Showing papers in "Dialogues in Clinical Neuroscience in 2015"

Epidemiology of anxiety disorders in the 21st century.

Abstract: Anxiety disorders, including panic disorder with or without agoraphobia, generalized anxiety disorder, social anxiety disorder, specific phobias, and separation anxiety disorder, are the most prevalent mental disorders and are associated with immense health care costs and a high burden of disease. According to large population-based surveys, up to 33.7% of the population are affected by an anxiety disorder during their lifetime. Substantial underrecognition and undertreatment of these disorders have been demonstrated. There is no evidence that the prevalence rates of anxiety disorders have changed in the past years. In cross-cultural comparisons, prevalence rates are highly variable. It is more likely that this heterogeneity is due to differences in methodology than to cultural influences. Anxiety disorders follow a chronic course; however, there is a natural decrease in prevalence rates with older age. Anxiety disorders are highly comorbid with other anxiety disorders and other mental disorders.

Comorbidity between post-traumatic stress disorder and major depressive disorder: alternative explanations and treatment considerations.

Abstract: Approximately half of people with post-traumatic stress disorder (PTSD) also suffer from Major Depressive Disorder (MDD). The current paper examines evidence for two explanations of this comorbidity. First, that the comorbidity reflects overlapping symptoms in the two disorders. Second, that the co-occurrence of PTSD and MDD is not an artifact, but represents a trauma-related phenotype, possibly a subtype of PTSD. Support for the latter explanation is inferred from literature that examines risk and biological correlates of PTSD and MDD, including molecular processes. Treatment implications of the comorbidity are considered.

Research Domain Criteria: toward future psychiatric nosologies.

Abstract: The Research Domain Criteria (RDoC) project was initiated by the National Institute of Mental Health (NIMH) in early 2009 as the implementation of Goal 1.4 of its just-issued strategic plan. In keeping with the NIMH mission, to “transform the understanding and treatment of mental illnesses through basic and clinical research,” RDoC was explicitly conceived as a research-related initiative. The statement of the relevant goal in the strategic plan reads: “Develop, for research purposes, new ways of classifying mental disorders based on dimensions of observable behavior and neurobiological measures.” Due to the novel approach that RDoC takes to conceptualizing and studying mental disorders, it has received widespread attention, well beyond the borders of the immediate research community. This review discusses the rationale for the experimental framework that RDoC has adopted, and its implications for the nosology of mental disorders in the future.

Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence.

Abstract: A large amount of research has accumulated on the efficacy and effectiveness of cognitive-behavioral therapy (CBT) for anxiety disorders including posttraumatic stress disorder, obsessive-compulsive disorder, panic disorder, generalized anxiety disorder, social anxiety disorder, and specific phobia. The purpose of the current article is to provide an overview of two of the most commonly used CBT methods used to treat anxiety disorders (exposure and cognitive therapy) and to summarize and discuss the current empirical research regarding the usefulness of these techniques for each anxiety disorder. Additionally, we discuss the difficulties that arise when comparing active CBT treatments, and we suggest directions for future research. Overall, CBT appears to be both efficacious and effective in the treatment of anxiety disorders, but dismantling studies are needed to determine which specific treatment components lead to beneficial outcomes and which patients are most likely to benefit from these treatment components.

Emotional responses to interpersonal rejection.

Abstract: A great deal of human emotion arises in response to real, anticipated, remembered, or imagined rejection by other people. Because acceptance by other people improved evolutionary fitness, human beings developed biopsychological mechanisms to apprise them of threats to acceptance and belonging, along with emotional systems to deal with threats to acceptance. This article examines seven emotions that often arise when people perceive that their relational value to other people is low or in potential jeopardy, including hurt feelings, jealousy, loneliness, shame, guilt, social anxiety, and embarrassment. Other emotions, such as sadness and anger, may occur during rejection episodes, but are reactions to features of the situation other than low relational value. The article discusses the evolutionary functions of rejection-related emotions, neuroscience evidence regarding the brain regions that mediate reactions to rejection, and behavioral research from social, developmental, and clinical psychology regarding psychological and behavioral concomitants of interpersonal rejection.

Pharmacological approaches to the challenge of treatment-resistant depression

Abstract: Although monoaminergic antidepressants revolutionized the treatment of Major Depressive Disorder (MDD) over a half-century ago, approximately one third of depressed patients experience treatment-resistant depression (TRD). Such patients account for a disproportionately large burden of disease, as evidenced by increased disability, cost, human suffering, and suicide. This review addresses the definition, causes, evaluation, and treatment of unipolar TRD, as well as the major treatment strategies, including optimization, augmentation, combination, and switch therapies. Evidence for these options, as outlined in this review, is mainly focused on large-scale trials or meta-analyses. Finally, we briefly review emerging targets for antidepressant drug discovery and the novel effects of rapidly acting antidepressants, with a focus on ketamine.

Animal models for screening anxiolytic-like drugs: a perspective.

Abstract: Contemporary biological psychiatry uses experimental animal models to increase our understanding of affective disorder pathogenesis. Modern anxiolytic drug discovery mainly targets specific pathways and molecular determinants within a single phenotypic domain. However, greater understanding of the mechanisms of action is possible through animal models. Primarily developed with rats, animal models in anxiety have been adapted with mixed success for mice, easy-to-use mammals with better genetic possibilities than rats. In this review, we focus on the three most common animal models of anxiety in mice used in the screening of anxiolytics. Both conditioned and unconditioned models are described, in order to represent all types of animal models of anxiety. Behavioral studies require careful attention to variable parameters linked to environment, handling, or paradigms; this is also discussed. Finally, we focus on the consequences of re-exposure to the apparatus. Test-retest procedures can provide new answers, but should be intensively studied in order to revalidate the entire paradigm as an animal model of anxiety.

The Overlap Between Anxiety, Depression, and Obsessive-Compulsive Disorder

Abstract: The anxiety disorders include generalized anxiety disorder, specific phobia, social phobia, agoraphobia, and panic disorder. In addition to the specific symptoms of these disorders, there may be a common experience of anxiety and even dysphoria across the conditions, and of course recourse to the same drug or choice of drugs for treatment. This overlap probably occurs because of universal dimensions of distress or negative affectivity, a shared genetic predisposition, and a common neurobiology Evidence of shared genes is still based mainly on twin studies, but the shared neurobiology can be investigated directly by the investigation of emotional or cognitive bias either behaviorally or using functional brain imaging. This intermediate phenotype can then provide a substrate for understanding and developing medicines and psychological treatments.

A history of anxiety: from Hippocrates to DSM.

Abstract: This article describes the history of the nosology of anxiety disorders. Greek and Latin physicians and philosophers distinguished anxiety from other types of negative affect, and identified it as a medical disorder. Ancient Epicurean and Stoic philosophers suggested techniques to reach an anxiety-free state of mind that are reminiscent of modern cognitive psychology. Between classical antiquity and the late 19(th) century there was a long interval during which anxiety was not classified as a separate illness. However, typical cases of anxiety disorders kept being reported, even if under different names. In the 17(th) century, Robert Burton described anxiety in The Anatomy of Melancholy. Panic attacks and generalized anxiety disorder may be recognized in the "panophobias" in the nosology published by Boissier de Sauvages in the 18(th) century. Also, anxiety symptoms were an important component of new disease constructs, culminating in neurasthenia in the 19(th) century. Emil Kraepelin devoted much attention to the possible presence of severe anxiety in manic-depressive illness, thereby anticipating the "anxious distress" specifier of bipolar disorders in DSM-5. A pitfall to consider is that the meaning of common medical terms, such as melancholia, evolves according to places and epochs.

A systematic review of the neural bases of psychotherapy for anxiety and related disorders.

Abstract: Brain imaging studies over two decades have delineated the neural circuitry of anxiety and related disorders, particularly regions involved in fear processing and in obsessive-compulsive symptoms. The neural circuitry of fear processing involves the amygdala, anterior cingulate, and insular cortex, while cortico-striatal-thalamic circuitry plays a key role in obsessive-compulsive disorder. More recently, neuroimaging studies have examined how psychotherapy for anxiety and related disorders impacts on these neural circuits. Here we conduct a systematic review of the findings of such work, which yielded 19 functional magnetic resonance imaging studies examining the neural bases of cognitive-behavioral therapy (CBT) in 509 patients with anxiety and related disorders. We conclude that, although each of these related disorders is mediated by somewhat different neural circuitry, CBT may act in a similar way to increase prefrontal control of subcortical structures. These findings are consistent with an emphasis in cognitive-affective neuroscience on the potential therapeutic value of enhancing emotional regulation in various psychiatric conditions.

Oxytocin in the socioemotional brain: implications for psychiatric disorders.

Abstract: The neuropeptide oxytocin (OXT), highly conserved during evolution, is an important modulator of social and emotional processes across many species. During the last decade, a large body of literature has revealed its effects on different aspects of social behavior, including social stress and anxiety, social memory, affiliation and bonding, emotion recognition, mentalizing, empathy, and interpersonal trust. In addition, as impairments in these social domains can be observed in a number of neuropsychiatric disorders, such as autism, social anxiety disorder, depression, schizophrenia, and borderline personality disorder, the role of OXT in mental disorders and their treatment has been intensively studied. The present paper gives a short overview of these lines of research and shows how OXT has become a promising target for novel treatment approaches for mental disorders characterized by social impairments.

Treatment-refractory anxiety; definition, risk factors, and treatment challenges

Abstract: A sizable proportion of psychiatric patients will seek clinical evaluation and treatment for anxiety symptoms reportedly refractory to treatment. This apparent lack of response is either due to "pseudo-resistance" (a failure to have received and adhered to a recognized and effective treatment or treatments for their condition) or to true "treatment resistance." Pseudo-resistance can be due to clinician errors in selecting and delivering an appropriate treatment effectively, or to patient nonadherence to a course of treatment. True treatment resistance can be due to unrecognized exogenous anxiogenic factors (eg, caffeine overuse, sleep deprivation, use of alcohol or marijuana) or an incorrect diagnosis (eg, atypical bipolar illness, occult substance abuse, attention deficit-hyperactivity disorder). Once the above factors are eliminated, treatment should focus on combining effective medications and cognitive behavioral therapy, combining several medications (augmentation), or employing novel medications or psychotherapies not typically indicated as first-line evidence-based anxiety treatments.

Challenges in the diagnosis and treatment of depression in autism spectrum disorders across the lifespan.

Abstract: Diagnosis and treatment of comorbid neuropsychiatric illness is often a secondary focus of treatment in individuals with autism spectrum disorder (ASD), given that substantial impairment may be caused by core symptoms of ASD itself However, psychiatric comorbidities, including depressive disorders, are common and frequently result in additional functional impairment, treatment costs, and burden on caregivers Clinicians may struggle to appropriately diagnose depression in ASD due to communication deficits, atypical presentation of depression in ASD, and lack of standardized diagnostic tools Specific risk and resilience factors for depression in ASD across the lifespan, including level of functioning, age, family history, and coping style, have been suggested, but require further study Treatment with medications or psychotherapy may be beneficial, though more research is required to establish guidelines for management of symptoms This review will describe typical presentations of depression in individuals with ASD, review current information on the prevalence, assessment, and treatment of comorbid depression in individuals with ASD, and identify important research gaps

Depression in adolescents and young adults with cancer.

Abstract: Adolescents and young adults (AYAs) with cancer are at risk for depression due to disruptions in their developmental trajectory, greater physical symptom burden, and increased likelihood of developing aggressive disease. Rates of depression and other psychological disorders are substantially higher in AYAs with cancer when compared with older adults. Psychiatrists caring for these patients must consider the age-appropriate developmental context of these patients along with familial and medical factors that may influence the presentation and treatment of depression. Previous research suggests that psychosocial interventions specifically designed for AYA patients are promising, but studies of psychopharmacology treatments for depression are lacking. There is a pressing need for prospective studies and controlled clinical trials that evaluate the optimal strategies for treating depression in this patient group.

Focus on psychosis

Abstract: The concept of psychosis has been shaped by traditions in the concepts of mental disorders during the last 170 years. The term "psychosis" still lacks a unified definition, but denotes a clinical construct composed of several symptoms. Delusions, hallucinations, and thought disorders are the core clinical features. The search for a common denominator of psychotic symptoms points toward combinations of neuropsychological mechanisms resulting in reality distortion. To advance the elucidation of the causes and the pathophysiology of the symptoms of psychosis, a deconstruction of the term into its component symptoms is therefore warranted. Current research is dealing with the delineation from "normality", the genetic underpinnings, and the causes and pathophysiology of the symptoms of psychosis.

Assessment and treatment of mood disorders in the context of substance abuse.

Abstract: Recognition and management of mood symptoms in individuals using alcohol and/or other drugs represent a daily challenge for clinicians in both inpatient and outpatient treatment settings. Diagnosis of underlying mood disorders in the context of ongoing substance abuse requires careful collection of psychiatric history, and is often critical for optimal treatment planning and outcomes. Failure to recognize major depression or bipolar disorders in these patients can result in increased relapse rates, recurrence of mood episodes, and elevated risk of completed suicide. Over the past decade, epidemiologic research has clarified the prevalence of comorbid mood disorders in substance-dependent individuals, overturning previous assumptions that depression in these patients is simply an artifact of intoxication and/or withdrawal, therefore requiring no treatment. However, our understanding of the bidirectional relationships between mood and substance use disorders in terms of their course(s) of illness and prognoses remains limited. Like-wise, strikingly little treatment research exists to guide clinical decision making in co-occurring mood and substance use disorders, given their high prevalence and public health burden. Here we overview what is known and the salient gaps of knowledge where data might enhance diagnosis and treatment of these complicated patients.

Compound facial expressions of emotion: from basic research to clinical applications.

Abstract: Emotions are sometimes revealed through facial expressions. When these natural facial articulations involve the contraction of the same muscle groups in people of distinct cultural upbringings, this is taken as evidence of a biological origin of these emotions. While past research had identified facial expressions associated with a single internally felt category (eg, the facial expression of happiness when we feel joyful), we have recently studied facial expressions observed when people experience compound emotions (eg, the facial expression of happy surprise when we feel joyful in a surprised way, as, for example, at a surprise birthday party). Our research has identified 17 compound expressions consistently produced across cultures, suggesting that the number of facial expressions of emotion of biological origin is much larger than previously believed. The present paper provides an overview of these findings and shows evidence supporting the view that spontaneous expressions are produced using the same facial articulations previously identified in laboratory experiments. We also discuss the implications of our results in the study of psychopathologies, and consider several open research questions.

Measuring facial expression of emotion.

Abstract: Research into emotions has increased in recent decades, especially on the subject of recognition of emotions. However, studies of the facial expressions of emotion were compromised by technical problems with visible video analysis and electromyography in experimental settings. These have only recently been overcome. There have been new developments in the field of automated computerized facial recognition; allowing real-time identification of facial expression in social environments. This review addresses three approaches to measuring facial expression of emotion and describes their specific contributions to understanding emotion in the healthy population and in persons with mental illness. Despite recent progress, studies on human emotions have been hindered by the lack of consensus on an emotion theory suited to examining the dynamic aspects of emotion and its expression. Studying expression of emotion in patients with mental health conditions for diagnostic and therapeutic purposes will profit from theoretical and methodological progress.

The history of nosology and the rise of the Diagnostic and Statistical Manual of Mental Disorders.

Abstract: The current Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 arose from a tradition filled with haphazard science and politically driven choices. The nosology of modern psychiatry began with the German classifiers of the late 19th century, especially Emil Kraepelin. Psychoanalysis then blotted out the classificatory vision for the next half-century, and most of this European psychopathological science failed to cross the Atlantic. The DSM series was a homegrown American product, beginning with Medical 203 in 1945, then guided by psychoanalytic insights through DSM-I in 1952 and DSM-II in 1968. In 1980, DSM-III represented a massive "turning of the page" in nosology, and it had the effect of steering psychoanalysis toward the exit in psychiatry and the beginning of a reconciliation of psychiatry with the rest of medicine. With the advent of DSM-5, however, questions are starting to be asked about whether this massive venture is on the right track.

The effects of drugs on human models of emotional processing: an account of antidepressant drug treatment.

Abstract: Human models of emotional processing suggest that the direct effect of successful antidepressant drug treatment may be to modify biases in the processing of emotional information. Negative biases in emotional processing are documented in depression, and single or short-term dosing with conventional antidepressant drugs reverses these biases in depressed patients prior to any subjective change in mood. Antidepressant drug treatments also modulate emotional processing in healthy volunteers, which allows the consideration of the psychological effects of these drugs without the confound of changes in mood. As such, human models of emotional processing may prove to be useful for testing the efficacy of novel treatments and for matching treatments to individual patients or subgroups of patients.

Anxiety and DSM-5.

Abstract: The DSM-5 process, and the publication of DSM-5 in 2013, have had a considerable impact on the classification of anxiety disorders. Major changes included the reorganization of the chapter structure, individual groupings of disorders within each chapter from a life span viewpoint, and the use of specifiers. The DSM-5 chapter on anxiety disorders does not include obsessive-compulsive disorder or post-traumatic stress disorder. The chapter itself now reflects a developmental approach. The text of each disorder has been enhanced with short sections on development and course, risk and prognostic factors, etc. It is expected that the reformulation of anxiety disorders in DSM-5 will lead to greater precision in a variety of ways, as illustrated in the papers in this issue of Dialogues in Clinical Neuroscience. In summary, these changes in the way we classify anxiety disorders reflect our best view on the clinical empirical data and should prove useful in the assessment of specific anxiety disorders.

What develops during emotional development? A component process approach to identifying sources of psychopathology risk in adolescence.

Abstract: Adolescence is a phase of the lifespan associated with widespread changes in emotional behavior thought to reflect both changing environments and stressors, and psychological and neurobiological development. However, emotions themselves are complex phenomena that are composed of multiple subprocesses. In this paper, we argue that examining emotional development from a process-level perspective facilitates important insights into the mechanisms that underlie adolescents' shifting emotions and intensified risk for psychopathology. Contrasting the developmental progressions for the antecedents to emotion, physiological reactivity to emotion, emotional regulation capacity, and motivation to experience particular affective states reveals complex trajectories that intersect in a unique way during adolescence. We consider the implications of these intersecting trajectories for negative outcomes such as psychopathology, as well as positive outcomes for adolescent social bonds.

The Kraepelinian tradition

Abstract: Emil Kraepelin (1856-1926) was an influential figure in the history of psychiatry as a clinical science. This paper, after briefly presenting his biography, discusses the conceptual foundations of his concept of mental illness and follows this line of thought through to late 20th-century "Neo-Kraepelinianism," including recent criticism, particularly of the nosological dichotomy of endogenous psychoses. Throughout his professional life, Kraepelin put emphasis on establishing psychiatry as a clinical science with a strong empirical background. He preferred pragmatic attitudes and arguments, thus underestimating the philosophical presuppositions of his work. As for nosology, his central hypothesis is the existence and scientific accessibility of "natural disease entities" ("naturliche Krankheitseinheiten") in psychiatry. Notwithstanding contemporary criticism that he commented upon, this concept stayed at the very center of Kraepelin's thinking, and therefore profoundly shaped his clinical nosology.

Affiliative and prosocial motives and emotions in mental health.

Abstract: This paper argues that studies of mental health and wellbeing can be contextualized within an evolutionary approach that highlights the coregulating processes of emotions and motives. In particular, it suggests that, although many mental health symptoms are commonly linked to threat processing, attention also needs to be directed to the major regulators of threat processing, ie, prosocial and affiliative interactions with self and others. Given that human sociality has been a central driver for a whole range of human adaptations, a better understanding of the effects of prosocial interactions on health is required, and should be integrated into psychiatric formulations and interventions. Insight into the coregulating processes of motives and emotions, especially prosocial ones, offers improved ways of understanding mental health difficulties and their prevention and relief.

Eugen Bleuler's schizophrenia--a modern perspective.

Abstract: The introduction of the term and concept schizophrenia earned its inventor, Swiss psychiatrist Eugen Bleuler, worldwide fame. Prompted by the rejection of the main principle of Kraepelinian nosology, namely prognosis, Bleuler's belief in the clinical unity of what Kraepelin had described as dementia praecox required him to search for alternative characterizing features that would allow scientific description and classification. This led him to consider psychological, and to a lesser degree, social factors alongside an assumed underlying neurobiological disease process as constitutive of what he then termed schizophrenia, thus making him an early proponent of a bio-psycho-social understanding of mental illness. Reviewing Bleuler's conception of schizophrenia against the background of his overall clinical and theoretical work, this paper provides a critical overview of Bleuler's key nosological principles and links his work with present-day debates about naturalism, essentialism, and stigma.

Descriptive psychopathology, phenomenology, and the legacy of Karl Jaspers.

Abstract: With his early publications (1910-1913), Karl Jaspers created a comprehensive methodological arsenal for psychiatry, thus laying the foundation for descriptive psychopathology. Following Edmund Husserl, the founder of philosophical phenomenology, Jaspers introduced phenomenology into psychopathology as "static understanding," ie, the unprejudiced intuitive reproduction (Vergegenwartigung) and description of conscious phenomena. In a longitudinal perspective, "genetic understanding" based on empathy reveals how mental phenomena arise from mental phenomena. Severance in understanding of, or alienation from, meaningful connections is seen as indicating illness or transition of a natural development into a somatic process. Jaspers opted for philosophy early. After three terms of law, he switched to studying medicine, came to psychopathology after very little training in psychiatry; to psychology without ever studying psychology; and to a chair in philosophy without ever studying philosophy. In the fourth and subsequent editions of his General Psychopathology, imbued by his existential philosophy, Jaspers partly abandoned the descriptive method.

Affective preclinical modeling of psychiatric disorders: taking imbalanced primal emotional feelings of animals seriously in our search for novel antidepressants.

Abstract: Preclinical animal models of psychiatric disorders are of critical importance for advances in development of new psychiatric medicine. Regrettably, behavior-only models have yielded no novel targeted treatments during the past half-century of vigorous deployment. This may reflect the general neglect of experiential aspects of animal emotions, since affective mental states of animals supposedly cannot be empirically monitored. This supposition is wrong-to the extent that the rewarding and punishing aspects of emotion circuit arousals reflect positive and negative affective states. During the past decade, the use of such affective neuroscience-based animal modeling has yielded three novel antidepressants (i) via the alleviation of psychic pain with low doses of buprenorphine; (ii) via the amplification of enthusiasm by direct stimulation of the medial forebrain bundle); and (iii) via the facilitation of the capacity for social joy with play facilitators such as rapastinel (GLYX13). All have progressed to successful human testing. For optimal progress, it may be useful for preclinical investigators to focus on the evolved affective foundations of psychiatrically relevant brain emotional disorders for optimal animal modeling.

Emotional and cognitive dysregulation in schizophrenia and depression: understanding common and distinct behavioral and neural mechanisms

Abstract: Emerging behavioral and neuroimaging studies in schizophrenia (SCZ) and major depressive disorder (MD) are mapping mechanisms of co-occurring and distinct affective disturbances across these disorders. This constitutes a critical goal towards developing rationally guided therapies for upstream neural pathways that contribute to comorbid symptoms across disorders. We highlight the current state of the art in our understanding of emotional dysregulation in SCZ versus MD by focusing on broad domains of behavioral function that can map onto underlying neural systems, namely deficits in hedonics, anticipatory behaviors, computations underlying value and effort, and effortful goal-directed behaviors needed to pursue rewarding outcomes. We highlight unique disturbances in each disorder that may involve dissociable neural systems, but also possible interactions between affect and cognition in MD versus SCZ. Finally, we review computational and translational approaches that offer mechanistic insight into how cellular-level disruptions can lead to complex affective disturbances, informing development of therapies across MD and SCZ.

Cognitive behavioral group therapy for anxiety: recent developments.

Abstract: Anxiety disorders occur frequently, and can have a negative impact on the quality of people's lives. They often begin at an early age and can have some serious consequences. This article is an overview of the recent studies concerning group cognitive-behavioral interventions for anxiety disorders. In the last few years, anxiety disorder prevention for children and adolescents has become an important focus of research work. Group prevention programs are based on standard cognitive behavioral therapy (CBT) strategies and are aimed at preventing anxiety disorders as early as possible. Numerous cognitive behavioral group therapies for children as well as adults have been well studied. There are many CBT protocols that have been developed for treating specific anxiety disorders. Now, specialized CBT programs are available for individuals who suffer from different anxiety disorders, enabling them to be treated together in groups.

Optimizing the treatment of mood disorders in the perinatal period.

Abstract: The perinatal period is a time of high risk for women with unipolar and bipolar mood disorders. We discuss treatment considerations for perinatal mood disorders, including unipolar and bipolar depression as well as postpartum psychosis. We further explore the unique issues faced by women and their families across the full trajectory of the perinatal period from preconception planning through pregnancy and following childbirth. Treatment of perinatal mood disorders requires a collaborative care approach between obstetrics practitioners and mental health providers, to ensure that a thoughtful risk : benefit analysis is conducted. It is vital to consider the risks of the underlying illness versus risks of medication exposure during pregnancy or lactation. When considering medication treatment, attention must be paid to prior medication trials that were most efficacious and best tolerated. Lastly, it is important to assess the impact of individual psychosocial stressors and lifestyle factors on treatment response.