Completed Suicide During Pregnancy and Postpartum

57 Ann Ist Super Sanità 2021 | Vol. 57, No. 1: 57-66 DOI: 10.4415/ANN_21_01_09 Completed suicide during pregnancy and postpartum Monica Vichi1, Isabella Berardelli2 and Maurizio Pompili2 SECTION 1Servizio di Statistica, Istituto Superiore di Sanità, Rome, Italy 2Dipartimento di Neuroscienze, Salute Mentale e Organi di Senso, Azienda Ospedaliero-Universitaria Sant’Andrea, Sapienza Università di Roma, Rome, Italy ONOGRAPHIC Abstract Key words M Both pregnancy and the postpartum are typical periods for the onset or relapse of psychi- • suicide atric symptoms and disorders, with depression and anxiety being the most common. The • pregnancy prevalence of suicide spectrum behaviour is significantly higher among women with a • postpartum diagnosis of depressive or bipolar disorder. Suicide during pregnancy and postpartum is a • peripartum multifactorial phenomenon and a history of psychiatric illness is only one of the possible risk factors involved in suicide spectrum behaviour. The present paper highlights the im- portance of a complete screening for both depression and suicide risk during peripartum. INTRODUCTION and disorders [7], with depression and anxiety being Pregnancy and the postpartum are generally char- the most common [8]. Depressive symptoms occurring acterized by positive feelings and expectations but during pregnancy often persist postpartum, suggesting they may also disguise maternal stress and difficulties. a strong relation between antenatal depressive symp- Suicide is a major public health issue, with more than toms and postpartum depression [9]. Furthermore, ap- 800,000 people dying annually, and over recent years proximately half of postpartum depression cases have a growing number of reports have also identified preg- onset during pregnancy [10]. nancy and postpartum as critical periods for suicide Data regarding the incidence of peripartum depres- risk. Failure to complete pregnancy, the unavailability sion vary in relation to the assessment method used, the of elective termination methods and psychiatric disor- timing of the assessment and the population in epide- ders not adequately treated may actually lead to sui- miological studies. In general, peripartum depression is cide during pregnancy. Unwanted pregnancies are, no present in 7-13% of pregnant women and in 7-15% of doubt, a major risk factor for suicide and this is particu- women 1 year postpartum [11, 12]. larly true for female adolescents, whose discovery of a Due to the profound physiological changes dur- pregnancy may lead them to commit suicide [1]. The ing pregnancy and childbirth and the perturbations in literature points to the early recognition of “baby blues” mood, appetite, energy and sleep associated with child- as opposed to peripartum depression [2, 3]. Further- birth and infant care, it has been proposed that postpar- more, the postpartum period is often associated with tum depression differs from depression that occurs at the onset of mood and psychotic disorders that can other periods of life [13]. The American Psychiatric As- cause post-traumatic stress, with lasting consequences sociation proposed the term “peripartum onset depres- for both mother and child. Postpartum psychosis is sion” to describe major depressive episodes developing associated with an increased risk of both suicide and during pregnancy and the postpartum period [14]. infanticide: up to 30% of mothers who commit filicide Peripartum depression is an important public health also commit suicide [4]. reality that affects not only the mother but also the in- Gelaye et al. [5], in a review of 57 studies, found that fant and the entire family system, worsening the couple’s suicidal ideation but not completed suicide was more relationship and parental care of the infant [5, 15]. The frequent among pregnant woman compared to the gen- clinical presentation of peripartum depression is char- eral population, suggesting that pregnancy was a protec- acterized by low mood, sadness, irritability, impaired tive factor for suicide. However, Lysell et al. [6] found a concentration, feelings of guilt about childcare and feel- weak association between pregnancy and suicide reduc- ing overwhelmed. However, even non-depressed post- tion, suggesting that previous studies may overestimate partum women regularly experience many symptoms the protective effects of this life period in women. that commonly reflect depression in non-postpartum Both pregnancy and the postpartum are typical pe- women, such as fatigue, appetite disturbances and riods for the onset or relapse of psychiatric symptoms sleep disturbances [16, 17]. Address for correspondence: Monica Vichi, Servizio di Statistica, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy. E-mail: [email protected]. 58 Monica Vichi, Isabella Berardelli and Maurizio Pompili Peripartum mood worsening and anxiety can prog- manic episode, whereas anxiety disorders are diagnosed ress rapidly and become an imminent risk to the pa- in about 15% of women during pregnancy and about tient and, in rare cases, the infant. Poor maternal–fetal 10% of women postpartum [25]. Moreover, women who attachment and adverse neonatal outcomes, including experience one episode of peripartum depression are at low birth weight, preterm birth, small for gestational increased risk of recurrence with subsequent pregnan- age and early childhood developmental delays, are cies, suggesting the need to assess and treat depressive some of the most frequent aspects of peripartum de- symptoms early during pregnancy [26]. pression [18] (Figure 1). Alterations in many endocrine systems are present SECTION Peripartum depression is a multifactorial phenom- in pregnancy and the influence of endocrine changes enon and several psychological features are involved in on maternal mood and behaviour and fetal and child its genesis, including a previous history of depression development has been widely investigated. Possible and anxiety, a negative attitude toward the recent preg- underlying mechanisms of maternal care alterations re- nancy, stressful life events, a history of sexual abuse, related to maternal depression include alterations in oes- luctance to accept the baby and low self-esteem [19]. trogen and progesterone levels, central involvement of ONOGRAPHIC While the role of obstetric risk factors is still controver- glucocorticoids in maternal care, altered hypothalamic- M sial, several studies have demonstrated that the number pituitary-adrenal axis function and the hypersecretion of deliveries, a high-risk pregnancy, postpartum compli- of cortisol [27-30]. cations and a mismatch between maternal expectations A history of psychiatric disorders or onset in the pe- and pregnancy events are associated with an increased ripartum period is one of the most important risk fac- rate of depression, whereas breastfeeding is associated tors for suicidal behaviour. Depression in particular is a with a reduction in the rate of postpartum depression strong predictor of suicidality in the postpartum period [20]. Glucose metabolic disorders during pregnancy [5, 6, 15, 31-37]. are also involved in the genesis of postpartum depression [21]. Among the protective factors, evidence has SUICIDE IN PREGNANCY demonstrated a key role for social support, including AND POSTPARTUM emotional support, financial support, intellectual sup- While being pregnant may actually protect against port and empathetic relations [12]. Factors related to suicide, several subgroups of women may be at elevated lifestyle, food intake patterns, sleep status, exercise and risk before or after delivery [38, 39]. Even if suicide dur- physical activity are also involved in the prevention of ing pregnancy and postpartum is rare, it is among the postpartum depression through direct and indirect ef- leading causes of maternal perinatal mortality [39]. fects on the level of serotonin in the brain [22]. Suicidal behaviour encompasses a wide spectrum, During the first year after delivery, women with a psy- from suicidal ideation (suicidal thoughts and plans) to chiatric disorder are at the highest risk of psychiatric self-harm, attempted suicide and completed suicide. hospitalization [23]. Conversely, increased risk of se- Completed and attempted suicide are often preceded vere postpartum psychiatric morbidity and substance by suicidal ideation, which is therefore one of the main use disorder was associated with severe maternal mor- risk factors for completed suicide [40]. In addition, at- bidity, with the highest period of risk extended to 4 tempted suicide and self-harm are strong predictors for months after hospital discharge [24]. completed suicide [41]. During the peripartum period, Among women with a diagnosed mood disorder, the the prevalence of suicidal ideation ranges from 5% to rate of relapse during the postpartum period is 30% for 14% [39, 42-43]. There is a strong association between unipolar depression and 52% for bipolar depression or a suicidal ideation and depression. Most women with post- Maternal outcomes Infant outcomes Somatic symptoms Low Apgar scores Preeclampsia Breastfeeding alterations Antepartum bleeding Failure to thrive Preterm delivery Antenatal depression Low motor tone and activity Low imitative behaviour MATERNAL DEPRESSION Stress behaviour Disruptive sleep Low social functioning Postnatal depression Irritability Psychological problems Infant illness Irritable bowel syndrome Cardiovascular diseases Figure 1 Most frequent aspects of peripartum depression. 59 SUICIDE DURING

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