The relationship between the perinatal period and maternal mental health disorders has received national attention (Gaynes et al. 2005
). Two primary focal areas include improving the detection of perinatal depression by standardized use of validated screening tools (Chaudron et al. 2007
; Olson et al. 2005
) and evaluating the safety of antidepressants during pregnancy (Yonkers et al. 2009
) and breastfeeding (Weissman et al. 2004
). Despite the co-morbidity of mood and anxiety disorders and the use of similar treatments (antidepressants and cognitive behavioral therapy), little attention has been given to the experience of maternal anxiety during the perinatal period. Recent studies have begun to demonstrate that maternal anxiety during pregnancy can negatively affect fetal outcomes as well as result in long-term behavioral disturbances for children (O’Connor et al. 2002
). These studies shed light on the crucial need to understand and treat anxiety disorders during the perinatal period.
One anxiety disorder, obsessive–compulsive disorder (OCD), has been linked to postpartum depression through overlapping symptoms such as obsessional and intrusive thoughts (Wisner et al. 1999
) as well as high rates of postpartum depressive symptoms in women with OCD (Williams and Koran 1997
; Labad et al. 2005
). Large epidemiological studies estimate the prevalence of OCD at 1–2.5% of the general population (Kessler et al. 1994
) with sub-threshold OCD estimated to affect 6% of primary care patients (Olfson et al. 1996
). Perinatal depression affects 14% of the general population (Gaynes et al. 2005
), and in low-income and minority groups of women, the rates exceed 25% (Chaudron et al. 2004
; Morris-Rush et al. 2003
). The incidence, prevalence, and impact of OCD, as well as sub-threshold OCD or obsessive–compulsive symptoms (OCS), during the perinatal period are essentially unknown (Abramowitz et al. 2003
). Furthermore, the relationship between perinatal OCD or OCS and perinatal depression is essentially unknown.
The etiology of perinatal OCS and OCD has not been established. Because of the heterogenous nature of OCD, many experts believe that its etiology may be ascribed to a variety of etiologic processes and their interactions. These include genetic, environmental, immunological, and hormonal factors (Brandes et al. 2004
). The dynamic nature of the hormonal environment of the perinatal woman has led to specific hypotheses regarding the effects of increased oxytocin in the postpartum period as well as the rapid shifts in estrogen and progesterone (Altemus 2001
; Stein et al. 1993
). Recent studies have begun to explore a link between OCS and increased oxytocin (Bartz and Hollander 2008
). The increase in symptoms in the perinatal period may be related to this increased concentration. Another area of exploration has been on the rapid shifts in estrogen and progesterone and their potential impact on serotonergic transmission which has been hypothesized to influence OCD and OCS (Williams and Koran 1997
). In addition to proposed biological processes, psychological stress of pregnancy and infant care may contribute to the development of OCS and even possibly OCD. Evolutionary, sociobiological, and cognitive vulnerability hypotheses have also been proposed (Abramowitz et al. 2003
). Similarly, perinatal depression is hypothesized to be multifactorial and similar etiologic mechanisms are under investigation (Bloch et al. 2003
Current data specific to OCD, sub-threshold OCD, and OCS in the perinatal period are limited by study design (i.e., majority are retrospective studies) or the sample population (majority are clinical populations of women who have OCD). One retrospective study found a prevalence of 2.7% for OCD and 5.4% for sub-syndromal OCD in postpartum women (Wenzel et al. 2005
). A recent prospective study conducted in Turkey found a 3.5% third trimester prevalence and a 0.5% second trimester incidence of OCD in 434 women during pregnancy (Uguz et al. 2007b
). Among the women with OCD, the most common obsessions were contamination and symmetry/exactness and the most common compulsions were cleaning and checking.
As described, there are a variety of mechanisms by which OCD and perinatal depression may overlap, co-exist, and/or interact. Based on the spectrum of possibilities, we hypothesize that there is a subset of women who are predisposed by pre-existing OCD, sub-threshold OCD, or OCS to develop postpartum depression. When these women are exposed to infant demands that require maternal adaptability and flexibility, they become increasingly anxious and, at times, depressed. To explore this hypothesis and describe a non-clinical sample of perinatal women, we conducted a prospective longitudinal study of pregnant women to describe the prevalence, incidence, types and severity of OCD/OCS, and co-morbid diagnoses during pregnancy and postpartum. We also examine, in a preliminary way, the associations between the OC spectrum and postpartum depression.