Psychiatric disorders in the postpartum period

The three psychiatric disorders most common after the birth of a baby are postpartum blues, postpartum depression, and postpartum psychosis. Depression and psychosis present risks to both the mother and her infant, making early diagnosis and treatment important. (A full description of pharmacological and nonpharmacological therapies for these disorders will appear in Part 2 of this theme issue in April 2005.)

Postpartum blues

Postpartum blues refers to a transient condition characterized by irritability, anxiety, decreased concentration, insomnia, tearfulness, and mild, often rapid, mood swings from elation to sadness. A large number of postpartum women (30% to 75%) develop these mood changes,[1] generally within 2 to 3 days of delivery. Symptoms peak on the fifth day postpartum and usually resolve within 2 weeks.[2] Typically, providing support and reassurance to the new mother and stressing the importance of adequate time for sleep and rest will be sufficient treatment for postpartum blues. The use of minor tranquilizers at low doses (e.g., lorazepam 0.5 mg) may be helpful for insomnia. Careful monitoring during this period is essential, since a small proportion of women with postpartum blues may develop postpartum depression.[3]

Postpartum depression

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) defines postpartum depression (PPD) as depression that occurs within 4 weeks of childbirth.[4] However, most reports on PPD suggest that it can develop at any point during the first year postpartum, with a peak of incidence within the first 4 months postpartum.[1] The prevalence of depression during the postpartum period has been systematically assessed; controlled studies show that between 10% and 28% of women experience a major depressive episode in the postpartum period, with the majority of studies favoring a 10% figure.[5]

Several key risk factors have been identified as major contributors to the development of PPD, including:

• A history of postpartum depression.[6] 
• A history of depression before conception.[7] 
• A family history of depression, particularly PPD.[7,8]

In addition, several other factors may contribute to the development of PPD, including poor social support, the experience of adverse life events during the postpartum period, marital instability, young maternal age, and infants with health problems or perceived “difficult” temperaments.

Symptoms of PPD are similar to the symptoms of a major depressive episode experienced at any other time (see the Table ). There are, however, subtle differences, including:

• Difficulty sleeping when the baby sleeps.
• Lack of enjoyment in the maternal role. 
• Feelings of guilt related to parenting ability.

A significant number of women also experience concomitant symptoms of anxiety, including panic attacks and obsessional fears or images of harm occurring to their babies. These can be very frightening for the mother.

Prior to making a psychiatric diagnosis in the postpartum period, it is important to rule out any underlying medical condition. Women suffering from early postpartum anemia may be at increased risk of developing postpartum depression.[9] Likewise, we know that the postpartum period is associated in some women with pathological changes in thyroid function, especially thyroiditis.[10] Testing for CBC and TSH should be part of a complete workup.

Despite the identified symptoms and risk factors associated with the illness, PPD is often missed at the primary care level. One explanation for this is that the care provider may be more focused on the health of the infant and may therefore miss any signs of maternal psychiatric illness. In addition, many women may try to conceal their illness because of shame or embarrassment about feeling depressed during what is supposed to be such a happy time. The consequences of misdiagnosing or not treating postpartum depression can be serious. For the mother, untreated depression can lead to the development of a chronic depressive illness and poses a risk of suicide. Untreated PPD can also have many negative consequences for the infant; the negative interactive patterns formed during the critical early bonding period may affect the later development of the child. For example, conduct disorders, inappropriate aggression, and cognitive and attention deficits have been described in children exposed to maternal psychiatric illnesses and these disturbances have continued even after remission of the maternal depression.

Every new mother should be asked about her psychological functioning. Women with a history of major depression or a family history of psychiatric illness should be identified in pregnancy and followed closely in the postpartum period. A very useful and easily administered screening tool for postpartum depression is the validated Edinburgh Postnatal Depression Scale (see Figure HTML, PDF); this scale can be copied and used free of charge).[11-13] The patient can complete the questionnaire at her physician’s office prior to her first postpartum follow-up appointment or when she brings her baby for immunization. For each question, the patient will choose one of four possible replies that reflect how she has been feeling over the past 7 days. Responses are scored as 0, 1, 2, or 3, for a maximum score of 30. A minimum score of 12 has been found to identify most women with a diagnosis of postpartum depression.

Postpartum psychosis

First-onset psychosis in the perinatal period is a rare condition. The prevalence of postpartum psychosis has consistently been reported as approximately 1 to 2 per 1000 live births. This condition has a rapid onset, usually manifesting itself within the first 2 weeks after childbirth or, at most, within 3 months postpartum, and should be considered a medical and obstetrical emergency.[15] The presence of a psychotic disorder may interfere with a woman obtaining proper prenatal and postpartum care.

Several major risk factors[16-18] have been identified in relation to postpartum psychosis:

• History of psychosis with previous pregnancies.
• History of bipolar disorder.
• Family history of psychotic illness (e.g., schizophrenia or bipolar disorder).

Patients may present with symptoms resembling an acute manic episode or a psychotic depression. They may present with delusions or hallucinations that are frightening to them. Many patients also have additional symptoms that resemble a delirium and involve distractability, labile mood, and transient confusion.[19]

Patients with postpartum psychosis have lost touch with reality and are at risk of harming themselves or their babies. Postpartum psychosis is an emergency that requires immediate medical attention. In most cases, it will be necessary for the mother to be hospitalized until she is stable. Medications (including antidepressants, neuroleptics, and mood stabilizers) or electroconvulsive therapy may be needed to control the psychosis.

The absolute risk of neonaticide (death of the baby within 24 hours of birth) and of infanticide (death within the first year of life) committed by the mother are not known. Both are relatively rare but attract much media attention when they occur. It is imperative to ask all women suffering from a postpartum illness if they have any thoughts or plans of harming themselves or their children. Patients presenting with suicidal or infanticidal plans require emergency hospitalization.

Summary

The postpartum period can be a vulnerable time for women, particularly those with a history of psychiatric illness or a family history of psychiatric illness. Not treating a psychiatric disorder in the postpartum period can have both short- and long-term consequences for both the infant and the mother. Administering a routine screening test, such as the Edinburgh Postnatal Depression Scale, can help identify those mothers who require treatment.[20-23]

Competing interests
None declared.

Table. Criteria for a major depressive episode.

Source: Adapted from DSM-IV-TR.

Figure. Edinburgh Postnatal Depression Scale.

Print friendly version availible (PDF)[12K Requires Adobe Reader]

Deirdre Ryan, MB, BCh, BAO, FRCPC, Xanthoula Kostaras, BSc

Dr Ryan is a consultant psychiatrist in the Reproductive Mental Health program at BC Women’s Hospital and St. Paul’s Hospital. Ms Kostaras is a research assistant in the Reproductive Mental Health program.