Postpartum Disorders

September 23, 2011

Any psychiatric illness may occur during the postpartum period. However, the most common disorders having an onset, recurrence, or exacerbation in the postpartum period include mood disorders and anxiety disorders. Difficulty with adjustment and problems in the mother-infant relationship may also occur after childbirth. Women who experienced a psychiatric disorder prior to or during the pregnancy are more likely to experience the symptoms in the postpartum period (up to 1 year after childbirth).

The postpartum period is a vulnerable time for emotional disturbances to occur. Physiologically, there is a rapid shift in hormones, fluid levels, and electrolytes. These changes affect neurotransmitter release and the neurological stress system (hypothalamic-pituitary-adrenal axis and peripheral nervous system) functioning. Psychologically and socioculturally, women and their families are adjusting to parenthood and the new roles they need to perform. This may create changes in the family system, particularly in the marital relationship. All these changes influence the development of postpartum psychiatric disorders.

POSTPARTUM MOOD DISORDERS

Mood disorders are the most common psychiatric illnesses to begin or exacerbate in the first few months to a year after childbirth. Major depression with postpartum onset occurs in 10-15% of women and includes identical symptoms to major depression in the general population of women. Major depression is a psychiatric disorder that is different from the more benign postpartum blues experienced by 50-80% of women just after delivery. Postpartum blues is a time-limited (4-10 days) disturbance of mood reactivity that includes unexpected mood changes (from sadness to elation) in response to seemingly minor details, tearfulness, irritability, and general anxiety, and does not usually interfere with daily functioning or overall enjoyment of life. Postpartum blues may result from a natural process of events following the extreme hormonal changes after delivery. Twenty percent of women experiencing “the blues” will develop major depression in the following months. Postpartum depression may begin in the first few weeks after delivery but is more commonly seen at 3-6 months postpartum. This is a serious disorder that requires treatment. Women with a prior history of a mood disorder or those who have had a previous postpartum depression are more likely to develop major depression after childbirth. Psychosocial factors influencing the development of postpartum depression include marital dissatisfaction, inadequate social support, and stressful life events.

Despite the relatively high prevalence of postpartum depression, many women with the disorder are not identified or treated. Women experiencing depression after the birth of a baby often feel the symptoms are evidence that they are bad mothers, influencing their decision not to disclose their symptoms. Some of the most difficult symptoms to disclose are obsessional thoughts of harming the baby or ambivalence and negative feelings toward the baby. However, the incidence of women with postpartum depression actually harming the baby is very low. Other symptoms include emotional lability, guilt, poor concentration and memory, poor sleep, and fatigue. Many of these symptoms are often labeled as expected in the postpartum period and are thus overlooked as an indication of a more serious illness. Although suicidal ideation is very common the actual rate of suicide is fairly low.

Major depression in the postpartum period has major consequences for mother-infant pairs as well as other family members. Depression can impair a woman’s interest in her infant. The symptoms of fatigue, negativity, and general low functioning can also affect how the woman interacts with her infant and other family members. These factors often lead to a decrease in the quality of mother-child interactions, altered maternal responsiveness toward the infant, and increased child behavior and mood disorders later on. Early detection and treatment is essential. Treatment involves interpersonal, cognitive, or family therapy in conjunction with antidepressant medication (e.g., fluoxetine or nortriptyline).

Postpartum psychoses are rare, yet severe disorders still affect 1-2 women per 1,000 births. This rate has not changed in the last 150 years and it is consistent throughout other cultures studied, including women in Africa, the Middle East, and Asia. These data suggest that psychoses in the first 4 weeks after delivery are related more strongly to physiological (biological) factors rather than psychosocial factors. Postpartum psychosis is most often a manifestation of bipolar disorder as there is frequently a depressive, manic, or mixed mood episode occurring with hallucinations and delusions. The mood episodes occur within 2-14 days following delivery and come on suddenly. Early symptoms include restlessness, irritability, and insomnia. Within a very short period of time, extreme mood lability, disorientation, erratic behavior, and hallucinations or delusions begin to emerge. The delusions are often paranoid delusions that center on the infant being evil or in some way dangerous. There is a high risk at this time of suicide, homicide, and infanticide. If untreated, the rate of infanticide has been as high as 4%. In some cases, the experience of psychosis is not associated with a mood disturbance and may be associated with schizophrenia.

Psychoses in the postpartum period could also be caused by other medical conditions that are common during this time, such as thyroid disease, vitamin B12 deficiency, and Tay-Sachs disease. Medication such as some antibiotics, medications to stop lactation, or mood-altering drugs can also induce psychosis.

Once potential medical and drug causes are examined, early and aggressive treatment is needed. Treatment typically includes inpatient hospitalization, mood stabilizers (e.g., lithium), antipsychotic medication (e.g., olanzapine or Zyprexa), and occasionally benzodiazepines (e.g., lorazepam or Ativan).

POSTPARTUM ANXIETY DISORDERS

Although not as common as the mood disorders, anxiety disorders also occur in the postpartum period and are frequently comorbid with a mood disorder. The diagnoses include generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD). These disorders may develop with or without panic attacks.

GAD occurs in 4.3% of all women and as many as 10% of postpartum women. It is highly comorbid with depression and panic disorder. GAD occurs when there is excessive and persistent worry and anxiety that lasts for at least 6 months and causes significant distress or impairment.

OCD occurs in 3-5% of postpartum women and may be a new onset or a recurrence of a previous illness. The disorder is characterized by intrusive, obsessional thoughts. Occasionally the obsessions are associated with rituals or compulsive behaviors to relieve anxiety about the particular obsession. New mothers who develop OCD typically have obsessional thoughts about harming the baby. Unlike the hallucinations and delusions of postpartum psychosis, these thoughts are very frightening and provoke extreme anxiety. Women who suffer from these intrusive thoughts know the thoughts are wrong and do not harm their infants.

PTSD develops in the postpartum period generally after a certain event triggers a stress reaction or a panic attack. The event may be remembrance of a previous trauma, a very traumatic delivery, extreme suffering, a long hard labor, or an emergency cesarean section. The risk of developing PTSD following delivery is higher in women who have experienced difficult births in addition to neonatal death or stillbirth.

Treatment of anxiety disorders after childbirth is usually a combination of psychotherapy and medication. Cognitive-behavioral therapy is very effective in the treatment of anxiety disorders. Selective serotonin reuptake inhibitors (e.g., fluoxetine or Prozac and others), tricyclic antidepressants (e.g., clomipramine or Anafranil and others), and benzodiazepines (e.g., lorazepam or Ativan and others) are some of the medications used to alleviate the symptoms of anxiety disorders.

Adjustment to life as a mother or even to being a mother of multiple children can be very stressful, especially if there are additional medical or family concerns. Adjustment disorders may develop under such conditions. These disorders are characterized by marked distress to a known stressor, such as childbirth, changing roles, loss of income, and marital discord, which is in excess of what would be expected. Adjustment disorders in the postpartum period often involve depressed mood and anxiety as the main symptoms without symptoms of a significant mood disorder.

Any of the postpartum disorders can contribute to difficulties in the mother-infant relationship. Mothers experiencing postpartum psychiatric illness may be unable to care for their infant, may be afraid to harm the infant, or may reject the infant. In some instances, delayed attachment results from these conditions and requires additional treatment for the mother and the infant.

SEE ALSO: Anxiety disorders, Bipolar disorder, Depression, Mood disorders

Suggested Reading

  • Dunnewold, A. L. (1997). Evaluation and treatment of postpartum emotional disorders. Sarasota, FL: Professional Resource Press.
  • Gold, L. H. (2002). Postpartum disorders in primary care: Diagnosis and treatment. Primary Care: Clinics in Office Practice, 29(1), 27-41, vi.
  • Miller, L. J. (Ed.). (1999). Postpartum mood disorders. Washington, DC: American Psychiatric Press.
  • Sadock, B. J., & Sadock, V. A. (2003). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (9th ed.). Philadelphia: Lippincott, Williams & Wilkins.
  • Stotland, N. L., & Stewart, D. E. (Eds.). (2001). Psychological aspects of women’s health care: The interface between psychiatry and obstetrics and gynecology (2nd ed.). Washington, DC: American Psychiatric Press.
  • Wisner, K. L., & Stowe, Z. N. (1997). Psychobiology of postpartum mood disorders. Seminars in Reproductive Endocrinology, 15(1), 77-89.

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