POSTPATUM PSYCHIATRIC SYNDROMES

1. POSTPATUM PSYCHIATRIC SYNDROMES H.Amini M.D. Roozbeh Hospital TUMS

2. History • Hippocrates: a mania related to lactation • Case reports of “puerpral insanity” in 1700-1800 in the French& German medical literature • Jean Esquirol,1818: quantitative data on 92 cases of puerperal psychosis • Victor Louis Marce,1856: foundation for modern conceptualizations of mental illness related to pregnancy & postpartum period • B. Pitt, 1960: an atypical depression ( later called :maternity blue”)

3. History • Large, population-based studies, 1970s: high rates of mild to moderate depression in women during the first 6 months after delivery • Recent studies: a sharp peak in the number of psychiatric admissions during the first 3 months after delivery

4. Definition • Postpartum blues: 30-85%, within 1th week • Nonpsychotin postpartum depression: 10-15%, within first 2-3 months • Puerperal psychosis: 0.1-0.2%, within first 2-4 weeks

5. Etiology • Demographic variable: - high rates(26%) of PP depression in adolescent mothers ?? - primiparous women are more vulnerable to PP psychosis than multiparous women • Psychosocial factors: - stressful life events during pregnancy or near the time of delivery - marital dissatisfaction or inadequate socialsupport

6. Etiology • History of psychiatric illness: - 70% risk of relapse at future pregnancy for PP psychosis - 50% risk of relapse at future pregnancy for PP depression - 20-50% risk of relapse at future pregnancy for BID - 30% risk of relapse at future pregnancy for MDD

7. Etiology • Hormonal factors: - declining progestrone?? - declining estrogen?? - rapid decreasing cortisol?? - thyroid dysfunction??

8. Diagnosis & Clinical Features • DSM-IV have no specific criteria for Dx of PP psychiatric illness • According DSM-IV, PP psychiatric illnesses may be indicated with a postpartum onset specifier • Marce society: any episode occuring within the first year after delivery

9. Diagnosis & Clinical Features… • Often overlooked or ignored by both patients and caregivers • <1/3 of women with PP ilness seek professional help • Untreated depression may contribute to the development of chronic and refractory depression in the mother • Adverse effects of maternal depression on the cognitive, emotional, and social development of the child

10. Postpartum Blues • Baby blues • 30-85% • Mild depressive symptoms: dysphoria, mood lability, irritability, tearfulness, anxiety, and insomnia • Peak on 4th or 5th day after delivery • Remit spontaneously by the 10th day • Relatively benign, time-limited • Some women with blues will go on to develop PP depression

11. Postpartum Depression • 10-15% PP minor or major depression • More commonly develops insidiously over the first 6 postpartum months • A significant proportion of women experience the onset of depressive symptoms during pregnancy • Indistinguishable from those characteristic of nonpsychotic MDD • Somatic complaints are common

12. Postpartum Depression… • Ambivalent or negative feelings toward the infant • suicidal ideation is frequent, but suicide rates appear to be relatively low • Generalized anxiety, panic disorder, and OCD are often observed

13. Puerpral Psychosis • 1-2/1000 women after childbirth • Onset as early as the first 48-72 hours • Within the first 2-4 weeks after delivery • Disorganized behavior is prominent • A rapidly evolving affective psychosis with manic, depressive, or mixed features • The earliest signs are restlessness, irritability, and insomnia

14. Puerpral Psychosis… • A rapidly shifting depressed or elated mood • Disorientation or depersonalization • Delusional beliefs often center on the infant • Auditory hallucinations that instruct the mother to harm or kill herself or her infant • Distinct in that it is more commonly associated with confusion and delirium than nonpuerperal psychotic mood disorder

15. Screening • It is advisable to screen all women for depression during the PP period • Clinicians fail to inquire about affective symptoms • The standard PP obstetrical visit at 6 weeks and subsequent pediatric appointments are ideal times • Edinburgh Postnatal Depression Scale(EPDS) is a 10-item, self-rated questionaire that has satisfactory sensitivity and specificity

16. Differential Diagnosis • Various medical illnesses • Schizophrenia or schizoaffective disorder • Anxiety disorders

17. Course & Prognosis • Often relatively short-lived(< 3months) • Depressive episodes tend to be longer and more severe in those with histories of MDD • Duration may be related to the severity of depression • In general, women with PP mood disorders have a good prognosis • In about half of the cases, PP depression or psychosis represents the first onset of psychiatric illness

18. Course & Prognosis • Rates of recurrence appeare to be high in women with BMD • Outcome is better in those that receive treatment early during the course of illness • Attachment and behavioral difficulties are common in new depressed or psychotic mothers • Child abuse and neglect • Infanticide

19. Treatment • Postpartum blues: - no specific treatment - support & reassurance - monitoring

20. Treatment • Postpartum Depression: - Nonpharmacological Therapy: * there are limitted data: for milder forms, for those who are reluctant to use medications, ideally performe in the home * interpersonal psychotherapy: role transition, disruption of relationships with the spouse,and interaction with the infant * CBT: inability to cope with the demands of caring for the child, perceived lack of support, absence of enjoyable activities

21. Treatment… • Pharmacological Therapy: - few studies have assessed the efficacy of Ads in PP depression - standard dosage - patient’s prior response - SSRIs are ideal first-line agents - TCAs are frequently used - BZDs as an adjunctive

22. Treatment… • Pharmacological Therapy: - women who plan to breastfeed must be informed - ADs secretion into the breast milk - concentrations in the breast milk appeare to vary widely - one ADs is not safer than another - severe complications are rare - long-term effects on brain development are not known - hormonal therapy??

23. Treatment… • Inpatient Hospitalization: - in severe cases - who are at risk for suicide or infanticide - mother-infant unit - ECT is safe and highly effective

24. Puerpral Psychosis • An emergency • Systematically derived guidelines are lacking • Should be treated like a manic psychosis? • An antipsychotic + a mood stabilizer(lithium) • Breastfeeding should be avoided • Bilateral ECT is well-tolerated and rapidly effective

25. Puerpral Psychosis • Treatment duration is cotroversial • Prolonged neuroleptic use should be minimized • A mood stabilizer should be maintained (up to 1 year?)

26. Prevention • Identification of women at greatest risk • Women with Hx of BMD or PP psychosis benefit from prophilactic lithium therapy • Just prior to delivery (at 36 weeks gestation) or no later than the first 48 hours PP • Ads?? • Psychosocial interventions? • “wait and see” approach is appropriate for women with PP blues or without Hx of psychiatric illness