytocin near the end of pregnancy and during puerperium might exacerbate or trigger the onset of OCD. 13 As neurobiological mechanisms cannot account for OCD onset in male partners, a cognitive-behavioural theory was suggested. According to this theory, patients with OCD attach exaggerated importance to the unwanted, intrusive thoughts, which are, in fact, experienced universally, and misinterpret them catastrophically. 10
Regardless of the timing of OCD onset, the most common obsessions in OCD patients during pregnancy or puerperium are fears of contaminating the neonate or infant, concerns about symmetry or exactness, and aggressive thoughts (such as intentionally or accidentally harming the infant), as well as associated cleaning and washing, checking, and avoidance compulsions. 3,12
Obsessive compulsive disorder during the perinatal period could interfere with the new mother's functional behaviour, ranging from avoidance of the child to excessive involvement with the child. The affected maternal functioning might adversely affect developing mother-infant bonding and a mother's ability to take care of her newborn, resulting in potential adverse cognitive-behavioural developmental effects in the newborn. 5 In addition, obsessions and compulsions in the stressed new mother could seriously interfere with her social functioning with other family members. There are no documented cases in the literature of women with OCD as their sole diagnosis who intentionally harm their infants. 8 By definition, patients with OCD have insight into their obsessions, identifying them as unwanted. In contrast, patients with postpartum psychosis typically lack insight and could cause harm to themselves or to their infants. 8
Untreated OCD has long-term effects on both mothers and their children; mothers admit that they are unable to enjoy their time with their children, and children have been found to suffer more from a range of internalizing disorders, including broadly defined OCD, 4 compared with controls.
The course of OCD during pregnancy and puerperium has been investigated in several small studies, which have reported varied outcomes; 8% to 50% of women experienced exacerbated symptoms with preexisting OCD,2,14–17 31% to 69% showed no change, 14,16,17 and 10% to 69% experienced improvements in their symptoms during the perinatal period. 14.16,17
In the general population, OCD coincides with anxiety, depressive, and bipolar disorders. 1 However, major depressive disorder is the most common comorbid diagnosis in patients with OCD in both the general and perinatal populations. Women with pre-existing or postpartum onset OCD could be at increased risk of developing postpartum depression approximately 2 to 3 weeks following the onset of OCD symptoms. 5
Women who experience the initial onset of obsessional problems during pregnancy or postnatally might not recognize their symptoms as being part of a disorder and therefore might not seek help accordingly. 4
Obstetricians or primary care clinicians should actively screen for symptoms of OCD during the course of pregnancy and early in the postpartum period (within 2 to 4 weeks) in all women, particularly in those with a history of OCD or other risk factors for perinatal OCD. 5 Two options have been proposed for screening: ask "It's not uncommon for new mothers to experience intrusive, unwanted thoughts and repetitive acts a result of concerns of causing harm to their baby. Have any such thoughts or acts occurred to you?" 5; or use the Edinburgh Depression Scale in combination with a risk questionnaire (assessing substance abuse, social support, and domestic violence). 7 Patients who have a positive screening result should receive a thorough psychiatric assessment for OCD and comorbid disorders, including depression.
Obsessive compulsive disorder is challenging to treat; only 20% of patients in the general population are estimated to achieve full remission. 18 Obsessive compulsive disorder during pregnancy and breastfeeding is even more challenging because obsessions during these periods often involve the safety of the fetus; patients might be more concerned because of fetal exposure to psychotropic agents.
To date, no controlled studies have been conducted to examine the effectiveness of different treatment regimens on perinatal OCD. Decision making is based on the severity and chronicity of the obsessions and compulsions, as well as the degree to which the disorder impairs patient and family functioning.
Selective serotonin reuptake inhibitors (SSRIs) are the most commonly indicated pharmacologic treatment of OCD or OCD with comorbid disorders such as major depression. 8 Augmentation with atypical antipsychotic medication is used for refractory cases. 19
Exposure to antidepressants during pregnancy has been shown to be associated with a small increased risk of spontaneous abortion 20,21 and premature births 22-24; however, it is unknown whether this increase is due to the medication exposure or the underlying psychopathology. Late exposure to SSRIs might also be associated with self-limited poor neonatal adaptation symptoms, such as jitteriness and difficulty feeding and breathing. Therefore, exposed neonates near term should be closely monitored after birth for at least 48 hours. 25
Large population-based studies have not found an increase in the rates of major congenital malformations in infants exposed to SSRIs or atypical antipsychotic medications, 26-29 nor have infants exposed to SSRIs been found to have any long-term behavioural effects. 30,31 However, recent controversial reports have suggested an association between SSRI administration during pregnancy and "persistent pulmonary hypertension of the newborn," which occurred in less than 1% of cases but with no associated mortalities. 32,33 Moreover, other meta-analyses have reported an increased risk of cardiac malformation with paroxetine (relative risk = 1.43, 95% CI 1.08 to 1.88; odds ratio = 1.72, 95% CI 1.22 to 2.42) 34,35; however, this could have been owing to detection bias. Therefore, management should be assessed on an individual basis, weighing the benefits of treatment against the potential risks.
With the exception of fluoxetine, all SSRIs were found at low levels in breast milk and would not be expected to cause adverse effects in breastfeeding infants. The average amount of fluoxetine in breast milk is higher than most other SSRIs, and adverse effects such as colic, drowsiness, and decreased infant weight gain have been reported in some breastfed infants. 36-38
Prophylactic treatment might be indicated if a patient has a history of postpartum onset or worsening of OCD following her previous pregnancies, given that recurrences might arise with later pregnancies. 39
Similar to OCD in nongravid patients, pharmacotherapy should be maintained for at least a year in postpartum OCD patients following therapeutic response. If medication is discontinued prematurely, the relapse episode is associated with poor response to treatment. 5 There are no recommendations in the literature for the treatment of OCD during pregnancy, but in our opinion, it should follow the same guidelines as for nongravid patients. Nonetheless, risk-benefit analysis should be applied individually.
A growing body of literature suggests that OCD is common in pregnancy and puerperium with risks of persisting consequences for both the mother and her child if untreated. Cognitive-behavioural therapy and pharmacologic therapy have been shown to be effective in nongravid women. The importance and benefit of treatment options along with their associated small risk of adverse events should be discussed, and management strategies should be tailored individually.
Motherisk questions are prepared by the Motherisk Team at The Hospital for Sick Children in Toronto, Ont. Drs. Namouz-Haddad and Nulman are members of the Motherisk Program.
Do you have questions about the effects of drugs, chemicals, radiation, or infections in women who are pregnant or breastfeeding? We invite you to submit them to the Motherisk Program by fax at 416 813-7562; they will be addressed in future Motherisk Updates.
Published Motherisk Updates are available on the Canadian Family Physician website (www.cfp.ca) and also on the Motherisk website.
Copyright © the College of Family Physicians of Canada
Can Fam Physician
Vol. 60, No. 2, February 2014 133-136
Copyright © 2014 by The College of Family Physicians of Canada
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
- Labad J, Menchon JM, Alonso P, Segalas C, Jimenez S, Vallejo J. Female reproductive cycle and obsessive-compulsive disorder. J Clin Psychiatry 2005;66(4):428-35. CrossRef/a> | Medline
- Uguz F, Akman C, Kaya N, Cilli AS. Postpartum-onset obsessive-compulsive disorder: incidence, clinical features, and related factors. J Clin Psychiatry 2007;68(1):132-8. CrossRef | Medline
- Challacombe FL, Salkovskis PM. Intensive cognitive-behavioural treatment for women with postnatal obsessive-compulsive disorder: a consecutive case series. Behav Res Ther 2011;49(6–7):422-6. CrossRef | Medline
- Brandes M, Soares CN, Cohen LS. Postpartum onset obsessive-compulsive disorder: diagnosis and management. Arch Womens Ment Health 2004;7(2):99-110. CrossRef | Medline
- Arnold LM. A case series of women with postpartum-onset obsessive-compulsive disorder. Prim Care Companion J Clin Psychiatry 1999;1(4):103-8. Medline
- Vythilingum B. Anxiety disorders in pregnancy. Curr Psychiatry Rep 2008;10(4):331-5. Medline
- Ross LE, McLean LM. Anxiety disorders during pregnancy and the postpartum period: a systematic review. J Clin Psychiatry 2006;67(8):1285-98. Medline
- Russell EJ, Mazmanian D. Risk of obsessive-compulsive disorder in pregnant and postpartum women: a meta-analysis. J Clin Psychiatry 2013;74(4):377-85. Medline
- Abramowitz J, Moore K, Carmin C, Wiegartz PS, Purdon C. Acute onset of obsessive-compulsive disorder in males following childbirth. Psychosomatics 2001;42(5):429-31. CrossRef | Medline
- Barr LC, Goodman WK, Price LH. The serotonin hypothesis of obsessive compulsive disorder. Int Clin Psychopharmacol 1993;8(Suppl 2):79-82. CrossRef | Medline
- Abramowitz JS, Schwartz SA, Moore KM, Luenzmann KR. Obsessive-compulsive symptoms in pregnancy and the puerperium: a review of the literature. J Anxiety Disord 2003;17(4):461-78. CrossRef | Medline
- McDougle CJ, Barr LC, Goodman WK, Price LH. Possible role of neuropeptides in obsessive compulsive disorder. Psychoneuroendocrinology 1999;24(1):1-24. CrossRef | Medline
- Williams KE, Koran LM. Obsessive-compulsive disorder in pregnancy, the puerperium, and the premenstruum. J Clin Psychiatry 1997;58(7):330-4. Medline
- Uguz F, Gezginc K, Zeytinci IE, Karatayli S, Askin R, Guler O, et al. Course of obsessive-compulsive disorder during early postpartum period: a prospective analysis of 16 cases. Compr Psychiatry 2007;48(6):558-61. Medline
- Vulink NC, Denys D, Bus L, Westenberg HG. Female hormones affect symptom severity in obsessive-compulsive disorder. Int Clin Psychopharmacol 2006;21(3):171-5. CrossRef | Medline
- Uguz F, Gezginc K, Zeytinci IE, Karatayli S, Askin R, Guler O, et al. Obsessive-compulsive disorder in pregnant women during the third trimester of pregnancy. Compr Psychiatry 2007;48(5):441-5. CrossRef | Medline
- Skoog G, Skoog I. A 40-year follow-up of patients with obsessive-compulsive disorder. Arch Gen Psychiatry 1999;56(2):121-7. CrossRef | Medline
- Decloedt EH, Stein DJ. Current trends in drug treatment of obsessive-compulsive disorder. Neuropsychiatr Dis Treat 2010;6:233-42. Medline
- Nakhai-Pour HR, Broy P, Berard A. Use of antidepressants during pregnancy and the risk of spontaneous abortion. CMAJ 2010;182(10):1031-7. Abstract/FREE Full Text
- Einarson A, Choi J, Einarson TR, Koren G. Rates of spontaneous and therapeutic abortions following use of antidepressants in pregnancy: results from a large prospective database. J Obstet Gynaecol Can 2009;31(5):452-6. Medline
- Reis M, Kallen B. Delivery outcome after maternal use of antidepressant drugs in pregnancy: an update using Swedish data. Psychol Med 2010;40(10):1723-33. CrossRef | Medline
- Einarson A, Choi J, Einarson TR, Koren G. Adverse effects of antidepressant use in pregnancy: an evaluation of fetal growth and preterm birth. Depress Anxiety 2010;27(1):35-8. Medline
- Urato AC. Antidepressant use and preterm birth. Am J Psychiatry 2009;166(10):1189-90. CrossRef | Medline
- Jefferies AL. Selective serotonin reuptake inhibitors in pregnancy and infant outcomes. Paediatr Child Health 2011;16(9):562-3. Medline
- Källén BA, Otterblad Olausson P. Maternal use of selective serotonin re-uptake inhibitors in early pregnancy and infant congenital malformations. Birth Defects Res A Clin Mol Teratol 2007;79(4):301-8. CrossRef | Medline
- Einarson A, Pistelli A, DeSantis M, Malm H, Paulus WD, Panchaud A, et al. Evaluation of the risk of congenital cardiovascular defects associated with use of paroxetine during pregnancy. Am J Psychiatry 2008;165(6):749-52. CrossRef | Medline
- McElhatton PR, Garbis HM, Elefant E, Vial T, Bellemin B, Mastroiacovo P, et al. The outcome of pregnancy in 689 women exposed to therapeutic doses of antidepressants. A collaborative study of the European Network of Teratology Information Services (ENTIS). Reprod Toxicol 1996;10(4):285-94. CrossRef | McKenna K, Koren G, Tetelbaum M, Wilton L, Shakir S, Diav-Citrin O, et al. Pregnancy outcome of women using atypical antipsychotic drugs: a prospective comparative study. J Clin Psychiatry 2005;66(4):444-9. CrossRef | Medline
- Nulman I, Rovet J, Stewart DE, Wolpin J, Gardner HA, Theis JG, et al. Neurodevelopment of children exposed in utero to antidepressant drugs. N Engl J Med 1997;336(4):258-62. CrossRef | Medline
- Nulman I, Rovet J, Stewart DE, Wolpin J, Pace-Asciak P, Shuhaiber S, et al. Child development following exposure to tricyclic antidepressants or fluoxetine throughout fetal life: a prospective, controlled study. Am J Psychiatry 2002;159(11):1889-95. CrossRef | Medline
- Koren G, Nordeng H. SSRIs and persistent pulmonary hypertension of the newborn. BMJ 2012;344:d7642. Search Google Scholar
- Occhiogrosso M, Omran SS, Altemus M. Persistent pulmonary hypertension of the newborn and selective serotonin reuptake inhibitors: lessons from clinical and translational studies. Am J Psychiatry 2012;169(2):134-40. CrossRef | Medline
- Grigoriadis S, Mamisashvili L, Roerecke M, Rehm J, Dennis C, Koren G, et al. Antidepressant exposure during pregnancy and congenital malformations: is there an association? A systemic review and meta-analysis of the best evidence. J Clin Psychiatry 2013;74(4):e293-308. CrossRef | Medline
- Bar-Oz B, Einarson T, Einarson A, Boskovic R, O'Brien L, Malm H, et al. Paroxetine and congenital malformations: meta-analysis and consideration of potential confounding factors. Clin Ther 2007;29(5):918-26. CrossRef | Medline
- Kristensen JH, Ilett KF, Hackett LP, Yapp P, Paech M, Begg EJ. Distribution and excretion of fluoxetine and norfluoxetine in human milk. Br J Clin Pharmacol 1999;48(4):521-7. CrossRef | Medline
- Hale TW, Shum S, Grossberg M. Fluoxetine toxicity in a breastfed infant. Clin Pediatr (Phila) 2001;40(12):681-4. FREE Full Text |
- Lanza di Scalea T, Wisner KL. Antidepressant medication use during breastfeeding. Clin Obstet Gynecol 2009;52(3):483-97. CrossRef | Medline
- Hertzberg T, Leo RJ, Kim KY. Recurrent obsessive-compulsive disorder associated with pregnancy and childbirth. Psychosomatics 1997;38(4):386-8. Medline