Many females experience a wide range of overwhelming emotions such as anticipation, excitement, happiness, fulfillment, as well as anxiety, frustration, confusion, or sadness/guilt during pregnancy and postpartum period. The postpartum period makes them highly vulnerable to various psychiatric disorders. Traditionally postpartum psychiatric disorders are classified as maternity blues, puerperal psychosis, and postnatal depression. However, the spectrum of postpartum phenomenology is wide. Postpartum phenomenology is characterized by a range of emotions from transient mood lability, irritability, and weepiness, to marked agitation, delusions, confusion, and delirium.
Perinatal mental illness is largely under-diagnosed, and undertreated. Untreated postpartum psychiatric disorders can have far-reaching ramifications for a family. At times, the postpartum psychiatric condition can become so severe that it warrants hospitalization. Moreover, postpartum psychiatric disorders can adversely affect mother-infant interaction and attachment. Hence, early diagnosis and management of the postpartum psychiatric disorder is extremely crucial.
DIAGNOSIS ACCORDING TO CURRENT SYSTEMS OF CLASSIFICATION
The current psychiatric nosology has not classified postpartum psychosis (PP) as a distinct entity. Classification of puerperal illnesses as discrete nosological entities has been debatable for more than 30 years. Some school of thought regard PP as the postpartum presentation of an underlying disorder within the bipolar spectrum while others consider it purely as a distinct nosological entity.
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) and the ICD-10 classification of mental and behavioural disorders: Clinical description and diagnostic guidelines, have classified postpartum mental disorders differently. DSM-IV-TR allows psychiatrists to use the “with postpartum onset” specifier to brief psychotic disorder or to a current or most recent major depressive, manic, or mixed episode with psychotic features in major depressive disorder or Bipolar Disorder, if onset occurred within 4 weeks postpartum. In the ICD-10, mental illnesses associated with puerperium are coded according to the presenting psychiatric disorder; a second code (e.g., 099.3) denotes association with the puerperium. In some cases, the ICD-10 allows for a special code, F53 when there is insufficient information for classification, or there are “special additional features.” F53 can only be used if the disorder occurs within 6 weeks of delivery. DSM-V has replaced the specifier “with postpartum onset” for depressive and bipolar disorders with the specifier “with peripartum onset.” The “with peripartum onset” specifier is used if the onset of mood symptoms occurs during pregnancy or within the 4 weeks following delivery. However, postpartum psychiatric disorders may manifest weeks beyond the 1st month or 6 weeks after delivery. Hence, the utility of DSM-V specifier and the ICD-10 special code in the classification of puerperal disorders is limited.
PP is observed in 1–2/1000 childbearing women within the first 2–4 weeks following delivery. The onset of PP is sudden and acute in nature. PP is seen as early as 2–3 days following delivery. The patient can have paranoid, grandiose, or bizarre delusions, mood swings, confused thinking, and grossly disorganized behavior and is usually characterized by a dramatic change from her previous functioning. Postpartum depression (PPD) is observed in 10–13% of new mothers, and maternity blues, is seen in 50–75% of postpartum women.
A community-based prospective study in India found out the incidence of PPD in rural women to be around 11% which is comparable to incidence in western culture, where 10–15% of all mothers are affected by PPD. In adolescent mothers, PPD was observed to be around 26%.
Postpartum psychiatric syndromes are seen more commonly (81%) in patients below 25 years of age. The majority of the Indian women conceive during this part of the childbearing age as the age at marriage is comparatively lower. The family history of mental illness was observed in 25% of the patients.
PP can be defined as a psychiatric manifestation with abrupt onset after delivery, a phase characterized by overwhelming major biopsychosocial changes. Causation of PP is generally multifactorial.
Pathogenesis of PP has a strong biological element as the onset is abrupt in nature. The early postpartum period is characterized by a marked decrease in gonadal steroids. There is a considerable decrease in the levels of progesterone between the first and second stages of labor, and estrogen levels drop suddenly following the expulsion of the estrogen-secreting placenta. Estrogen primarily affects the monoaminergic system, especially serotonin and dopamine; influencing affective symptoms and psychotic symptoms respectively.
Pregnancy and the transition to motherhood give birth to a variety of psychological stressors. A woman has to adjust to changes in her body image, her relationships with her husband and family members, her responsibilities and the manner in which she is perceived by the society.
Risk factors associated with postpartum disorders
The risk factors associated with the development of postpartum disorders are: Primigravida; unmarried mother; cesarean sections or other perinatal or natal complication; past history of psychotic illness, especially past history of anxiety and depression; family history of psychiatric illness, especially mother and sister having postpartum disorder; previous episode of postpartum disorder; stressful life events especially during pregnancy and near delivery; history of sexual abuse; vulnerable personality traits and social isolation/unsupportive spouse.
Earlier postpartum disorders were classified as: (i) Postpartum blues (PBs), (ii) PPD (iii) PP. This was an oversimplification. However, in addition to these, there are miscellaneous groups of anxiety and stress-related disorders occurring in the puerperium. In recent times, postpartum disorders have been classified into five major categories: (i) PBs, (ii) PPD, (iii) PP, (iv) postpartum post-traumatic stress disorder (PTSD), and (v) postpartum anxiety and obsessive compulsive disorder (OCD). The characteristics of each postpartum disorder are described below.
PBs, also known as “baby blues” or “maternity blues,” is a phase of emotional lability following childbirth, characterized by frequent crying episodes, irritability, confusion, and anxiety. However, elation might also be observed during the first few days following childbirth.
“Baby blues” are very common and experienced by most of the women to some extent. However, PB is more commonly seen in western countries because of the lack of strong familial support and bonding. It is observed to be as high as 40–85%. The symptoms arise within the first 10 days and peak around 3–5 days. Generally symptoms of PB do not interfere with the social and occupational functioning of women. PB is self-limiting with no requirement for active intervention except social support and reassurance from the family members. PB can be attributed to changes in hormonal levels of women, further compounded by the stress following delivery. However, PBs persisting for more than 2 weeks may make women vulnerable to a more severe form of mood disorders.
PPD is the most common psychiatric disorder observed in the postpartum period. PPD is generally difficult to distinguish from depression occurring at any other time in a women's life. However, in PPD the negative thoughts are mainly related to the newborn. It is seen in 10–15% of postpartum women and, in addition to postpartum time specifier, the diagnostic criteria is difficult to differentiate from that of major depressive episode characterized by pervasive depressed mood, disturbances of sleep and appetite, low energy, anxiety, and suicidal ideation. Additionally feelings of guilt or inadequacy about the new mother's ability to care for the infant, and a preoccupation with the infant's well-being or safety severe enough to be considered obsessional. A large number of studies have observed that higher incidence of anxiety symptoms is observed in PPD than in non-PPD. Onset can range from few days to few weeks following delivery, generally in the first 2–3 months following childbirth. History of major depression increases the risk for PPD by 25%, and past history of PPD increases the risk of recurrence to 50%.
PP has an acute and abrupt onset, usually observed within the first 2 weeks following delivery or, at most, within 3 months postpartum, and should be regarded as a psychiatric and obstetrical emergency. The presence of a psychotic disorder affects the prenatal and postpartum care adversely. Past history of psychosis with previous pregnancies, history of bipolar disorder, family history of psychotic illness (e.g., schizophrenia or bipolar disorder) are some of the major risk factors for the development of PP.
Most commonly symptoms include elation, lability of mood, rambling speech, disorganized behavior, and hallucinations or delusions. However, presentation and course of PP may be more diverse and complex, with transient or alternating episodes of delusions of guilt, persecution, auditory hallucinations; delirium-like symptoms and confusion; and excessive activity. At times, delusions revolves around the infant, especially that the infant is possessed, has special powers, is divine, or is dead. Infanticide and suicide are observed in 4% and 5% of the women suffering from PP respectively. Enquiring about suicidal and infanticidal thoughts is crucial during the assessment of women suffering from PP.
Postpartum posttraumatic stress disorder
Bydlowski and Raoul-Duval did landmark study on postpartum PTSD. Many studies have shown the incidence of postpartum PTSD to be around 5.6%. It is generally characterized by tension, nightmares, flashbacks and autonomic hyperarousal that can continue for some weeks or months, and may recur toward the end of the next pregnancy. This can also result in secondary tocophobia.
Anxiety disorders specific to the puerperium
Many studies have observed that postpartum anxiety disorders are under-diagnosed and are in fact more common than PPD. De Armond observed that fear of cot death can reach up to a level of pathological degree. The most common feature is nocturnal vigilance characterized by the mother lying awake listening to the infant's breathing, and frequent checking resulting in sleep deprivation. Many mothers are excessively worried and preoccupied about the health and safety of their children which is known as “maternity neurosis.”
Obsessions of child harm
Women diagnosed with postpartum onset of major depression may have repetitive, intrusive thoughts related to some occurring to the baby associated with compulsive checking behavior. Postpartum onset of OCD can occur during gestation or within 6 weeks following delivery. The theme of the obsessions is frequently related to thoughts/gruesome images of harming the baby.
DIAGNOSIS OF POSTPARTUM PSYCHIATRIC DISORDERS
Postpartum psychiatric disorders have largely been under-diagnosed, reiterating the fact that routine screening during postpartum clinic visits should form an integral part of the assessment. Use of a population-specific screening tool such as the “Edinburgh Postnatal Depression Scale,” and the “Mood Disorder Questionnaire” can improve awareness of healthcare providers and aid in the early diagnosis of postpartum psychiatric disorders. Studies employing screening procedures have reported considerable increases in rates of detection of postpartum psychiatric disorders. Laboratory investigations and thorough physical examination should be done to exclude organic etiology. Sometimes rare medical conditions, such as frontotemporal dementia or frontal lobe tuberculoma, and Sheehan syndrome can mimic postpartum psychiatric disorders.
Important tests include a complete blood count, electrolytes, blood urea nitrogen, creatinine, glucose, Vitamin B12, folate, thyroid function tests, calcium, urinalysis and urine culture in the patient with fever; and a urine drug screen. A careful neurological evaluation is mandatory including a brain scan (cranial computerized tomography or magnetic resonance imaging) to rule out the presence of a stroke related to ischemia (vascular occlusion) or hemorrhage (due to uncontrolled hypertension, ruptured arteriovenous malformation, or aneurysm).
TREATMENT OF POSTPARTUM PSYCHIATRIC DISORDERS
The treatment of PPDs is generally holistic and includes reassurance, familial and social support, psychoeducation, and in some cases, psychotherapy and/or pharmacologic treatment.
Individual psychotherapy is an integral part of treatment, especially for females finding it difficult adjusting to motherhood and/or apprehensions about new responsibilities. Psychoeducation and emotional support for the partner and other family members are important. Patient and the family members should be involved in the formulation of the treatment plan. Respite care services should be recommended especially at night to minimize the patient's sleep disruption. In some cases, interpersonal therapy (IPT) might be beneficial. IPT is shown to result in greater reduction in depressive symptoms and improvement in social adjustment. In cases of PP, separation from the infant might be necessary. Reassurance and emotional support toward the mother can boost the self-esteem and confidence of the mother. Peer support and psychoeducation about PP are important interventions. Sometimes, group psychotherapy may also be helpful.
In moderate to severe depression and PP, medication becomes necessary. Safety and hazards of use of psychotropic medications during lactation should be addressed. The amount of medication to which an infant is exposed depends on several factors like, maternal dosage of medication, timing and frequency of dosing, rate of maternal drug metabolism, and metabolism of the ingested drug in the infant.
Most psychotropic drugs are metabolized in the liver. During the first few weeks of a full-term infant's life capacity for hepatic drug metabolism, is about one-third to one-fifth of the adult capacity. The capacity increases gradually and by about 3 months it reaches to the level of adult's capacity. In premature infants or infants with signs of compromised hepatic metabolism breastfeeding should be deferred if the mother is on psychotropic medication. Peak concentrations in breast milk are attained 6–8 h after ingestion of medication. Therefore, breastfeeding can be restricted to times when the breast milk drug concentration is lowest, that is, just before or after taking medication.
Pharmacologic treatment studies for PPD are few and include one double-blind study demonstrating the efficacy of fluoxetine or cognitive-behavioral therapy for major or minor depression; One open study each for sertraline, venlafaxine, and fluvoxamine. Approximately, 60% of mothers initiate nursing, and most of the antidepressants are excreted into breast milk. Sertraline, paroxetine, and nortriptyline may be the preferred choices for nursing women. However, the total number of cases reported for any given medication is small, and concern for infant safety must be considered.
Atypical antipsychotics are often first-line choices for psychosis and mania because of their tolerability. On the basis of a recent review of data on adverse effects in infants, olanzapine and quetiapine were considered the most acceptable. Chlorpromazine, haloperidol, and risperidone were classified as possible with breastfeeding, with medical supervision. Breastfed infants must be carefully observed for hydration status, excessive sedation, feeding difficulties, and failure to gain weight, which are possible signs of drug toxicity, and inform mothers to contact their physicians when they observe such symptoms. Physicians who prescribe medications to breastfeeding mothers could limit infant drug exposure by choosing the lowest effective dose, avoiding polypharmacy, and dividing daily doses to reduce peak concentrations.
Lithium is an important medication for the management of PP. Monitoring of lithium levels, thyroid and renal function, and adequate hydration is mandatory during the use of lithium. The use of lithium for breastfeeding mothers has generally been discouraged by the American Academy of Pediatrics (AAP) because of concerns regarding secretion of the drug through breast milk. Plasma levels in the infant may exceed 10% of the mother's plasma levels, causing toxicity in the infant especially in cases of dehydration. Lithium has been effective in decreasing relapse rates after subsequent pregnancies, although it is not clear if lithium should be restarted during pregnancy or immediately after parturition. A recent study suggests that lithium prophylaxis may be more useful in women who only have a past history of PP than in women with bipolar disorder who have had mood episodes outside the postpartum period as well.
Valproic acid or carbamazepine may be used to manage PP. The AAP reported that both these drugs were compatible with breastfeeding. Lamotrigine is Food and Drug Administration-approved for bipolar depression, but no studies have examined its efficacy in PP. It is unlikely to be used in the acute treatment phase since its titration takes weeks, but it may have a role in maintenance treatment. Lamotrigine may be used with caution because high plasma levels of the drug have been found in breastfeeding infants.
Benzodiazepines may have a role in the acute treatment of PP. Intramuscular lorazepam and haloperidol can be used to achieve rapid tranquilization. Once the patient becomes more stable, oral agents can be used. However, benzodiazepines are not recommended as monotherapy for PP. In a study of 51 women with first-onset psychosis in the postpartum period, 67% achieved remission with a combination of lithium, antipsychotics, and benzodiazepines; 18% with antipsychotics and benzodiazepines; and 6% with benzodiazepines alone.
Electroconvulsive therapy (ECT) can yield rapid symptomatic improvement in mothers with PP or severe PPD, but it may be challenging for women who have not previously received any psychiatric treatment to accept this treatment option. The only risks of ECT to a breastfeeding infant are the medications given for anesthesia and muscle relaxation, but since these medications are short-acting, it is expected that there is minimal transfer to the infant.
Women with PP should be advised against breastfeeding their infants. Both breastfeeding and nocturnal childcare are important causes of sleep loss, which in turn can lead to further mood instability particularly in women with bipolar disorder. Additionally, owing to psychotic state many women are incapable of breastfeeding. However, for suppression of lactation, dopamine agonists should be used cautiously as these drugs may result in psychosis in vulnerable women. Women who choose to breastfeed after improvement should be informed about the fact that all psychotropic drugs are excreted in breast milk at varying concentrations. The decision to breastfeed while taking medication should be made after careful weighing the risks and benefits to the mother as well as the infant.
COURSE AND PROGNOSIS
The prognosis of postpartum disorders is generally good if diagnosed early and adequately treated, especially in cases of affective psychosis and brief psychotic disorders. Women experiencing PP arising from bipolar illness have a good prognosis; 75–86% remained symptom-free after a single episode of PP. Chances of chronic disability increase in symptoms mimicking schizophrenia. The chances of recurrence are also very high. The relapse rate in subsequent pregnancies can be as high as 25–40%. Women who sought help within 1 month of delivery had more favorable outcomes and were less likely to suffer a long-term disability as compared to women with late-onset PP (13% and 33%, respectively).
Perinatal mental illness is under-diagnosed and may have far-reaching ramifications for the mother, her infant, her relationships with her partner and other family members. Early screening and diagnosis is very important. Healthcare professionals should regularly screen mothers during antepartum and postpartum visits by using a few simple questions. The postpartum period is a time of increased risk for the onset or exacerbation of mood instability particularly in women with bipolar disorder. Though the nosological status of PP remains controversial, it is generally considered a psychotic episode of bipolar disorder. Early identification of women at high-risk for developing PP and initiation of timely therapeutic approaches, consisting of the combination of pharmacological strategies and psychotherapeutic approaches, are the key factors to the successful management of PP. Prospective studies higher in the hierarchy of evidence is the need of the hour in order to provide guidelines on prevention and treatment interventions for postpartum psychiatric disorders.
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Conflict of Interest: None declared