The document discusses postpartum psychiatric disorders, highlighting the prevalence and risk factors of conditions such as postpartum blues, postpartum depression (PPD), and postpartum psychosis. Approximately 85% of women experience some mood disturbance during the postpartum period, with 10-15% developing significant symptoms of depression or anxiety, while postpartum psychosis is rare but severe, necessitating immediate medical intervention. Treatment options vary from psychosocial support for postpartum blues to pharmacological options for PPD and urgent care for postpartum psychosis.

1. POSTPARTUM
PSYCHIATRIC
DISORDERS
DR PARUL PRASAD
MBBS, MD, FGMH, MIPS
ASSISTANT PROFESSOR (PSYCHIATRY)
CIMS&H, LUCKNOW

3. Adapted from: Wisner KL, Sit DKY, McShea MC, et al. (2013). Onset Timing, Thoughts of Self-harm, and Diagnoses in Postpartum
Women With Screen-Positive Depression Findings. JAMA Psychiatry. 70(5):490–498.
ONSET OF MENTAL HEALTH SYMPTOMS
33%
27%
40% Prenatal
Prior to Pregnancy
Postpartum

4. THE POSTPARTUM PERIOD
During the postpartum period, about 85% of women experience some
type of mood disturbance.
Postpartum period is a risky period for psychiatric diseases.
Women experience 22 times more psychotic or mania episodes in
postpartum period than in any other periods of their lives
For most the symptoms are mild and short-lived; however, 10 to 15%
of women develop more significant symptoms of depression or
anxiety.

5. PSYCHOLOGICAL DISTURBANCES DURING
PUERPERIUM
Postpartum Blues
Postpartum
Depression
Puerperal
psychosis

6. INCIDENCE OF PSYCHIATRIC ILLNESS
DURING PUERPERIUM
85
10
0.1
0
10
20
30
40
50
60
70
80
90
Category 1 Category 2 Category 3
Postpartum Blues Postpartum Depression Postpartum Psychosis

7. POSTPARTUM
“BLUES”

8. Low mood and mild depressive symptoms that are transient and self-
limited
These symptoms typically develop within 2-3 days of childbirth, peak
over the next few days, and resolve by themselves within two weeks
of their onset.
About 50 to 85% of women experience postpartum blues during the
first few weeks after delivery.

9. Tearfulness
Decreased sleep
Labile mood
Irritability
Anxiety
Exhaustion

10. EPIDEMIOLOGY
Postpartum blues are extremely common and are estimated to occur in
about 50% or more of women
 Within the first few weeks after delivery.
 Postpartum major depression is approximately 4 to 11 times more
common among women who have postpartum blues

11. ETIOPATHOGENESIS
Hormonal changes have long been suggested as one of the primary
causative factors in developing postpartum mood changes.
Typically, there is a drastic decrease in estradiol, progesterone, and
prolactin in the time following delivery.
Various studies have also proposed that elevated monoamine oxidase
levels or decreased serotoninergic activity in the immediate
postpartum period are significant risk factors that could predispose a
woman to the development of postpartum blues

12. RISK
FACTORS
H/O menstrual
cycle related
mood changes
H/O major
depression or
dysthymia
Mood changes
associated
with
pregnancy
A larger
number of
lifetime
pregnancies
Family H/O
post-partum
depression

13. TREATMENT
By its diagnostic criteria, postpartum blues are transient and self-
limited.
Therefore, it resolves on its own and requires no treatment other than
validation, education, reassurance, and psychosocial support
 They should be carefully evaluated to see if the diagnostic criteria for
postpartum depression are met.

14. Patients should be carefully screened for suicidal ideation, paranoia,
or homicidal ideation towards the infant.
If insomnia persists, cognitive therapy and/or pharmacotherapy can be
recommended.

15. PROGNOSIS
Postpartum blues involve mood changes that are typically mild,
transient, and self-limited.
However, a diagnosis of postpartum blues can predispose an
individual to postpartum depression or postpartum anxiety disorders.
The risk of postpartum depression in an individual with “baby blues”
significantly increases in those who had mood or anxiety symptoms
during pregnancy

16. POSTPARTUM DEPRESSION

17. PPD typically emerges over the first 2-3 postpartum months but may
occur at any point after delivery.
Postpartum depression is clinically indistinguishable from depression
occurring at other times during a woman’s life.

18. Persistent
sadness
Feelings of guilt
Hopelessness,
helplessness &
wortlessness
Inability to
concentrate
Thoughts of
harming the
baby
Suicidal
thoughts
Sleep/appetite
changes
Loss of pleasure
in activities
Anger

19. Significant anxiety symptoms may also occur.
Generalized anxiety is common, but some women also develop panic
attacks or hypochondriasis.
Postpartum obsessive-compulsive disorder has also been reported,
where women report disturbing and intrusive thoughts of harming
their infant.

20. EPIDEMIOLOGY
Postpartum depression (PPD) is the most common medical
complication of childbearing
PPD occurs in 10 to 15% of new mothers
One of every 7 to 10 pregnant women and 1 of every 5 to 8
postpartum women develop a depressive disorder
No race or socioeconomic group is spared

21. Adapted from: Ayoub, Khubaib. (2015). prevalence of postpartum depression among Palestinian Women.

22. ETIOPATHOGENESIS
The postpartum period is characterized by a rapid shift in the
hormonal environment.
Within the first 48 hours after delivery, estrogen and progesterone
concentrations fall dramatically.
While it appears that there is no consistent correlation between serum
levels of estrogen, progesterone, cortisol, or thyroid hormones and the
occurrence of postpartum mood disturbance, a subgroup of women are
particularly sensitive to the hormonal changes that take place after
delivery.

23. RISK
FACTORS
Previous
episode of
PPD
Recent
stressful
life events
History of
depression
or bipolar
disorder
Depression
during
pregnancy
Marital
problem
Inadequate
social
supports

24. While all of these factors may act together to cause PPD, the
emergence of this disorder probably reflects an underlying
vulnerability to affective illness.
 Women with histories of major depression or bipolar disorder are
more vulnerable to PPD, and women who develop PPD will often go
on to have recurrent episodes of depression unrelated to pregnancy or
childbirth.

26. Postpartum depression presents along a continuum, and the type of
treatment selected is based on the severity and type of symptoms
present.
However, before initiating psychiatric treatment, medical causes for
mood disturbance must be excluded.
 Initial evaluation should include a thorough history, physical
examination, and routine laboratory tests.

27. Non-pharmacological therapies are useful in the treatment of
postpartum depression.
Interpersonal therapy (IPT) has also been shown to be effective for
the treatment of women with mild to moderate postpartum depression.
These non-pharmacological interventions may be particularly
attractive to those patients who are reluctant to use psychotropic
medications
Women with more severe postpartum depression may choose to
receive pharmacological treatment

28. PHARMACOLOGICAL MANAGEMENT
Specific serotonin reuptake inhibitors (SSRIs)
Tricyclic antidepressants (TCAs)
Benzodiazepine
Brexanolone

29. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for
the Management of Adults with Major Depressive Disorder
1st line Monotherapy: cognitive behavioural therapy (CBT), interpersonal
psychotherapy (IPT) (individual or group)
2nd line Monotherapy: citalopram, escitalopram, sertraline
Combination therapy: combination SSRI + CBT or IPT
3rd line (in order of evidence) • Structured exercise, acupuncture (depression specific), bright-light
therapy
• Bupropion, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, m
irtazapine, TCAs (caution with clomipramine due to risk of cardiac
malformations!), venlafaxine
• Electroconvulsive therapy (for severe, psychotic, or treatment-
resistant depression)
• Therapist-assisted Internet CBT, mindfulness-
based CBT, supportive psychotherapy, couples
therapy, psychodynamic psychotherapy, rTMS
• Combination SSRI + CBT or IPT

30. How Long Should Antidepressant Use Continue?
Based on recommendations and studies from the general adult
population, it is recommended that women for low risk of relapse
remain on antidepressants for another 6 to 12 months after achieving
remission of symptoms

31. PREVENTION OF PPD
Prophylactic interventions may be instituted near or at the time of
delivery to decrease the risk of postpartum illness.
Women with histories of bipolar disorder or puerperal psychosis
benefit from prophylactic treatment with lithium instituted either prior
to delivery (at 36 weeks gestation) or no later than the first 48 hours
postpartum.
For women with histories of postpartum depression, prophylactic
antidepressant (either TCAs or SSRIs) administered after delivery.

33. • “…I was so tired of being in pain. Of sleeping on the couch. Of waking up
throughout the night. Of throwing up. Of taking things out on the wrong people.
Of not enjoying life. Of not seeing my friends. Of not having the energy to take my
baby for a stroll. My doctor pulled out a book and started listing symptoms. And I
was like, “Yep, yep, yep.” I got my diagnosis: postpartum depression and anxiety.”
• Chrissy Teigen
• Glamour Magazine, March 6, 2017

34. POSTPARTUM PSYCHOSIS

35. Postpartum psychosis is the most severe form of
postpartum psychiatric illness.
The prevalence of postpartum psychosis has been
reported to be 0.1-0.2%
The nosological status of postpartum psychosis remains
doubtful; however, evidence indicates most episodes to be
manifestations of bipolar disorder

36. In DSM-5, classified in the "short psychotic disorder" section of the
schizophrenia spectrum and other psychotic disorders.
Its presentation is often dramatic, with onset of symptoms as early as
the first 48 to 72 hours after delivery.
The majority of women with puerperal psychosis develop symptoms
within the first two postpartum weeks.
The mean age of onset in PP is 26.3 years

38. SYMPTOMS
Early manifestations include symptoms such as insomnia, mood
changes, obsessive thoughts about baby, and later delusions,
hallucinations, disorganized behavior, psychomotor agitation, food
rejection, catatonia, and severe mood changes.
Delusion of reference, persecution, jealousy, grandiosity that are
incompatible with mood.
Delusions often have a bizarre character.
Tactile and visual hallucinations that point to the organic syndrome
Severe mood symptoms such as depression, mania or mixed episodes

39. Sometimes atypical cognitive symptoms such as disorientation, confusion
Due to cognitive disorganization, patients may neglect the newborn and/or
dangerous practices may arise while they are meeting the baby's needs .
Strange beliefs and thoughts about birth or baby
The risk of suicide increased by 70 times in the first year after birth.
Suicidal attempts may be aggressive and irreversible.
Although rare, the prevalence of infanticide, which is the most dramatic
picture, has been reported to be 4% and is associated with the denial of the
pregnancy.

40. Phenomenology
Mania/mixed mood state
Depression
Anxiety
Perplexity
”Kaleidoscopic” presentation
Psychotic symptoms
Mood lability
Prevalence 0.001–0.002% (1–2/1000)
Peak timing of postpartum onset Days 1–14
Duration Weeks to months

41. Risk
factors
Primiparity
Puerperal
hormone
changes
H/o bipolar
disorder
PP episode
history
Congenital
malformation
Perinatal
death during
delivery
Increased
environmental
stress
Sleep
deprivation

42. ETIOPATHOGENESIS
The temporal proximity of PP onset to childbirth, its high relapse rate,
and its relatively stable prevalence and nature across societies and
cultures, indicates that risk for the condition may be substantially
influenced by biological factors
 The maternal body undergoes extreme physiological changes in the
postpartum period, notably a massive drop in circulating oestrogens
upon expulsion of the placenta.
 Abnormal sensitivity to this endocrinological disturbance may confer
vulnerability to PP in some women, an idea supported by the fact that
oestrogen supplementation may be beneficial to some patients

43. Abnormal serotonergic and/or dopaminergic function may play a role
in its pathogenesis; there is a well-established link between oestrogen
levels and serotonergic function
Immune system dysfunction

44. TREATMENT
PP is an emergency that requires immediate medical intervention and
hospital admission.
 The patient must be hospitalized for maternal care and for the safety
of the baby.
Mood stabilizers, antipsychotics, ECT and benzodiazepines are used.

45. PROGNOSIS
Longitudinal studies indicate a good prognosis for women who have
experienced PP following bipolar disorder diagnosis.
 After a single PP episode, 75-86% of the symptoms are fully
recovered
 Of the patients diagnosed with schizophrenia; 50% recovered after
PP episode, 33% had recurrent PP episodes and 5% became treatment
resistant after a large number of puerperal and non-puerperal
recurrence
PP has been reported to recur in 65% of long-term follow-up studies

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