Postpartum Psychiatric Disorders

The postpartum (PP) period is a common time for the emergence or exacerbation of psychiatric disorders. Postpartum blues, PP depression, and PP psychosis are 3 of the most common psychiatric disorders experienced in the PP period. Although both genders are affected, PP is more common in women. Postpartum blues and PP depression affect up to 80% and 25% of women, respectively. Postpartum psychosis is less common but can be more serious. Unfortunately, perinatal mental illness is largely underdiagnosed and undertreated. Diagnosis is clinical, and management typically involves psychotherapy and antidepressants. Antipsychotics are used in the management of PP psychosis.

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Overview

Definitions

  • Postpartum (PP) blues: mild depressive symptoms that are transient and self-limiting in the perinatal period
  • PP depression: depressive symptoms beginning within the 1st 12 months following childbirth and lasting for at least 2 weeks
  • PP psychosis: a psychiatric manifestation with abrupt onset after delivery that is characterized by psychotic symptoms

Classification

The American Psychiatric Association (APA)’s Diagnostic and Statistical Manual 5th Edition (DSM-V) currently:

  • Does not classify PP psychiatric disorders as distinct entities
  • Allows providers to use the “with peripartum onset” specifier with the following diagnoses: 
    • Adjustment disorder with depressed mood 
    • Depressive disorder not otherwise specified
    • Major depressive disorder
    • Brief psychotic disorder
    • Major depressive, manic, or mixed episode in bipolar I or II disorders

According to the DSM-V, to use the “with peripartum onset” modifier, the onset of symptoms must occur during pregnancy or within 4 weeks PP (rather than within 1 year, which is commonly considered in clinical practice).

Epidemiology

  • Prevalence:
    • PP blues: very common, up to 80% of pregnancies
    • PP depression: often underdiagnosed, approximately 10%–25% of pregnancies 
    • PP psychosis: rare, < 1–2 per 1000 births
  • Gender: primarily occur in women
  • Age: more common in women < 25 years of age

Risk factors

  • Young age (< 25 years)
  • Poor social support
  • Difficulties with breastfeeding
  • Cesarean sections, traumatic birth experience, or other perinatal complications
  • Women with infants having health problems and/or with infants admitted to the NICU
  • History of psychotic illnesses (especially anxiety and depression)
  • Family history of psychiatric illnesses
  • Previous episode of PP psychiatric disorder
  • Stressful life events (during pregnancy and near delivery)
  • Childcare stress (e.g., inconsolable crying infant)
  • History of sexual abuse
  • Financial difficulties

Pathophysiology

The exact mechanisms are unclear and often multifactorial. 

  • Estrogen can affect the monoaminergic system (serotonin and dopamine) → changes in estrogen influence affective and psychotic symptoms
  • Drastic changes in hormone levels are thought to be major contributing factors in PP psychiatric disorders: early PP period is characterized by a marked ↓ in both estrogen and progesterone
  • Genetic factors may contribute.

Screening tools

There are a number of validated screening questionnaires that can help identify patients with or at risk for PP psychiatric disorders. Some of the most common questionnaires include:

  • Edinburgh Postnatal Depression Scale (EPDS): 
    • Used to assess patients for PP depression specifically (as opposed to major depressive disorder in general)
    • Self-reported 10-item questionnaire
    • Includes anxiety symptoms, which are a prominent feature in perinatal mood disorders
    • Excludes constitutional symptoms (e.g., changes in sleeping patterns) that are common in the PP period
    • An EPDS score > 11 indicates a risk for PP depression.
  • PP Depression Screening Scale (PDSS): 
    • Self-reported 35-item questionnaire 
    • High sensitivity and specificity
  • Patient Health Questionnaire-9 
    • Used to assess depression severity and monitor effects of treatment (though not specific for PP depression)
    • Self-reported 9-item questionnaire
    • Includes constitutional symptoms → reduces specificity in PPD

Postpartum Blues

Clinical presentation

  • Symptoms may include:
    • Feeling guilty and/or overwhelmed (especially about being a mother)
    • Crying, sadness
    • Rapid changes in mood and irritability
    • Anxiety 
    • Poor concentration
    • Eating too much or too little
    • Insomnia or frequent awakenings at night
  • Symptoms are mild and do not interfere with activities of daily living.
  • Onset of symptoms: within a couple of days after birth 
  • Duration of symptoms: lasting up to and no more than 2 weeks
  • Does not meet the criteria for major depressive disorder

Management

  • Resolves spontaneously
  • Provide reassurance. 
  • Encourage self-care.

Postpartum Depression

Clinical presentation

  • Symptoms may include:
    • Disinterest in self, in child, and in normal activities
    • Feeling isolated, unwanted, or worthless
    • Feeling a sense of shame or guilt about parenting skills
    • ↑ Anger outbursts
    • Suicidal ideation or frequent thoughts of death
  • Symptoms are more severe and patients have an inability to cope.
  • Onset of symptoms: 
    • American College of Obstetrics and Gynecology (ACOG): 2 weeks to 1 year after delivery 
    • APA: within 4 weeks of delivery
    • WHO: within 6 weeks of delivery
  • Duration of symptoms: > 2 weeks

Diagnosis

Postpartum depression is a clinical diagnosis. The following information may assist in establishing the diagnosis:

  • Screening questionnaires (e.g., EPDS, PDSS, or Patient Health Questionnaire-9) 
  • DSM-V criteria for major depressive disorder with peripartum onset:
    • Patients must meet at least 5 out of 9 symptoms for > 2 weeks.
    • Depressed mood or anhedonia (reduced pleasure from previously enjoyable habits) must be among the patient’s symptoms.
    • Symptoms include:
      • Depressed mood, almost everyday
      • Anhedonia
      • Appetite/weight changes (↓ or ↑)
      • Sleep disturbances (↓ or ↑)
      • Psychomotor agitation or retardation (patient is anxious and moves a lot, or barely moves)
      • Loss of energy/fatigue
      • Feeling worthless or excessively guilty
      • Trouble concentrating
      • Suicidal ideation and/or attempts
    • Symptoms cause a significant decline in function in social and occupational/school settings.
    • The patient does not have a history of:
      • Other psychiatric disorders (especially bipolar disorder)
      • Substance use 
      • Medical conditions such as hypothyroidism, nutritional deficiency, and cerebrovascular disease, which cause depressive mood
    • Limitations of the DSM-V criteria:
      • Many symptoms, especially weight changes and sleep disturbances, are common and frequently unrelated to depression in the PP period.
      • Restricts the diagnosis to symptoms beginning within 4 weeks of delivery → may lead to underdiagnosis
  • Laboratory studies:
    • If patients do have a history of medical conditions known to cause depressive symptoms, tests should be ordered to assess status.
    • Should be ordered if patients have other findings consistent with these conditions (e.g., new-onset constipation and goiter, which are suggestive of hypothyroidism)

Management

  • Psychotherapy:
    • Cognitive-behavioral therapy 
    • Family-centered therapy
    • Nondirective counseling
  • Antidepressants: Weigh risks against benefits for breastfeeding mothers.
    • Selective serotonin reuptake inhibitors (SSRIs): 1st line, best studied
    • Serotonin-norepinephrine reuptake inhibitors (SNRIs)
  • A combination of psychotherapy and SSRIs is most effective.
  • Electroconvulsive therapy (ECT) can also be considered (no risk to infant).
  • Most women recover within 6–12 months.

Complications

  • Risk of impaired maternal-child bonding → risk of behavioral problems and/or developmental delay in the infant
  • ↑ Risk of developing major depressive disorder later in life
  • Suicide (preventable with adequate treatment)
  • Infanticide

Postpartum Psychosis

Clinical presentation

Symptoms are similar to those of non-obstetric psychosis. The presenting symptoms are often severe, interfere with daily activities, and require hospitalization.

  • Symptoms may include:
    • Visual or auditory hallucinations
    • Paranoia, confusion, or delusions (especially regarding issues of parenthood) 
    • Mood symptoms (e.g., mania, depression, or both)
    • Disorganized speech
    • Disorganized or catatonic behavior
    • Obsession with caring for the infant 
    • Severe insomnia or frequent awakenings at night
    • Irritability, anxiety, hyperactivity, and psychomotor agitation 
    • Homicidal or violent thoughts related to the infant
    • Suicidal ideation or attempts
  • Onset: few days to 1 year after delivery (most commonly 2 weeks after delivery)
  • More common in patients with bipolar disorder or other psychiatric disorders characterized by psychosis (e.g., schizophrenia)

Etiology and diagnosis

According to the DSM-V, PP psychosis is not recognized as a distinct disorder. Instead, PP is classified as a primary psychiatric disorder and given the modifier “with peripartum onset” if symptoms begin within 4 weeks of delivery. 

  • Most common associated psychiatric disorders:
    • Bipolar disorder
    • Schizoaffective disorder
    • Schizophrenia
    • Major depression with psychotic features
    • Substance abuse disorder
    • Psychosis due to general medical conditions
    • Brief psychotic disorder
  • Other potential causes of psychosis: (work-up based on presentation)
    • Illicit drug use
    • Infectious diseases (e.g., mastitis, endometritis)
    • Metabolic encephalopathy
    • Endocrine dysfunction
    • CNS events
  • Laboratory studies to evaluate other potential causes:
    • Urine drug screen
    • CBC: Leukocytosis may indicate infectious diseases.
    • CMP: Abnormal electrolytes may suggest metabolic encephalopathy.
    • Thyroid studies: may suggest hypothyroidism

Management

Postpartum psychosis is considered a psychiatric emergency.

  • Hospitalization:
    • Especially if there is homicidal or suicidal ideation
    • The patient should be under the care of a psychiatrist (not an obstetrician).
  • Medical therapy:
    • Antipsychotics 
    • May be combined with antidepressants or mood stabilizers depending on the symptoms
  • Psychotherapy:
    • Generally only useful after the initial crisis 
    • Family-centered therapy can provide support for recovery.
  • ECT can be used to reduce depressive symptoms.

Complications

  • Temporary disruption to the maternal-infant bond → risk of behavioral problems and/or developmental delay in the infant
  • Suicide and/or homicide (preventable with adequate treatment)

Summary

Table: Summary of PP psychiatric diseases
PP bluesPP depressionPP psychosis
Epidemiology50%–80% of pregnancies10%–25% of pregnancies< 1% of pregnancies
Common symptomsGuilt, crying, feeling of being overwhelmedInability to cope, disinterest in self, disinterest in infantVisual or auditory hallucinations
OnsetBirth to 2 weeks PP2 weeks to 1 year after deliveryDays to 1 year after delivery
TreatmentResolves spontaneouslyPsychotherapy, antidepressantsAntipsychotics
Differential diagnoses
  • PP depression
  • Major depressive disorder
  • Seasonal affective disorder
  • Acute stress disorder
  • Dysthymia
  • PP blues
  • PP psychosis
  • Major depressive disorder
  • Bipolar disorder
  • Dysthymia
  • Seasonal affective disorder
  • Acute stress disorder
  • Hypothyroidism
  • Anemia
  • PP blues
  • PP depression
  • Acute psychosis
  • Schizophrenia
  • Delirium
  • Bipolar disorder
  • Seasonal affective disorder
  • Acute stress disorder
PP: postpartum

Differential Diagnosis

  • Acute stress disorder: presents after an individual has experienced a life-threatening event. Symptoms last > 3 days and < 1 month and involve re-experiencing the event as flashbacks or nightmares, avoidance of reminders of the event, irritability, hyperarousal, and poor memory and concentration. Management uses cognitive behavioral therapy and medications including anxiolytics. 
  • Major depressive disorder: a unipolar mood disorder characterized by persistent low mood and loss of interest, in association with somatic symptoms for at least a 2-week duration. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Biological, psychosocial, and genetic factors contribute to depression. Treatment modalities include pharmacotherapy, psychotherapy, and neuromodulation, such as ECT. Suicide is the leading cause of mortality in major depressive disorder.
  • Bipolar disorder: a recurrent psychiatric illness characterized by periods of manic and hypomanic features. Manic features include distractibility, impulsivity, increased activity, decreased sleep, talkativeness, grandiosity, and flight of ideas. These features may present with or without depressive symptoms. Management of bipolar disorder varies based on the presenting features, but usually involves pharmacotherapy with mood stabilizers. 
  • Schizophrenia: a chronic psychiatric disorder characterized by the presence of psychotic symptoms such as delusions and hallucinations. The signs and symptoms of schizophrenia include both positive symptoms (delusions, hallucinations, disorganized speech, and behavior) and negative symptoms (flat affect, avolition, anhedonia, poor attention, and alogia). Management includes antipsychotics in conjunction with behavioral therapy.
  • Brief psychotic disorder: defined as the presence of 1 or more psychotic symptoms lasting more than a day and less than a month. Brief psychotic disorder usually has a sudden onset and is often stress related. The diagnosis is clinical and management includes a brief course of 2nd-generation antipsychotics for 1–3 months along with education on the condition and reassurance, and potentially, psychotherapy. 
  • Delusional disorder: a condition in which the patient suffers from 1 or more delusions for a duration of 1 month or longer, without any other psychotic symptoms or behavioral changes and without a decline in the ability to function. Diagnosis is clinical, and the 1st-line treatment is with antipsychotic medications provided within the context of a trusting therapeutic relationship. Psychotherapy based on support and education may be helpful.
  • Schizoaffective disorder: a psychiatric disorder that includes both a psychotic component and a mood component. The diagnosis is clinical and management consists of both pharmacotherapy and psychotherapy similar to that used for schizophrenia and mood disorders.

References

  1. Gavin, N., Gaynes, B.N., et al. (2005). Perinatal depression: A systematic review of prevalence and incidence. Obstet Gynecol. 106, 1071–1083.
  2. Katherine, L. Wisner, Eydie, L. Moses-Kolko, and Dorothy K.Y. Sit. (2010). Postpartum depression: A disorder in search of a definition. Arch Women’s Ment Health. 13(1), 37–40.
  3. O’Hara, M.W., McCabe J.E. (2013). Postpartum depression: Current status and future directions. Annu Rev Clin Psychol. 9, 379-407.
  4. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Publishing, Washington, DC2013: 186–187.
  5. Howard, L.M., Molyneaux. E., Dennis, C.L., Rochat, T., Stein, A., Milgrom, J. (2014). Non-psychotic mental disorders in the perinatal period. Lancet. 384(9956), 1775–1788.
  6. The American College of Obstetrics and Gynecology Committee on Obstetrics. (2018). Committee Opinion No. 757: Screening for Perinatal Depression. Retrieved May 7, 2021, from https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/11/screening-for-perinatal-depression 
  7. Viguera, A. (2021). Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and diagnosis. In Solomon, D. (Ed.), UpToDate. Retrieved May 7, 2021, from https://www.uptodate.com/contents/postpartum-unipolar-major-depression-epidemiology-clinical-features-assessment-and-diagnosis 
  8. Payne, J. (2018). Postpartum psychosis: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. In Friedman, M. (Ed.), UpToDate. Retrieved May 7, 2021, from https://www.uptodate.com/contents/postpartum-psychosis-epidemiology-pathogenesis-clinical-manifestations-course-assessment-and-diagnosis 

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