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Home , Postpartum blues, Postpartum depression, Postpartum psychosis

BCMJ /#47Vol2.wrap3 2/18/05 3:52 PM Page 100

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

Psychiatric disorders in the

Postpartum mood disorders and psychoses must be identified to prevent negative long-term consequences for both mothers and .

ABSTRACT: Pregnant women and he three psychiatric disor- proportion of women with postpartum their families expect the postpartum ders most common after the blues may develop postpartum de- period to be a happy time, charac- birth of a baby are postpar- pression.3 terized by the joyful arrival of a new Ttum blues, postpartum de- baby. Unfortunately, women in the pression, and postpartum . Postpartum postpartum period can be vulnera- Depression and psychosis present The Diagnostic and Statistical Man- ble to psychiatric disorders such as risks to both the mother and her , ual of Mental Disorders, Fourth , depression, and making early diagnosis and treatment Edition, Text Revision (DSM-IV-TR) psychosis. Because untreated post- important. (A full description of phar- defines (PPD) partum psychiatric disorders can macological and nonpharmacological as depression that occurs within have long-term and serious conse- therapies for these disorders will 4 weeks of .4 However, most quences for both the mother and appear in Part 2 of this theme issue in reports on PPD suggest that it can her infant, screening for these dis- April 2005.) develop at any point during the first orders must be considered part of year postpartum, with a peak of inci- standard postpartum care. Postpartum blues dence within the first 4 months post- Postpartum blues refers to a transient partum.1 The prevalence of depression condition characterized by irritability, during the postpartum period has been , decreased concentration, in- systematically assessed; controlled somnia, tearfulness, and mild, often studies show that between 10% and rapid, mood swings from elation to 28% of women experience a major sadness. A large number of postpar- depressive episode in the postpartum tum women (30% to 75%) develop period, with the majority of studies these mood changes,1 generally with- favoring a 10% figure.5 in 2 to 3 days of delivery. Symptoms Several key risk factors have been peak on the fifth day postpartum and identified as major contributors to the usually resolve within 2 weeks.2 Typ- development of PPD, including: ically, providing support and reassur- ¥ Ahistory of postpartum depression.6 ance to the new mother and stressing ¥ A history of depression before con- the importance of adequate time for ception.7 sleep and rest will be sufficient treat- ment for postpartum blues. The use of Dr Ryan is a consultant psychiatrist in the minor tranquilizers at low doses (e.g., Reproductive program at BC lorazepam 0.5 mg) may be helpful for Women’s Hospital and St. Paul’s Hospital. . Careful monitoring during Ms Kostaras is a research assistant in the this period is essential, since a small Reproductive Mental Health program.

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Psychiatric disorders in the postpartum period

¥ A family history of depression, par- A significant number of women Every new mother should be asked ticularly PPD.7,8 also experience concomitant symp- about her psychological functioning. In addition, several other factors toms of anxiety, including panic attacks Women with a history of major may contribute to the development of and obsessional fears or images of depression or a family history of psy- PPD, including poor social support, harm occurring to their babies. These chiatric illness should be identified in the experience of adverse life events can be very frightening for the mother. and followed closely in the during the postpartum period, marital Prior to making a psychiatric diag- postpartum period. A very useful and instability, young maternal age, and nosis in the postpartum period, it is easily administered screening tool for infants with health problems or per- important to rule out any underlying postpartum depression is the validat- ceived “difficult” temperaments. medical condition. Women suffering ed Edinburgh Postnatal Depression Symptoms of PPD are similar to from early postpartum anemia may be Scale (seeFigure ; this scale can be the symptoms of a major depressive at increased risk of developing post- copied and used free of charge).11-13 episode experienced at any other time partum depression.9 Likewise, we The patient can complete the ques- (see theTable ). There are, however, know that the postpartum period is tionnaire at her physician’s office subtle differences, including: associated in some women with prior to her first postpartum follow-up ¥ Difficulty sleeping when the baby pathological changes in func- appointment or when she brings her sleeps. tion, especially thyroiditis.10 Testing baby for immunization. For each ¥ Lack of enjoyment in the maternal for CBC and TSH should be part of a question, the patient will choose one role. complete workup. of four possible replies that reflect ¥ Feelings of guilt related to parenting Despite the identified symptoms how she has been feeling over the past ability. and risk factors associated with the ill- 7 days. Responses are scored as 0, 1, ness, PPD is often missed at the pri- 2, or 3, for a maximum score of 30. A Table. Criteria for a major depressive mary care level. One explanation for minimum score of 12 has been found episode. this is that the care provider may be to identify most women with a diag- more focused on the health of the nosis of postpartum depression. A.Five or more of the following symptoms* infant and may therefore miss any must be present daily or almost daily for signs of maternal psychiatric illness. at least two consecutive weeks: In addition, many women may try to First-onset psychosis in the perinatal 1. Depressed mood. conceal their illness because of shame period is a rare condition. The preva- 2. Loss of interest or pleasure. or embarrassment about feeling de- lence of postpartum psychosis has 3. Significant increases or decreases in pressed during what is supposed to be consistently been reported as approx- appetite. such a happy time. The consequences imately 1 to 2 per 1000 live births.14 4. Insomnia or . 5. or retardation. of misdiagnosing or not treating post- This condition has a rapid onset, usu- 6. or loss of energy. partum depression can be serious. For ally manifesting itself within the first 7. Feelings of worthlessness or guilt. the mother, untreated depression can 2 weeks after childbirth or, at most, 8. Diminished concentration. lead to the development of a chronic within 3 months postpartum, and 9. Recurrent thoughts of suicide or depressive illness and poses a risk of should be considered a medical and death. suicide. Untreated PPD can also have obstetrical emergency.15 The presence *At least one of which must be 1 or 2. many negative consequences for the of a psychotic disorder may interfere B.The symptoms do not meet the criteria infant; the negative interactive pat- with a woman obtaining proper pre- for other psychiatric conditions. terns formed during the critical early natal and postpartum care. C.The symptoms cause significant impair- bonding period may affect the later Several major risk factors16-18 have ment in usual functioning at work, development of the child. For exam- been identified in relation to postpar- school, and in social activities. ple, conduct disorders, inappropriate tum psychosis: D.The symptoms are not caused by the aggression, and cognitive and atten- ¥ History of psychosis with previous direct effects of a substance or a gener- tion deficits have been described in . al medical condition. children exposed to maternal psychi- ¥ History of . E. The symptoms are not better accounted atric illnesses and these disturbances ¥ Family history of psychotic illness for by the loss of a loved one. have continued even after remission (e.g., or bipolar dis- Source: Adapted from DSM-IV-TR.3 of the maternal depression. order).

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Psychiatric disorders in the postpartum period

Patients may present with symp- Competing interests 12. Murray L, Carothers AD. The validity of toms resembling an acute manic epi- None declared. the Edinburgh Post-natal Depression sode or a psychotic depression. They Scale on a community sample. Br J Psy- may present with or halluci- References chiatry 1990;157:288-290. nations that are frightening to them. 1. O’Hara MW, Zekoski EM, Phillips LH, et 13. Beck CT, Gable RK. Further validity of the Many patients also have additional al. A controlled prospective study of post- postpartum depression screening scale. symptoms that resemble a partum mood disorders: Comparison of Nurs Res 2001;50:155-164. and involve distractability, labile childbearing and non-childbearing wo- 14. Kumar R. Postnatal mental illness: A tran- mood, and transient .19 men. J Abnorm Psychol 1990;99:3-15. scultural perspective. Soc Patients with postpartum psy- 2. O’Hara MW, Schlechte JA, Lewis DA, et Psychiatr Epidemiol 1994;29:250-264. chosis have lost touch with reality and al. Prospective study of postpartum 15. Altshuler LL, Cohen LS, Szuba MP, et al. are at risk of harming themselves or blues. Biologic and psychosocial factors. Pharmacologic management of psychi- their babies. Postpartum psychosis is Arch Gen Psychiatry 1991;48:801. atric illness during pregnancy: Dilemmas an emergency that requires immediate 3. Cox JL, Murray D, Chapman G. A con- and guidelines. Am J Psychiatry 1996; medical attention. In most cases, it trolled study of the onset, duration and 153:592-606. will be necessary for the mother to be prevalence of postnatal depression. Br J 16. Kendell RE, Chalmers JC, Platz C. Epi- hospitalized until she is stable. Med- Psychiatry 1993;163:27-31. demiology of puerperal psychoses. Br J ications (including , 4. Diagnostic and Statistical Manual of Psychiatry 1987;150:662-673. neuroleptics, and mood stabilizers) or Mental Disorders, Fourth Edition, Text 17. McNeil TF. A prospective study of post- electroconvulsive therapy may be Revision. Washington, DC: American partum psychoses in a high-risk group. 2. needed to control the psychosis. Psychiatric Association; 2000. Relationships to demographic and psy- The absolute risk of neonaticide 5. O’Hara MW, Swain AM. Rates and risk of chiatric history characteristics. Acta Psy- (death of the baby within 24 hours of postpartum depression—a meta-analysis. chiatr Scand 1987;75:35-43. birth) and of (death within Int Rev Psychiatry 1996;8:37-54. 18. Nonacs R, Cohen LS. Postpartum mood the first year of life) committed by the 6. Llewellyn AM, Stowe ZN, Nemeroff CB. disorders: Diagnosis and treatment mother are not known. Both are rela- Depression during pregnancy and the guidelines. J Clin Psychiatry 1998;59 tively rare but attract much media puerperium. J Clin Psychiatry 1997; (suppl 2):34-40. attention when they occur. It is imper- 58(suppl 15):26-32. 19. Steiner M. Postpartum psychiatric disor- ative to ask all women suffering from 7. O’Hara MW. Social support, life events, ders. Can J Psychiatry 1990;35:89-95. a postpartum illness if they have any and depression during pregnancy and the 20. Georgiopoulos AM, Bryan TL, Wollan P, thoughts or plans of harming them- puerperium. Arch Gen Psychiatry 1986; et al. Routine screening for postpartum selves or their children. Patients pre- 43:569-573. depression. J Fam Pract 2001;50:117- senting with suicidal or infanticidal 8. Kumar R, Robson MK. A prospective 122. plans require emergency hospitaliza- study of emotional disorders in child- 21. Yamashita H, Yoshida K. Screening and tion. bearing women. Br J Psychiatry 1984; intervention for depressive mothers of 144:35-47. new-born infants. Seishin Shinkeigaku Summary 9. Corwin EJ, Murray-Kolb LE, Beard JL. Zasshi 2003;105:1129-1135. The postpartum period can be a vul- Low haemoglobin level is a for 22. Teissedre F, Chabrol H. Detecting nerable time for women, particularly postpartum depression. J Nutr 2003; women at risk for postnatal depression those with a history of psychiatric ill- 133:4139-4142. using the Edinburgh Postnatal Depres- ness or a family history of psychiatric 10. Lucas A, Pizarro E, Granada ML, et al. sion Scale at 2 to 3 days postpartum. Can illness. Not treating a psychiatric dis- Postpartum thyroid dysfunction and J Psychiatry 2004;49:51-54. order in the postpartum period can postpartum depression: Are they two 23. Davies BR, Howells S, Jenkins M. Early have both short- and long-term conse- linked disorders? Clin Endocrinol (Oxf) detection and treatment of postnatal quences for both the infant and the 2001;55:809-814. depression in primary care. J Adv Nurs mother. Administering a routine 11. Cox JL, Holdon JM, Sagovsky R. Detec- 2003;44:248-255. screening test, such as the Edinburgh tion of postnatal depression: Develop- Postnatal Depression Scale, can help ment of the 10-item Edinburgh Postnatal identify those mothers who require Depression Scale. Br J Psychiatry 1987; treatment.20-23 150:782-786.

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Psychiatric disorders in the postpartum period

Name: ______Date: ______Number of months postpartum: ______

As you have recently had a baby, we would like to know how you are feeling. Please mark the answer which comes closest to how you have felt in the past 7 days, not just how you feel today.

Here is an example, already completed:

I have felt happy: Yes, all the time This would mean “I have felt happy most x Yes, most of the time of the time during the past week.” Please complete the following questions No, not very often in the same way. No, not at all

In the past 7 days:

1. I have been able to laugh and see the funny side of things 6. Things have been getting on top of me As much as I always could 0 Yes, most of the time I haven’t been able to cope 3 Not quite so much now 1 Yes, sometimes I haven’t been coping as well as usual 2 Definitely not so much now 2 No, most of the time I have coped quite well 1 Not at all 3 No, I have been coping as well as ever 0

2. I have looked forward with enjoyment to things 7. I have been so unhappy that I have had difficulty sleeping As much as I ever did 0 Yes, most of the time 3 Rather less than I used to 1 Yes, sometimes 2 Definitely less than I used to 2 Not very often 1 Hardly at all 3 No, not at all 0

3. I have blamed myself unnecessarily when things went wrong 8. I have felt sad or miserable Yes, most of the time 3 Yes, most of the time 3 Yes, some of the time 2 Yes, quite often 2 Not very often 1 Not very often 1 No, never 0 No, not at all 0

4. I have been anxious or worried for no good reason 9. I have been so unhappy that I have been crying No, not at all 0 Yes, most of the time 3 Hardly ever 1 Yes, quite often 2 Yes, sometimes 2 Only occasionally 1 Yes, very often 3 No, never 0

5. I have felt scared or panicky for no very good reason 10. The thought of harming myself has occurred to me Yes, quite a lot 3 Yes, quite often 3 Yes, sometimes 2 Sometimes 2 No, not much 1 Hardly ever 1 No, not at all 0 Never 0

Figure. Edinburgh Postnatal Depression Scale.11

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