Williams Manual of Pregnancy Complications, 23 ed.

CHAPTER 80. Postpartum Depression or “Blues”

Pregnancy and the puerperium are at times sufficiently stressful to provoke mental illness. Such illness may represent recurrence or exacerbation of a preexisting psychiatric disorder, or it may be the onset of a new disorder (Table 80-1). Approximately 10 to 15 percent of recently delivered women will develop a non-psychotic postpartum depressive disorder. In some, severe, psychotic depressive or manic illness follows delivery.

TABLE 80-1. The 12-Month Prevalence of Mental Disorders in Adults in the United States

image

image

ADJUSTMENT TO PREGNANCY

Throughout pregnancy, and especially toward term, anxiety develops about childcare and the lifestyle changes that will ensue after delivery. In a number of women, the fear of childbirth pain is particularly stressful. Pregnancy experiences may be altered by medical and obstetrical complications that may ensue, and women who suffer complicated pregnancies are twice as likely to become depressed.

PRENATAL SCREENING

Screening for mental illness should be performed during the first prenatal examination. This includes obtaining a history of any prior psychiatric disorders, including hospitalizations, outpatient care, and prior or current use of psychoactive medications. Risk factors for mental illness should be carefully evaluated. A history of sexual abuse increases the risk for depressive illness. Substance abuse, violence, and depression also appear to be linked.

MATERNITY “BLUES”

Also called postpartum blues, the “blues” is a mood disturbance experienced by approximately 50 percent of women within the first week after delivery. Although a variety of symptoms have been described, core features include insomnia, weepiness, depression, anxiety, poor concentration, irritability, and changeable mood. These women may be transiently tearful for several hours and then recover completely, only to be tearful again the next day. Importantly, symptoms are mild and usually only last between a few hours to a few days. Supportive treatment is indicated, and mothers can be reassured that the depression is transient and most likely due to the biochemical changes. However, they should be monitored for development of more severe psychiatric disturbances, including postpartum depression or psychosis.

POSTPARTUM DEPRESSION

Postpartum depression is similar to other major and minor depressions that develop at any time. Typically, depression is considered postpartum if it begins within 3 to 6 months after childbirth. Risk factors for development of postpartum depression are listed in Table 80-2.

TABLE 80-2. Risk Factors for Development of Postpartum Depression

image

Certain groups of women have a much higher likelihood of developing depression during the puerperium. Adolescents and women with a history of a depressive illness each have a risk of postpartum depression of about 30 percent. Up to 70 percent of women with previous postpartum depression will have a subsequent episode. Finally, if a woman has both a previous puerperal depression and current episode of blues, her chances of developing a major depression increase to 85 percent.

Course and Treatment

The natural course is one of gradual improvement over the 6 months after delivery. The prospects for full recovery are generally good. Almost 15 percent of women have a monophasic course with full recovery, and half have a multiphasic course with an average of 2.5 depressive episodes per patient and eventual full recovery.

Because in some cases the woman may remain symptomatic for months to years, maternal depressive illness may affect the quality of her relationship with her child. Depressed mothers have shown less social interaction and play facilitation with their children. Supportive treatment alone is not sufficient for major postpartum depression. Pharmacological intervention is needed in most instances, and affected women should be managed in conjunction with a psychiatrist (see Table 80-3).

TABLE 80-3. Some Drugs Used for Treatment of Major Mental Disorders in Pregnancy

image

image

Treatment options include antidepressants, anxiolytic agents, and electro-convulsive therapy. As discussed in Chapter 8, psychotropic medications pass into breast milk and can cause neonatal sedation, and lithium toxicity has been reported. Bottle feeding should therefore be considered. Treatment also includes monitoring for thoughts of suicide or infanticide, emergence of psychosis, and response to treatment. Psychotherapy should focus on the woman’s fears and concerns regarding her new responsibilities and roles. For some women, the course of illness is severe enough to warrant hospitalization.

POSTPARTUM PSYCHOSIS

This illness is the most worrisome and severe puerperal mental disorder. It is estimated to occur in 1 to 4 of 1000 births. Women with postpartum psychosis lose touch with reality. They have stretches of lucidity alternating with psychosis. Also frequently noted are symptoms of confusion and disorientation similar to those often seen in toxic states or delirium.

Two types of women seem to be susceptible: (1) women with an underlying depressive, manic, schizophrenic, or schizoaffective disorder and (2) women who have had a history of depression or a severe life event in the preceding year. Other risk factors are biologically related and include younger age, primiparity, and family history of psychiatric illness.

Approximately 50 percent of women who have had one episode of postpartum psychosis will have a recurrence in the next pregnancy. This fact emphasizes the need to identify women with a prior history and to monitor them closely. The peak onset of psychotic symptoms is 10 to 14 days after delivery, but the risk remains high for months. In most instances, women with this disorder will go on to develop a relapsing psychotic illness with recurrences unrelated to pregnancy or parturition.

Course and Treatment

The course of postpartum psychosis is variable and depends upon the type of underlying illness. For those with manic-depressive and schizoaffective psychoses, the time to recovery is about 6 months. The clinical course of bipolar illness or schizoaffective disorder in puerperal women is comparable to that of nonpuerperal women. The most impaired level of functioning at follow-up is among those suffering from schizophrenia. These women should be referred for psychiatric care.

The severity of postpartum psychosis mandates pharmacological treatment and, in most cases, hospitalization. The woman who is psychotic usually will have difficulty in caring for her infant, and may have delusions leading to thoughts of self-harm or harm of the infant.


For further reading in Williams Obstetrics, 23rd ed.,

see Chapter 55, “Neurological and Psychiatric Disorders.”