Post Partum Disorders [2001]

Postgraduate Presentation 2001

1. Post Partum Disorders Diagnosis and Treatment Issues

2. Perinatal Psychiatry Perinatal psychiatry deals with mental illness associated with choldbearing. Also concerned with antenatal disorders, associated psychiatric problems in fathers and the special needs of parents who are psychiatrically ill. Nosologically, puerperal psychiatric states may be divided into 3 categories which overlap to some extent.

3. Historical Consideration 1858 Marce , a French psychiatrist, described a series of 310 women with a mental illness a/w childbirth. Delirium and lability of mood were common and it often started at the fourth or fifth postpartum day. 20 years later, Esquirol said ‘large number of mild to moderate cases’ of mental illness were cared for at home and ‘never recorded’.

4. Diagnostic Issues Are Postpartum disorders distinct entities ? are they different from non-puerperal illness? How to differentiate the 3 categories? because of their overlapping symptoms Why are they often undiagnosed? they are masked by constitutional symptoms of childbirth

5. Treatment Issues Is the medication safe for the baby? i.e. during pregnancy and breastfeeding If left untreated, will there be any long-term consequences ? Can we identify those women at risk ? the predisposing and precipitating factors

6. Postnatal Blues Most common postnatal problem, it requires only education, reassurance and support

7. Postnatal Blues Also known as baby or maternity blues, or transitory mood disturbances (Cox 1993) In the first few days after childbirth In up to 70% of women (most common) Anxiety, depression and confusion peak at 4th to 5th day transient, lasted 2-3 days

8. Characteristics Victoroff (1952) coined the term “ maternity blues ”, seeing it as a similar state to premenstrual syndrome. Prevalence vary 30-70% Perhaps a non-specific reaction to hormonal change following delivery

9. Characteristics O’Hara (1991) described it as “specific affective syndrome associated with childbirth” characterized by symptoms of labile mood with tearfulness, irritability, anxiety, hypochondriasis, and sleeplessness in the 10 days after childbirth. In a large prospective study - it belong to the spectrum of affective disorders

10. Common Psychological Symptoms Low mood Anxiety Tiredness Ambivalence about the baby Reduced sexual interest Anger & bitterness

11. Etiology Harris (1994), found a small but robust association between maternity blues and change in level of progesterone immediately after birth. The higher the antenatal progesterone level , the steeper the gradient of the rise , and the bigger the drop in progesterone level after delivery, the more severe were the blues. blues peaked when progesterone levels at their lowest

12. Biological and Social Factors Body weight and fluid, and levels of electrolytes (Stein 1981), monoamines (Treadway 1969), serum tryptophan (Handley 1980) History of premenstrual syndrome , antepartum depression (O’Hara 1991) Poor general social adjustment during pregnancy, rather than partnership problems, were the strongest predictors of the blues (O’Hara 1991)

13. A Review by Alain Gregoire (2000) Biological causes: nature & timing of blues, h/o PMS The only protective social factor is supportive social relationship Social class, chronic stresses and life events do not seem related No evidence for difficult and exhaustive delivery, being in hospital, and perineal pain.

14. Postnatal Depression Responsible for most postnatal psychiatric morbidity and suffering in the community and requires careful planning of services for prevention, detection and treatment in primary and secondary care.

15. Postnatal Depression Peaks at 4-6 weeks Prevalence of major depression is 10-15% in the first 3 months postpartum 4-6 weeks if treated, up to 1 year if untreated

16. Characteristics Clasically described as “ smiling depression ” (Dalton 1971) characterized by an outward display of normality The psychic aspects of depression in postpartum period are probably little different to depressive episodes at any other time. Prevalence: 20% in 6 weeks postpartum had at least mild depressive episode (Paykel 1980)

17. Clinical Features Excessive anxiety about her baby’s health that cannot be diminished by reassurance Self-blame : the mother believes she cannot live up to her own expectations of a ‘good mother’ nor is she competent as her own mother. She also compare herself unfavorably with others in the neighbourhood. Sleep difficulty due to mood disturbances, but often masked by the disruption of night feeds or noisy hospital routine A complaint of a depressed mood or behaviorally tearful etc

18. Clinical Features Suicidal thoughts or fear of harming the baby Irritability and loss of libido leading to deterioration of marital relationship Worry at her rejection of the baby and a reluctant to feed or handle it A fear that the baby may not be hers, or could be deformed in some ways

19. Etiology In contrast to maternity blues, postnatal depression has a clear set of associated factors. Older and younger women (Paykel 1980) Unsupportive partners (Watson 1984) Twice more life events (Paykel 1980) Previous mental illness (Paykel 1980) Thyroid dysfunction

20. Factors for Apparent Neglect An assumption that all mood disturbances in the puerperium are ‘ just postnatal blues’ , i.e. They are not only common but transitory and therefore of no clinical importance Transfer from hospital occur at/about the same time when the illness begins , so the the likelihood of an accurate diagnosis being made is diminished The health worker and family may be more concerned with physical health and developmental milestones of the baby,

21. Factors for Apparent Neglect Limited psychiatric training of GP, midwives may delay diagnosis The mothers may not report their depressed mood, because they do not recognize their distress as an illness or they fear that their guilt and inadequacy will be reinforced Therefore, early identification of postnatal depression is often difficult absence of antenatal predictors , other than hereditary predisposition and previous psychiatric history Often develops unexpectedly ‘out of the blue’

22. Detection Weight loss, menstrual change, low libido, appetite change, and change of general interest may be normal postpartum phenomena EPDS rates core features of low mood, anhedonia, anxiety, and sleep disturbances due to anxiety. EPDS superior than BDI in postpartum period (self-rated) Equal to 17-item Hamilton scale & MADRS (observer-rated)

23. Impact on Child Development (Cooper & Murray 1998) Cognitive development is adversely affected, especially among male and socioeconomically disadvantage groups The children tend to have insecure attachment at 18 months and the boys then show high level of frank behavioral disturbances at 5 years The adverse child outcome is related to the disturbances in mother-infant interactions

24. Classification of Postpartum Mental Illness (Sichel, 1998) Postpartum blues Pure depression of postpartum onset (no h/o previous depression) Depression of antenatal onset Depression with previous h/o non-pueperial depression Depression with comorbid diagnoses

25. DSM-IV Criteria for Postpartum Onset Specifier Specify if With Postpartum Onset (can be applied to the current or most recent Major Depression, Manic, or Mixed Episode in Major Depressive Disorder, Bipolar I Disorder, or Bipolar II Disorder; or to Brief Psychotic Disorder) Onset of episode within 4 weeks postpartum

26. ICD-10 F53 Mental and behavioral disorders associated with the pueperium, not elsewhere classified Commencing within 6 weeks of delivery and, either insufficient data because it is considered that special additional features are present which make classification elsewhere inappropriate

27. ICD-10 F53.0 Mild Mental and behavioral disorders associated with the pueperium, not elsewhere classified Postnatal depression NOS Postpartum depression NOS F53.1 Severe Mental and behavioral disorders associated with the pueperium, not elsewhere classified Puerperal psychosis NOS F53.8 Other Mental and behavioral disorders associated with the pueperium, not elsewhere classified F53.9 Puerperal mental disorder, unspecified

28. Treatment Based on principles similar to depression at other time

29. Puerperal Psychosis Most severe postnatal disorder, it requires specialist psychiatric care and usually admission, preferably to a specialist mother-and-baby service

30. Puerperal Psychosis 1-2 per 1000 birth (0.1-0.2%) Usually begins in first week after delivery In most cases, affective disorder akin the manic depressive illness

31. Characteristics One of the most serious psychiatric conditions - may endanger the lives of both mother and baby Prevalence: 1-2 in 1000 births (Kendel 1987) - the majority bipolar illness. Risk of developing bipolar at postpartum period is 35 times more than at any other time during a woman’s life.

32. Clinical Presentation Severe insomnia and early morning waking Lability of mood, sudden tearfulness or inappropriate laughter Persistent perplexity, disorientation or depersonalization Unusual behavior such as restlessness, excitement or sullen withdrawal

33. Clinical Presentation Unexpected rejection of the baby or a conviction that the baby is deformed or dead Paranoid ideas that may involve hospital staff or close family relations Suicidal or infanticidal threats Excessive guilt, depression or anxiety

34. Etiology Puerperal psychosis is associated with (Kendel 1987) A family history of bipolar illness A personal history of bipolar illness Primiparity Perinatal mortality Lack of partner support

35. Etiology Puerperal psychosis is related to the vast postnatal hormonal changes . Relapse could be predicted by apomorphine challenge test in immediate postpartum period - increase GH secretion (Wieck 1991) Not replicated by Mearkin 1995 study Efficacy of estrogen treatment (Henderson 1991)

36. Predisposing and precipitating factors according to Gregoire review (2000) a previous or family history of psychosis , particularly pueperal first pregnancy perinatal death alcohol or drug abuse poor marital relationship poor social support

37. Treatment Usually includes antipsychotic, and possibly antidepressant medication. In breastfeeding women: traditional antipsychotic is preferable. In non breast-feeding women: atypical antipsychotic ECT Hospitalization

38. FDA Rating of Drug Safety in Pregnancy Category A : No fetal risks in controlled human studies e.g., folic acid, iron. Category B : No fetal risk in animal studies but no controlled human studies OR fetal risk in animals but no risk in well-controlled human studies e.g., caffeine, nicotine, acetaminophen. Category C : Adverse fetal effect in animals and no human data available e.g., aspirin, haloperidol , chlorpromazine .

39. FDA Rating of Drug Safety in Pregnancy Category D : Human fetal risk seen (may be used in life-threatening situation) e.g., lithium , tetracycline, ethanol. Category X : Proved fetal risk in humans (no indication for use, even in life-threatening situations) e.g., valproic acid , thalidomide.

40. Antipsychotic and Lactation Milk-to-plasma ratio: chlorpromazine 0.3:1 and perphenazine 1:1 Phenothiazine use in lactating women Has not been associated with serious consequences Breast feeding is contraindicated

41. Lithium Principle indication: prophylaxis of bipolar illness Use in pregnancy: avoid if possible in first 10 weeks of pregnancy (small increased risk of cardiac abnormalities), levels need more frequent monitoring, dose need to be increased Use during breast-feeding: monitor levels and infant closely

42. Carbamazepine & Valproate Principle indication: prophylaxis of bipolar illness Use in pregnancy: avoid if possible ( increased risk of neural tube defects) lithium preferred Use during breast-feeding: safe

43. Benzodiazepines Principle indication: brief (max 4 weeks) treatment of acute anxiety or insomnia Use in pregnancy: Avoid in first trimester (possible increased risk of oral cleft) short-acting type preferred Use during breast-feeding: short-acting type preferred

44. Transcultural Issues Remarkable similarity in prevalence across different culture (Kumar 1994) Postnatal blues are not generally affected by cultural factors Intercultural differences cannot be shown for postnatal depression Puerperal psychosis is consistent across cultural and ethnic divides Unchanging incidence over the past 150 years

45. Transcultural Issues Howard 1993, stated that puerperal psychosis are more common in the developing world, which suggest the importance of organic factor. Hypothesis: lack of ‘rites of incorporation’ are related to postnatal depression (present-day ambiguity about social norms postpartum)

46. Thank You Presenter: Dr. Zahiruddin Supervisor: Dr. Wan Mohd Rusdi