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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.
Treatment:
Untreated postpartum affective illness places both the mother and infant at risk and is associated with significant longterm effects on child development and behavior; therefore, prompt recognition and treatment of postpartum depression are essential for both maternal and infant well-being.
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:(cont)
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.