Pregnancy is a period of substantial neuroendocrine changes. These changes are not limited to the hypothalamic-pituitary-gonadal hormones, but also involve the placenta and its secreted hormones, especially the corticotropin releasing hormone that is a major component of the stress axis. These hormonal changes are also associated with changes in the immune/inflammatory and cardiovascular systems. The cumulative evidence that dysregulation in this multifactorial interactional field may cause deleterious effects on the fetus and its future development emphasizes the importance and clinical relevance of this line of research. When vulnerability and genetic predisposition to gestational stress and its adverse effects are added to the equation, the importance of adequate treatments and possible preventive interventions is underscored.

Pregnancy is usually perceived as a happy period. However, as demonstrated by Uriel Halbreich, MD, severe mood, behavior, and cognitive symptoms are quite prevalent during pregnancy. The magnitude of the problem is probably not reflected by the reported prevalence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition or International Classification of Diseases, Ninth Edition major mental disorders. A closer evaluation and treatment of symptoms, especially when they are associated with impairment, stress, and distress, may improve the mental health of the mother and the expected baby.

A review of the literature demonstrates that the incidence of new mental disorders and their prevalence during pregnancy is similar to the 12-month incidence of mental disorders in women during other periods of their lives. The prevalence of severe mood, behavior, and cognitive symptoms during pregnancy is rather high. Severe mental symptoms during pregnancy have been reported to be associated with an increased rate of complications during pregnancy and delivery, preterm deliveries, low birth weight, a higher rate of postpartum depression, and a longer-term impact on the offspring's development. Several pre-pregnancy risk factors to develop dysphoric symptoms have been reported, but their utility for primiparous women with no previous history of mental disorders is unclear. The association of mental symptoms with general symptoms and biological changes during pregnancy is also unclear. Given the short- and long-term impact of dysphoric symptoms and stress during pregnancy on mother and child, efficacious, efficient, and safe prevention and treatment modalities are essential and achievable. Clarification of the nature and phenotyping of mental and general symptoms during pregnancy is an important step for the development of effective interventions.

Pregnancy and childbirth typically are associated with positive emotions and with motherhood, but the reality is that this is not the case for all women or for all pregnancies. This review addresses a different aspect of these reproductive events, focusing on stressful circumstances surrounding pregnancy, as well as times when the pregnancy itself becomes a stressful life event. Pregnancy-related topics that tend to receive less attention will be emphasized. These include issues related to infertility; unplanned pregnancy; stress associated with testing and diagnosis of common medical complications; peripartum cardiomyopathy; fear of childbirth; and pregnancy foss as a risk factor for psychopathology. Epidemiologie information wiu be presented, as will relevant psychosocial factors related to each phenomenon. Healtitcare providers should be sensitive to the distress and anxiety experienced by many women and their families as a consequence of these adverse events and the stressful challenge of any consequential decisionmaking, as well as stressors in their broader life context that can further exacerbate their distress, and make mental health referrals as appropriate.

Women's mental health during pregnancy has important implications not only for the well-being of the mother, but also for the development, health, and well-being of her unborn child. A growing body of empirical evidence from population-based studies suggests that two indicators of women's mental health during pregnancy—psychosocial stress and social support—may exert a significant influence on fetal development and infant birth outcomes, such as birth weight and length of gestation, even after controlling for the effects of established sociodemographic, obstetric, and behavioral risk factors. This paper describes the role of three major biological systems involved in the physiology of pregnancy and stress physiology: neuroendocrine, immune/inflammatory, and cardiovascular systems. These systems have been hypothesized to mediate the effects of maternal mental health on fetal developmental and health outcomes, and a central role has been proposed for placental corticotropin-releasing hormone in this process. However, not all women reporting high prenatal stress and/or low social support proceed to develop adverse birth outcomes, raising the question of the determinants of susceptibility/vulnerability in the context of high stress and/or low social support. In this context, the role of race/ethnicity and genetic predisposition are. discussed as two promising avenues of further investigation.

Pregnancy has frequently been described as a time of affective well-being. However, a growing literature suggests that women are neither “protected” against new-onset or recurrence of depression during this time. Diagnosis and effective treatment of depression during pregnancy requires a careful weighing of risk of treatment which may include psychotropic medications against the risks associated with failure to adequately manage affective distress and its potential impact of maternal and fetal well-being. Treatment options during pregnancy are reviewed in the context of developing the most appropriate risk/benefit decision for individual patients with past or current depression who either anticipate pregnancy or who become pregnant.

Background:This study examined the prevalence of irritability in patients with bipolar I disorder during an episode of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) major depression who do not meet criteria for a mixed episode.

Method:A chart review of 111 patients with bipolar I disorder treated at the Massachusetts General Hospital Bipolar Clinic between 1998 and 2000 identified 34 patients who met criteria for a DSM-IV major depressive episode in the absence of (1) mood elevation and/or (2) irritability associated with any additional above threshold DSM-IV symptoms of mania. Data gathered from the charts utilized prospective ratings made routinely at each clinic visit using the Clinical Monitoring Form (CMF), a structured assessment instrument which includes modified versions of the mood modules of the Structured Clinical Interview for DSM-IV. Data from these 34 patients were reviewed to determine the presence of irritability.

Results:The frequency of abnormal irritability in these 34 patients followed a bimodal distribution: 26% of the patients showed abnormal irritability ≥75% of the time, compared with 68% of the patients with abnormal irritabihty ≤30% of the time. Of the high-irritability patients, psychomotor agitation was rated as definitely present to a significant degree in 44%. Talkativeness and distractibility were rated present but subthreshold in one patient each. All other symptoms of DSM-IV mania were absent.

Conclusion:Approximately 25% of patients with bipolar I disorder who meet criteria for a DSM-IV major depressive episode also experienced substantial irritability in the absence of associated symptoms of mania. Our results suggest that abnormal irritability is not limited to mania or mixed states.