Review articleAnxiety disorders in postpartum women: A systematic review and meta-analysis
Introduction
Childbirth is a momentous event in the life of a woman and the time following can be one of heightened vulnerability to mental disorders. Psychopathology during the postpartum period is common (O’Hara and Wisner, 2014). Research regarding the mental health of postpartum women has primarily focused on depression and psychosis, with considerable less attention devoted to anxiety (Farr et al., 2014; Matthey et al., 2003). Anxiety, however, has been recently acknowledged as a significant component of maternal postpartum distress (Matthey, 2004, Miller et al., 2006). Evidence suggests that postpartum anxiety is relatively common among postpartum women, (Heron et al., 2004, Stuart et al., 1998, Woolhouse et al., 2009), and may even be more common than depression (Giardinelli et al., 2012, Grigoriadis et al., 2011; Woolhouse et al., 2009). Research, however, has thus far largely relied on self-report anxiety symptoms rather than diagnosed anxiety disorders. Because of limitations inherent in self-report questionnaires, such as self-report bias and differing interpretations of questions, results from such studies cannot be used to generalize to postpartum maternal anxiety disorders, which may differ qualitatively and in severity. Anxiety meeting diagnostic criteria for a disorder represents anxiety at its most severe, distressing, and persistent, and thus it is most important to identify, understand, and treat.
A clear understanding of postpartum anxiety disorders is important in order to more fully appreciate and treat the spectrum of psychiatric illness among postpartum women. Determining postpartum anxiety disorder prevalence is necessary for a clear understanding of the extent of the problem and for planning clinical and public health efforts. Identification of risk factors can assist in identifying women for targeted preventive and/or early interventions. Understanding the course of anxiety disorders in the postpartum period can assist in prevention and treatment strategies for women with pre-existing or newly diagnosed disorders. Identification of negative outcomes associated with postpartum anxiety disorders can inform pregnancy planning, prevention and treatment. Because of the potential impact of maternal psychopathology on the infant and young child (Glasheen et al., 2010, Stein et al., 2014), it is especially important to assess if and how maternal anxiety disorders may pose a risk to children. Treatment of diagnosed anxiety disorders in postpartum women is imperative in order to alleviate maternal suffering, improve functioning during such a critical time in a family’s life, and minimize potential negative outcomes; thus, identification of evidence-based treatments that are safe, effective, and acceptable to postpartum women is of paramount importance.
Case studies and qualitative studies provided the first descriptions of anxiety symptoms and disorders after childbirth (Arnold, 1999, Beck, 1998, Beck, 2004a, Beck, 2004b, Metz et al., 1988, Sichel et al., 1993). As studies have accumulated, a few research reviews have provided preliminary evidence regarding postpartum anxiety (Abramowitz et al., 2003, Ayers, 2004, Glasheen et al., 2010, Olde et al., 2006, Speisman et al., 2011); however these reviews have predominantly focused on anxiety symptoms rather than anxiety disorder diagnoses. An exception is a 2013 meta-analysis of perinatal OCD (Russell et al., 2013) which reported a significantly higher risk of OCD diagnosis in pregnant and postpartum women compared to the general female population, with the highest prevalence among postpartum women. In addition, a systematic review of perinatal anxiety meeting diagnostic criteria for specific anxiety disorders was published by Ross and McLean (2006). The review revealed a lack of quality research evidence regarding anxiety disorders in postpartum women.
The purpose of the current review is to provide a comprehensive, systematic evaluation of the literature on anxiety disorders determined with clinical diagnosis among postpartum women, and a meta-analysis of prevalence of each anxiety disorder and anxiety disorders as a whole. Although there have been recent changes in categorization and some criteria for anxiety disorders in the new Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition: DSM-V) (American Psychiatry Association, 2013), the research presented in this review was all conducted prior to these changes. The following anxiety disorders were considered: panic disorder (PD), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), agoraphobia, specific phobia, social phobia, post-traumatic stress disorder (PTSD), and anxiety disorder not otherwise specified (ADNOS). A systematic review of relevant published studies was conducted to answer the following questions:
- 1.
How common are postpartum anxiety disorders?
- 2.
Does childbirth have an effect on the onset and course of anxiety disorders?
- 3.
Are there known correlates and risk factors for postpartum anxiety disorders?
- 4.
Are there known maternal, infant, or mother-infant outcomes associated with postpartum anxiety disorders?
- 5.
What are the evidence-based treatments for postpartum anxiety disorders?
Section snippets
Methods
This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist (Liberati et al., 2009).
Study selection
Database searches yielded 731 citations after duplicates were removed. Initial screening of titles and abstracts yielded 160 potentially eligible studies. Full text review of these identified 49 which met eligibility criteria. Five additional studies were identified through hand searches and 4 by PubMed search for in-process or recently published studies. A total of 58 studies were included in the review. A flow chart of study selection is shown in Fig. 1.
Overview of selected studies
Characteristics of included studies are
Discussion
This paper describes a comprehensive systematic review of anxiety disorders among postpartum women, along with meta-analysis of the prevalence of individual anxiety disorders and anxiety disorders as a whole. Findings are based on a thorough search of the literature, strict inclusion of only studies which utilized the gold standard of diagnostic interviews for anxiety disorder determination, and critical appraisal and review of included studies. Fifty-eight studies were included in the review,
Conclusion
Although the last decade has shown increased research regarding anxiety disorders in postpartum women, compared with postpartum depression, these disorders have been neglected. As this review reveals, the research is in its early stages, with much work yet to be done to accurately determine prevalence, understand course, identify risk factors and outcomes, and determine effective treatments for postpartum anxiety disorders. Increased research and clinical attention to these disorders is
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