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

History Hippocrates: a mania related to lactation Case reports of “puerpral insanity” in 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”)

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

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

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 social support

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 % risk of relapse at future pregnancy for BID - 30% risk of relapse at future pregnancy for MDD

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

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

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

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

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

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

Puerpral Psychosis 1-2/1000 women after childbirth Onset as early as the first 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

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

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

Differential Diagnosis Various medical illnesses Schizophrenia or schizoaffective disorder Anxiety disorders

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

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

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

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

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

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??

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

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

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

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