Puerperal mental disorders

Introduction
During the postpartum period, up to 85% of women suffer from some type of
mood disturbance. For most women, symptoms are transient and relatively
mild (ie, postpartum blues).
however, 10-15% of women experience a more disabling and persistent
form of mood disturbance (eg, postpartum depression, postpartum
psychosis).
Postpartum psychiatric illness was initially conceptualized as a group of
disorders specifically linked to pregnancy and childbirth and thus was
considered diagnostically distinct from other types of psychiatric illness.
More recent evidence suggests that postpartum psychiatric illness is
virtually indistinguishable from psychiatric disorders that occur at other times
during a woman's life.
Types:
– Postpartum blues.
– Postpartum depression.
– Postpartum psychosis.
 Postpartum Blues:
Up to 85% of women experience postpartum
affective instability.
Rapidly fluctuating mood, tearfulness, irritability,
and anxiety are common symptoms.
Symptoms peak on the fourth or fifth day after
delivery and last for several days, but they are
generally time-limited and spontaneously remit
within the first 2 postpartum weeks.
Symptoms do not interfere with a mother's ability
to function and to care for her child.
 Postpartum depression:

Postpartum depression occurs in 10-15% of women in the general

population.
Typically, postpartum depression develops insidiously over the first 3
postpartum months, although the disorder may have a more acute onset.
Postpartum depression is more persistent and debilitating than postpartum
blues.
Signs and symptoms are clinically indistinguishable from major depression
that occurs in women at other times. Symptoms may include depressed
mood, tearfulness, inability to enjoy pleasurable activities, insomnia, fatigue,
appetite disturbance, suicidal thoughts, and recurrent thoughts of death.
Anxiety is prominent, including worries or obsessions about the infant's
health and well-being.
The mother may be ambivalent or have negative feelings toward the infant.
She may also have intrusive and unpleasant fears or thoughts about
harming the infant.
Postpartum depression often interferes with the mother's ability to care for
herself or her child.
 :Postpartum Psychosis

Postpartum psychosis is the most severe form of postpartum

psychiatric illness.
The condition is rare and occurs in approximately 1-2 per 1000
women after childbirth.
Postpartum psychosis has a dramatic onset, emerging as early as
the first 48-72 hours after delivery. In most women, symptoms
develop within the first 2 postpartum weeks.
The condition resembles a rapidly evolving manic episode with
symptoms such as restlessness and insomnia, irritability, rapidly
shifting depressed or elated mood, and disorganized behavior.
The mother may have delusional beliefs that relate to the infant (eg,
baby is defective or dying, infant is Satan or God), or she may have
auditory hallucinations that instruct her to harm herself or her infant.
Risks for infanticide and suicide are high among women with this
disorder.
 :Pathophysiology
Hormonal factors
– Levels of estrogen, progesterone, and cortisol fall dramatically within 48
hours after delivery.
– Women with postpartum depression do not differ significantly from
nondepressed women with regard to levels of estrogen, progesterone,
prolactin, and cortisol or in the degree to which these hormone levels
change; however, affected individuals may be abnormally sensitive to
changes in the hormonal milieu and may develop depressive symptoms
when treated with exogenous estrogen or progesterone.
Psychosocial factors
– Women who report inadequate social supports, marital discord or
dissatisfaction, or recent negative life events are more likely to
experience postpartum depression.
Biologic vulnerability
– Women with prior history of depression or family history of a mood
disorder are at increased risk for postpartum depression.
– Women with a prior history of postpartum depression or psychosis have
up to 90% risk of recurrence.
Screening for postpartum Mood
:disorders
Predicting who is at risk for postpartum depression is difficult.
Individuals at greatest risk often have a prior history of postpartum
depression, personal or family history of mood disorder, or
depression during a current pregnancy. Other risk factors include
inadequate social supports, marital dissatisfaction or discord, and
recent negative life events such as a death in the family, financial
difficulties, or loss of employment.
Screening of all mothers during the postpartum period is indicated.
The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item
self-rated questionnaire used extensively for detection of
postpartum depression. A score of 12 or more on EPDS or an
affirmative answer on question 10 (presence of suicidal thoughts)
requires more thorough evaluation. Include EPDS in routine well-
baby and pediatric visits.
 :Treatment

Untreated postpartum affective illness

places both the mother and infant at risk
and is associated with significant long-
term effects on child development and
behavior; therefore, prompt recognition
and treatment of postpartum depression
are essential for both maternal and infant
well-being.
 Postpartum blues treatment

Postpartum blues typically is mild in

severity and resolves spontaneously.
No specific treatment is required, other
than support and reassurance.
Further evaluation is necessary if
symptoms persist more than 2 weeks.
 Postpartum depression
treatment
Exclude medical causes for mood disturbance (eg, thyroid dysfunction, anemia).
Severity of illness should guide treatment. Milder forms of depression may respond to supportive psychotherapy.
More severe depression may require pharmacological treatment.
Nonpharmacological treatment strategies are useful for women with mild-to-moderate depressive symptoms.
These modalities may be especially useful for mothers who are nursing and who wish to avoid taking
medications. Psychoeducational groups may be helpful. Individual or group psychotherapy (cognitive-behavioral
and interpersonal therapy) are effective.
Pharmacological strategies are indicated for moderate-to-severe depressive symptoms or when a woman fails to
respond to nonpharmacological treatment. Medication may also be used in conjunction with nonpharmacological
therapies.
– Selective serotonin reuptake inhibitors (SSRIs) are first-line agents and are effective in women with
postpartum depression. Use standard antidepressant dosages, eg, fluoxetine 10-60 mg/d, sertraline 50-200
mg/d, paroxetine 20-60 mg/d, or citalopram 20-60 mg/d. Adverse effects of this drug category include
insomnia, jitteriness, nausea, appetite suppression, headache, and sexual dysfunction.
– Serotonin-norepinephrine reuptake inhibitors (SNRIs) or tricyclic antidepressants may be useful for women
with sleep disturbance, although some studies suggest that women respond better to the SSRI drug
category. Nortriptyline 50-150 mg/d and venlafaxine 37.5-150 mg/d may be effective. Adverse effects of the
tricyclic antidepressants include sedation, weight gain, dry mouth, constipation, and sexual dysfunction.
Typically, symptoms start to diminish in 2-4 weeks. A full remission may take several months. In partial
responders, it may be helpful to increase the dosage.
– Anxiolytic agents such as lorazepam and clonazepam may be useful as adjunctive treatment in patients
with anxiety and sleep disturbance.
– Preliminary data suggest that estrogen, alone or in combination with an antidepressant, may be beneficial;
however, antidepressants remain the first line of treatment.
If this is the first episode of depression, 6-12 months of treatment is recommended. For women with recurrent
major depression, long-term maintenance treatment with an antidepressant is indicated.
Inadequate treatment increases the risk of morbidity in both mother and infant.
Earlier initiation of treatment is associated with better prognosis.
Inpatient hospitalization may be necessary for severe postpartum depression.
Electroconvulsive therapy (ECT) is rapid, safe, and effective for women with severe postpartum depression,
especially those with active suicidal idea.
Puerperal psychosis treatment

Puerperal psychosis is a psychiatric emergency

that typically requires inpatient treatment.
Most patients with puerperal psychosis suffer
from bipolar disorder. Acute treatment includes a
mood stabilizer (eg, lithium, valproic acid,
carbamazepine) in combination with
antipsychotic medications and benzodiazepines.
ECT (often bilateral) is tolerated well and rapidly
effective.
Risk of suicide is significant in this population.
Rates of infanticide associated with untreated
puerperal psychosis are as high as 4%.
 :Special concerns

Breastfeeding and psychotropic medications

Women who plan to breastfeed must be informed that all
psychotropic medications, including antidepressants, are secreted
into breast milk. Concentrations in breast milk vary widely.
Data on the use of tricyclic antidepressants, fluoxetine, sertraline,
and paroxetine during breastfeeding are encouraging, and serum
antidepressant levels in the nursing infant are either low or
undetectable. Reports of toxicity in nursing infants are rare, although
the long-term effects of exposure to trace amounts of medication
are not known.
Avoid breastfeeding in women treated with lithium because this
agent is secreted at high levels in breast milk and may cause
significant toxicity in the infant.
Avoid breastfeeding in premature infants or in those with hepatic
insufficiency who may have difficulty metabolizing medications
present in breast milk.
 Special concerns:(con’t)

Impact of postpartum depression on child development

A large body of literature suggests that a mother's attitude and
behavior toward her infant significantly affect mother-infant bonding
and infant well being and development. Postpartum depression may
negatively affect these mother-infant interactions.
Mothers with postpartum depression are more likely to express
negative attitudes about their infant and to view their infant as more
demanding or difficult. Depressed mothers exhibit difficulties
engaging the infant, either being more withdrawn or inappropriately
intrusive, and more commonly exhibit negative facial interactions.
These early disruptions in mother-infant bonding may have a
profound impact on child development.
Children of mothers with postpartum depression are more likely than
children of nondepressed mothers to exhibit behavioral problems
(eg, sleep and eating difficulties, temper tantrums, hyperactivity),
delays in cognitive development, emotional and social
dysregulation, and early onset of depressive illness.