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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 Affect The feeling-tone accompaniment of an idea or mental representation. It is the most direct psychic derivative of instinct and the psychic representative of the various bodily changes by means of which instincts manifest themselves. Psychiatric Assessment 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 Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy and antidepressants. Antipsychotics are used in the management of PP psychosis.

Last updated: Mar 29, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definitions

  • Postpartum (PP) blues: mild depressive symptoms that are transient and self-limiting Self-Limiting Meningitis in Children 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 Psychotic symptoms Brief Psychotic Disorder

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 Adjustment disorder Adjustment disorder is a psychological response to an identifiable stressor. The condition by emotional or behavioral symptoms that develop within 3 months of exposure, and do not last more than 6 months. Adjustment Disorder with depressed mood 
    • Depressive disorder not otherwise specified
    • Major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder
    • Brief psychotic disorder Brief psychotic disorder Brief psychotic disorder is the presence of 1 or more psychotic symptoms lasting more than 1 day and less than 1 month. An episode is often stress-related with a sudden onset, and the patient fully returns to baseline functioning after an episode. Brief Psychotic Disorder
    • Major depressive, manic, or mixed episode in bipolar Bipolar Nervous System: Histology I or II disorders

According to the DSM-V, to use the “with peripartum onset” modifier, the onset of symptoms must occur during pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care or within 4 weeks PP (rather than within 1 year, which is commonly considered in clinical practice).

Epidemiology

  • Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency:
    • 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 Gender Gender Dysphoria: 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 Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. 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 Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder and depression)
  • Family history Family History Adult Health Maintenance of psychiatric illnesses
  • Previous episode of PP psychiatric disorder
  • Stressful life events (during pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care and near delivery)
  • Childcare stress (e.g., inconsolable crying infant)
  • History of sexual abuse Sexual Abuse Sexual abuse and assault are major public health problems that affect many people from all walks of life, including people of all ages and genders, but it is more prevalent in women and girls, with reports of up to 1 in 3 experiencing sexual assault at some time in their life. Sexual Abuse
  • Financial difficulties

Pathophysiology

The exact mechanisms are unclear and often multifactorial. 

  • Estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy can affect Affect The feeling-tone accompaniment of an idea or mental representation. It is the most direct psychic derivative of instinct and the psychic representative of the various bodily changes by means of which instincts manifest themselves. Psychiatric Assessment the monoaminergic system ( serotonin Serotonin A biochemical messenger and regulator, synthesized from the essential amino acid l-tryptophan. In humans it is found primarily in the central nervous system, gastrointestinal tract, and blood platelets. Serotonin mediates several important physiological functions including neurotransmission, gastrointestinal motility, hemostasis, and cardiovascular integrity. Receptors and Neurotransmitters of the CNS and dopamine Dopamine One of the catecholamine neurotransmitters in the brain. It is derived from tyrosine and is the precursor to norepinephrine and epinephrine. Dopamine is a major transmitter in the extrapyramidal system of the brain, and important in regulating movement. Receptors and Neurotransmitters of the CNS) → changes in estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy influence affective and psychotic symptoms Psychotic symptoms Brief Psychotic Disorder
  • 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 Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy and progesterone Progesterone The major progestational steroid that is secreted primarily by the corpus luteum and the placenta. Progesterone acts on the uterus, the mammary glands and the brain. It is required in embryo implantation; pregnancy maintenance, and the development of mammary tissue for milk production. Progesterone, converted from pregnenolone, also serves as an intermediate in the biosynthesis of gonadal steroid hormones and adrenal corticosteroids. Gonadal Hormones
  • Genetic factors may contribute.

Screening Screening Preoperative Care tools

There are a number of validated screening Screening Preoperative Care questionnaires that can help identify patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship 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 Screening Preoperative Care Scale Scale Dermatologic Examination (PDSS): 
    • Self-reported 35-item questionnaire 
    • High sensitivity Sensitivity Binary classification measures to assess test results. Sensitivity or recall rate is the proportion of true positives. Blotting Techniques and specificity Specificity Specificity is the probability of correctly determining the absence of a condition. Immunoassays
  • Patient Health Questionnaire-9 

Postpartum Blues

Clinical presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor

  • Symptoms may include:
    • Feeling guilty and/or overwhelmed (especially about being a mother)
    • Crying, sadness
    • Rapid changes in mood and irritability
    • Anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder 
    • Poor concentration
    • Eating too much or too little
    • Insomnia Insomnia Insomnia is a sleep disorder characterized by difficulty in the initiation, maintenance, and consolidation of sleep, leading to impairment of function. Patients may exhibit symptoms such as difficulty falling asleep, disrupted sleep, trouble going back to sleep, early awakenings, and feeling tired upon waking. 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 Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder

Management

Postpartum Depression

Clinical presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor

  • 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 Obstetricians and Gynecologists (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 Anhedonia Inability to experience pleasure due to impairment or dysfunction of normal psychological and neurobiological mechanisms. It is a symptom of many psychotic disorders (e.g., depressive disorder, major; and schizophrenia). Schizophrenia (reduced pleasure from previously enjoyable habits) must be among the patient’s symptoms.
    • Symptoms include:
      • Depressed mood, almost everyday
      • Anhedonia Anhedonia Inability to experience pleasure due to impairment or dysfunction of normal psychological and neurobiological mechanisms. It is a symptom of many psychotic disorders (e.g., depressive disorder, major; and schizophrenia). Schizophrenia
      • Appetite/weight changes (↓ or ↑)
      • Sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep disturbances (↓ or ↑)
      • Psychomotor agitation Agitation A feeling of restlessness associated with increased motor activity. This may occur as a manifestation of nervous system drug toxicity or other conditions. St. Louis Encephalitis Virus or retardation (patient is anxious and moves a lot, or barely moves)
      • Loss of energy/ fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia
      • Feeling worthless or excessively guilty
      • Trouble concentrating
      • Suicidal ideation Suicidal ideation A risk factor for suicide attempts and completions, it is the most common of all suicidal behavior, but only a minority of ideators engage in overt self-harm. Suicide 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 Bipolar Nervous System: Histology disorder)
      • Substance use 
      • Medical conditions such as hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto’s disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism, nutritional deficiency, and cerebrovascular disease, which cause depressive mood
    • Limitations Limitations Conflict of Interest of the DSM-V criteria:
      • Many symptoms, especially weight changes and sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of 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 Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship do have a history of medical conditions known to cause depressive symptoms, tests should be ordered to assess status.
    • Should be ordered if patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship have other findings consistent with these conditions (e.g., new-onset constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation and goiter Goiter A goiter is a chronic enlargement of the thyroid gland due to nonneoplastic growth occurring in the setting of hypothyroidism, hyperthyroidism, or euthyroidism. Morphologically, thyroid enlargement can be diffuse (smooth consistency) or nodular (uninodular or multinodular). Goiter, which are suggestive of hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto’s disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism)

Management

Complications

  • Risk of impaired maternal-child bonding → risk of behavioral problems and/or developmental delay in the infant
  • ↑ Risk of developing major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder later in life
  • Suicide Suicide Suicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death. Suicide (preventable with adequate treatment)
  • Infanticide

Postpartum Psychosis

Clinical presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor

Symptoms are similar to those of non-obstetric psychosis. The presenting symptoms are often severe, interfere with daily activities, and require hospitalization Hospitalization The confinement of a patient in a hospital. Delirium.

  • Symptoms may include:
    • Visual or auditory hallucinations Hallucinations Subjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders. Schizophrenia
    • Paranoia, confusion, or delusions (especially regarding issues of parenthood) 
    • Mood symptoms (e.g., mania Mania A state of elevated excitement with over-activity sometimes accompanied with psychotic symptoms (e.g., psychomotor agitation, inflated self esteem and flight of ideas). It is often associated with mental disorders (e.g., cyclothymic disorder; and bipolar diseases). Bipolar Disorder, depression, or both)
    • Disorganized speech
    • Disorganized or catatonic behavior
    • Obsession with caring for the infant 
    • Severe insomnia Insomnia Insomnia is a sleep disorder characterized by difficulty in the initiation, maintenance, and consolidation of sleep, leading to impairment of function. Patients may exhibit symptoms such as difficulty falling asleep, disrupted sleep, trouble going back to sleep, early awakenings, and feeling tired upon waking. Insomnia or frequent awakenings at night
    • Irritability, anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder, hyperactivity Hyperactivity Attention Deficit Hyperactivity Disorder, and psychomotor agitation Agitation A feeling of restlessness associated with increased motor activity. This may occur as a manifestation of nervous system drug toxicity or other conditions. St. Louis Encephalitis Virus 
    • Homicidal or violent thoughts related to the infant
    • Suicidal ideation Suicidal ideation A risk factor for suicide attempts and completions, it is the most common of all suicidal behavior, but only a minority of ideators engage in overt self-harm. Suicide or attempts
  • Onset: few days to 1 year after delivery (most commonly 2 weeks after delivery)
  • More common in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with bipolar Bipolar Nervous System: Histology disorder or other psychiatric disorders characterized by psychosis (e.g., schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). 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 Bipolar Nervous System: Histology disorder
    • Schizoaffective disorder Schizoaffective disorder Schizoaffective disorder is a mental disorder that is marked by 2 components: a psychotic component (hallucinations or delusions) and a mood component (mania or depression). Patients must therefore meet the diagnostic criteria for both major mood disorder and schizophrenia. Schizoaffective Disorder
    • Schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia
    • Major depression with psychotic features
    • Substance abuse disorder
    • Psychosis due to general medical conditions
    • Brief psychotic disorder Brief psychotic disorder Brief psychotic disorder is the presence of 1 or more psychotic symptoms lasting more than 1 day and less than 1 month. An episode is often stress-related with a sudden onset, and the patient fully returns to baseline functioning after an episode. Brief Psychotic Disorder
  • Other potential causes of psychosis: (work-up based on presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor)
    • Illicit drug use
    • Infectious Infectious Febrile Infant diseases (e.g., mastitis Mastitis Mastitis is inflammation of the breast tissue with or without infection. The most common form of mastitis is associated with lactation in the first few weeks after birth. Non-lactational mastitis includes periductal mastitis and idiopathic granulomatous mastitis (IGM). Mastitis, endometritis Endometritis Endometritis is an inflammation of the endometrium, the inner layer of the uterus. The most common subtype is postpartum endometritis, resulting from the ascension of normal vaginal flora to the previously aseptic uterus. Postpartum Endometritis)
    • Metabolic encephalopathy Encephalopathy Hyper-IgM Syndrome
    • Endocrine dysfunction
    • CNS events
  • Laboratory studies to evaluate other potential causes:
    • Urine Urine Liquid by-product of excretion produced in the kidneys, temporarily stored in the bladder until discharge through the urethra. Bowen Disease and Erythroplasia of Queyrat drug screen
    • CBC: Leukocytosis Leukocytosis A transient increase in the number of leukocytes in a body fluid. West Nile Virus may indicate infectious Infectious Febrile Infant diseases.
    • CMP: Abnormal electrolytes Electrolytes Electrolytes are mineral salts that dissolve in water and dissociate into charged particles called ions, which can be either be positively (cations) or negatively (anions) charged. Electrolytes are distributed in the extracellular and intracellular compartments in different concentrations. Electrolytes are essential for various basic life-sustaining functions. Electrolytes may suggest metabolic encephalopathy Encephalopathy Hyper-IgM Syndrome.
    • Thyroid Thyroid The thyroid gland is one of the largest endocrine glands in the human body. The thyroid gland is a highly vascular, brownish-red gland located in the visceral compartment of the anterior region of the neck. Thyroid Gland: Anatomy studies: may suggest hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto’s disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism

Management

Postpartum psychosis is considered a psychiatric emergency.

  • Hospitalization Hospitalization The confinement of a patient in a hospital. Delirium:
    • Especially if there is homicidal or suicidal ideation Suicidal ideation A risk factor for suicide attempts and completions, it is the most common of all suicidal behavior, but only a minority of ideators engage in overt self-harm. Suicide
    • 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 Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. 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 Suicide Suicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death. Suicide and/or homicide (preventable with adequate treatment)

Summary

Table: Summary of PP psychiatric diseases
PP blues PP depression PP psychosis
Epidemiology 50%–80% of pregnancies 10%–25% of pregnancies < 1% of pregnancies
Common symptoms Guilt, crying, feeling of being overwhelmed Inability to cope, disinterest in self, disinterest in infant Visual or auditory hallucinations Hallucinations Subjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders. Schizophrenia
Onset Birth to 2 weeks PP 2 weeks to 1 year after delivery Days to 1 year after delivery
Treatment Resolves spontaneously Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy, antidepressants Antipsychotics
Differential diagnoses
  • PP depression
  • Major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder
  • Seasonal affective disorder
  • Acute stress disorder Acute stress disorder Acute stress disorder describes stress reactions displayed after an individual has experienced a traumatic event. Symptoms last more than 3 days but less than 1 month and include re-experiencing the event as flashbacks or nightmares, avoidance of reminders of the event, irritability, hyperarousal, and poor memory and concentration. Acute Stress Disorder
  • Dysthymia
  • PP blues
  • PP psychosis
  • Major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder
  • Bipolar Bipolar Nervous System: Histology disorder
  • Dysthymia
  • Seasonal affective disorder
  • Acute stress disorder Acute stress disorder Acute stress disorder describes stress reactions displayed after an individual has experienced a traumatic event. Symptoms last more than 3 days but less than 1 month and include re-experiencing the event as flashbacks or nightmares, avoidance of reminders of the event, irritability, hyperarousal, and poor memory and concentration. Acute Stress Disorder
  • Hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto’s disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism
  • Anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview and Types
  • PP blues
  • PP depression
  • Acute psychosis
  • Schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia
  • Delirium Delirium Delirium is a medical condition characterized by acute disturbances in attention and awareness. Symptoms may fluctuate during the course of a day and involve memory deficits and disorientation. Delirium
  • Bipolar Bipolar Nervous System: Histology disorder
  • Seasonal affective disorder
  • Acute stress disorder Acute stress disorder Acute stress disorder describes stress reactions displayed after an individual has experienced a traumatic event. Symptoms last more than 3 days but less than 1 month and include re-experiencing the event as flashbacks or nightmares, avoidance of reminders of the event, irritability, hyperarousal, and poor memory and concentration. Acute Stress Disorder
PP: postpartum

Differential Diagnosis

  • Acute stress disorder Acute stress disorder Acute stress disorder describes stress reactions displayed after an individual has experienced a traumatic event. Symptoms last more than 3 days but less than 1 month and include re-experiencing the event as flashbacks or nightmares, avoidance of reminders of the event, irritability, hyperarousal, and poor memory and concentration. 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 Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment and concentration. Management uses cognitive behavioral therapy Cognitive behavioral therapy A directive form of psychotherapy based on the interpretation of situations (cognitive structure of experiences) that determine how an individual feels and behaves. It is based on the premise that cognition, the process of acquiring knowledge and forming beliefs, is a primary determinant of mood and behavior. The therapy uses behavioral and verbal techniques to identify and correct negative thinking that is at the root of the aberrant behavior. Psychotherapy and medications including anxiolytics. 
  • Major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder: a unipolar Unipolar Nervous System: Histology mood disorder characterized by persistent low mood and loss of interest, in association with somatic symptoms Somatic symptoms Major Depressive Disorder for at least a 2-week duration. Major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder has the highest lifetime prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency among all psychiatric disorders. Biological, psychosocial, and genetic factors contribute to depression. Treatment modalities include pharmacotherapy, psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy, and neuromodulation, such as ECT. Suicide Suicide Suicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death. Suicide is the leading cause of mortality Mortality All deaths reported in a given population. Measures of Health Status in major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder.
  • Bipolar Bipolar Nervous System: Histology disorder: a recurrent psychiatric illness characterized by periods of manic and hypomanic features. Manic features include distractibility, impulsivity Impulsivity Attention Deficit Hyperactivity Disorder, increased activity, decreased sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep, talkativeness, grandiosity, and flight of ideas. These features may present with or without depressive symptoms. Management of bipolar Bipolar Nervous System: Histology disorder varies based on the presenting features, but usually involves pharmacotherapy with mood stabilizers. 
  • Schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia: a chronic psychiatric disorder characterized by the presence of psychotic symptoms Psychotic symptoms Brief Psychotic Disorder such as delusions and hallucinations Hallucinations Subjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders. Schizophrenia. The signs and symptoms of schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia include both positive symptoms (delusions, hallucinations Hallucinations Subjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders. Schizophrenia, disorganized speech, and behavior) and negative symptoms (flat affect Affect The feeling-tone accompaniment of an idea or mental representation. It is the most direct psychic derivative of instinct and the psychic representative of the various bodily changes by means of which instincts manifest themselves. Psychiatric Assessment, avolition Avolition Lack of initiative. Schizophrenia, anhedonia Anhedonia Inability to experience pleasure due to impairment or dysfunction of normal psychological and neurobiological mechanisms. It is a symptom of many psychotic disorders (e.g., depressive disorder, major; and schizophrenia). Schizophrenia, poor attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment, and alogia Alogia Poverty of speech. Schizophrenia). Management includes antipsychotics in conjunction with behavioral therapy.
  • Brief psychotic disorder Brief psychotic disorder Brief psychotic disorder is the presence of 1 or more psychotic symptoms lasting more than 1 day and less than 1 month. An episode is often stress-related with a sudden onset, and the patient fully returns to baseline functioning after an episode. Brief Psychotic Disorder: defined as the presence of 1 or more psychotic symptoms Psychotic symptoms Brief Psychotic Disorder lasting more than a day and less than a month. Brief psychotic disorder Brief psychotic disorder Brief psychotic disorder is the presence of 1 or more psychotic symptoms lasting more than 1 day and less than 1 month. An episode is often stress-related with a sudden onset, and the patient fully returns to baseline functioning after an episode. 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 Reassurance Clinician–Patient Relationship, and potentially, psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy
  • Delusional disorder Delusional disorder In delusional disorder, the patient suffers from 1 or more delusions for a duration of 1 month or more, without any other psychotic symptoms or behavioral changes and no decline in functioning abilities. 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 Psychotic symptoms Brief Psychotic Disorder or behavioral changes and without a decline in the ability to function. Diagnosis is clinical, and the 1st-line treatment is with antipsychotic Antipsychotic Antipsychotics, also called neuroleptics, are used to treat psychotic disorders and alleviate agitation, mania, and aggression. Antipsychotics are notable for their use in treating schizophrenia and bipolar disorder and are divided into 1st-generation antipsychotics (FGAs) and atypical or 2nd-generation antipsychotics. First-Generation Antipsychotics medications provided within the context of a trusting therapeutic relationship Relationship A connection, association, or involvement between 2 or more parties. Clinician–Patient Relationship. Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy based on support and education may be helpful.
  • Schizoaffective disorder Schizoaffective disorder Schizoaffective disorder is a mental disorder that is marked by 2 components: a psychotic component (hallucinations or delusions) and a mood component (mania or depression). Patients must therefore meet the diagnostic criteria for both major mood disorder and schizophrenia. 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 Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy similar to that used for schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). 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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