Focus on Mental Health

Postpartum Psychiatric Disorders

WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).

The incidence of depression is higher for women in the postpartum period that at any other stage of life. In addition, the rate of psychiatric hospital is markedly increased during the first 3 months after childbirth. Despite societal expectations that having a baby should be a completely joyful experience, many women are ambivalent about the birth experience. Some women are not prepared for the postpartum blues, nor are they aware of the risk of postpartum depression or psychosis. Women who unexpectedly develop postpartum blues may find her experiencing guilt, concern, or fear that having the baby was a mistake. These fears may worsen if the women's partner is not supportive and if there are no close relatives or friends to give emotional and physical assistance after delivery. A new father may feel worried, frustrated, and helpless in response to his wife's postpartum tearfulness and irritability, which can intensify the mother's sense of inadequacy. Postpartum symptoms can be traumatic for both new parents and may prolong the postpartum syndrome.

The purpose of this document is to discuss the postpartum psychiatric disorders and to help primary care physicians to recognize and manage the emotional and psychiatric problems that can occur in the postpartum period.

Clinical Presentation and Epidemiology:

Postpartum psychiatric disorders can be viewed as a spectrum of conditions that present with an onset as early as the first postpartum day and as late as several months after delivery. Patients experiencing a postpartum disorder may become demanding of the primary care physician's attention. They may seek constant reassurance, making multiple phone calls and requesting frequent office visits. Patients may present with physical complaints and concerns that are unrelated to their mental or emotional state. When managing a demanding and anxious patient, the healthcare provider should avoid speaking abruptly to the patient, acting out irritation, or failing to return the patient's phone calls in a timely manner. These actions may exacerbate the problem. Women with a history of affective disorder may become anxious as they approach their delivery date, fearing that their illness will reappear. For those patients who have been advised to discontinue maintenance psychotropic medications during pregnancy, the situation is particularly frightening.

The three major syndromes are:

Postpartum blues
Postpartum depression
Postpartum psychosis

1. Postpartum Blues: it is the mildest of the postpartum disorders and is often a relatively normal part of the birth experience. It affects 50% to 80% of new mothers in the first week of birth experience and usually resolves by the end of the first postpartum month. Postpartum/ maternity blues is characterized tearfulness, irritability, sleep disturbance, anxiety, fatigue, forgetfulness, and day after delivery. Risk factors for postpartum blues include primiparous pregnancy and a history of premenstrual syndrome.

2. Postpartum Depression: it is present in 10% to 15% of new mothers. This is a more severe disorder than postpartum blues and is clinically similar to major depressive disorder. Women may present as sad and tearful, may complain of sleep and appetite disturbances, and may have difficulty concentrating. They sometimes experience suicidal ideation and impairment in daily functioning. The diagnosis of postpartum depression is usually apparent by the second or third week postpartum.

3. Postpartum Psychosis: it is most severe but the least common of the postpartum psychiatric disorders affecting 1 to 2 per 1,000 new mothers. It is defined as a psychosis occurring within the first six months after childbirth. Clinical features include obsessive thoughts of hurting the baby or oneself, as well as more classic psychotic symptoms such as auditory hallucinations, delusions, and disorganized thoughts. Postpartum psychosis must be rapidly identified and treated, as the risk of infanticide during an episode of postpartum psychosis may be as high as 4%.

Risk Factors:

The most important risk factor for postpartum depression and postpartum psychosis is a past history of psychiatric illness. The risk is greatest if the patient has history of bipolar disorder and slightly lower if she has a history of unipolar depression. Women with a prior diagnosis of an affective disorder have a 20% to 25% chance of a postpartum psychosis. Other risk factors for these disorders include having a first baby, an unwanted pregnancy, and environmental stressors during the third trimester or early postpartum period, giving birth by cesarean section, an unstable or absent marital relationship, and a lack of social supports. Women who have a complicated delivery or a premature, abnormal, or sick child are at higher risk for postpartum disorders than are those who have lost the child through stillbirth or perinatal death.

Women with bipolar disorder who have little insight into the recurrent nature of their illness, who have not taken psychotropic medications during their pregnancy, and who are determined to breast feed present special problems. These patients often refuse to take their mood stabilizer during pregnancy, both because of the potential risk to the fetus and because they lack insight into the risks of discontinuing their medications. For the same reasons, some bipolar patients may refuse to restart medication immediately after delivery and may not recognize or report recurrent symptoms, thus risking exacerbation of their disorder and psychiatric hospitalization during the postpartum period. Recurrent illness can cause a woman with bipolar illness to become progressively fearful that her husband and physicians are not to be trusted and that she and her baby are in danger. Such a situation can be volatile, even if the primary care physician has a good rapport with the patient and there is close family involvement.

Diagnostic Issues:

The diagnosis of postpartum blues, postpartum depression, and postpartum psychosis is based on the clinical interview and on history from the patient and her family. In treating patients with a history of depression or bipolar disorder, vigilance is essential so that signs of developing postpartum psychiatric illness can be caught early. A patient with affective disorder will do best when she is assured that her primary care physician understands postpartum depression and psychosis and has a plan to manage such problems if they arise. The patient's anxiety may decrease markedly if she and her family are given concrete instructions to observe for new or worsening psychiatric symptoms, such as vegetative signs of depression, suicidal or violent thoughts, and auditory hallucinations.

Postpartum blues is a mild adjustment disorder that commonly presents during the first week after delivery in which the new mother has a protracted period of mildly depressed mood with tearfulness, irritability, sleep disturbance, forgetfulness, and mild confusion. Auditory hallucinations, paranoid ideation, obsessive thoughts of harming the baby, or thought disturbances are not present. Reality testing is intact, and the patient is able to function at an adequate level and receive some pleasure from the baby. Symptoms peak by the 7th day and typically last throughout the first 3 to 4 weeks of postpartum period.

Symptoms of postpartum depression usually begin in the second week and peak in the third or fourth week after delivery. Women with this disorder generally meet criteria for major depressive disorder. Common symptoms are feelings of hopelessness or helplessness, decreased self-care, and inadequate care for baby. Suicidal and homicidal ideation is not infrequent. The clinician should monitor patients with a prior diagnosis of major depressive disorder or bipolar disorder, as postpartum depression is much more common in these patients.

Postpartum psychosis is an extremely serious condition, with an incidence of about 4% and a high suicide risk. This psychosis is most common in patients with a history of bipolar disorder. Patients with psychotic disorder such as schizophrenia may experience an exacerbation of their symptoms in the postpartum period, which can be confused with postpartum psychosis. Patients with postpartum psychosis may experience auditory hallucinations and paranoid delusions with impaired reality testing. They may also demonstrate signs and symptoms of delirium, such as a waxing and waning mental state and confusion. The patient may believe that hospital personnel or family members are planning to harm her baby and may attempt to escape from a situation she perceives as dangerous. If a patient develops psychotic symptoms in the postpartum period and has no prior history of psychosis, the first step is to rule out possible medical causes of psychosis, such as thyroid dysfunction, stokes, CNS tumors, metabolic disturbances, and Sheehan's syndrome.

Evaluation and Treatment:

It necessitates a good rapport with the patient and her family. All pregnant patients should be educated about the potential risk of developing maternity blues. This may decrease the shame or guilt that some women feel when reporting depressive symptoms to their physicians. Pregnant patients who have a history of affective illness present a greater management challenge. The primary care physician may find it easier to manage these patients in collaboration with a psychiatric consultant. Patients and their partners must be carefully apprised of the risks and benefits, and they must agree to careful physician follow-up.

As pregnancy nears term, it is important to reinforce the availability of the physician after delivery. Women who have a history of a psychiatric disorder should be seen by their primary or their psychiatrist as frequently as every week for the first 2 to 3 months following delivery. Patients and their partners should be treated as a team, educated to contact the physician if they see that the new mother is becoming symptomatic or decompensating.

When a postpartum patient reports emotional complaints, she should be seen as soon as possible. Most of the women will be suffering from postpartum blues. However, missing the diagnosis of postpartum depression or psychosis can be fatal. Women who appear to be suffering from postpartum blues respond well to reassurance and increased emotional support from her clinician and family. Adequate home support is crucial to avoid chronic sleep deprivation, which exacerbates the symptoms of postpartum blues. A healthy diet low in simple sugars may diminish the intensity of dysphoria.

A patient who meets the criteria for major depression but who is able to care for herself and her baby often can be treated in a primary care setting. However, psychiatric consultation is helpful to strengthen the patient's safety net and improve the early recognition of emerging psychotic, suicidal or homicidal symptoms. Patients, who do demonstrate suicidal, homicidal, or psychotic symptoms or are neglecting care of themselves or their baby, need emergency psychiatric treatment. If a psychiatrist is not readily available, the patient should be escorted to a hospital emergency room. Outpatient treatment is not appropriate in cases in which the patient presents a potential danger to herself or to the baby. The patient suffering from postpartum depression who is not suicidal or homicidal can be managed as an outpatient; however, this requires the involvement of the patient's entire support system. The patient's significant other will probably have little or no experience in dealing with his partner's depression and will need to be educated about the disorder. He will need to understand that postpartum depression is a psychiatric disorder caused by temporary chemical imbalances in the brain and that the mother is not to blame. If a depressed mother is not able to take care of her infant, home care can help protect the infant from adverse sequelae of maternal depression. Such assistance also enables the patient to feel less pressured and less guilty during the illness and can enable her to have some quality time with her baby.

Antidepressant medications generally are prescribed in the treatment of postpartum depression. However, as most antidepressants are secreted in breast milk, pharmacotherapy often precludes breast feeding. Although many women and their partners may choose breastfeeding over treatment with antidepressants, treatment should begin without delay. This is because maternal depression in the postpartum period can interfere significantly with mother-infant bonding, and severe maternal depression is associated with infant depressive symptoms, failure to thrive, delayed infant development, and behavioral problems. SSRIs have become first-line treatment for depressive disorders. If a patient has responded previously to an antidepressant, she generally should resume the drug.

One of the most serious potential adverse effects of all antidepressants is mania. Patients with a history of bipolar disorder should be treated with antidepressants only after they are on a therapeutic dose of a mood stabilizer, such as valproate, lithium, or carbamazepine. It is very important to involve a psychiatric consultant in the care of such patients. Patients without a past history of psychiatric disorders may experience postpartum depression as a first manifestation of bipolar disorder. Such patients may have a greater tendency to become manic on antidepressants and should be monitored closely for manic symptoms. If pressured speech, increasing insomnia, racing thoughts, or psychotic symptoms develop in a patient on an antidepressant medication, the medication should be discontinued and the patient referred immediately for an emergency psychiatric consultation.

Editor's Note

Various investigators have argued that postpartum mental illness consists of a group of psychiatric disorders that are specifically related to pregnancy and childbirth and therefore exists as a distinct diagnostic entity. However, recent evidence suggests that affective illness that emerges during the postpartum period does not differ significantly from affective illness occurring in women at other times. This opinion is reflected in the fourth edition of Diagnostic and Statistic Manual of Mental Disorders (DSM-IV), which includes postpartum psychiatric illness as a subtype of either bipolar disorder or major depressive disorder.

Resources:

World Health Organization
Maternal Health & Child Health and Development
Literature review of risk factors and interventions on Postpartum Depression (pdf)
National Institutes of Health
Postpartum Depression
Centers for Disease Control and Prevention
Pregnancy Risk Assessment Monitoring System (PRAMS): PRAMS and Postpartum Depression