Postpartum Psychiatric Disorders
Postpartum Psychiatric Disorders
Postpartum Psychiatric Disorders
General Information
The Postpartum Period
During the postpartum period, about 85% of women experience some type of mood disturbance. For most the symptoms are mild and short-lived; however, 10 to 15% of women develop more significant symptoms of depression or anxiety. Postpartum psychiatric illness is typically divided into three categories: (1) postpartum blues (2) postpartum depression and (3) postpartum psychosis. It may be useful to conceptualize these disorders as existing along a continuum, where postpartum blues is the mildest and postpartum psychosis the most severe form of postpartum psychiatric illness.
Postpartum Blues
It appears that about 50 to 85% of women experience postpartum blues during the first few weeks after delivery. Given how common this type of mood disturbance is, it may be more accurate to consider the blues as a normal experience following childbirth rather than a psychiatric illness. Rather than feelings of sadness, women with the blues more commonly report mood lability, tearfulness, anxiety or irritability. These symptoms typically peak on the fourth or fifth day after delivery and may last for a few hours or a few days, remitting spontaneously within two weeks of delivery. While these symptoms are unpredictable and often unsettling, they do not interfere with a womans ability to function. No specific treatment is required; however, it should be noted that sometimes the blues heralds the development of a more significant mood disorder, particularly in women who have a history of depression. If symptoms of depression persist for longer than two weeks, the patient should be evaluated to rule out a more serious mood disorder.
Postpartum Depression
PPD typically emerges over the first two to three postpartum months but may occur at any point after delivery. Some women actually note the onset of milder depressive symptoms during pregnancy. Postpartum depression is clinically indistinguishable from depression occurring at other times during a womans life. The symptoms of postpartum depression include:
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Depressed or sad mood Tearfulness Loss of interest in usual activities Feelings of guilt Feelings of worthlessness or incompetence Fatigue Sleep disturbance Change in appetite Poor concentration Suicidal thoughts
Significant anxiety symptoms may also occur. Generalized anxiety is common, but some women also develop panic attacks or hypochondriasis. Postpartum obsessive-compulsive disorder has also been reported, where women report disturbing and intrusive thoughts of harming their infant. Especially with milder cases, it may be difficult to detect postpartum depression because many of the symptoms used to diagnose depression (i.e., sleep and appetite disturbance, fatigue) also occur in postpartum women in the absence of depression. The Edinburgh Postnatal Depression Scale is a 10-item questionnaire that may be used to identify women who have PPD. On this scale, a score of 12 or greater or an affirmative answer on question 10 (presence of suicidal thoughts) raise concern and indicate a need for more thorough evaluation.
Postpartum Psychosis
Postpartum psychosis is the most severe form of postpartum psychiatric illness. It is a rare event that occurs in approximately 1 to 2 per 1000 women after childbirth. Its presentation is often dramatic, with onset of symptoms as early as the first 48 to 72 hours after delivery. The majority of women with puerperal psychosis develop symptoms within the first two postpartum weeks. It appears that in most cases, postpartum psychosis represents an episode of bipolar illness; the symptoms of puerperal psychosis most closely resemble those of a rapidly evolving manic (or mixed) episode. The earliest signs are restlessness, irritability, and insomnia. Women with this disorder exhibit a rapidly shifting depressed or elated mood, disorientation or confusion, and erratic or disorganized behavior. Delusional beliefs are common and often center on the infant. Auditory hallucinations that instruct the mother to harm herself or her infant may also occur. Risk for infanticide, as well as suicide, is significant in this population.
While all of these factors may act together to cause PPD, the emergence of this disorder probably reflects an underlying vulnerability to affective illness. Women with histories of major depression or bipolar disorder are more vulnerable to PPD, and women who develop PPD will often go on to have recurrent episodes of depression unrelated to pregnancy or childbirth.
standard antidepressant doses were effective and well tolerated. The choice of an antidepressant should be guided by the patients prior response to antidepressant medication and a given medications side effect profile. Specific serotonin reuptake inhibitors (SSRIs) are ideal first-line agents, as they are anxiolytic, non-sedating, and well tolerated. For women who cannot tolerate SSRIs, bupropion (Wellbutrin) may be an alternative; although one pilot study suggests bupropion may not be as effective as SSRIs. Tricyclic antidepressants (TCAs) are frequently used and, because they tend to be more sedating, may be more appropriate for women who present with prominent sleep disturbance. Given the prevalence of anxiety symptoms in this population, adjunctive use of a benzodiazepine (e.g., clonazepam, lorazepam) may be very helpful. Puerperal psychosis is considered a psychiatric emergency that typically requires inpatient treatment. Acute treatment with either typical or atypical anti-psychotic medications is indicated. Given the wellestablished relationship between puerperal psychosis and bipolar disorder, postpartum psychosis should be treated as an affective psychosis and a mood stabilizer is indicated. Electroconvulsive therapy (ECT) is well tolerated and rapidly effective for severe postpartum depression and psychosis.
Clinical evaluation for postpartum mood and anxiety disorders Medication management Consultation regarding breastfeeding and psychotropic medications Recommendations regarding non-pharmacological treatments Referral to support services within the community
concern, or fear that having the baby was a mistake. These fears may worsen if the women's partner is not supportive and if there are no close relatives or friends to give emotional and physical assistance after delivery. A new father may feel worried, frustrated, and helpless in response to his wife's postpartum tearfulness and irritability, which can intensify the mother's sense of inadequacy. Postpartum symptoms can be traumatic for both new parents and may prolong the postpartum syndrome. The purpose of this document is to discuss the postpartum psychiatric disorders and to help primary care physicians to recognize and manage the emotional and psychiatric problems that can occur in the postpartum period.
1. Postpartum Blues: it is the mildest of the postpartum disorders and is often a relatively normal part of the birth experience. It affects 50% to 80% of new mothers in the first week of birth experience and usually resolves by the end of the first postpartum month. Postpartum/ maternity blues is characterized tearfulness, irritability, sleep disturbance, anxiety, fatigue, forgetfulness, and day after delivery. Risk factors for postpartum blues include primiparous pregnancy and a history of premenstrual syndrome. 2. Postpartum Depression: it is present in 10% to 15% of new mothers. This is a more severe disorder than postpartum blues and is clinically similar to major depressive disorder. Women may present as sad and tearful, may complain of sleep and appetite disturbances, and may have difficulty concentrating. They sometimes experience suicidal ideation and impairment in daily functioning. The diagnosis of postpartum depression is usually apparent by the second or third week postpartum. 3. Postpartum Psychosis: it is most severe but the least common of the postpartum psychiatric disorders affecting 1 to 2 per 1,000 new mothers. It is defined as a psychosis occurring within the first six months after childbirth. Clinical features include obsessive thoughts of hurting the baby or oneself, as well as more classic psychotic symptoms such as auditory hallucinations,
delusions, and disorganized thoughts. Postpartum psychosis must be rapidly identified and treated, as the risk of infanticide during an episode of postpartum psychosis may be as high as 4%.
Risk Factors:
The most important risk factor for postpartum depression and postpartum psychosis is a past history of psychiatric illness. The risk is greatest if the patient has history of bipolar disorder and slightly lower if she has a history of unipolar depression. Women with a prior diagnosis of an affective disorder have a 20% to 25% chance of a postpartum psychosis. Other risk factors for these disorders include having a first baby, an unwanted pregnancy, and environmental stressors during the third trimester or early postpartum period, giving birth by cesarean section, an unstable or absent marital relationship, and a lack of social supports. Women who have a complicated delivery or a premature, abnormal, or sick child are at higher risk for postpartum disorders than are those who have lost the child through stillbirth or perinatal death. Women with bipolar disorder who have little insight into the recurrent nature of their illness, who have not taken psychotropic medications during their pregnancy, and who are determined to breast feed present special problems. These patients often refuse to take their mood stabilizer during pregnancy, both because of the potential risk to the fetus and because they lack insight into the risks of discontinuing their medications. For the same reasons, some bipolar patients may refuse to restart medication immediately after delivery and may not recognize or report recurrent symptoms, thus risking exacerbation of their disorder and psychiatric hospitalization during the postpartum period. Recurrent illness can cause a woman with bipolar illness to become progressively fearful that her husband and physicians are not to be trusted and that she and her baby are in danger. Such a situation can be volatile, even if the primary care physician has a good rapport with the patient and there is close family involvement.
Diagnostic Issues:
The diagnosis of postpartum blues, postpartum depression, and postpartum psychosis is based on the clinical interview and on history from the patient and her family. In treating patients with a history of depression or bipolar disorder, vigilance is essential so that signs of developing postpartum psychiatric illness can be caught early. A patient with affective disorder will do best when she is assured that her primary care physician understands postpartum depression and psychosis and has a plan to manage such problems if they arise. The patient's anxiety may decrease markedly if she and her family are given concrete instructions to observe for new or worsening psychiatric symptoms, such as vegetative signs of depression, suicidal or violent thoughts, and auditory hallucinations. Postpartum blues is a mild adjustment disorder that commonly presents during the first week after delivery in which the new mother has a protracted period of mildly depressed mood with tearfulness, irritability, sleep disturbance, forgetfulness, and mild confusion. Auditory hallucinations, paranoid ideation, obsessive thoughts of harming the baby, or thought disturbances are not present. Reality testing is intact, and the patient is able to function at an adequate level and receive some pleasure from the baby. Symptoms peak by the 7th day and typically last throughout the first 3 to 4 weeks of postpartum period.
Symptoms of postpartum depression usually begin in the second week and peak in the third or fourth week after delivery. Women with this disorder generally meet criteria for major depressive disorder. Common symptoms are feelings of hopelessness or helplessness, decreased self-care, and inadequate care for baby. Suicidal and homicidal ideation is not infrequent. The clinician should monitor patients with a prior diagnosis of major depressive disorder or bipolar disorder, as postpartum depression is much more common in these patients. Postpartum psychosis is an extremely serious condition, with an incidence of about 4% and a high suicide risk. This psychosis is most common in patients with a history of bipolar disorder. Patients with psychotic disorder such as schizophrenia may experience an exacerbation of their symptoms in the postpartum period, which can be confused with postpartum psychosis. Patients with postpartum psychosis may experience auditory hallucinations and paranoid delusions with impaired reality testing. They may also demonstrate signs and symptoms of delirium, such as a waxing and waning mental state and confusion. The patient may believe that hospital personnel or family members are planning to harm her baby and may attempt to escape from a situation she perceives as dangerous. If a patient develops psychotic symptoms in the postpartum period and has no prior history of psychosis, the first step is to rule out possible medical causes of psychosis, such as thyroid dysfunction, stokes, CNS tumors, metabolic disturbances, and Sheehan's syndrome.
treatment. If a psychiatrist is not readily available, the patient should be escorted to a hospital emergency room. Outpatient treatment is not appropriate in cases in which the patient presents a potential danger to herself or to the baby. The patient suffering from postpartum depression who is not suicidal or homicidal can be managed as an outpatient; however, this requires the involvement of the patient's entire support system. The patient's significant other will probably have little or no experience in dealing with his partner's depression and will need to be educated about the disorder. He will need to understand that postpartum depression is a psychiatric disorder caused by temporary chemical imbalances in the brain and that the mother is not to blame. If a depressed mother is not able to take care of her infant, home care can help protect the infant from adverse sequelae of maternal depression. Such assistance also enables the patient to feel less pressured and less guilty during the illness and can enable her to have some quality time with her baby. Antidepressant medications generally are prescribed in the treatment of postpartum depression. However, as most antidepressants are secreted in breast milk, pharmacotherapy often precludes breast feeding. Although many women and their partners may choose breastfeeding over treatment with antidepressants, treatment should begin without delay. This is because maternal depression in the postpartum period can interfere significantly with mother-infant bonding, and severe maternal depression is associated with infant depressive symptoms, failure to thrive, delayed infant development, and behavioral problems. SSRIs have become first-line treatment for depressive disorders. If a patient has responded previously to an antidepressant, she generally should resume the drug. One of the most serious potential adverse effects of all antidepressants is mania. Patients with a history of bipolar disorder should be treated with antidepressants only after they are on a therapeutic dose of a mood stabilizer, such as valproate, lithium, or carbamazepine. It is very important to involve a psychiatric consultant in the care of such patients. Patients without a past history of psychiatric disorders may experience postpartum depression as a first manifestation of bipolar disorder. Such patients may have a greater tendency to become manic on antidepressants and should be monitored closely for manic symptoms. If pressured speech, increasing insomnia, racing thoughts, or psychotic symptoms develop in a patient on an antidepressant medication, the medication should be discontinued and the patient referred immediately for an emergency psychiatric consultation.
Editor's Note
Various investigators have argued that postpartum mental illness consists of a group of psychiatric disorders that are specifically related to pregnancy and childbirth and therefore exists as a distinct diagnostic entity. However, recent evidence suggests that affective illness that emerges during the postpartum period does not differ significantly from affective illness occurring in women at other times. This opinion is reflected in the fourth edition of Diagnostic and Statistic Manual of Mental Disorders (DSM-IV), which includes postpartum psychiatric illness as a subtype of either bipolar disorder or major depressive disorder.
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