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Postpartum Psychiatric Disorders SEMINAR Seminar Postpartum psychiatric disorders Ian Brockington This review summarises the psychiatry of the puerperium, in the light of publications during the past 5 years. A wide variety of disorders are seen. Recognition of disorders of the mother–infant relationship is important, because these have pernicious long-term effects but generally respond to treatment. Psychoses complicate about one in 1000 deliveries. The most common is related to manic depression, in which neuroleptic drugs should be used with caution. Post-traumatic stress disorder, obsessions of child harm, and a range of anxiety disorders all require specific psychological treatments. Postpartum depression necessitates thorough exploration. Cessation of breastfeeding is not necessary, because most antidepressant drugs seem not to affect the infant. Controlled trials have shown the benefit of involving the child’s father in therapy and of interventions promoting interaction between mother and infant. Owing to its complexity, multidisciplinary specialist teams have an important place in postpartum psychiatry. The traditional view that there are three postpartum Disorders of the mother-infant relationship psychiatric disorders—the maternity blues, puerperal Childbirth presents many challenges to the mother: psychosis, and postnatal depression—is an oversimpli- trauma, sleep deprivation, breastfeeding, adjustments in fication. The range of disorders is wide. This review focuses conjugal and other relationships, and social isolation. on those important to general psychiatrists and family However, the central and most important psychological practitioners. It does not cover mild disorders that require no process is development of the relationship with the infant. treatment (such as the maternity blues), nor grieving over Disturbances in this process were recognised long ago, fetal loss, nor rare complications (such as organic when hatred of children12,13 and child abuse14 were psychoses), nor the effect of childbirth on eating disorders or described. Various terms have been used for these ethanol misuse. It draws attention to gaps in knowledge and disturbances. “Bonding” is a useful lay term, but neither research priorities. “bonding” nor “attachment” describes the essential symptom, which is the mother’s emotional response to the Postpartum psychoses infant—aversion, hatred, or pathological anger. “Mother- The sudden onset of psychosis after childbirth has intrigued infant interaction” reflects this response and has the medical practitioners for centuries. More than 2000 papers advantage that it can be recorded and measured. But the have been published. This group of disorders is diverse, concept of “postnatal depression with impaired mother- including psychogenic and organic psychoses.1 Only one infant interaction” is inadequate to encompass such a form is commonly seen in countries with modern obstetric profound emotional disorder, which can occur without services. This form is generally called puerperal psychosis depression.15 The concept of mother-infant relationship and takes the form of mania, severe depression (with disorder is controversial. It is not recognised in the tenth delusions, confusion, or stupor), or acute polymorphic revision of the International Classification of Diseases (cycloid) psychosis. Record-linkage studies2,3 give an (ICD-10) nor the Diagnostic and Statistical Manual IV incidence of about one per 1000 births. The claim that this is (DSM-IV). One of the challenges for ICD-11 and DSM- a “disease in its own right” was disproved long ago by the V is to find a place for these disorders, so that they can be long-term case studies of Esquirol,4 and there is now much recognised by practitioners and referred for expert evidence for a link with manic depressive psychosis.1 1,5 6 Childbirth, together with abortion and menstruation, is Search strategy one of the triggers of bipolar episodes in susceptible women. Research on these triggers is a promising avenue to a greater Motherhood and Mental Health reviewed published work up to understanding of manic depression. Puerperal psychosis has the end of 1995, citing over 2000 articles on postpartum a high and specific heritability (figure 1).7 The recurrence disorders. For this review, I used PubMed to screen articles rate is about one in four pregnancies. In treatment, published in the past 7 years, under the headings haloperidol should be used with caution, because dangerous “postpartum depression” (760 articles since 1995), “mother- side-effects including neuroleptic malignant syndrome have infant relationship disorders” (290 articles), “postpartum been reported.1,8,9 The newer neuroleptic drugs, such as anxiety” (370 articles, overlapping considerably with olanzepine, seem to be safer, although their safety has not yet postpartum depression), “postpartum post-traumatic stress been proven by treatment trials. Electroconvulsive treatment disorder” (26 articles), and “postpartum obsessive is useful,10 and lithium can be effective prophylaxis.11 compulsive disorder” (20 articles). I passed over those in eastern European and far eastern languages, or in journals Lancet 2004; 363: 303–10 I could not obtain before the deadline set by The Lancet. After See Commentary page 262 studying the abstracts, I obtained about 200 articles for See Personal account page 311 closer study. They included all substantial investigations. Given the constraints on space, the decision on what to Professor Emeritus, University of Birmingham (Prof I Brockington FRCP) include was a personal judgment. I selected all controlled Correspondence to: Prof Ian Brockington, Lower Brockington Farm, treatment and prevention trials, weighty and unusual studies, Bredenbury, Bromyard HR7 4TE, UK and those that best illustrated well-affirmed points. (e-mail: [email protected]) THE LANCET • Vol 363 • January 24, 2004 • www.thelancet.com 303 For personal use. Only reproduce with permission from The Lancet publishing Group. SEMINAR 90 Deliveries not followed by For more direct evidence, there are studies of the effects 80 puerperal psychosis of “postnatal depression” on the child. Most have not 70 Deliveries followed by assessed the mother-infant relationship, but Murray and puerperal psychosis 19 60 colleagues made brief audio recordings and videotapes of 50 mother-child interaction. They compared 61 mothers in Cambridge, UK, depressed 5–6 weeks after childbirth, 40 with 42 controls. Mother-child interaction was assessed at 30 2 months, and the children were followed up for 5 years. 20 Cognitive functioning was not affected by maternal Proportion of deliveries 10 depression but was predicted by mother-infant interaction 0 (r=0·29, p<0·05). More research should be focused on Relative with No relative with the effects of these disorders on children’s intellectual puerperal psychosis puerperal psychosis development and mental health, and their relation to child abuse and neglect. Figure 1: Proportion of deliveries followed by postpartum The diagnosis is facilitated by screening psychosis in manic depressive patients with and without a questionnaires,20,21 which can also be used to chart family history of puerperal episodes progress in treatment (figure 2). An interview, in which Reproduced with permission from Ian Jones.7 24 probes explore the mother-infant relationship, has been published.1 Observational data can be obtained in treatment. This process will involve a difficult innovation, hospital22,23 or at home.24 Other objective measures, such because “hatred” does not fit comfortably with the as videotapes,25 can be used. However, more research is concept of disease or illness. If hatred of a rival or political needed to improve our recognition and measurement of enemy is not an illness, why should a mother’s hatred and these disorders, clarifying the link between symptoms rejection of an infant be listed as a disease? But medicine explored by interviews and questionnaires and direct has pragmatic rather than logical boundaries, and observations of mother-infant interaction. psychiatry often challenges the definition of disease. In management, depression should be treated, even Disorders of the mother-infant relationship are when signs are negligible. The specific psychological prominent in 10–25% of women referred to psychiatrists treatment is play therapy in various forms,26 interaction after childbirth.1 At the extreme of rejection of the infant, coaching, or baby massage,27,28 which can be undertaken the mother may try to persuade a family member to take by nursing staff or psychologists. The aim is to help the over care permanently or may demand that the baby be mother to enjoy her interactions with the child. There adopted. She may try to escape. The most poignant have been two prophylactic intervention studies. In Brazil, manifestation is the wish that the baby disappear—be Wendland-Carro and colleagues29 randomly assigned stolen or succumb to cot death. Rejection is accompanied videotape instruction of two kinds to 37 mothers: one in many cases by pathological anger, with shouting, group received information about interaction with their cursing, or screaming at the infant, accompanied by babies, and the other information about care-giving skills. impulses to strike, shake, or smother the child. These A month later, home observations showed increased disorders are more common, intractable, and serious in sensitive responsiveness in mothers receiving guidance on their effects than puerperal psychosis. With treatment,
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