Postpartum Psychiatric Disorders

General Information
The Postpartum Period
During the postpartum period, about 85% of women experience some type of mood disturbance. For most the symptoms are mild and short-lived; however, 10 to 15% of women develop more significant symptoms of depression or anxiety. Postpartum psychiatric illness is typically divided into three categories: (1) postpartum blues (2) postpartum depression and (3) postpartum psychosis. It may be useful to conceptualize these disorders as existing along a continuum, where postpartum blues is the mildest and postpartum psychosis the most severe form of postpartum psychiatric illness.

Postpartum Blues
It appears that about 50 to 85% of women experience postpartum blues during the first few weeks after delivery. Given how common this type of mood disturbance is, it may be more accurate to consider the blues as a normal experience following childbirth rather than a psychiatric illness. Rather than feelings of sadness, women with the blues more commonly report mood lability, tearfulness, anxiety or irritability. These symptoms typically peak on the fourth or fifth day after delivery and may last for a few hours or a few days, remitting spontaneously within two weeks of delivery. While these symptoms are unpredictable and often unsettling, they do not interfere with a womans ability to function. No specific treatment is required; however, it should be noted that sometimes the blues heralds the development of a more significant mood disorder, particularly in women who have a history of depression. If symptoms of depression persist for longer than two weeks, the patient should be evaluated to rule out a more serious mood disorder.

Postpartum Depression
PPD typically emerges over the first two to three postpartum months but may occur at any point after delivery. Some women actually note the onset of milder depressive symptoms during pregnancy. Postpartum depression is clinically indistinguishable from depression occurring at other times during a womans life. The symptoms of postpartum depression include:
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Depressed or sad mood Tearfulness Loss of interest in usual activities Feelings of guilt Feelings of worthlessness or incompetence Fatigue Sleep disturbance Change in appetite Poor concentration Suicidal thoughts

Significant anxiety symptoms may also occur. Generalized anxiety is common, but some women also develop panic attacks or hypochondriasis. Postpartum obsessive-compulsive disorder has also been reported, where women report disturbing and intrusive thoughts of harming their infant. Especially with milder cases, it may be difficult to detect postpartum depression because many of the symptoms used to diagnose depression (i.e., sleep and appetite disturbance, fatigue) also occur in postpartum women in the absence of depression. The Edinburgh Postnatal Depression Scale is a 10-item questionnaire that may be used to identify women who have PPD. On this scale, a score of 12 or greater or an affirmative answer on question 10 (presence of suicidal thoughts) raise concern and indicate a need for more thorough evaluation.

Postpartum Psychosis
Postpartum psychosis is the most severe form of postpartum psychiatric illness. It is a rare event that occurs in approximately 1 to 2 per 1000 women after childbirth. Its presentation is often dramatic, with onset of symptoms as early as the first 48 to 72 hours after delivery. The majority of women with puerperal psychosis develop symptoms within the first two postpartum weeks. It appears that in most cases, postpartum psychosis represents an episode of bipolar illness; the symptoms of puerperal psychosis most closely resemble those of a rapidly evolving manic (or mixed) episode. The earliest signs are restlessness, irritability, and insomnia. Women with this disorder exhibit a rapidly shifting depressed or elated mood, disorientation or confusion, and erratic or disorganized behavior. Delusional beliefs are common and often center on the infant. Auditory hallucinations that instruct the mother to harm herself or her infant may also occur. Risk for infanticide, as well as suicide, is significant in this population.

What Causes Postpartum Depression?

The postpartum period is characterized by a rapid shift in the hormonal environment. Within the first 48 hours after delivery, estrogen and progesterone concentrations fall dramatically. As these gonadal steroids modulate neurotransmitter systems involved in the regulation of mood, many investigators have proposed a role for these hormonal shirts in the emergence of postpartum affective illness. While it appears that there is no consistent correlation between serum levels of estrogen, progesterone, cortisol, or thyroid hormones and the occurrence of postpartum mood disturbance, some investigators hypothesize that there is a subgroup of women who are particularly sensitive to the hormonal changes that take place after delivery. This population of women may be more vulnerable to PPD and to other hormonally driven mood disturbances, such as those occurring during the premenstrual phase of the menstrual cycle or during the perimenopause. Other factors may play a role in the etiology of PPD. One of the most consistent findings is that among women who report marital dissatisfaction and/or inadequate social supports, postpartum depressive illness is more common. Several investigators have also demonstrated that stressful life events occurring either during pregnancy or near the time of delivery appear to increase the likelihood of postpartum depression.

While all of these factors may act together to cause PPD, the emergence of this disorder probably reflects an underlying vulnerability to affective illness. Women with histories of major depression or bipolar disorder are more vulnerable to PPD, and women who develop PPD will often go on to have recurrent episodes of depression unrelated to pregnancy or childbirth.

Who is at Risk for Postpartum Depression?

All women are vulnerable to postpartum depression, regardless of age, marital status, education level, or socioeconomic status. While it is impossible to predict who will develop PPD, certain risk factors for PPD have been identified, including: Previous episode of PPD Depression during pregnancy History of depression or bipolar disorder Recent stressful life events Inadequate social supports Marital problem Do you think you may be suffering from Postpartum Depression? Take this quiz. Click here to read a 2005 blog post on risk factors for PPD. Click here to read about obesity linked to postpartum risk.
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Treatment for Postpartum Illness

Postpartum depression presents along a continuum, and the type of treatment selected is based on the severity and type of symptoms present. However, before initiating psychiatric treatment, medical causes for mood disturbance (e.g., thyroid dysfunction, anemia) must be excluded. Initial evaluation should include a thorough history, physical examination, and routine laboratory tests. Non-pharmacological therapies are useful in the treatment of postpartum depression. In a randomized study it was demonstrated that short-term cognitive-behavioral therapy (CBT) was as effective as treatment with fluoxetine in women with postpartum depression. Interpersonal therapy (IPT) has also been shown to be effective for the treatment of women with mild to moderate postpartum depression. Not only is IPT effective for treating the symptoms of depression, women who receive IPT also benefit from significant improvements in the quality of their interpersonal relationships. Read this 2004 blog post and this 2007 post to learn more about CBT as a treatment option. These non-pharmacological interventions may be particularly attractive to those patients who are reluctant to use psychotropic medications (e.g., women who are breast-feeding) or for patients with milder forms of depressive illness. Women with more severe postpartum depression may choose to receive pharmacological treatment, either in addition to or instead of these non-pharmacological therapies. To date, only a few studies have systematically assessed the pharmacological treatment of postpartum depression. Conventional antidepressant medications (fluoxetine, sertraline, fluvoxamine, and venlafaxine) have shown efficacy in the treatment of postpartum depression. In all of these studies,

standard antidepressant doses were effective and well tolerated. The choice of an antidepressant should be guided by the patients prior response to antidepressant medication and a given medications side effect profile. Specific serotonin reuptake inhibitors (SSRIs) are ideal first-line agents, as they are anxiolytic, non-sedating, and well tolerated. For women who cannot tolerate SSRIs, bupropion (Wellbutrin) may be an alternative; although one pilot study suggests bupropion may not be as effective as SSRIs. Tricyclic antidepressants (TCAs) are frequently used and, because they tend to be more sedating, may be more appropriate for women who present with prominent sleep disturbance. Given the prevalence of anxiety symptoms in this population, adjunctive use of a benzodiazepine (e.g., clonazepam, lorazepam) may be very helpful. Puerperal psychosis is considered a psychiatric emergency that typically requires inpatient treatment. Acute treatment with either typical or atypical anti-psychotic medications is indicated. Given the wellestablished relationship between puerperal psychosis and bipolar disorder, postpartum psychosis should be treated as an affective psychosis and a mood stabilizer is indicated. Electroconvulsive therapy (ECT) is well tolerated and rapidly effective for severe postpartum depression and psychosis.

Using Medications While Breastfeeding

The nutritional, immunologic and psychological benefits of breastfeeding have been well documented. Women who plan to breastfeed must be informed that all psychotropic medications, including antidepressants, are secreted into the breast milk. Concentrations in the breast milk appear to vary widely. The amount of medication to which an infant is exposed depends on several factors, including dosage of medication, rate of maternal drug metabolism, and frequency and timing of feedings (Llewelyn and Stowe). Over the past five years, data have accumulated regarding the use of various antidepressants during breastfeeding (reviewed in Newport et al 2002). Available data on the tricyclic antidepressants, fluoxetine, paroxetine, and sertraline during breastfeeding have been encouraging and suggest that significant complications related to neonatal exposure to psychotropic drugs in breast milk appear to be rare. While less information is available on other antidepressants, there have been no reports of serious adverse events related to exposure to these medications. For women with bipolar disorder, breastfeeding may be more problematic. First is the concern that ondemand breastfeeding may significantly disrupt the mothers sleep and thus may increase her vulnerability to relapse during the acute postpartum period. Second, there have been reports of toxicity in nursing infants related to exposure to various mood stabilizers, including lithium and carbamazepine, in breast milk. Lithium is excreted at high levels in the mothers milk, and infant serum levels are relatively high, about one-third to one-half of the mothers serum levels, increasing the risk of neonatal toxicity. Exposure to carbamazepine and valproic acid in the breast milk has been associated with hepatotoxicity in the nursing infant.

Learn more in our Breastfeeding and Psychiatric Medication specialty area.

How to Prevent PPD

Although it is difficult to reliably predict which women in the general population will experience postpartum mood disturbance, it is possible to identify certain subgroups of women (i.e., women with a history of mood disorder) who are more vulnerable to postpartum affective illness. Current research indicates that prophylactic interventions may be instituted near or at the time of delivery to decrease the risk of postpartum illness. Several studies demonstrate that women with histories of bipolar disorder or puerperal psychosis benefit from prophylactic treatment with lithium instituted either prior to delivery (at 36 weeks gestation) or no later than the first 48 hours postpartum. For women with histories of postpartum depression, several studies have described a beneficial effect of prophylactic antidepressant (either TCAs or SSRIs) administered after delivery. Patients with postpartum psychiatric illness are offered a variety of services by clinicians with particular expertise in this area:
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Clinical evaluation for postpartum mood and anxiety disorders Medication management Consultation regarding breastfeeding and psychotropic medications Recommendations regarding non-pharmacological treatments Referral to support services within the community

How do I get an appointment?

Consultations regarding treatment options can be scheduled by calling our intake coordinator at 617-7247792. At this time the Center does not have any active studies investigating mood changes in pregnancy and the postpartum period. New studies may become active in the near future. In order to remain informed about any studies for which you may be eligible, you may join our research registry.

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:
1. Postpartum blues 2. Postpartum depression 3. 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:

1. World Health Organization

Maternal Health & Child Health and Development Literature review of risk factors and interventions on Postpartum Depression (pdf) 2. National Institutes of Health Postpartum Depression 3. Centers for Disease Control and Prevention Pregnancy Risk Assessment Monitoring System (PRAMS): PRAMS and Postpartum Depression