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Vincent van Gogh Sorrow

Image: “Sorrow [section]” by Vincent van Gogh. License: Public Domain


Definition of Psychiatric Disorders in Pregnancy

Postpartum depression, or the “baby blues,” affects 40 to 80% of new mothers after childbirth. This state is characterized by low mood, irritability, sleep disturbances, and guilty feelings. It begins shortly after giving birth and lasts up to two weeks. The symptoms can interfere with the activities of daily living, including the mother’s ability to care for herself and the infant.

The condition is triggered by physical changes that occur in the body after childbirth. Hormone levels drop immediately and there are breast changes due to the production of milk by lactiferous tubules. Physical fatigue and emotions are other factors as the mother adjusts to a new routine and responsibilities.

Postpartum psychosis is much rarer than the baby blues and postpartum depression. It involves the onset, usually within two weeks after delivery, of hallucinations, irritability, unusual thought patterns, mood swings, and difficulty sleeping that lasts for at least two weeks.

Epidemiology

The baby blues, postpartum psychosis, and postpartum depression, occur in about 80% of all women, regardless of age or ethnicity. Women who have had difficulties with pregnancy or giving birth, and women who are prone to low mood, have an increased likelihood of developing the baby blues.

About 10 to 20% of women experience postpartum depression. Women who were depressed in pregnancy, have high-stress levels, upheavals in life events, low incomes, decreased social support, unemployment, rigid parental beliefs, anxiety disorders, past history of mental illness, and are a minority have an increased chance of developing postpartum depression.

Postpartum psychosis occurs in 1 – 2 out of every one thousand pregnancies. Women at the greatest risk for this disorder are those with previous psychiatric illnesses or those who suffered from psychosis during pregnancy. The onset is usually within two weeks of giving birth.

Etiology and Pathophysiology of Psychiatric Disorders in Pregnancy

Some studies have evaluated the etiology of the baby blues, postpartum depression, and postpartum psychosis. It is believed that both internal and external factors lead to the development of postpartum psychiatric disorders. Abrupt decreases in progesterone and estrogen occur after pregnancy, which may trigger emotional changes in susceptible women.

Risk Factors

Women who have little social support, have low socioeconomic status, a complicated birth, an unwanted gender of baby, unemployment, a history of mental illness, or previous anxiety, depressive, or psychotic disorder during pregnancy are at a greater risk of developing the disorder.

Pathophysiology

There is little data on the pathophysiology of the baby blues; however, some researchers have discovered that the sudden decline in estrogen and progesterone that occurs shortly after birth can trigger emotional symptoms in susceptible women. Even women without a past history of mental illness or pregnancy complications can suffer from the baby blues.

Postpartum depression studies implicate environmental and biological factors. Some researchers have found that sudden decreases in estrogen levels will trigger mood changes that can be diagnosed as postpartum depression. Others suggest that difficulties regulating the gamma-aminobutyric acid (GABA) receptor may cause the development of the disorder.

Cell GABA Receptor

Image: “Cell GABA Receptor.” by BruceBlaus – Own Work. License: CC BY-SA 4.0

There is strong evidence that environmental influences affect the pathophysiology of postpartum depression. Patients with depression during pregnancy, a difficult pregnancy, a history of any type of mental illness, difficult childbirth, poor social support, low income, and psychosocial stressors have a high incidence of developing postpartum depression, even without biological or genetic factors.

The evidence for a genetic origin for postpartum psychosis is much stronger than for the baby blues and postpartum depression. Postpartum psychosis seems to run in families, although no specific gene or set of genes has been associated with postpartum psychosis.

Having a history of bipolar disorder before or during pregnancy contributes to the pathophysiology of postpartum psychosis. Women with psychosis during pregnancy have a greater incidence of postpartum psychosis.

Symptoms and Signs of Psychiatric Disorders in Pregnancy

The baby blues can develop shortly after pregnancy as the hormone fluctuations happen immediately after delivery. The main symptoms include the following:

  • Rapid changes in mood
  • Anxiousness
  • Periods of sadness and irritability
  • Feelings of being overwhelmed about mothering
  • Episodes of crying
  • Difficulty concentrating
  • Eating too much or too little
  • Insomnia or frequent awakenings at night

These symptoms last for only about one to two weeks after delivery.

The main symptoms of postpartum depression include the following:

  • Low mood
  • Periods of sadness
  • Frequent episodes of crying
  • Feeling insecure about being able to care for the infant
  • Anxiety over caring for the infant
  • Insomnia or frequent awakenings at night
  • Eating too much or too little
  • Difficulty concentrating
  • Periods of confusion
  • Irritability
  • Feelings of isolation
  • Feeling unwanted or worthless
  • Feeling sensations of shame
  • Feeling guilty about parenting skills
  • Having increased angry outbursts
  • Being unable to care for the infant because of symptoms
  • Losing the ability to care for oneself because of symptoms
  • Feeling suicidal or having frequent thoughts of death

These symptoms can occur at any time within the first year of childbirth and must last at least two weeks to have the diagnosis of postpartum depression.

Symptoms of postpartum psychosis include the following:

  • Periods of paranoia
  • Episodes of confusion
  • Feelings of disorientation
  • Being obsessed with caring for the infant
  • Hallucinations, which are usually auditory in nature
  • Insomnia or frequent awakenings at night
  • Homicidal or violent thoughts toward the infant
  • Suicidal thoughts or suicide attempts
  • Irritability
  • Hyperactivity
  • Difficulty communicating

Because postpartum psychosis symptoms are severe, it is considered a psychiatric emergency and almost always results in hospitalization for psychiatric treatment.

Individuals with the baby blues show signs of sadness and can be observed as having frequent crying spells. These patients often can care for themselves and their infant,s so they are capable of caring for themselves and their infants. There are no signs of child abuse or neglect.

Individuals with postpartum depression have more severe symptoms than the baby blues. They show signs of being disheveled because the symptoms interfere with the woman’s ability to care for herself. She shows signs of frequent crying and is disinterested in activities she once enjoyed. She also shows evidence of child neglect, but evidence of child abuse is rare. This is a woman who is extremely overwhelmed but makes efforts to care for her infant.

An individual with postpartum psychosis has apparent signs of the disorder. She appears confused and delusional around issues related to parenthood. She may show evidence of hallucinations and has a marked inability to care for herself and her infant. Hospitalization as soon as the signs appear is warranted.

Tests and Investigations for Psychiatric Disorders in Pregnancy

There are no lab tests that can diagnose the baby blues, postpartum depression, or postpartum psychosis. However, blood tests may be done to rule out any physical disease that may mimic psychiatric illnesses, such as hypothyroidism. There are psychological tests that can identify postpartum mental diseases. Most obstetricians will administer a Patient Health Questionnaire, or PHQ-9, which helps identify women at risk for postpartum depression.

If the symptoms appear to be severe, an Edinburgh Postnatal Depression Scale (EPDS) can be administered. The EPDS is a longer test that has a high correlation with postpartum depression if the woman shows evidence of being depressed.

Another test, called the Postpartum Depression Screening Scale (PDSS), has a high correlation with postpartum depression if the woman shows evidence of being depressed. These tests are done if the PHQ-9  indicates problems suggestive of depression.

There are ongoing research studies on the etiology, pathophysiology, and treatment of postpartum psychiatric disorders. The disorder’s etiology and incidence have already been well-established in the literature. However, recent research is delving into the biological causes of these disorders. By understanding the biological cause of the disorder, treatments can be developed based on biology rather than on symptoms.

Pathology of Psychiatric Disorders in Pregnancy

There are no pathological tests that can diagnose the baby blues, postpartum depression, or postpartum psychosis. There are no routine tests that can diagnose postpartum psychiatric diseases using CT scanning, MRI scanning, or SPECT imaging. There is ongoing research on the use of SPECT scanning in depression that may, one day, be used to find brain pathology indicative of depression.

Differential diagnosis

The differential diagnosis of baby blues includes postpartum depression, major depressive disorder, seasonal affective disorder, acute stress disorder, and dysthymia.

The differential diagnosis of postpartum depression includes major depression, hypothyroidism, anemia, bipolar disorder, dysthymia, baby blues, seasonal affective disorder, acute stress disorder, and postpartum psychosis.

The differential diagnosis of postpartum psychosis includes baby blues, postpartum depression, acute stress disorder, seasonal affective disorder, bipolar disorder, acute psychosis, delirium, and schizophrenia.

Treatment of Psychiatric Disorders in Pregnancy

There is no treatment for the baby blues. They tend to resolve spontaneously; only supportive measures, such as reassurance and brief talk therapy, are warranted if the woman feels she needs these things to support her in the short time that the disorder lasts.

Fluoxetine

Image: “Fluoxetine structural formula.” No machine-readable author provided. Sunridin assumed (based on copyright claims). License: CC BY-SA 4.0

Women with postpartum depression can be treated with selective serotonin reuptake inhibitors, such as fluoxetine, paroxetine, escitalopram, sertraline, and fluvoxamine. The risks need to be weighed against the benefits before breastfeeding women use these drugs.

Some women benefit from electroconvulsive therapy since it has no risks for the infant. Psychotherapy is also a first-line treatment for postpartum depression. Cognitive-behavioral and family-centered therapies are the best options.

Women with postpartum psychosis represent a psychiatric emergency since they are significantly symptomatic and are at a high risk of suicide and homicide. These women are often treated aggressively with atypical antipsychotic medications, such as ziprasidone, quetiapine, and risperidone. Other antipsychotics, such as olanzapine, haloperidol, and clozapine are effective in treating these patients.

Psychotherapy generally only helps postpartum psychosis after the initial crisis has been averted. Family-centered therapy can help the patient and her family as she recovers. Electroconvulsive therapy can be used to decrease any depressive symptoms.

Postpartum blues Postpartum depression Postpartum psychosis
Epidemiology 50 – 80% of pregnancies 15 – 25% of pregnancies Less than 1% of pregnancies
Symptoms Guilt, crying, overwhelmed Inability to cope, disinterest in self or child Visual or auditory hallucinations
Onset 2 weeks 2 weeks – 1 year after delivery 2 weeks – 1 year after delivery
Treatment Resolves spontaneously Psychotherapy and SSRIs Anti-psychotics under the care of a psychiatrist

Complications and Prognosis of Psychiatric Disorders in Pregnancy

Fortunately, there are no complications of the baby blues, which resolves spontaneously without treatment. The care of the infant is generally not affected, and the mother and infant do well after the disorder has resolved.

Women with postpartum depression generally resolve their symptoms over several weeks or months after being treated for the disorder. The major complication of this disorder is impaired maternal-child bonding, which may not be reversible.

Infants of mothers who have had postpartum depression show behavioral problems and developmental delays during early childhood.

Children of women with postpartum psychosis also show behavioral problems and developmental delays in early childhood because of the breakdown of the maternal-child bond. The most significant complication of this disorder is homicide, or the killing of the infant, and maternal suicide.

A patient who is experiencing homicidal or suicidal ideation should be immediately referred to the emergency room for hospitalization.

The prognosis of the baby blues is excellent although some of these women will go on to develop postpartum depression and have a greater than average risk of developing the disorder.

Women with postpartum depression usually resolve their symptoms within 6-12 months after treatment. They are at a higher risk of developing a major depressive disorder later in life than women who do not have postpartum depression. There is also a disruption of the maternal-infant bond, which can leave lasting changes in the child’s behavior and developmental progress.

The prognosis of postpartum psychosis is excellent, with good response to antipsychotic medication, brief hospitalization, and family-centered supportive therapy after they resolve their psychosis. There is a temporary disruption of the maternal-infant bond, which can lead to developmental delays and behavioral problems in the infant that can last through early childhood. Suicide and homicide are possible but can be prevented with adequate treatment.

Prevention of Psychiatric Disorders in Pregnancy

Postpartum psychiatric disorders are treatable, especially when diagnosed early through the use of the Patient Health Questionnaire or PHQ-9. Most obstetric and family practice clinics providing obstetrical care will administer a questionnaire similar or identical to the PHQ-9 to detect early changes in mood. The questionnaire results can be used to reduce the incidence of psychiatric disease and its sequelae by offering early supportive treatment for the mother, the infant, and her family.

Prognosis

The prognoses of postpartum disorders are good if appropriately treated; 75–86% of patients remain symptom-free after a single episode. The relapse rate in subsequent pregnancies can be as 25–40%.

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