Late Onset Postpartum Psychoses Brockington, Ian

View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by University of Birmingham Research Portal University of Birmingham Late onset postpartum psychoses Brockington, Ian DOI: 10.1007/s00737-016-0680-y License: Creative Commons: Attribution (CC BY) Document Version Publisher's PDF, also known as Version of record Citation for published version (Harvard): Brockington, I 2016, 'Late onset postpartum psychoses', Archives of Women's Mental Health. https://doi.org/10.1007/s00737-016-0680-y Link to publication on Research at Birmingham portal General rights Unless a licence is specified above, all rights (including copyright and moral rights) in this document are retained by the authors and/or the copyright holders. 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Take down policy While the University of Birmingham exercises care and attention in making items available there are rare occasions when an item has been uploaded in error or has been deemed to be commercially or otherwise sensitive. If you believe that this is the case for this document, please contact [email protected] providing details and we will remove access to the work immediately and investigate. Download date: 01. Mar. 2020 Arch Womens Ment Health DOI 10.1007/s00737-016-0680-y ORIGINAL ARTICLE Late onset postpartum psychoses Ian Brockington1 Received: 20 September 2016 /Accepted: 20 September 2016 # The Author(s) 2016. This article is published with open access at Springerlink.com Abstract It has been known since the eighteenth century that medicines given to bring on the menses; but her raving postpartum psychoses can begin several weeks after child- increased more and more, and she had to be restrained. It birth, not during the first fortnight. There are almost 400 was 2 months before she calmed down. She non-organic episodes in the literature, starting more than immediately became pregnant again remained well. 3 weeks after the birth; some of them are recurrent. The dis- tinction of this disorder from early onset puerperal psychosis Burns (1809) asserted that puerperal mania in some cases is supported by the distribution of onsets (which shows a steep started several weeks after delivery. Marcé (1858) believed fall after 14–15 days), survey data and the association with that it could start either immediately after the birth or several later pregnancies, not the first. Marcé believed that these late weeks later at the first menses; in separate enumerations, he onsets were related to the resumption of menstruation. This is gave ratios of 11/44 (1:4) and 12/60 (1:5) late/early postpar- a hypothesis worth investigating. tum psychoses; among his cases that meet my definition of psychosis, his figures were 10/29 (1:2.9). Fürstner (1875)sup- Keywords Postpartum psychosis . 4–13 week onsets . Late ported this, stating that puerperal psychosis broke out either – – postpartum onset . Weaning onset between days 10 12 or at 4 6 weeks, with a free period between, and two of his hallucinatorische Irresein der Wöchnerinnen had late onset. It is remarkable how little attention has been paid to this. Introduction Late onset postpartum psychosis was first described in the Onsets of postpartum psychosis eighteenth century (Hoffmann 1721): Data on onset are often given in vague terms—“immediately Four weeks after childbirth a 20-year old, rather melan- after the birth”, “in a few days”, “in the second week”, et choly and anxious by temperament, had a severe fright - cetera. Focusing on those with more precise information, the ‘ ’ she saw the ghost of her long-dead mother. Three days day-to-day and week-to-week onset of non-organic episodes later she became confused and started to rave. She was in the literature showed a sharp fall after 15 days, with few in restless, talked day and night (mainly in rhyme), and ate the third week. This was confirmed in 155 from my series, and drank little, but had no fever. The infant was given which had better information (Brockington 2014). This sug- to a wet-nurse, leaches were applied to her feet, and gested that the limit for early puerperal onset was not 6 weeks, or 4 weeks, or 3 weeks, but 15 days. Charted week-by-week Table 1 shows the onset of over 1400 episodes in the literature * Ian Brockington and 206 in my series, the totals are higher because cases with [email protected] more approximate onset could be included. In both series, there is a steep fall from week 2 to week 3; if this 1 University of Birmingham, Edgbaston, Birmingham B15 2TT, UK rate of fall were continued, one would expect only 21 onsets in I. Brockington Table 1 Week-by-week onset of non-organic postpartum psychoses 326 single and 73 recurrent cases (409 episodes). The Week Literature Myseries rate/trimester (531/trimester) is one tenth that of early postpartum onset (5629/trimester), but much higher than those All cases Bipolar/cycloids starting during pregnancy (146/trimester) or after abortion (108/trimester). The ratio of 4–13 week onsets to early post- Episodes % fall Episodes % fall Episodes % fall partum onset is 1 to 3. In my series, there were only 41 epi- – 1 610 159 139 sodes with 4 13 week onsets, and of these only 19 were – 2 405 34 59 63 45 68 bipolar/cycloid; the ratio of 4 13 week to early postpartum 3 92771181687 onset was 1 to 7, lower than in the literature. 4106 6 4 526 11 3 Parity Only 109 (32 %) were primiparae. Restricting the 673 10 4 analysis to bipolar/cycloid patients in my series the mean par- 714 4 4 ity was 2.19, with 38 % primiparae.Thiscompareswitha 882 5 1 mean of 1.58, with 58 % primiparae in early onset postpartum episodes. There is confirmation of this higher parity in a Danish survey of 750,000 women: in primiparae, the highest the literature, and only two onsets in my series, in week 4. In the relative risk of psychiatric disorder (not just psychoses) oc- literature, there are peaks in week 1, week 4, week 6, and week 8. curred 10–19 days postpartum (RR 8.7), but, when the first In my series, which had relatively good data, there is a second psychiatric episode followed the second birth, it was 60– mode at week 5–6, supporting Marcé’s idea. But this does not 89 days postpartum (RR 2.7) (Munk-Olsen et al. 2014). survive the study of bipolar/cycloid patients, which shows a long tail, but no second mode; it does, however, show the same sharp fallfromweek2toweek3,and,ifcontinued,thereshouldbeonly Recurrent cases There are eight cases in the literature, and one case in the fourth week, and none thereafter. four in my series, with two 4–13 week onsets and no other Table 2 shows the month-by-month onset. reproductive episodes. One mother had three episodes, but This shows relatively few episodes with onset more than only a vague description—“Shebecameinsanesomeweeks 3 months after the birth. In my series, there were only 18 episodes, later, each time with various delusions” (Gilmore 1892). In andonly3bipolar/cycloidsafter6monthsandnoneafter8months. addition to multiple episodes limited to this time frame, one mother had seven postpartum episodes, including three late onsets—at 4 weeks, 2 months and 3 months, with the rest of unknown onset (Ideler 1851). This Danish patient (Holm 4–13 week onsets 1874) had three early and three 4–13 week postpartum onsets: In the literature, 447 patients had onset in this time frame. Alabourer’swife,aged19,gavebirthtohersecondchildin There were only 48 organic psychoses (11 %), much fewer 1834; on day 3 she became manic, and remained ill for than after abortion, during pregnancy or in the early puerperi- 7 months. In 1837 she gave birth for the 3rd time, and um (all over 30 %). Almost all were infective delirium. The breast-fed for 2 months, at which point she became manic remaining 399 mothers had non-organic episodes, including for 11 months. In 1839 she gave birth for the 4th time and breast-fed for 1 month, when she became manic for an Table 2 Month-by- entire year. In 1841 she had her 5th child, whom she month onset Month Literature My series breast-fed for 2½ months; when she weaned the child she 11213235 became manic for 13 months. In 1844, after her 6th deliv- 219530 ery, she failed to lactate, and immediately became manic, 3808 lasting 8 months. In 1847 she gave birth to her 7th child, 4614 who died on the 8th day; she broke out into mania, less 5343 severe but chronic with remissions. In 34 years’ observa- 6352 tion, she also had four episodes unrelated to childbearing. 7193 8192 The six postpartum episodes, all within the first trimester, 9192cannot have been sporadic because she had only four unrelat- 10 13 1 ed episodes in 104 non-reproductive trimesters (p =0.0001); 11 6 nil but the postpartum episodes started in two separate time frames.

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