Postpartum Psychosis and other Postpartum Mental Disorders
Essentials
Postpartum depression is common.
Identify the risk group and symptoms suggesting depression; reserve sufficient time for discussion.
The onset of postpartum psychosis should be observed as early as possible.
Epidemiology
As many as 80% of mothers experience depressed mood ("baby blues") after childbirth, and this is a normal phenomenon.
After childbirth approximately 10-20% of mothers fulfill the diagnostic criteria for postpartum depression.
The incidence of postpartum psychosis requiring hospitalization is 1-2 per 1000 childbirths.
General
The risk of a woman developing depression during the first month after childbirth is three-fold compared with other women of the same age.
If the mother has suffered from depression before the pregnancy, the risk of postpartum depression is 25%. If the mother has suffered from postpartum depression before, the risk of recurrence is 40%.
Other risk factors for postpartum mental disorders include first childbirth, relationship difficulties, being unmarried, caesarean section and a family history of mood disorders.
A history of bipolar mood disorder is the greatest known risk factor for postpartum psychosis.
Thyroid dysfunction is rather common after childbirth and should be excluded as a part of the investigations for depressive symptoms.
Depressed mood after childbirth
Up to 80% of all mothers experience postpartum melancholy of some degree, and the symptoms are at their strongest 3-5 days after childbirth. This phenomenon is common, and is therefore often considered as a normal reaction to childbirth. However, it does increase the risk of the mother developing postpartum depression.
Symptoms include tearfulness, mood changes, headache, irritability, occasional loss of appetite and sleep disturbances.
The condition usually resolves spontaneously and does not need treatment other than a supportive attitude from the family and physician.
Postpartum depression
Appears most often within the first three months after delivery, but the incidence remains increased for up to 6 months after childbirth.
Predisposing factors include a history of severe depression, stress, negative experiences during the perinatal period and insufficient social support. The prevalence of postpartum depression is lower in cultures where the family or the community offer the new mother a great deal of support.
Typical symptoms are sleep disturbances, anhedonia, inability to concentrate, feelings of inadequacy, excessive concern and fear about the infant. The symptoms may be as severe as in psychosis.
Thyroiditis and hypothyroidism may also be the cause of maternal depression.
A mother's depression affects her ability to care for the infant and may jeopardize the development of a normal mother-child relationship. Furthermore, maternal postpartum depression increases the child's, and the entire family's, subsequent risk of psychiatric disorders. The incidence of sudden infant death syndrome is higher in the children of mothers with postnatal depression than in controls.
At maternal and child health services, screening for depression is often performed routinely or on the slightest suspicion (Edinburgh Postnatal Depression Scale, EPDS). Discussion with the mother and the father at the maternal or child health clinic helps the family to assess and identify the situation Psychosocial and Psychological Interventions for Preventing Postpartum Depression.
If the symptoms of depression persist, the situation needs re-assessment, by a psychiatrist if necessary, in order to avoid harmful consequences for the child and the family.
Postpartum psychosis
The rarest but the most severe of the psychiatric disorders after childbirth.
The symptoms most often start 3-14 days after childbirth. At this stage the mother and child have usually been discharged home, and the family members notice the mother's strange behaviour.
The first symptoms include restlessness, insomnia, agitation and mood changes which develop into confusion and usually into manic psychosis.
Postpartum psychosis is a psychiatric emergency and requires hospitalization. Suicidal risk is considerable and the newborn may also be at risk.
Treatment consists of antipsychotics, psychotherapy and social support for the mother and the family. Feasibility of breastfeeding is considered individually and depending on the drug.
In psychotic depression, electrotherapy can bring faster relief than drugs.
The prognosis is good after the first episode, but the psychosis often recurs after subsequent childbirths and this should be explained to the patient and her family.
The patient should be referred for psychiatric consultation during any subsequent pregnancies. Antidepressive medication started early enough may prevent the condition from developing.
References
Kroska EB, Stowe ZN. Postpartum Depression: Identification and Treatment in the Clinic Setting. Obstet Gynecol Clin North Am 2020;47(3):409-419. [PubMed]
Osborne LM. Recognizing and Managing Postpartum Psychosis: A Clinical Guide for Obstetric Providers. Obstet Gynecol Clin North Am 2018;45(3):455-468. [PubMed]
Pearlstein T, Howard M, Salisbury A et al. Postpartum depression. Am J Obstet Gynecol 2009;200(4):357-64.[PubMed]
Miller LJ. Postpartum depression. JAMA 2002 Feb 13;287(6):762-5. [PubMed]
Cogill SR, Caplan HL, Alexandra H, Robson KM, Kumar R. Impact of maternal postnatal depression on cognitive development of young children. Br Med J (Clin Res Ed) 1986 May 3;292(6529):1165-7. [PubMed]
Gregoire AJ, Kumar R, Everitt B, Henderson AF, Studd JW. Transdermal oestrogen for treatment of severe postnatal depression. Lancet 1996 Apr 6;347(9006):930-3. [PubMed]
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