Dr Robert London

Treating anxiety in pregnancy

Clinical Psychiatry News - 06/10/13

When a working woman becomes pregnant, one of her main questions is: What will I do about maternity leave?

When a working woman suffers from anxiety because she becomes pregnant, she might ask: Which will I choose – the baby or the job?

All too often, women I’ve talked to and treated discover that they have no maternity leave and that the only way to take time off is to do so under the Family Medical Leave Act. This law, which allows certain employees to take up to 12 unpaid weeks of leave, might be great for some women (and men). However, taking time off without pay is not an option for many women.

In fact, a recent study by the Pew Research Center showed that a record 40% of all U.S. households with children under 18 have mothers who are either the only source of income for the family or the primary source. In other words, a large percentage of households depend on the mother’s income.

The angst caused by these income pressures brings unnecessary stress to our pregnant patients, which in turn can lead to adverse effects for the fetus as well as the mother. One review of 13 studies published from 1966 to 2006 found that in 8 of the studies, anxiety during pregnancy was tied to prematurity and low birthweight (Cad. Saude Publica. 2007;23:747-56).

Psychiatrists and mental health professionals who treat pregnant women with anxiety issues would do best using cognitive-behavioral therapy and relaxation techniques coupled with guided imagery, thus avoiding medications. From a philosophical point of view, we need to be active in advocating on behalf of public policies that support paid maternity leave for mothers of newborns and allow the United States to join the ranks of other industrialized nations.

For example, Canada provides its citizens with paid maternity benefits for up to a maximum of 15 weeks, in addition to parental benefits for up to a maximum of 35 weeks. The parental leave benefit can be divided between partners in any way a couple so chooses. In addition, Canada does the right thing by extending eligibility for maternity benefits to surrogate mothers and parental benefits to adoptive parents, according to Service Canada.

Training self-help strategies

The potential risk of psychotropic medications to both the mother and the fetus remains controversial. I have stayed away from prescribing medications for pregnant patients suffering from anxiety, and I have had positive results. My approach has been to treat these disorders using cognitive-behavioral therapy (CBT) and relaxation/hypnosis, coupled with guided imagery.

Pregnant women with anxiety tend to ruminate about the future and "what will be" on a number of issues. These concerns become more excessive and intense in their minds when the baby is born into an economically challenging financial situation to a mother with limited or no maternity leave. Using the CBT approach for such patients offers a new and lasting perspective on thoughts driving the anxiety, giving a wider berth for negative thoughts to be challenged, changed, and channeled into the more here-and-now thinking with an emphasis on focusing the patient on taking the best care of herself each day.


Anxiety and future worries can play tricks on the person’s thinking. The key is to get the patient to live "where her feet are" and avoid the frightening thoughts of "what ifs" tied to the future. This allows the patient to shift away from negative "all or nothing" or "this or that" thinking. The clinician allows the person to stay more in the moment with a new and broader perspective on the issues facing her and to think about the beauty of childbirth. This shift in thinking that occurs with CBT, which reduces anxiety, will allow the patient to tap into clearer thinking and into her strength, to develop a better idea about the future, including how much time she will be able to free up for child care. She also will be better able to determine what types of plans, including financial planning, can be developed after childbirth.

In some cases, relaxation/hypnotic techniques coupled with guided imagery is most helpful in lowering anxiety levels on a daily basis. I give the patient instruction in these techniques and teach her how to do the techniques on her own on a daily basis. It’s extremely helpful for the patient to practice the relaxation and guided imagery techniques on her own for a few moments many times a day to increase proficiency.

Policy changes are needed

When did the thinking change on how much time a woman should take off with her baby? Back when my father graduated from medical school in the 1930s, the universal thinking among his medical and surgical peers (who often did prenatal and delivery care) was that it took at least a year or more before the mother was back physically and mentally. But these days, that age-old clinical concept is not really accepted, and women are given clearance to return to work within 6 weeks after a vaginal birth. From a psychological perspective, that’s just not enough time.

Canada is certainly not the only industrialized country with maternity leave policies that are more reasonable. A recent report by Institute for Women’s Policy Research says that the United States is the only high-income country that does not mandate paid maternity leave for employees. The Family and Medical Leave Act 2012 survey estimates that about 35% of employees work for companies that provide paid maternity leave, and about 20% provide paid paternity leave. Of course, lower-paid employees are least likely to have paid leave.

Interestingly, Marissa Mayer, chief executive officer of Yahoo, has recently started offering new mothers and fathers 8 weeks of paid parental leave, and mothers have the option of taking an additional 8 weeks. This is not as generous as the family policies of Google, Mayer’s former employer, which offers 7 weeks of paid leave for parents who did not give birth and up to 22 weeks for new mothers. Facebook reportedly gives mothers and fathers 4 months of paid leave as well as $4,000 in "baby cash." The model set by Silicon Valley companies does a great job of addressing the needs of new mothers.


We regularly speak of the importance of mental health. However, when it comes to the mental health of expectant mothers (and fathers), we have failed to provide what most industrialized countries accept as normal: a financially secure year to heal from giving birth, and to nourish and nurture the newborn child.

We must encourage mental health advocacy organizations and politicians to put more emphasis on addressing this important issue.

Dr. London is a psychiatrist with NYU Langone Medical Center. He has no conflicts of interest to disclose.