Puerperal mental disorders

1. Puerperal mental disorders Done by: Hisham Hassan Al-Hammadi

2. Introduction • During the postpartum period, up to 85% of women suffer from some type of mood disturbance. For most women, symptoms are transient and relatively mild (ie, postpartum blues). • however, 10-15% of women experience a more disabling and persistent form of mood disturbance (eg, postpartum depression, postpartum psychosis). • Postpartum psychiatric illness was initially conceptualized as a group of disorders specifically linked to pregnancy and childbirth and thus was considered diagnostically distinct from other types of psychiatric illness. • More recent evidence suggests that postpartum psychiatric illness is virtually indistinguishable from psychiatric disorders that occur at other times during a woman's life. • Types: • Postpartum blues. • Postpartum depression. • Postpartum psychosis.

3. Postpartum Blues: • Up to 85% of women experience postpartum affective instability. • Rapidly fluctuating mood, tearfulness, irritability, and anxiety are common symptoms. • Symptoms peak on the fourth or fifth day after delivery and last for several days, but they are generally time-limited and spontaneously remit within the first 2 postpartum weeks. • Symptoms do not interfere with a mother's ability to function and to care for her child.

4. Postpartum depression: • Postpartum depression occurs in 10-15% of women in the general population. • Typically, postpartum depression develops insidiously over the first 3 postpartum months, although the disorder may have a more acute onset. Postpartum depression is more persistent and debilitating than postpartum blues. • Signs and symptoms are clinically indistinguishable from major depression that occurs in women at other times. Symptoms may include depressed mood, tearfulness, inability to enjoy pleasurable activities, insomnia, fatigue, appetite disturbance, suicidal thoughts, and recurrent thoughts of death. • Anxiety is prominent, including worries or obsessions about the infant's health and well-being. • The mother may be ambivalent or have negative feelings toward the infant. She may also have intrusive and unpleasant fears or thoughts about harming the infant. • Postpartum depression often interferes with the mother's ability to care for herself or her child.

5. Postpartum Psychosis: • Postpartum psychosis is the most severe form of postpartum psychiatric illness. • The condition is rare and occurs in approximately 1-2 per 1000 women after childbirth. • Postpartum psychosis has a dramatic onset, emerging as early as the first 48-72 hours after delivery. In most women, symptoms develop within the first 2 postpartum weeks. • The condition resembles a rapidly evolving manic episode with symptoms such as restlessness and insomnia, irritability, rapidly shifting depressed or elated mood, and disorganized behavior. • The mother may have delusional beliefs that relate to the infant (eg, baby is defective or dying, infant is Satan or God), or she may have auditory hallucinations that instruct her to harm herself or her infant. • Risks for infanticide and suicide are high among women with this disorder.

6. Pathophysiology: • Hormonal factors • Levels of estrogen, progesterone, and cortisol fall dramatically within 48 hours after delivery. • Women with postpartum depression do not differ significantly from nondepressed women with regard to levels of estrogen, progesterone, prolactin, and cortisol or in the degree to which these hormone levels change; however, affected individuals may be abnormally sensitive to changes in the hormonal milieu and may develop depressive symptoms when treated with exogenous estrogen or progesterone. • Psychosocial factors • Women who report inadequate social supports, marital discord or dissatisfaction, or recent negative life events are more likely to experience postpartum depression. • Biologic vulnerability • Women with prior history of depression or family history of a mood disorder are at increased risk for postpartum depression. • Women with a prior history of postpartum depression or psychosis have up to 90% risk of recurrence.

7. Screening for postpartum Mood disorders: • Predicting who is at risk for postpartum depression is difficult. Individuals at greatest risk often have a prior history of postpartum depression, personal or family history of mood disorder, or depression during a current pregnancy. Other risk factors include inadequate social supports, marital dissatisfaction or discord, and recent negative life events such as a death in the family, financial difficulties, or loss of employment. • Screening of all mothers during the postpartum period is indicated. • The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self-rated questionnaire used extensively for detection of postpartum depression. A score of 12 or more on EPDS or an affirmative answer on question 10 (presence of suicidal thoughts) requires more thorough evaluation. Include EPDS in routine well-baby and pediatric visits.

8. Treatment: • Untreated postpartum affective illness places both the mother and infant at risk and is associated with significant long-term effects on child development and behavior; therefore, prompt recognition and treatment of postpartum depression are essential for both maternal and infant well-being.

9. Postpartum blues treatment • Postpartum blues typically is mild in severity and resolves spontaneously. • No specific treatment is required, other than support and reassurance. • Further evaluation is necessary if symptoms persist more than 2 weeks.

10. Postpartum depression treatment • Exclude medical causes for mood disturbance (eg, thyroid dysfunction, anemia). • Severity of illness should guide treatment. Milder forms of depression may respond to supportive psychotherapy. More severe depression may require pharmacological treatment. • Nonpharmacological treatment strategies are useful for women with mild-to-moderate depressive symptoms. These modalities may be especially useful for mothers who are nursing and who wish to avoid taking medications. Psychoeducational groups may be helpful. Individual or group psychotherapy (cognitive-behavioral and interpersonal therapy) are effective. • Pharmacological strategies are indicated for moderate-to-severe depressive symptoms or when a woman fails to respond to nonpharmacological treatment. Medication may also be used in conjunction with nonpharmacological therapies. • Selective serotonin reuptake inhibitors (SSRIs) are first-line agents and are effective in women with postpartum depression. Use standard antidepressant dosages, eg, fluoxetine 10-60 mg/d, sertraline 50-200 mg/d, paroxetine 20-60 mg/d, or citalopram 20-60 mg/d. Adverse effects of this drug category include insomnia, jitteriness, nausea, appetite suppression, headache, and sexual dysfunction. • Serotonin-norepinephrine reuptake inhibitors (SNRIs) or tricyclic antidepressants may be useful for women with sleep disturbance, although some studies suggest that women respond better to the SSRI drug category. Nortriptyline 50-150 mg/d and venlafaxine 37.5-150 mg/d may be effective. Adverse effects of the tricyclic antidepressants include sedation, weight gain, dry mouth, constipation, and sexual dysfunction. Typically, symptoms start to diminish in 2-4 weeks. A full remission may take several months. In partial responders, it may be helpful to increase the dosage. • Anxiolytic agents such as lorazepam and clonazepam may be useful as adjunctive treatment in patients with anxiety and sleep disturbance. • Preliminary data suggest that estrogen, alone or in combination with an antidepressant, may be beneficial; however, antidepressants remain the first line of treatment. • If this is the first episode of depression, 6-12 months of treatment is recommended. For women with recurrent major depression, long-term maintenance treatment with an antidepressant is indicated. • Inadequate treatment increases the risk of morbidity in both mother and infant. • Earlier initiation of treatment is associated with better prognosis. • Inpatient hospitalization may be necessary for severe postpartum depression. • Electroconvulsive therapy (ECT) is rapid, safe, and effective for women with severe postpartum depression, especially those with active suicidal idea.

11. Puerperal psychosis treatment • Puerperal psychosis is a psychiatric emergency that typically requires inpatient treatment. • Most patients with puerperal psychosis suffer from bipolar disorder. Acute treatment includes a mood stabilizer (eg, lithium, valproic acid, carbamazepine) in combination with antipsychotic medications and benzodiazepines. • ECT (often bilateral) is tolerated well and rapidly effective. • Risk of suicide is significant in this population. • Rates of infanticide associated with untreated puerperal psychosis are as high as 4%.

12. Special concerns: • Breastfeeding and psychotropic medications • Women who plan to breastfeed must be informed that all psychotropic medications, including antidepressants, are secreted into breast milk. Concentrations in breast milk vary widely. • Data on the use of tricyclic antidepressants, fluoxetine, sertraline, and paroxetine during breastfeeding are encouraging, and serum antidepressant levels in the nursing infant are either low or undetectable. Reports of toxicity in nursing infants are rare, although the long-term effects of exposure to trace amounts of medication are not known. • Avoid breastfeeding in women treated with lithium because this agent is secreted at high levels in breast milk and may cause significant toxicity in the infant. • Avoid breastfeeding in premature infants or in those with hepatic insufficiency who may have difficulty metabolizing medications present in breast milk.

13. Special concerns:(con’t) • Impact of postpartum depression on child development • A large body of literature suggests that a mother's attitude and behavior toward her infant significantly affect mother-infant bonding and infant well being and development. Postpartum depression may negatively affect these mother-infant interactions. • Mothers with postpartum depression are more likely to express negative attitudes about their infant and to view their infant as more demanding or difficult. Depressed mothers exhibit difficulties engaging the infant, either being more withdrawn or inappropriately intrusive, and more commonly exhibit negative facial interactions. These early disruptions in mother-infant bonding may have a profound impact on child development. • Children of mothers with postpartum depression are more likely than children of nondepressed mothers to exhibit behavioral problems (eg, sleep and eating difficulties, temper tantrums, hyperactivity), delays in cognitive development, emotional and social dysregulation, and early onset of depressive illness.