Perinatal Psychiatric Disorders: An Overview: Obstetrics
Perinatal Psychiatric Disorders: An Overview: Obstetrics
Perinatal Psychiatric Disorders: An Overview: Obstetrics
org
OBSTETRICS
Perinatal psychiatric disorders: an overview
Elena Paschetta, MD; Giles Berrisford, MD; Floriana Coccia, MD; Jennifer Whitmore, MD; Amanda G. Wood, PhD;
Sam Pretlove, MD; Khaled M. K. Ismail, PhD
FIGURE 1
Classification of common perinatal mental disorders
This figure summarizes common perinatal psychiatric disorders that can occur during the perinatal period.
GAD, generalized anxiety disorder; OCD, obsessive-compulsive disorder; PNMD, perinatal mental disorders; PTSD, posttraumatic stress disorder.
Paschetta. Perinatal Mental Health. Am J Obstet Gynecol 2014.
BPAD is characterized by episodes of Their reported prevalence rates range Psychotic disorders
mania or hypomania, typically alter- from 4.5%34 to 15%.20,22,31,44 Some au- The lifetime prevalence of schizophrenia
nating with episodes of depression. thors suggest that following childbirth, is approximately 1-2%.58 Key manifes-
Childbirth is often related to the initial an increasing proportion of women tations of disease include psychotic
onset of BPAD.38,39 Up to 50% of women experience PTSD.45-48 However, other symptoms such as hallucinations and
with a history of BPAD have a risk of studies report higher rates of OCD and delusions, affective disturbances such
relapse perinatally,40,41 especially after GAD in postpartum women compared as emotional blunting, and signicant
childbirth, when this risk is higher for with general population.49-52 occupational and social dysfunction.
BPAD than any other form of mental Among specic phobias, tokophobia The risk of relapse during the rst 3
illness.42 Studies indicate that the risk of (a morbid fear of childbirth) is gaining months postpartum is approximately
relapse is highest in the rst 2 weeks increased attention in clinical practice, 24-25%,59,60 especially following treat-
postpartum, typically commencing as especially for the high perinatal comor- ment discontinuation.61,62
early as between days 2 and 4.43 bidity with mood and anxiety disor-
ders53 and the frequent request of Puerperal psychosis
Anxiety disorders elective cesarean section. Preliminary This is reported to occur following 1-2
A wide range of anxiety disorders reports have shown that treatment for per 1000 births,29,63-65and has its onset
are seen perinatally; these include tokophobia and comorbid psychiatric commonly within the rst 2 weeks
obsessive compulsive disorder (OCD), conditions53 during pregnancy can lead postpartum.42,66 Women usually develop
posttraumatic stress disorder (PTSD), to a signicant reduction of the fear of paranoid, grandiose, or bizarre de-
generalized anxiety disorder (GAD), vaginal delivery with a withdrawal in lusions, mood lability, and perplexity.
panic disorder, and specic phobias. request for cesarean sections.54-57 These features represent a dramatic
temperament, and vulnerable maternal visits. Attention should be paid to any history of serious affective disorder
personality traits90,101,102 seem to be sign of poor self-care and over- or un- (59%), such as puerperal psychosis
other important and stable determinants deractivity. Particular care should be and severe depression4 ; substance use;
of PPD.103,104 given to suicidal ideation or thoughts and intimate partner problems.126,135
Finally, small but signicant pre- of harming the baby, substance abuse, Furthermore, maternal suicide can
dictors include obstetric and pregnancy and domestic violence. One of the be associated with a risk of infanti-
complications,8,83,105 especially hyper- most important risk factor is a previ- cide.133,136 It is a rare event but can have
emesis and premature contractions,106 ous personal or family history of psy- tragic consequences, so it is important
and socioeconomic status,90,101,107-112 chopathology. It is essential to take a to highlight.
which conversely represents a strong focused history on past or present Up to 50% of pregnancies in the
predictor of PPD in the developing severe mental illness, previous treatment general population are unplanned, and
world.15,113 The disparity in the rates of by a psychiatrist or specialist mental the rate is even higher in women
perinatal mental disorders between health team, and any personal or suffering from mental illness.137 Among
women living in high- and low-income family history of perinatal mental health these women, the frequency of sexual
settings suggests social rather than bio- problems. activity may be normal, but contracep-
logical determinants.113 The literature shows a wide variability tive use may be lower and autonomous
Predictors of puerperal psychosis of antenatal screening tools for perinatal reproductive decision-making compro-
include previous episodes or family psychiatric disorders in different coun- mised.138 Women with mental illnesses
history; personal history of psychotic tries.127 The British National Institute often start their pregnancy without
disorders, especially schizophrenia; per- for Health and Clinical Excellence having their medications optimized and
sonal or family history of BPAD114; guidelines2 specically recommend the often stop taking them abruptly when
medication nonadherence; poor social utilization of the Whooley questions128 they nd out they are pregnant, which
support115-117; younger age; and un- to screen for antenatal depression. frequently leads to a relapse of their
planned pregnancy.118 Sleep distur- However, some authors127 highlighted a psychiatric symptoms.40,42,66,69,115,139
bances have also been found as an lack of evidence in its effectiveness and They are more likely to default ante-
important risk factor for puerperal psy- also a need for further research to iden- natal care appointments, use substances,
chosis relapse in susceptible women.119 tify universal screening tools. have a poor diet, and be overweight, all
Considering anxiety disorders, previ- When these strategies are instigated, of which are lifestyle factors associated
ous lifetime episodes, low social support, care must be taken to ensure that with poor obstetric outcomes.59,140-143
a history of child abuse, and a perception all women are screened and assessed It is increasingly recognized that
of high peripartum stress are all risk because it has been recognized that severe mental illnesses can be an un-
factors for experiencing anxiety disor- in practice, implementation can be derlying cause of pregnancy-related
ders during the perinatal period.120,121 patchy.129 All pregnant women identi- medical disorders and obstetric compli-
Multiparity has also been identied as ed as high risk should have a shared cations.83,144-159 It is suggested that one
another potential contributor to gener- multidisciplinary care plan for their biological mechanism linking severe
alized anxiety in pregnancy.121 With re- late pregnancy and early postnatal mental illnesses and some pregnancy-
gard specically to PTSD, during the management.117 related complications is a result of the
postpartum period, PTSD has been promoting effect of these illnesses on
found to be associated with behavioral Effects on short-term outcomes the immune system that subsequently
health risks and PTSD at the onset of Mental illness in the perinatal period increases the levels of inammatory
pregnancy.122 Other known risk factors can have a signicant impact on markers and altering proinammatory
of postpartum PTSD include younger maternal health, birth outcomes, and cytokines regulation.160
age, severe preeclampsia, cesarean fetal development. The British Con- Another possible biological mecha-
section, lower gestational age, lower dential Enquiries into Maternal Deaths nism is represented by the overactivity
birthweight, baby admitted to the reported that psychiatric disorders of the maternal neuroendocrine system
neonatal intensive care unit, and peri- contributed to 12% of all maternal caused by maternal psychosocial stress
natal death.123,124 deaths in 2002-2005.130 Currently, sui- and preexisting psychiatric symp-
Finally, women with a past or current cide is a leading cause of perinatal toms.161,162 Several studies reported an
psychiatric disorder, especially puerperal maternal deaths in industrialized coun- association between maternal mental
psychosis and severe depression,4 a tries, but there is still little research on illness/stress and changes in the fetal heart
substance-use disorder, and intimate its prevalence and correlates,131,132 rate and vascular distribution as well as
partner problems have been found at especially in the developing world.133 negative fetal outcomes, including intra-
increased risk of postpartum suicide Among female suicide victims of uterine growth retardation,83,154,161,163
attempt compared with controls.125,126 reproductive age, recent data show a lower Apgar scores,164,165 congenital
Inquiries about psychiatric symptoms high prevalence of an existing mental malformations,143,151,154,165-168 and peri-
should be made at the initial antenatal health diagnosis126,132,134 or a past natal loss.146,154,165,168-171
Management
FIGURE 2
Multidisciplinary nonpharmacological
Multidisciplinary models for managing PNMDs
interventions
All current guidelines2,3 recommend
obstetricians and hospital/community
midwives identify women (preferably
at their early pregnancy assessment) with
past or present severe mental illness
including schizophrenia and other psy-
choses, BPAD and moderate to severe
depression, a previous psychiatric treat-
ment, and a family history of perinatal
psychiatric disorder. Women identied
at risk need to be referred to specialist
perinatal mental health professionals
for further assessment, specic in-
terventions, and the monitoring of their
mental health both during pregnancy
and postpartum.
Some of these guidelines2 recognize
the need for a written care plan for
women so that information can be
shared between obstetric and specialist
This figure summarizes all the proposed multidisciplinary models for the management of perinatal
perinatal mental health services and
mental disorders.
all professionals involved in their care.
CPN, community psychiatric nurse; PNMD, perinatal mental disorders; PNMH, perinatal mental health.
Conditions such as substance abuse
Paschetta. Perinatal Mental Health. Am J Obstet Gynecol 2014.
and domestic violence should also be
considered as risk factors for perinatal
mental health morbidity and should be
managed by specialist services. risk of relapse. Based on individual need, for depression in both antenatal and
In women whose pregnancy or post- these women may be advised to start postnatal period.2,3 In pregnant women
partum year is complicated by serious prophylactic treatment during preg- with recurrent depressive disorder, it is
mental illness, apart from specic phar- nancy or soon after delivery and may be important to continue pharmacological
macological interventions, the available referred to mother and baby units as a treatment because moderate to severe
guidelines2 recommend establishing spe- precaution should their mental health depression is unlikely to respond to
cialized community perinatal teams to deteriorate. talking therapies. Moreover, discontin-
monitor their mental state during preg- Nonpharmacological treatment such uation of antidepressants can often lead
nancy and postpartum. Mother and as cognitive behavioral therapy and to relapse (75%) in the rst trimester.139
baby units are used to treat acutely ill interpersonal therapy228 may be of Women with a previous history of
women who cannot be safely managed benet, but evidence is limited for this puerperal psychosis and who are drug
in the community within the last weeks except for the treatment of depression.2 free during pregnancy should be advised
of pregnancy or after childbirth.227 The recommendations for screening to start an atypical antipsychotic and/or
Women who develop a puerperal psy- at booking have been widely but not a mood stabilizer at 32 weeks gestation.
chosis or who are at a very high risk universally implemented. It is of huge Because of the higher risk of relapse
of relapse227 should ideally be admitted concern that access to specialized peri- after subsequent pregnancies,68 during
with their baby to these specialized units. natal mental health services is still not which these women are reluctant to
This enables mothers to remain with readily available in most countries.5,229 consider medication in pregnancy, it is
their baby in a safe supervised environ- Figure 2 summarizes the proposed recommended to commence treatment
ment in which they can also be treated multidisciplinary models for managing immediately after delivery, preferably
for their psychiatric illness. perinatal mental disorders. before the discharge from hospital. This
Women with a past personal or family way therapeutic levels will be established
history of severe mental illness should be Pharmacological interventions when the woman enters the high-risk
carefully monitored by specialist mental Selective serotonin reuptake inhibitors period in the rst week postpartum.43
health professionals throughout the (SSRIs; with the exception of paroxe- Puerperal psychosis is usually very
perinatal period because of the higher tine)230 are advised as rst-line treatment responsive to treatment, but delays in
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