PostPartum PSYCHIATRIC DISORDERS

1. POST PARTUM
PSYCHIATRIC DISORDERS
Jibi Achamma Jacob

2. Contents
 Women and psychiatric illness.
 Biological and psychological changes.
 Classificatory system.
 Post partum psychiatric disorders.
 Challenges in diagnosing .
 Impact of mental illness in the post partum period.
 Case scenario.
 Confidential enquiries in maternal death.
 Indian studies.
 Assessment tools.
 Treatment guidelines.
 Treatment .
 Conclusions.

3. Introduction
 Childbirth
◦ supreme moments.
◦ Euphoria or elation - common.
◦ Some may be too excited to sleep.
◦ Feelings of peace, fulfilment, and
accomplishment help sustain mothers during
the weeks of strain that follow.

4. Challenges of newly delivered mothers
 Physical exhaustion.
 Breast feeding.
 Insomnia .
 Recovery of normal figure and attractiveness.
 Loss of libido.
 Social privation.

5. Women and psychiatric
illness
 Rapid biological, social, and emotional transition -variety of
psychiatric disorders occur.
 Complex than in any other human situation.
 Increased risk of developing severe psychiatric illness.
 Studies- increased risk of being admitted to a psychiatric hospital
within the first month postpartum than at any other time in her life.
 Up to 12.5% of all psychiatric hospital admissions of women - the
postpartum period.

6. Classificatory system
 Peurperal insanity-Esquirol.
 Marce-1857-morbid sympathy.
 Controversies with etiology and hence nomenclature based on
symptoms .
 First DSM term post partum introduced.
 DSM 3 –atypical psychosis.
 DSM 4 post partum onset specifier for mood and psychotic
disorder. Occuring within four weeks of delivery.
 DSM 5 –“peri partum”.

7. Classificatory system
 ICD- Episodes within six weeks of delivery.
 Atheoretical
 Drawback with the classificatory system:
- emergence of symptoms beyond six weeks.
- first ever /recurrence /pre existing
- spectrum of illness.

8. Biologic changes
 Drop in progesterone levels and estrogen levels.
 Prolactin progressively increase.
 Cortisol levels, decrease markedly.
 Rapid losses of weight and sodium begin about
day 3.

9. Biologic changes
 Calcium excretion decrease during the first
week.
 Tryptophan levels - rise markedly on days 1 and
2 post partum and then return to normal.
 B-endorphins -high during labour and falls
rapidly within 1 hour of delivery.

10. Psychological changes
 Transition to motherhood -psychological stress.
 Changes in her body image.
 Relationships with her husband and parents.
 Responsibilities as well as society's perception of her
role.
 Jealousy and hostility toward the infant.
 Fear of losing her identity.
 Financial or housing difficulties.

11. Post partum psychiatric disorders
 Post partum blues.
 Post partum psychosis.
 Post partum depression.
 Mother infant relationship disorders.
 Anxiety, obsession and stress related neurosis.

12. The maternity blues
 Most common observed puerperal mood disturbance .
 Prevalence - 40-75%.
 Begin within a few days of delivery, usually on day 3 or
4, and persist for hours up to several days.
 Mood lability, irritability, tearfulness, generalized
anxiety, and sleep and appetite disturbance.
 Greater fall in progesterone -one study, but consistent
finding is a reduction of noradrenaline levels in the urine
or the serum.

13. The maternity blues
 Unrelated to psychiatric history, environmental
stressors, cultural context, breastfeeding, or parity.
 Up to 20% -develop major depression in the first year
postpartum.
 Time-limited and mild.

14. Postpartum psychosis
 A variety of different psychosis.
 Belongs to a group of biological bipolar
brain disorders, with high heritability and
an inborn tendency to develop episodes
throughout life.

15. Post partum psychosis
 Epidemiology -1 in 1000 pregnancies.
 Lactational psychosis-no evidence with prolactin.
 All women susceptible.
 Most common in primiparous-54%
 No increase in incidence with twin studies, stillbirth or neonatal
death.
 Increase in incidence 20% of psychosis in first degree relative with
BPAD.

16. Aetiology
 Trigger that provokes the episode.
 Specific to puerperal psychosis.
- abortion.
- pregnancy itself, especially the last
trimester.
- postpartum menstruation.
- weaning.
- surgery.
- adreno-cortical steroid treatment.

17. Prodrome of postpartum psychosis
 Sleep disturbances.
 Restlessness.
 Fatigue.
 Irritability.
 Headache.
 Emotional lability.

18. Onset and course
 Acute
 Severity between 2 and 14 days after delivery.
 Delusions, hallucinations, passivity phenomena, and catatonic
features.
 Appear confused, bewildered, perplexed and dreamy, complaining
of poor memory.
 Infanticide and death from ‘lethal catatonia' or suicide - rare
outcomes.

19. Course
 With treatment, remits in few weeks.
 Puerperal recurrences -20 to 25 per cent of subsequent pregnancies.
 Risk one in five succeeding pregnancies.
 Non-puerperal recurrences - also common.
 Protheroe study- women with symptoms of schizophrenia-
recurrence rate is 47%.

20. Differential diagnosis
 Post eclamptic psychosis.
 Infective psychosis.
 Ethanol withdrawal.
 Cortical venous thrombosis.
 Encephalitis .
 Autoimmune disorders.
 Endocrine disorders.
 Electrolyte disturbances.

21. Post partum depression
 Post partum melancholia-important disorder identified.
 Under-represented in hospital.
 Similar to other depression.

22. Epidemiology
 10-15%
 Within six weeks of childbirth.
 Etiology: hormonal effect of tryptophan metabolism
 Decreased plasma level of free tryptophan.
 Increase level of urinary cyclic adenosine
monophosphate.

23. Causes
 Hereditary.
 History of previous prenatal depression.
 Neuroticism.
 Social conditions.
 Social isolation.
 Life events.
 Burden of child rearing.
 Not associated with parity/breast feeding.

24. Effects of post partum depression
 Lack of attention.
 Decrease quality, quantity and variety of interaction with child.
 Social withdrawal.
 Anxiety.
 Effect on child-poor communication: affects speech, language and
social skills.

25. Clinical features
 Low mood, anhedonia, psychomotor retardation.
 Tearfulness.
 Emotional lability.
 Sleep disturbances.
 Feeling of inadequacy.
 Anxiety about baby’s health.
 Self blame
 Rejection/reluctance.
 Suicidal thoughts.

26. Contributing factors
 Poor family /marital relationship.
 Increasing age.
 Marital conflicts.
 Mixed feeling about the baby.
 Physical problems in pregnancy.

27. Quantitative studies on predictors of
post partum depression
Strong to Moderate
 Depression during pregnancy
 Anxiety during pregnancy
 Stressful recent life events
 Lack of social support (either perceived or received)
 Previous history of depression
Moderate
 High levels of childcare stress
 Low self-esteem
 Neuroticism
 Difficult infant temperament

28. Quantitative studies on predictors of
post partum depression
Small
 Obstetric and pregnancy complications
 Cognitive attributions
 Quality of relationship with partner assessed using DYAS.
 Socioeconomic status
 No effect
 Ethnicity
 Maternal age
 Level of education
 Parity
 Gender of child (within Western societies)

29. Anxiety, obsessional, and stress-related
neurosis
 Post-traumatic stress disorder.
 Puerperal panic.
 Fear of cot death.
 Generalized anxiety.
 Phobic avoidance of the infant.
 Obsessions of child harm.

30. Mother–infant relationship disorders
 A key psychological process in the puerperium.
 Consists essentially of ideas and emotions aroused by the infant,
which find their expression in affectionate and protective behaviour.
 Lack of emotional response.
 Rejection of the infant.
 Pathological anger.

31. Mother–infant relationship disorders
Diagnosis
 Multidisciplinary team
-The psychiatrist
-The social worker/Occupational therapist
-The nursery nurse
-Psychiatric nurses

32. Mother–infant relationship disorders
Treatment
 Settings : Home treatment /Day-hospital
treatment/Inpatient mother-and-baby unit.
 Delay in the maternal emotional response-explanation
and reassurance.
 Dyadic relationship.

33. Challenges in identification and diagnosis
 Under-diagnosed.
 Perceived stigma.
 Lack of knowledge.
 Lack of awareness.
 Screening –timing and tools used.
 Organic causes mimicking.

34. Impact of mental illness in the post partum
period
 Emotional consequences.
 Loss of control over happening.
 Feeling of inadequacy.
 Low self esteem.
 Poor coping skills.
 Disruption of family unit.
 Life threatening events.
 Effect on the infant-growth , social skills.

35. Confidential enquiries of maternal
death
 Designed to improve health and health care by collecting data,
identifying any shortfalls in the care provided and devising
recommendations to improve future care.
 2002- SUICIDE- highest cause of maternal death secondary to post
partum disorders.
 “Avoidable death.”
 2012-mental health problems still the greatest cause of maternal
death.

36. Confidential enquiries of maternal
death
Recommendations
 ANC- details about past psychiatric illness.
 Protocol for management of women at risk/relapse/recurrence.
 Assessment by psychiatrist.
 Counsel about possible recurrence in further pregnancies.

37. Post-partum depression in the community: a qualitative
study from rural South India.Savarimuthu RJ, Ezhilarasu P,
Charles H, Antonisamy B, Kurian S, Jacob KS
 Assessed using the Tamil versions of the Short Explanatory Model
Interview, the Edinburgh Postnatal Depression Scale and a semi-
structured interview to diagnose ICD 10 depression.
 137 women were recruited and assessed, 26.3% were diagnosed to
have post-partum depression.
 Age less than 20 or over 30 years, schooling less than five years,
thoughts of aborting current pregnancy, unhappy marriage, physical
abuse during current pregnancy and after childbirth, husband's use
of alcohol, girl child delivered in the absence of living boys and a
preference for a boy, low birth weight, and a family history of
depression.
 Post-partum depression - associated with an increased number of
causal models of illness, a number of non-medical models,
treatment models and non-medical treatment models.

38. Post-partum depression in a cohort of women from a rural
area of Tamil Nadu, India Incidence and risk factors
M.Chandran,P.Tharyan,J,Muliyil,SAbraham
 359 women in the last trimester of pregnancy and 6-12weeks after
delivery for depression and for putative risk factors.
 Results -incidence of post-partum depression was 11% (95%CI 7.1-
14.9).
 Low income, birth of a daughter when a son was desired,
relationship difficulties with mother-in-law and parents, adverse life
events during pregnancy and lack of physical help - risk factors for
the onset of post-partum depression.
 Depression occurred as frequently during late pregnancy and after
delivery as in developed countries, but there were cultural
differences in risk factors.

39. Treatment
 Primary prevention -reduce the vulnerability
 Secondary prevention-reduce the severity and the duration of
symptoms.
 Tertiary prevention-improve functioning , relationships, prognosis
for women and the offspring.

40. Treatment
 Assessing the risk factors
-biologic factors
-psychosocial factors
-assess the current available supports.
-patients attitude towards child bearing and
rearing.

41. Considerations for women of childbearing
potential
 A new, existing, or past mental health problem.
 contraception and any plans for a pregnancy.
 Effect of pregnancy and childbirth in mental
health problem, including the risk of relapse.
 Impact of mental health problem and treatment
on woman, the foetus, baby, on parenting.
 Family history of severe antenatal or postnatal
mental illness in a first degree relative.

42. Recognising mental health problems in
pregnancy, postnatal period and referral
During the past month have you often been bothered by
 Feeling down, depressed, or hopeless?
 Having little interest or pleasure in doing things?
 Feeling nervous, anxious, or on edge?
 Not been able to stop or control worrying?
 Alcohol misuse,drug misuse

43. Recognising mental health problems in
pregnancy, postnatal period and referral
 Patient health questionnaire (PHQ-9),the Edinburgh
postnatal depression scale (EPDS), or GAD-79 and
referral to a general practitioner or mental health
professional.
 Assess within two weeks of referral : provide
psychological interventions within one month of initial
assessment.
 At all subsequent contacts during pregnancy and the first
year after birth, asking the two depression questions and
using GAD-2 as well as the EPDS or the PHQ-9 as part
of monitoring.

44. Assessment
 Physical wellbeing and history of any physical health problem.
 The woman’s attitude to and experience of the pregnancy.
 The mother-baby relationship.
 Social networks, living conditions, and social isolation.
 Domestic violence and abuse, sexual abuse, trauma, or childhood
maltreatment.
 Housing, employment, economic and immigration status.
 Responsibilities as a carer for other children and young people or
other adults.

45. Assessment tools
 Edinburgh Postnatal Depression Scale 1 (EPDS)
 Birmingham Interview for Maternal Mental Health
 The post partum bonding instrument.

46. Advice on treatment for women with mental health
problems in pregnancy and postnatal period or who are
planning a
pregnancy
 Uncertainty about the benefits, risks, and harms of treatments for
mental health problems and risk associated with no treatment.
 Benefits of each treatment, and the woman’s response to any
previous treatment.
 Risks or harms to the woman and the fetus or baby associated with
each treatment option.
 Possibility of the sudden onset of mental health symptoms,
particularly in the first few weeks after childbirth.
 The need for prompt treatment and risk or harms to the woman and
the fetus or baby associated with stopping or changing a treatment.

47. Starting, using, and stopping
treatment
 Taken psychotropic drug(s) with known teratogenicity at any time
in the first trimester:
- Confirm the pregnancy as soon as possible
- Explain that stopping or switching the drug after
pregnancy
is confirmed may not remove the risk of foetal
malformations
- Offer screening for foetal abnormalities and counselling
about continuing the pregnancy
- Explain the need for additional monitoring and the risks
to
the foetus if she continues to take the drug.
 Seek advice from a specialist if there is uncertainty about the risks
associated with specific drugs.

48. Deciding on the treatment option
 Previous response to treatment with these drugs.
 The stage of pregnancy.
 The reproductive safety profile.
 The uncertainty about whether any increased risk of fetal
abnormalities and other problems for the woman or
baby.
 The risk of discontinuation symptoms.

49. The Scottish Intercollegiate Guidelines Network
(SIGN)
Psychosocial management
 Psychological therapies - early response to pregnant and
postnatal women.
 Cognitive behavioural therapies- mild to moderate
depression
 Impairment in the mother-infant relationship-additional
interventions.
 Physical activity- support for structured exercise

50. Risk factors Interventions
 Stress
 Insufficient social support
 Nutritional deficiencies
 Insufficient physical
activity
 CBT, relaxation strategies,
problem solving skills.
 Interpersonal psychotherapy
 Supplementation and
education
 Education and support:
maintain realistic way to
increase physical activity

51. Risk factors Interventions
 Breast feeding
 Family planning
 Lactation support
Weaning is too stressful
 Pro-active, non coercive
family planning counseling
- Support for assertiveness and
effective communication
partner if needed.

52. General principles
 Switch to a low risk drug.
 Do not stop abruptly.
 Lowest effective dose.
 Avoid poly-pharmacy.
 Time the feed to avoid peak drug level in milk.
 Express milk to give later.
 Involve the parents /husband in all possible decisions.
 Monitor neonatal withdrawal effects.
 Document all decisions.

53. Treatment
 Antipsychotics.
 Antidepressants.
 Mood stabilisers.
 Sedation.
 Anxiolytics.

54. Other therapies
 ECT
 Mindfulness meditation
 Relaxation techniques
 Cognitive behavioral therapy.
 Interpersonal therapy.
 Psychodynamic therapy
 Family therapy.
 Parent infant psychotherapy.
 Bright light therapy

55. Occupational Therapy
 Child rearing skills
 Watch for ADR- explain
 Time management
 Ensure support
 Suicide risk
 Managing home and work

56. To conclude

57. To conclude
 A serious mental health problem for women
and its consequences have important
implications for the welfare of the family and
the development of the child.
 Biological and psychological basis.
 Early identification and treatment.
 Special population.
 Alert in identifying .

58. To conclude
 Maternal and infant health policies forms a
priority in low-income countries.
 Must integrate maternal depression as a
disorder of public health significance.
 Interventions should target mothers in the
antenatal period and incorporate a strong
gender-based component.

59. “A Nation thrives when mothers survive; we must
strive to keep them alive”
Ellen Johnson
Sirleaf
Thankyou

60. REFERENCES
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depression in the community: A qualitative study from rural South India. Int J Soc
Psychiatry. 2010;56:94–102
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