64. Postpartum Psychiatryc Disorders

8/12/2019 64. Postpartum Psychiatryc Disorders

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Postpar tum Psychiatric Disorders 6

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64. POSTPARTUM PSYCHIATRIC DISOR DE RSDoris C Gundersm, M . D .

1. What psychiatric disorders are seen in the postpartum period?Maternity blues, postpartum psychosis, and postpartum depression are the psychiatric diagnoses

most often m ade after delivery.

2. Define maternity blues.Maternity blues, or baby blues, isa term used to describe a self-limiting, relatively mild mood

syndrome experiencedby 30-80 of all postpartum women. Symptoms include lability of mood,anxiety, sadness, crying spells, insomnia, and fatigue. The onset of m aternity blues is usually3-10days after parturition. The symptoms typically remit within2 weeks.

3. Which risk factors predispose women to maternity blues?Many regard maternity bluesas a normal postpartum phenom enon because of its frequency and

spontaneous remission. However, some women appear to be at higher risk. Major p redictive factors

include primiparous pregnancy, history of late luteal phase dysphoria (PMS), personal historyof de-pression, or first-degree relative with depression .

4. What causes maternity blues?The precise cause of m aternity blues is unknow n. Because the condition is com mo n in all cul-

tures and races and appears to occur independentlyof psychosocial factors,a biologic cau se is likely.Studies have demonstrated that estrogen and progesterone influence the sensitivityof neurotransmit-ter-binding sites much like chronic administration of antidepressant drugs. With the delivery of the


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364 Postpartum Psychiatric Disorders

placenta, the elevated estrogen and progesterone levels maintained throughout pregnancy fall precip-itously, and pregravid serum concentrations are reached within days, coinciding with peak symp-toms of m aternity blues. It is hypothesized that this rapid declin e in reproductive ho rmones afterdelivery destabilizes neurotransmitter mech anisms involved in mo od regulation.

5. Describe postpartum psychosis.Postpartum psychosis is som etimes called peurperal psychosis o r postpartum psychotic depres-

sion. It develops in 1-2 per 1000 postpartum wom en w orldwide. In the majority of cases, the symp-toms are manifest within the first 2 w eeks after delivery. However,a second peak has been observed1-3 months after delivery.

A comm on prodrom e for postpartum psychosis is worsening insom nia in the absence of a cryinginfant or physical discomfort in the mother. Psychomotor agitation may precede the psychosis.Wom en experience confusion, m emory impairment, irritability, and anxiety. Intrusive thoughts,usu-ally about harming the infant, are not uncommon. Paranoid and religious delusions, auditory halluci-nations, thought insertion, thought withdrawal, and thought broadcasting have been reported. Faultyinteractions with the infant, either misreading cuesor blatant disinterest,also may be manifestations.

A unique feature of postpartum psychosisis the mercurial changeability of the symptoms. Abrief period of elation characterized by incessant talking, increased energy, and euphoric m ood m ayshift rapidly to profound , inexplicable sadness or rage. Lucid intervals are com mo n and m ay give adeceptive impression of recovery. Abrupt ep isodes of floridly psychotic behavior m ay resurface afterweeks of calm. Postpartum psychosis may resolve abruptly, but more often it evolves into serious,protracted depression. Postpartum psychosis frequently resembles mania and may prove to be a vari-ant of bipolar affective disorder.

6. How frequently do women with postpartum psychosis harm their infants?Th e level of infant morbidity correlates well with the severity of psychiatric symptoms in the

mother. Infants of mildly to m oderately impaired m others may dem onstrate difficulty with feedingor bonding. Infants of mo re severely afflicted m others present with failure to thrive or evidence offrank physical abuse. Infanticide occurs in an estimated4 of cases. Approximately 80-120 infanti-cides are comm itted by psycho tic new m others in the United States each year. At least 50% of theinfant deaths take place weeks to months after the acute sym ptoms have subsided, Suc h numbersemp hasize the importance of continuo us monitoring of the mothers behavior, well beyond the initialpsychotic episode. Th e capacity for the psychosis to recur after lucid periods m ust always be kept inmind.

7. Are there specific risk factors for postpartum psychosis?Hereditary factors and prior history of affective episodes confer the greatest risk. A woman

with a history of depression unrelated to pregnancy hasa 20-25% risk of developing postpartum psy-chosis. This risk is higher for women with bipolar moo d disorders than for w omen with a history ofunipolar depression. If a bipolar wom an develops postpartum psychosis, she carries a 50% risk for re-currence with subsequent deliveries. Women with a historyof postpartum psychosis have a1 in 3chance of recurrence with future deliveries. The same w omen havea 38% risk for developing nonpsy-chotic postpartum depression. T he need f or carefu l prenatal screening and counselingis obvious.Other risk factors include single or primiparous women, cesarean section, or perinatal death.Postpartum psychosis peaks between ages25-29 and 30-34 years, which coincide with vulnerable

times for the developm ent ofPMS. A relationship between the two disorders has yet to be established.8. What is the cause of postpartum psychosis?

Postpartum psychosis is regardedas an organic syndrome. Psychological and social variablesare considered secondary to organic factors. After delivery of the placenta, a large source of hor-mon e production is lost. As with maternity b lues, the sudden and dram atic decline in serum estrogenmay initiate a sequenceof neuroendocrine events that produce serious psychiatric sy mp toms insus-ceptible women. E strogen has antidopam inergic properties. It is hypo thesized that the abru ptwith-


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Postpartum Psychiatric Disorders 365

drawal of estrogen exposes sensitive postsynaptic receptors in the brain; this may be the triggeringevent for development of psychosis. The propensity for relapse at the time of m enses further impli-cates sex hormon es in development of this disorder.

A d ecline in serum estrogen also leads to a fall in serum binding proteins, including transcortin.Cortisol levels

are elevated during pregn ancy. A surge of cortisol at labor is followed by an acceler-ated decline to second trimester levels within 7 2 hours. Acute psychotic reactions have been reportedwith ad renal insufficiency and/or steroid withdrawal. Sm all dose s of the cortisol analog given towomen with postpartum illness appear to decrease the severity and duration of symptoms.Unfortunately, no controlled studies of this regimen have been conducted.

Finally, women with postpartum illness have a high incidence ofthyroid abnormalities. T 3levels are significantly lowered in women with postpartum psychosis com pared with controls. Theabsolute values often fall within the normal range, w ith no overt physical signs of hypothyroid ism.Perhaps it is the slope of the T 3 decline rather than the specific serum concentration that influencesthe development of psychosis.

9. Describe postpartum depression,Between the extremes of maternity blues and postpartum psychosis lies postpartum depression,

which develops in 10-20% of women after delivery. Unlike the blues or psychosis, postpartum de-pression tends to develop insidiously3 or more w eeks after delivery. The m ood symptoms are moresustained, and the course of the illness is typically prolonged. Symptoms include crying spells, poorconcentration, indecisiveness, and profound sadness. Thoughts are characterized by themes of fail-ure and inadequacy. Suicidal ideation is comm on. Postpartum depression is characterized by physi-cal signs and symptom s resemb ling moderate-to-severe hypothyroidism. Cold intolerance, fatigue,dry sk in, slowed m entation, constipation, and fluid retention are common ly reported.

10. What are the risk factors for postpartum depression?As with the blues and psychosis,hereditary factors and a history of previous psychiatric ill-

ness are identified as significant risk factors for postpartum depression. Women with previousepisodes of depression unrelated to reproduction have a 1 0 4 0 % chance of developing postpartumdepression. Women with a history of postpartum depression have a 50% rate of recurrence with sub-sequent pregnancies. S everal psychosocial risk factors have been identified, including marital dis-cord , stressful life events during pregnancy, am bivalence about motherhood, low socioeconomicstatus, isolation from extended fam ily or friends, and single status. Unrealistic expectations or ro-manticized ideas about motherhood, which inevitably clash with reality, may predispose a w oman todepression. High prenatal scores on neuroticism scales are associated with postpartum depression.

11. Is postpartum depression considered to be primarily a biologic illness?Not entirely. Ethnographic literature about childbirth suggests that the depressive reaction is at

least partly attributable to cultural patterning of the postpartum period. Postpartum depressionis notexpressed globally; it appears rarely in non-W estern cultures in which a new mother is absolved ofall responsibilities beyond self-care and feeding her infant. Rituals practiced in third-world countriesinclud e provisions of social support for the new mother and clearly define her role. With modernbirthing practices in Western society, there is less social structuring of postpartum events and a lackof clear role definition and social support for new mothers.

12. Are there endocrine or biologic correlates for postpartum depression?Postpartum depression often is accompanied by symptoms related to hypothyroidism, and re-

search points to varying degrees of pituitary dy sfunction and related thyroid abnorm alities as con-tributing factors in development of the illness.

After normal delivery, blood supply to the pituitary gland wanes. Trophic hormone secretion isreduced to prepregnancy quantities. If the delivery is com plicatedby shock (e.g., massive hemor-rhage), the anterior pituitary may be damaged by infarction. In this scenario, secretion of trophichormones ceases. Targeted endocrine glands fail. The patient develops profound apathy, cold sensi-


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tivity, loss of libido, mem ory impairm ent, lethargy, and thinning of axillary and pubic hair. Psychosisand eventually coma develop in untreated cases. This is known asSheehan s syndrome.

It is hypothesized that postpartum depression is an interm ediate condition. A sluggish pituitarymay compromise endocrine functioning. After delivery thyroxine levels tend to decline and remain at

values below the nonpregnant average for up to1 year. Althoug h depressed, the thyroxine level tendsto overlap with the normal range, possibly masking hypothyroidism. The level of thyroid-stimulatinghormone (TSH) usually is normal inhypothyroidism of pituitary origin (secondary hypothy-roidism).

Case studies support the link between subclinical hypothyroidism of pituitary origin and post-partum illness. Antidepressant and antipsychotic medications, alone or in combination, frequentlyfail to treat adequately the sym pto m s of postpartum depression. W ith the addition of thyroid hor-mone, som e patients exp erience rapid alleviation of psychiatric sy mpto ms.

Further support for partial p ituitary dysfunction or dam age is suggested by the heightened sensi-tivity to sunburn or dim inished capacity to tan reported by several postpartum wom en. This findingsuggests reduced o r absent melanin production by the pituitary gland. Finally,5-30 of postpartumcases become chronic, imp lying so m e degree of residual dam age.

Primary hypothyroidism, which originates in thethyroid gland, is also diagnosed in the post-partum period. Painless autoimmune thyroiditis, characterized by positive thyroid antibodies, occursin 2-9% of postpartum w omen, surp assing the number observed in nonpregnant controls. Thyroxinemay rise briefly w ith the inflamm ation. This rise is followed bya reduction in thyroid hormone anda corresponding rise in TS H. O ne study revealed persistent thyroid abnorm alities3 years after deliv-ery in 50 of women.

In summary, postpartum depression often includes symptoms identical to moderate-to-severehypothyroidism. Routine laboratory screening may fail to identify the abnormality if it is of pituitaryorigin. Such subclinical hypothyroidism may render postpartum depression refractory to treatment.

13. Can postpartum disorders be prevented?Postpartum illnesses are notoriously difficult to treat. For this reason, efforts should be made to

prevent their onset by eliminating o r at least reducing known risk factors. High-risk patients can beidentified early in the courseof pregnancy through the use ofrisk assessment checklists, deally atthe first prenatal visit. When significant vulnerability is identified, interventions may include reduc-ing environmental stress, enlisting the aid of family mem bers, and mobilizing additional sources ofsupport. Prenatal anticipatory guidance p reparesa new mo ther for maternity blues and helps her todistinguish the blues from m ore om inous sym ptom s that w arrant professional attention. Women withpast histories of depression or psychosis should be followed m ore closely. The earliera postpartum

illness is identified, the greater the opportunity f or secondary prevention.

14. What are the barriers to diagnosis?Early detection of postpartum illnessis rare, in part as a result of modern obstetric practices. In

the United States, postpartum women are discharged fro m the hospital within48 hours. The symp-toms of postpartum illnesses are usually m anifest after the third postpartum day, when the expert ob-servation of nursing staff and physicians is no longer available. Six weeks pass before the nextprofessional contact is made, resulting ina window of extreme vulnerability for new mothers.

The stigm a placed by American culture on mental illness creates another barrier to early diagnosis.Patients and their families may conceal the severity of the prob lem out of sham e, guilt, or embarrass-

ment. Furtherm ore, depression after delivery contradicts the cultural expectation of parental bliss.''The prodrom e for serious postpartum pathology often mim ics the blues. Wom en who vo ice con-cerns about such sy mp toms m ay be reassured without further investigation. Finally, the focus of thefirst postnatal visit is the reproductive health of the mother; her emotional well-being is not routinelyaddressed.

15. What biologic treatment strategies are available?Maternity blues is a mild, transitory mood syndro me that typically resolves w ithina few days.


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Postpartum Psychiatric Disorders 67

Reassurance, observation, and occasionally a short-acting sedative are the primary interventions. Itis importan t, however, to take the patients complaints seriously. This increases the likelihood of h erreporting sym ptoms that linger or become mo re severe.

Postpartum psychosis usually merits hospitalization because of the level of dysfunction and

grave risk fo r both infanticide and suicide. The sym ptoms of postpartum psychosis are predomi-nantly affective. Lithiumor other mood-stabilizing medications are often helpful. Antipsychoticdoses are typically lower than those required for other psychotic disorders. Electroconvulsive ther-apy (ECT) is indicated for severe, pharmacologically refractory cases.

For postpartum depression antidepressants, especially those that are selective for seroton in,appear to have som e efficacy in targeting sym ptoms. Low dosesof antipsychotic medications shouldbe included if sym ptoms of psychosis are present. As with postpartum psychosis, som e wom en m ayrespond preferentially to ECT .

Thyroid screening should be performed routinely. For all postpartum cases, levels of serumthyroxine, TSH, and autoimmune antibodies should be assessed. Weekly thyroxine levels should beobtained. If a downward trend is identified, thyroxine replacement therapy should be initiated. Atypical starting dose is0.05 mg per day.

In women at risk for recurrence psychotropic drugs to preventor mitigate serious psychiatricsymptoms should be given serious consideration. Women with histories of postpartum psychosisshould receive lithium immediately after delivery. Rapid achievement of therapeutic blood levels isthe goal. Care must be exercised to prevent toxicity. Lithium excretion m ay be imp aired by fluid andelectrolyte changes in the immediate postpartum period. Low-dose antipsychotic medications arealso recommended f or at least2-3 weeks after delivery. In w omen with previous nonpsychotic post-partum depressions, antidepressant medication may be initiated somewhat earlier than on set of theprevious episode.

Postpartum disorders that developa more chronic course warrant endocrino logy consultationto rule out more subtle disorders of the hypo thalamic-pituitary-thyro id axis.

16. Which psychosocial interventions are effective?Psychotherapy is crucial for preventing psy chological scarring. Most patients have not experi-

enced prior mental illness and may have difficulty with accepting the need to participate in treat-ment. It is often helpful to emphasize the biologic aspects of postpartum illness, which should beconsidered a com plication of pregnancy-a medical illness with psychiatric symp toms related tophysiologic changes after childbirth. Oppo rtunities for eliminating feelings of failure and guiltbecome o bvio us. Gro up therapy is particularly helpful fo r postpartum women. It is impo rtant toconvey that postpartum illness has an excellent prognosis.

New fathers are often the silent victims of postpartum disorders. They benefit fr om supportiveoutreach and education. S tudies demon strate that a fathers support positively influences his part-ners recovery.

Extended fam ily must be recruited to supp ort a postpartum wom an during recovery. Providingliterature and directing them to local support groups are often helpful.

17. How may the infant be affected?Aggressive treatment of the mothers depression may prevent complications in the newborn.

Studies show that depressed mothers dem onstrate less positive attunementto their infants. They tendto be less affectionate and misread cues. Infants of depressed m others are atrisk for poorer mental

and m otor development, as well as emotional d isturbances in childhood.

18. What areas are the focus of current research?Depressed levels of tryptophan and a slower than normal rise in tryptophan levels after deliv-

ery predict the blues. Attempts to avert the blues through tryptophan loading have failed, leading tospeculation that a defect in metabolism rather than an absolu te deficiency in tryptophan may becausally related to maternity blues.

Pyridoxine is a cofactor required for n euronal utilization of tryptophan . With oral administra-


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tion for 28 days after delivery, an experimental gro up of high-risk wom en dem onstrateda recurrencerate of the blues several times lower than th e rate in a control gro up receiving placebo.A tryptophanstudy including pyridoxine supplementation may y ield valuable information.

Another highly experimental strategy for preventing more severe postpartum disorders involves

administering long-acting estrogen to high-risk wom en at delivery. It is theorized tha t the supple-mentation of estrogen cushions th e fall of the horm one after the placenta is delivered, In a series of50 high-risk women receiving estrogen at delivery, none had recurrences. Because of concerns aboutthe risk of thromboembolic pheno mena , this strategy is not currently recom mended for routine pro-phylactic treatment in women with histories of postpartum disorders.

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64. Postpartum Psychiatryc Disorders

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