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 period Postpartum mood disorders and psychoses must be identified to prevent negative long-term consequences for both mothers and infants. 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 psychosis. Postpartum depression 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 infant, ual of Mental Disorders, Fourth postpartum blues, depression, and making early diagnosis and treatment Edition, Text Revision (DSM-IV-TR) psychosis. Because untreated post- important. (A full description of phar- defines postpartum depression (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 childbirth.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 anxiety, 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 Mental Health program at BC lorazepam 0.5 mg) may be helpful for Women’s Hospital and St. Paul’s Hospital. insomnia. Careful monitoring during Ms Kostaras is a research assistant in the this period is essential, since a small Reproductive Mental Health program. 100 BC MEDICAL JOURNAL VOL. 47 NO. 2, MARCH 2005 BCMJ /#47Vol2.wrap3 2/18/05 3:52 PM Page 101 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. pregnancy 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 thyroid 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. Postpartum psychosis 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 hypersomnia. 5. Psychomotor agitation or retardation. of misdiagnosing or not treating post- This condition has a rapid onset, usu- 6. Fatigue 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 pregnancies. al medical condition. children exposed to maternal psychi- • History of bipolar disorder. 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., schizophrenia or bipolar dis- Source: Adapted from DSM-IV-TR.3 of the maternal depression. order). VOL. 47 NO. 2, MARCH 2005 BC MEDICAL JOURNAL 101 BCMJ /#47Vol2.wrap3 2/18/05 3:52 PM Page 102 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 delusions 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 delirium 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 confusion.19 men. J Abnorm Psychol 1990;99:3-15. scultural perspective. Soc Psychiatry 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.