Psychiatric Disorders

BC MEDICAL JOURNAL VOL. 47 NO. 2, MARCH 2005100

The three psychiatric disor-ders most common after thebirth of a baby are postpar-tum blues, postpartum de-

pression, and postpartum psychosis.Depression and psychosis presentrisks to both the mother and her infant,making early diagnosis and treatmentimportant. (A full description of phar-macological and nonpharmacologicaltherapies for these disorders willappear in Part 2 of this theme issue inApril 2005.)

Postpartum bluesPostpartum blues refers to a transientcondition characterized by irritability,anxiety, decreased concentration, in-somnia, tearfulness, and mild, oftenrapid, mood swings from elation tosadness. A large number of postpar-tum women (30% to 75%) developthese mood changes,1 generally with-in 2 to 3 days of delivery. Symptomspeak on the fifth day postpartum andusually resolve within 2 weeks.2 Typ-ically, providing support and reassur-ance to the new mother and stressingthe importance of adequate time forsleep and rest will be sufficient treat-ment for postpartum blues. The use ofminor tranquilizers at low doses (e.g.,lorazepam 0.5 mg) may be helpful forinsomnia. Careful monitoring duringthis period is essential, since a small

proportion of women with postpartumblues may develop postpartum de-pression.3

Postpartum depressionThe Diagnostic and Statistical Man-ual of Mental Disorders, FourthEdition, Text Revision (DSM-IV-TR)defines postpartum depression (PPD)as depression that occurs within 4 weeks of childbirth.4 However, mostreports on PPD suggest that it candevelop at any point during the firstyear postpartum, with a peak of inci-dence within the first 4 months post-partum.1 The prevalence of depressionduring the postpartum period has beensystematically assessed; controlledstudies show that between 10% and28% of women experience a majordepressive episode in the postpartumperiod, with the majority of studiesfavoring a 10% figure.5

Several key risk factors have beenidentified as major contributors to thedevelopment of PPD, including:• Ahistory of postpartum depression.6

• A history of depression before con-ception.7

Deirdre Ryan, MB, BCh, BAO, FRCPC, Xanthoula Kostaras, BSc

ABSTRACT: Pregnant women and

their families expect the postpartum

period to be a happy time, charac-

terized by the joyful arrival of a new

baby. Unfortunately, women in the

postpartum period can be vulnera-

ble to psychiatric disorders such as

postpartum blues, depression, and

psychosis. Because untreated post-

partum psychiatric disorders can

have long-term and serious conse-

quences for both the mother and

her infant, screening for these dis-

orders must be considered part of

standard postpartum care.

Psychiatric disorders in thepostpartum periodPostpartum mood disorders and psychoses must be identified toprevent negative long-term consequences for both mothers andinfants.

Dr Ryan is a consultant psychiatrist in theReproductive Mental Health program at BCWomen’s Hospital and St. Paul’s Hospital.Ms Kostaras is a research assistant in theReproductive Mental Health program.

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VOL. 47 NO. 2, MARCH 2005 BC MEDICAL JOURNAL 101

• A family history of depression, par-ticularly PPD.7,8

In addition, several other factorsmay contribute to the development ofPPD, including poor social support,the experience of adverse life eventsduring the postpartum period, maritalinstability, young maternal age, andinfants with health problems or per-ceived “difficult” temperaments.

Symptoms of PPD are similar tothe symptoms of a major depressiveepisode experienced at any other time(see the ). There are, however,subtle differences, including: • Difficulty sleeping when the baby

sleeps.• Lack of enjoyment in the maternal

role. • Feelings of guilt related to parenting

ability.

Table

A significant number of womenalso experience concomitant symp-toms of anxiety, including panic attacksand obsessional fears or images ofharm occurring to their babies. Thesecan be very frightening for the mother.

Prior to making a psychiatric diag-nosis in the postpartum period, it isimportant to rule out any underlyingmedical condition. Women sufferingfrom early postpartum anemia may beat increased risk of developing post-partum depression.9 Likewise, weknow that the postpartum period isassociated in some women withpathological changes in thyroid func-tion, especially thyroiditis.10 Testingfor CBC and TSH should be part of acomplete workup.

Despite the identified symptomsand risk factors associated with the ill-ness, PPD is often missed at the pri-mary care level. One explanation forthis is that the care provider may bemore focused on the health of theinfant and may therefore miss anysigns of maternal psychiatric illness.In addition, many women may try toconceal their illness because of shameor embarrassment about feeling de-pressed during what is supposed to besuch a happy time. The consequencesof misdiagnosing or not treating post-partum depression can be serious. Forthe mother, untreated depression canlead to the development of a chronicdepressive illness and poses a risk ofsuicide. Untreated PPD can also havemany negative consequences for theinfant; the negative interactive pat-terns formed during the critical earlybonding period may affect the laterdevelopment of the child. For exam-ple, conduct disorders, inappropriateaggression, and cognitive and atten-tion deficits have been described inchildren exposed to maternal psychi-atric illnesses and these disturbanceshave continued even after remissionof the maternal depression.

Every new mother should be askedabout her psychological functioning.Women with a history of majordepression or a family history of psy-chiatric illness should be identified inpregnancy and followed closely in thepostpartum period. A very useful andeasily administered screening tool forpostpartum depression is the validat-ed Edinburgh Postnatal DepressionScale (see ; this scale can becopied and used free of charge).11-13

The patient can complete the ques-tionnaire at her physician’s officeprior to her first postpartum follow-upappointment or when she brings herbaby for immunization. For eachquestion, the patient will choose oneof four possible replies that reflecthow she has been feeling over the past7 days. Responses are scored as 0, 1,2, or 3, for a maximum score of 30. Aminimum score of 12 has been foundto identify most women with a diag-nosis of postpartum depression.

Postpartum psychosisFirst-onset psychosis in the perinatalperiod is a rare condition. The preva-lence of postpartum psychosis hasconsistently been reported as approx-imately 1 to 2 per 1000 live births.14

This condition has a rapid onset, usu-ally manifesting itself within the first2 weeks after childbirth or, at most,within 3 months postpartum, andshould be considered a medical andobstetrical emergency.15 The presenceof a psychotic disorder may interferewith a woman obtaining proper pre-natal and postpartum care.

Several major risk factors16-18 havebeen identified in relation to postpar-tum psychosis:• History of psychosis with previous

pregnancies.• History of bipolar disorder.• Family history of psychotic illness

(e.g., schizophrenia or bipolar dis-order).

Figure

Psychiatric disorders in the postpartum period

A.Five or more of the following symptoms*must be present daily or almost daily forat least two consecutive weeks:1. Depressed mood.2. Loss of interest or pleasure.3. Significant increases or decreases in

appetite.4. Insomnia or hypersomnia.5. Psychomotor agitation or retardation.6. Fatigue or loss of energy.7. Feelings of worthlessness or guilt.8. Diminished concentration.9. Recurrent thoughts of suicide or

death.*At least one of which must be 1 or 2.

B.The symptoms do not meet the criteriafor other psychiatric conditions.

C. The symptoms cause significant impair-ment in usual functioning at work,school, and in social activities.

D.The symptoms are not caused by thedirect effects of a substance or a gener-al medical condition.

E. The symptoms are not better accountedfor by the loss of a loved one.

Table. Criteria for a major depressiveepisode.

Source: Adapted from DSM-IV-TR.3


BC MEDICAL JOURNAL VOL. 47 NO. 2, MARCH 2005102

Competing interests

None declared.

References

1. O’Hara MW, Zekoski EM, Phillips LH, etal. A controlled prospective study of post-partum mood disorders: Comparison ofchildbearing and non-childbearing wo-men. J Abnorm Psychol 1990;99:3-15.

2. O’Hara MW, Schlechte JA, Lewis DA, etal. Prospective study of postpartumblues. Biologic and psychosocial factors.Arch Gen Psychiatry 1991;48:801.

3. Cox JL, Murray D, Chapman G. A con-trolled study of the onset, duration andprevalence of postnatal depression. Br JPsychiatry 1993;163:27-31.

4. Diagnostic and Statistical Manual ofMental Disorders, Fourth Edition, TextRevision. Washington, DC: AmericanPsychiatric Association; 2000.

5. O’Hara MW, Swain AM. Rates and risk ofpostpartum depression—a meta-analysis.Int Rev Psychiatry 1996;8:37-54.

6. Llewellyn AM, Stowe ZN, Nemeroff CB.Depression during pregnancy and thepuerperium. J Clin Psychiatry 1997;58(suppl 15):26-32.

7. O’Hara MW. Social support, life events,and depression during pregnancy and thepuerperium. Arch Gen Psychiatry 1986;43:569-573.

8. Kumar R, Robson MK. A prospectivestudy of emotional disorders in child-bearing women. Br J Psychiatry 1984;144:35-47.

9. Corwin EJ, Murray-Kolb LE, Beard JL.Low haemoglobin level is a risk factor forpostpartum depression. J Nutr 2003;133:4139-4142.

10. Lucas A, Pizarro E, Granada ML, et al.Postpartum thyroid dysfunction andpostpartum depression: Are they twolinked disorders? Clin Endocrinol (Oxf)2001;55:809-814.

11. Cox JL, Holdon JM, Sagovsky R. Detec-tion of postnatal depression: Develop-ment of the 10-item Edinburgh PostnatalDepression Scale. Br J Psychiatry 1987;150:782-786.

12. Murray L, Carothers AD. The validity ofthe Edinburgh Post-natal DepressionScale on a community sample. Br J Psy-chiatry 1990;157:288-290.

13. Beck CT, Gable RK. Further validity of thepostpartum depression screening scale.Nurs Res 2001;50:155-164.

14. Kumar R. Postnatal mental illness: A tran-scultural perspective. Soc PsychiatryPsychiatr Epidemiol 1994;29:250-264.

15. Altshuler LL, Cohen LS, Szuba MP, et al.Pharmacologic management of psychi-atric illness during pregnancy: Dilemmasand guidelines. Am J Psychiatry 1996;153:592-606.

16. Kendell RE, Chalmers JC, Platz C. Epi-demiology of puerperal psychoses. Br JPsychiatry 1987;150:662-673.

17. McNeil TF. A prospective study of post-partum psychoses in a high-risk group. 2.Relationships to demographic and psy-chiatric history characteristics. Acta Psy-chiatr Scand 1987;75:35-43.

18. Nonacs R, Cohen LS. Postpartum mooddisorders: Diagnosis and treatmentguidelines. J Clin Psychiatry 1998;59(suppl 2):34-40.

19. Steiner M. Postpartum psychiatric disor-ders. Can J Psychiatry 1990;35:89-95.

20. Georgiopoulos AM, Bryan TL, Wollan P,et al. Routine screening for postpartumdepression. J Fam Pract 2001;50:117-122.

21. Yamashita H, Yoshida K. Screening andintervention for depressive mothers ofnew-born infants. Seishin ShinkeigakuZasshi 2003;105:1129-1135.

22. Teissedre F, Chabrol H. Detectingwomen at risk for postnatal depressionusing the Edinburgh Postnatal Depres-sion Scale at 2 to 3 days postpartum. CanJ Psychiatry 2004;49:51-54.

23. Davies BR, Howells S, Jenkins M. Earlydetection and treatment of postnataldepression in primary care. J Adv Nurs2003;44:248-255.

Patients may present with symp-toms resembling an acute manic epi-sode or a psychotic depression. Theymay present with delusions or halluci-nations that are frightening to them.Many patients also have additionalsymptoms that resemble a deliriumand involve distractability, labilemood, and transient confusion.19

Patients with postpartum psy-chosis have lost touch with reality andare at risk of harming themselves ortheir babies. Postpartum psychosis isan emergency that requires immediatemedical attention. In most cases, itwill be necessary for the mother to behospitalized until she is stable. Med-ications (including antidepressants,neuroleptics, and mood stabilizers) orelectroconvulsive therapy may beneeded to control the psychosis.

The absolute risk of neonaticide(death of the baby within 24 hours ofbirth) and of infanticide (death withinthe first year of life) committed by themother are not known. Both are rela-tively rare but attract much mediaattention when they occur. It is imper-ative to ask all women suffering froma postpartum illness if they have anythoughts or plans of harming them-selves or their children. Patients pre-senting with suicidal or infanticidalplans require emergency hospitaliza-tion.

SummaryThe postpartum period can be a vul-nerable time for women, particularlythose with a history of psychiatric ill-ness or a family history of psychiatricillness. Not treating a psychiatric dis-order in the postpartum period canhave both short- and long-term conse-quences for both the infant and themother. Administering a routinescreening test, such as the EdinburghPostnatal Depression Scale, can helpidentify those mothers who requiretreatment.20-23



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Figure. Edinburgh Postnatal Depression Scale.11

1. I have been able to laugh and see the funny side of things

As much as I always could 0

Not quite so much now 1

Definitely not so much now 2

Not at all 3

2. I have looked forward with enjoyment to things

As much as I ever did 0

Rather less than I used to 1

Definitely less than I used to 2

Hardly at all 3

3. I have blamed myself unnecessarily when things went wrong

Yes, most of the time 3

Yes, some of the time 2

Not very often 1

No, never 0

4. I have been anxious or worried for no good reason

No, not at all 0

Hardly ever 1

Yes, sometimes 2

Yes, very often 3

5. I have felt scared or panicky for no very good reason

Yes, quite a lot 3

Yes, sometimes 2

No, not much 1

No, not at all 0

6. Things have been getting on top of me

Yes, most of the time I haven’t been able to cope 3

Yes, sometimes I haven’t been coping as well as usual 2

No, most of the time I have coped quite well 1

No, I have been coping as well as ever 0

7. I have been so unhappy that I have had difficulty sleeping


Yes, sometimes 2

Not very often 1

No, not at all 0

8. I have felt sad or miserable


Yes, quite often 2

Not very often 1

No, not at all 0

9. I have been so unhappy that I have been crying


Yes, quite often 2

Only occasionally 1

No, never 0

10. The thought of harming myself has occurred to me

Yes, quite often 3

Sometimes 2

Hardly ever 1

Never 0

x

Name: ___________________________________________ Date: ______________________ Number of months postpartum: ___________

As you have recently had a baby, we would like to know how you are feeling. Please mark the answer which comes closest to how youhave felt in the past 7 days, not just how you feel today.

Here is an example, already completed:

I have felt happy:

Yes, all the time

Yes, most of the time

No, not very often

No, not at all

This would mean “I have felt happy mostof the time during the past week.” Please complete the following questionsin the same way.

In the past 7 days:


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Psychiatric Disorders