and Meir Steiner, MD, PhD, FRCPC
Primary Psychiatry. 2004;11(3):29-36
• Perinatal mental illness is underdiagnosed and may have serious
• Risk factors for postpartum mental illness include depressed or anxious mood during pregnancy, personal or family history of psychiatric disorder (especially in first-degree relatives and including alcoholism), unplanned pregnancy, perinatal sleep deprivation, and major psychosocial stressors.
• Women suffering from perinatal mood disturbances are more likely to seek help from their primary care physicians or obstetricians rather than mental health professionals. Screening new mothers should be implemented by these healthcare providers using a few simple questions during regular antepartum and postpartum visits.
In spite of greater awareness that childbirth can be accompanied by severe emotional disorders, problems with timely identification of perinatal mental illness persist. Controversy as to whether puerperal illnesses are discrete nosological entities or instead episodes of mood, anxiety, or psychotic disorders that occur coincidentally in the puerperium or are precipitated by it, has endured for over 30 years. Recent research suggests that significant adverse mood reactions may be induced by major, albeit normal, changes in estrogen and progesterone levels in women with a biologic vulnerability to depression. Despite the fact that the etiology of perinatal mental illness is unknown, early recognition of the risk factors and the signs and symptoms of a postpartum disorder is crucial. Women who are at risk for or who may be suffering from a postpartum mood disorder can and should be identified by being asked a few simple questions during routine pregnancy or postpartum primary care, gynecologic, or pediatric visits. Rapid identification and treatment can in many cases prevent a major episode.
For many women, pregnancy and postpartum are times of powerful emotions that can contain anticipation, excitement, happiness, fulfillment, as well as anxiety, frustration, confusion, or sadness. Brockington1 called childbirth “a period of rapid biological, social, and emotional transition,” a time of enormous personal and interpersonal adaptation, especially for first-time mothers. Postpartum phenomenology can range from transient mood lability, irritability, and weepiness, to marked agitation, delusions, confusion, and delirium.
Mental illness that occurs following the birth of a child can become a familial catastrophe. In spite of greater awareness over the past 30 years that childbirth can be accompanied by severe emotional disorders, problems with timely identification of perinatal mental illness persist. Perinatal mental illness is underrecognized, underdiagnosed, and undertreated.2 To this day, obstetricians, family physicians, and even psychiatrists are surprised to the point of disbelief when they hear that the prevalence of depressive symptoms in the first weeks following delivery is between 10% and 20%.3-5 Women are more likely to seek help for perinatal psychiatric illness from their primary care physicians or obstetricians rather than mental health professionals. While severe depression and psychoses during pregnancy or postpartum are easily recognized, milder or more insidious forms of depressive or other psychiatric illness are frequently missed.6 A postpartum psychiatric condition can persist and eventually become so severe that the patient may require hospitalization. Furthermore, accumulating data suggest that maternal depressed mood can adversely affect mother-infant interaction and attachment,7-9 and that severity and chronicity of maternal depressive symptoms have been significantly related to higher levels of child behavior problems.10 Early identification and treatment are therefore extremely important.
The Postpartum Period: An Increased Biologic Vulnerability to Affective Disturbance?
Up to 80% of women of reproductive age may experience some fluctuations in mood either antepartum or postpartum and up to 20% may meet criteria for an affective disorder.3,5,11 As changes in mood can start within hours of childbirth and correspond with dramatic changes in hormones that occur at parturition and across the first 3 postpartum days, a causal link between the postpartum period and affective disorders has been assumed.
While numerous investigations have attempted to implicate gonadal or thyroid hormones or other neuromodulators including cortisol, prolactin, corticotropin-releasing hormone, or endorphins in the etiology of postpartum depressive disorders, very few conclusive data have emerged.12 This has to do in part with a snapshot approach within a complex, rapidly changing neuroendocrine milieu and the difficulties in correlating the fluctuating hormonal levels with their impact on central monoamine and peptide pathways. Given that gonadal hormones have been found to moderate monoamine systems,13 it is likely that some precipitating factors are associated with the rates of change of gonadal hormones and not necessarily with the actual serum levels.14
One current theory posits that some women have an inherent neuroendocrine sensitivity to psychosocial, environmental, and physiologic factors, triggered by the onset of menarche, which increases biologic vulnerability to mood dysregulation during their reproductive years.13 In susceptible women, a cascade of events triggered initially along the hypothalamic-pituitary-gonadal axis produces the shift from an existing vulnerability to manifestations of female-specific mood disorders. Particularly vulnerable times include the periods which mark shifts in the reproductive stages—menarche, the premenstruum, the puerperium, and menopause—which are all associated with major hormonal fluctuations, as well as psychosocial stress.
Evidence from studies of premenstrual dysphoria has shown that the serotonergic system is in close reciprocal relationship with gonadal hormones.12 Moreover, there is preliminary evidence of a genetic predisposition to altered activity of the serotonin transporter system in women with severe premenstrual dysphoria (M Steiner, MD, and colleagues, unpublished data). The reciprocal relationship between the serotonergic system and gonadal hormones during pregnancy or in postpartum women has not as yet been studied.
Along these lines, Bloch and colleagues15 experimentally simulated supraphysiologic gonadal steroid levels of pregnancy and subsequent withdrawal (parturition) in women with and without a history of postpartum depression (PPD). Ratings of depression were significantly higher during the first 4 weeks of withdrawal for women with a history of PPD compared to women with no history. There was a subsequent improvement in mood ratings with returning ovarian function. The results suggest that significant adverse mood reactions may be induced by major, albeit normal, changes in estrogen and progesterone levels in women with a biologic vulnerability to depression.
Additional evidence of a biological component of postpartum mood disorders comes from family history studies. The lifetime prevalence of mood-related disorders in the first-degree relatives of women presenting with postpartum mood disorders is much higher than in the general population and may indicate potential genetic or familial components of the disorders.16,17
Postpartum Onset: A Distinct Entity?
Controversy as to whether puerperal illnesses are discrete nosological entities or episodes of a known psychiatric disorder such as mood, anxiety, or psychotic disorders, which occur coincidentally in the puerperium or are precipitated by it, has endured for more than 30 years.18-22 Research has shown that the rates of admission to a psychiatric hospital within the first month postpartum rise to higher levels than at any other time across the female lifespan.23
In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV),24 a link between mood disorders and childbearing is acknowledged by the inclusion of a postpartum-onset specifier that can be applied to a current or recent major depressive episode, manic episode, or mixed episode of bipolar I or bipolar II disorder; or to a brief psychotic disorder. The DSM-IV does not recognize postpartum psychiatric disorders as discrete diagnoses. As some authors have pointed out, if PPD is really a discrete diagnostic entity, it would present with specific symptomatology, risk factors, and course.25 The symptomatology for PPD is not specific, but rather is influenced by the puerperal context. Several population-based studies in the United States and the United Kingdom have revealed similar rates of less severe depressive illness in puerperal and nonpuerperal cohorts.26-28 The course of PPD resembles depression occurring at other times, and even considering contextual factors, the differences are not very marked.25,29
The literature concerning postpartum psychosis, however, is more complex. Chaudron and Pies30 have evaluated evidence from studies of women with a history of bipolar disorder, longitudinal studies of women with puerperal episodes of psychosis, and family studies, and found that there is support for a link between postpartum psychosis and bipolar disorder. While some consider postpartum psychosis a postpartum presentation of an underlying disorder within the bipolar spectrum, others have documented patients with exclusively puerperal manifestations.31 Notwithstanding, the diagnostic classification of psychotic episodes is similar whether the episode occurs postpartum or outside the puerperium.
Diagnosis According to Current Classification Systems
The two internationally recognized classification systems for psychiatric illness, the DSM-IV and the International Classification of Diseases (and Related Problems), Tenth Revision (ICD-10),32 have differing approaches to the classification of postpartum mental disorders. The DSM-IV has a course-specific designation—“with postpartum onset”—which can be applied to all Axis I disorders. It refers to the current or most recent episode if the onset of the episode lies within the first 4 weeks postpartum. The DSM-IV, which represents North American psychiatry, seems to ignore the uniqueness of both the situation (ie, antepartum or postpartum) and the presentation of mental illness associated with childbearing. In the ICD-10, mental illnesses associated with the puerperium are coded according to the presenting psychiatric disorder and a second code (eg, 099.3) indicates association with the puerperium. In exceptional cases, the ICD-10 allows for a special code, F53, a category used when there is insufficient information for classification according to known disorders, but also used when there are “special additional features.” F53 can only be used if the disorder occurs within 6 weeks of delivery.
The DSM-IV specifier and the ICD-10 special code are problematic though, since the full manifestation of psychiatric illness postpartum may occur weeks beyond the first month or 6 weeks after delivery. The US National Library of Medicine defines puerperium as the period up to 8 weeks after delivery.33 In clinical practice, however, it is not uncommon to consider postpartum as the period up to 12 months following delivery. As yet, there is not a consensus in the literature as to the exact length of time that the term postpartum denotes. The specifier and special code are often used beyond their indicated time period. Further, there is no clear distinction in either system as to whether an episode (especially in first-time mothers) is the first ever or a recurrence of a preexisting disorder.
Current Diagnostic Labels and Epidemiology
Brockington1 also noted that childbirth, as with any major life stressor, can precipitate an episode of mental illness. Indeed, for some women—especially primiparous mothers—the transition to motherhood may be difficult, and compounded by low self-esteem.34,35 In general, factors that can increase the risk for severe postpartum emotional disturbance include: a personal psychiatric history of mood or anxiety disorders, as well as a history of premenstrual syndrome or sexual abuse17,36-38; a family history of psychiatric disorder—particularly in first-degree relatives—including alcoholism, PPD, or postpartum psychosis5,17,35,39; unplanned pregnancy40,41; and sleep deprivation across late pregnancy, during labor, and during the immediate postpartum period (Table 1).42,43
Postpartum blues, also known as “baby blues” or “maternity blues,” is a period of emotional lability after delivery, with frequent crying episodes, irritability, confusion, and anxiety (Table 2). Symptoms of elation may also be present during the first days after delivery.44 It has been estimated that 15% to 85% of women may experience postpartum blues.45 One prospective study has shown that ratings of depression, crying, anxiety, and mood lability rise during the first 5 days after delivery and then taper in the days thereafter. Irritability may linger for an additional 2 weeks.46 Postpartum blues is typically a transient phenomenon, and does not require treatment. However, in approximately 20% of blues cases, the mood disturbance may persist for >3 weeks and lead to a more serious mood disorder.46,47
The etiology of postpartum blues has yet to be determined, and investigators have been unable to consistently pinpoint biological or psychosocial predictive factors.48 An association between postpartum blues and sleep deprivation in late pregnancy or labor at night has been suggested.49
PPD usually begins in the first 6–12 weeks after parturition, although its onset can be later following a period of well-being (Table 2). The symptom profile resembles that of a nonpsychotic major depressive episode experienced at other times in life, including depressed mood, sleep and appetite disturbance, low energy, anxiety, and suicidal ideation. Additional symptoms include feelings of guilt or inadequacy about the new mother’s ability to care for the infant, and a preoccupation with the infant’s well-being or safety severe enough to be considered obsessional.1,50 Epidemiological studies have identified the prevalence of PPD as ranging between 10% and 20%.3,5 PPD is distinguished from emotional reactions to spontaneous abortion, termination of pregnancy, and late pregnancy or neonatal loss.51
The overlap between symptoms of major depression and symptoms typically associated with having a new baby, such as sleep and appetite disturbance, diminished libido, and low energy, can thwart detection of PPD.52,53 Mild to moderate depression can be overlooked as natural consequences of childbirth, whereas severe levels of PPD are more easily detected. Approximately 10% of women who experienced PPD still show signs and symptoms of depression 1 year after delivery.54
The past decade has witnessed an abundance of research on predictive factors for PPD, including mood during pregnancy, life events, social relationships, and infant and obstetric factors. Depressed or anxious mood during pregnancy or symptoms of elation in the early puerperium are associated with subsequent PPD,5,35,42,55 as are neurotic or vulnerable personality traits.5,56,57 Social isolation (perceived or actual) from family, friends, or partner has been associated with postpartum depressive symptoms,58 as have infant factors such as neonatal complications, child temperament, or childcare stress.34,59 Obstetric complications related to pregnancy or to delivery, such as antepartum hemorrhage or emergency caesarian section have also been associated with increased risk for PPD.5,39,40,60
Postpartum psychosis, also called puerperal psychosis, occurs in approximately 1 in 500–1,000 births, and usually starts within the first 48–72 hours after parturition.23 The risk for onset, though, can remain high for up to 4 months.60 Typically, presenting symptoms include elation, lability of mood, rambling speech, disorganized behavior, and hallucinations or delusions (Table 2). The presentation and course of postpartum psychosis may be more heterogeneous and complex than current diagnostic classifications, with transient or alternating episodes of delusions of guilt, persecution, auditory hallucinations; delirium-like symptoms and confusion; and excessive activity.61 Often the delusional content relates directly to the infant, typically that the infant is possessed, has special powers, is divine, or is dead.62
Recent research has shown the likelihood that women with a family history of postpartum psychosis will themselves have an episode is >50%.16 Other risk factors include a personal or family psychiatric history (including alcoholism) and being primiparous.63,64 Having depressive symptoms during pregnancy has been linked with recurrence of a bipolar depressive episode postpartum.65 Approximately one in two women with bipolar disorder will experience a relapse of illness postpartum.30
Postpartum psychosis often necessitates involuntary admission to the hospital, as daily function is severely compromised and the risks of infanticide or suicide are high.66,67 Typically, the length of stay in the hospital is approximately 2 months, but a full recovery may require a year or longer.64 It has been estimated that between 39% and 81% of patients may experience nonpuerperal relapse of illness. Postpartum psychosis may recur following subsequent deliveries.68,69
Postpartum Anxiety Disorders
Parturition for some women can be a stressful time, and the circumstances surrounding delivery can impact early puerperal psychological adjustment. For example, the experience of parturition may provoke recall of earlier sexual trauma and the patient may experience the onset of posttraumatic stress symptoms. Moreover, the early postpartum phase is typically wrought with disrupted sleep and stress of caring for a newborn.
In women with existing anxiety disorders, the early postpartum period (the first 3 months in particular) seems to be associated with worsening of panic and obsessive-compulsive disorder (OCD) symptoms.70 Women who have a history of panic attack or generalized anxiety disorder may be at risk for the onset of OCD several weeks after delivery.71 In women with depression prior to or during pregnancy, first lifetime onset of panic disorder can occur within the first 3 months after delivery.72
Women diagnosed with postpartum onset of major depression may also experience disturbing aggressive obsessional thoughts (eg, about something harmful happening to the baby) with related compulsive checking behavior.48
Women without pre-existing anxiety or psychiatric disorders can experience the first onset of OCD during gestation or within 6 weeks postpartum.71,73 In the presentation of OCD, the content of the obsessions (gruesome thoughts and/or visual images) frequently pertains to harming the baby.74 First onset of panic disorder has also been noted in the early puerperal period.75 Generalized anxiety, with subsyndromal or syndromal levels, and with or without concurrent depressive symptoms, may be found in as many as one out of three postpartum women.76
Challenges in Identification and Diagnosis
PPD has been identified as being considerably underdiagnosed, stressing the need for routine screening during postpartum clinic visits.77-79 Studies that implemented screening procedures have reported dramatic increases in rates of detection of PPD compared to the number of patients identified with PPD without use of a screening tool.80-82 While screening has been implemented successfully in a number of projects, Tam and colleagues83 encountered significant difficulties when trying to introduce postpartum screening procedures in a primary care context. These difficulties centered around resistance on both the part of primary care providers and the postpartum women themselves, and it was largely attributed to the perceived stigma and lack of knowledge about PPD.
In addition, questions about the suitability of existing measures, and the method or timing of screening have emerged.83-86 To date, much of the research in perinatal mental health has focused on depressive disorders, often relying on screening tools which are not in themselves diagnostic. This is despite repeated observations that anxiety, anger, or irritability may be the primary feature or a core symptom.87-91 In the administration of a screening tool, significant input from the patient is usually required, but many women may be unable to complete such scales or to provide accurate information.92 As the symptoms of anemia and thyroid disease often mirror depressive or anxiety symptoms,93-94 laboratory investigations should be used to eliminate the underlying medical cause for the disorder. Rare medical conditions, such as frontotemporal dementia or frontal lobe tuberculoma, can mimic PPD.95,96
Depressive symptoms and complaints of impaired memory and concentration have been documented in patients with subclinical and clinical hypothyroidism.97,98 Preliminary data suggest that lower normal range total and free thyroxine concentrations during late pregnancy are related to postpartum depressive symptoms, although no relationship between postpartum thyroid hormone levels and postpartum mood symptoms was found.99 An association between severity of PPD and the presence of antithyroid antibodies (AB+) has been found in some prospective studies.98,100 AB+ status has also been linked with postpartum thyroiditis and persistence of mental and physical symptoms across 12 months following delivery.100 More recently, the presence of thyroid peroxidase antibodies in pregnancy has been associated with a 3-fold increase in the incidence of PPD.101
Early recognition of a perinatal mental illness is crucial. Use of a population-specific screening tool (eg, the Edinburgh Postnatal Depression Scale [EPDS]), can improve awareness of healthcare providers and aid in the early detection of PPD.102,103 Since its introduction over 25 years ago, the EPDS has been extensively validated and has been translated into more than 20 languages worldwide.104 It can be easily utilized as a telephone screen.105 Currently, research is underway to determine reliable and valid methods to assess anxiety91 and irritability106 in perinatal populations.
Women who are at risk for or who may be suffering from a postpartum mood disorder may be identified by asking a few simple questions during routine primary care visits.17 These questions should establish the woman’s current state of mind and mood. It is also essential to inquire about any personal history of anxiety or mood disorder and/or a family psychiatric history of mood disorders and alcoholism. Early recognition of risk for or onset of PPD or postpartum psychosis will enhance the clinician’s ability to provide preventative or timely interventions for these significant psychiatric disorders. A guideline for the identification and treatment of postpartum disorders is shown in the accompanying Algorithm.107
Impact of Mental Illness in the Postpartum Period
The emotional consequences of experiencing a postpartum mental illness can be painful and long lasting: in interviews, women have reported feelings of loss of control over what was happening to them and missing out on motherhood in the first months of their infant’s life. Feelings of inadequacy about their ability to mother and guilt about the impact of their illness on their children are common, as is feeling isolated from others. They may also become afraid of having more children.108,109
Partners or spouses commonly report to a healthcare provider that “my wife is not herself.” The joy of fatherhood can be replaced by despair, anger, and worry, as well as guilt and helplessness as the mother of the child suffers with a postpartum mood disorder and her coping abilities and self-esteem decrease. The family unit may be disrupted as mother and father struggle to cope with a serious—even life-threatening—illness, care for one or more children, maintain a household, and provide financial stability. Postpartum emotional disorders can distance a couple from family and friends, and each other.110 Many men whose partners experience PPD may be affected emotionally.111
There is increasing attention to the impact of maternal psychological status on fetal and neonatal health. Maternal psychological stress is a significant and independent risk factor for a range of adverse reproductive outcomes including preterm birth.112 High levels of depressive, anxiety, and anger symptoms in pregnancy can have an adverse influence on neonatal physiological, neurobiological, and behavioral measures, and infant development.113 A recent, comprehensive review of animal studies114 suggests that maternal depression may represent a child’s “first adverse life event.” Prepartum and postpartum laboratory stressors that either directly or indirectly impair maternal care have been shown to produce a persistent deleterious biobehavioral impact on offspring.
Infants as young as 3 months are able to “detect” depression in their mothers.115 At 6 months of age, infant affective displays and physiologic reactions have been linked on a “moment-by-moment” basis with changing affective display in the mother.116
A correlation has been noted between mothers who are depressed or anxious, frequently expressing critical or hostile remarks at their children, and risk for children’s lower self-esteem, behavioral inhibition, and psychopathology.117,118 A longitudinal controlled study showed that mothers who were depressed in the postpartum months were significantly more hostile to their infants than nondepressed mothers, and they were less likely to respond to them as active and interactive beings.119 Highly critical and hostile maternal behavior toward the child at 5 years of age was associated with child expressions of negativity about themselves and the likelihood of cognitive vulnerability.120
Perinatal mental illness is underdiagnosed and may have serious consequences for the mother, her infant, her relationship to her partner, and her relationship to other family members. Early screening and identification are crucial. Risk factors for postpartum mental illness include depressed or anxious mood during pregnancy; personal or family history of psychiatric disorder, especially in first-degree relatives and including alcoholism; unplanned pregnancy; perinatal sleep disruption; and major psychosocial stressors. Women suffering from perinatal mood disturbances are more likely to seek help from their primary care physician or obstetrician, rather than a mental health professional. Screening new mothers can and should be implemented by these healthcare providers using a few simple questions during regular antepartum and postpartum visits. PP
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Dr. Born is postdoctoral research fellow at Motherisk, the Hospital for Sick Children, in Toronto, and at the Women’s Health Concerns Clinic at St. Joseph’s Healthcare in Hamilton, both in Ontario, Canada.
Dr. Zinga is assistant professor in the Department of Child and Youth Studies at Brock University in St. Catharines, Ontario.
Dr. Steiner is director of the Women’s Health Concerns Clinic at St. Joseph’s Healthcare, and professor in the Departments of Psychiatry and Behavioural Neurosciences and Obstetrics and Gynecology at McMaster University in Hamilton.
Disclosure: Dr. Steiner acts as consultant to, serves on the speaker’s bureau of, and has received grants from AstraZeneca, Barr Laboratories, Eli Lilly, GlaxoSmithKline, Lundbeck, Novartis, Ortho-McNeil, Pfizer, Procter & Gamble, Warner-Chilcott, and Wyeth.
Acknowledgments: The authors would like to thank Carol Ballantyne, Alison Shea, and Shauna-dae Phillips for their assistance in the preparation of this manuscript.
Please direct all correspondence to: Dr. Meir Steiner, Women’s Health Concerns Clinic, St. Joseph’s Healthcare, Rm FB-639, 50 Charlton Ave East, Hamilton, ON L8N 4A6; Tel: 905-522-1155 ext. 3605; Fax: 905-521-6098; E-mail: firstname.lastname@example.org.