Antenatal Psychiatric Disorders:
Depression in pregnancy
Depression is the most common psychiatric disorder associated with pregnancy. Pregnant women may also suffer from anxiety disorders, such as panic disorder, obsessive-compulsive disorder, and eating disorders.
In a recent study, more women became depressed between 18 and 32 weeks gestation than between 32 weeks gestation and 8 weeks postpartum. The prevalence of depression has been reported to be between 10 and 16% during pregnancy. Major depression is twice as common in women than in men and frequently clusters during the childbearing years.
Risk factors: a previous history of depression, discontinuation of medication by a woman who has a history of depression, a previous history of postpartum depression, and a family history of depression.
Psychosocial factor: a negative attitude toward the pregnancy, a lack of social support, maternal stress associated with negative life events, and a partner or family member who is unhappy about the pregnancy.
Anxiety disorders in pregnancy
Panic disorder and obsessive- compulsive disorder.
Eating disorders: The prevalence is approximately 4.9%.
Bipolar mood disorder
Schizophrenia: The limited data on schizophrenia in pregnancy.
Treatment of psychiatric disorders during pregnancy
- Toxicity to the neonate
- Neurobehavioral sequelae
- Risk of no treatment
- Risk of medication discontinuation
b) Treatment of specific psychiatric disorders
Psychotherapies: Interpersonal therapy (IPT) is ideal for the treatment of the depressed pregnant women. Cognitive behavior therapy (CBT) has also been reported to be beneficial. Education and support are also important.
Antidepressant treatment: During pregnancy, fluoxetine is usually the first line antidepressant choice. Other first-line choices include TCAS, particularly nortryptiline and desipramine, as they are less anticholinergic and therefore less likely to exacerbate orthostatic hypotension during pregnancy. Electro-convulsive therapy (ECT)
- 1st line: fluoxetine, nortryptilline and desipramine
- 2nd line: sertraline, paroxetine, fluvoxamine, citalopram and venlafaxine
- Drugs best avoided due to lack of sufficient data : monoamine oxidase inhibitors, bupropion, nefazodone and mirtazapine
- 1st line: lithium (possible risk- cardiac anomalies 0.05-0.1 %)
- 2nd line: carbamazepine (possible risks–multiple congenital anomalies, neural tube defects 0.5-1%, craniofacial anomalies, microcephaly, growth retardation), valproic acid
- Drugs best avoided due to lack of sufficient data : divalproex, lamotrigine, gabapentine
- 1st line: fluoxetine, tricyclic antidepressants
- Drugs best avoided due to lack of sufficient data – benzodiazepines (possible risks – cleft lip, cleft palate, toxicity syndromes including muscular hypotonia, failure to feed, impaired temperature regulation, apnea and depressed apgar scores).
- 1st line: higher potency antipsychotics
- 2nd line : clozapine, olanzapine
- Drugs best avoided due to lack of sufficient data – quetiapine, risperidone, aripiprazole and ziprasidone
Postnatal Psychiatric Disorders
- Postnatal or maternity blues;
- Postnatal depression;
- Postnatal psychosis; and
- Pre-existing psychiatric disorders in pregnancy.
The prevalence of postnatal blues has been estimated in different western studies to be anywhere from 50 to 70%. Postnatal depression is somewhat less common at 10%. Postnatal psychosis is rare and estimated to occur in about 2 per 1000 births.
1. Biological factors
Oestrogen and progesterone both increase greatly during late pregnancy and fall precipitously after childbirth. Changes also occur in the corticosteroids and corticosteriod-binding globulin.
2. Psychological Factors
Marital conflicts are known to precipitate such disorders. Some couples use the pregnancy as an attempt to cement an already shaky relationship. Others struggle with the “death” of the couple as they are “invaded” by another person, the infant.
The woman herself has to struggle with major changes in body image during the pregnancy, delivery as well as in the puerperium. Dramatic physical changes in her body occur during these phases in response to hormonal shifts.
In late pregnancy, the changes are most dramatic as her girth enlarges to incorporate the growing foetus. At this time, severe fatigue often forces a rethinking of the woman’s priorities. She may have to decide how to balance her roles as mother and career woman. If she decides to stop work, there is the loss of income. In addition expenses on the new baby add stress on the new father, now the sole breadwinner.
Risk of developing puerperal psychiatric morbidity:
- those with a poor marital relationship
- those who lack a confiding relationship
- those with adverse social and economic circumstances
- those with a family history of mental illness
- Benign onset in first three days post delivery
- Adjustment reaction to puerperium
- Resolves in two weeks with no treatment
- Depressed and anxious Poor concentration Lability of mood
- Sleep disturbance
- Lasts more than 2 weeks
- Depressed mood Anxious Tiredness
- Psychomotor retardation or agitation
- Depressive cognitions Poor concentration Indecisiveness Suicidal thoughts
- Insomnia or hypersomnia
Postpartum depression is characterized by a depressed mood, excessive anxiety, insomnia, and change in weight. The onset is generally within 12 weeks after delivery.
- All features present in postpartum depression.
- And Suspiciousness Incoherence or confusion Irrational statements
- Obsessive concern about baby’s health / welfare
- Thoughts of harming self / baby
- Delusions that baby is not normal
- Hallucinations of voices telling her to harm baby
Postpartum psychosis (sometimes called puerperal psychosis) is an example of psychotic disorder not otherwise specified that occurs in women who have recently delivered a baby. The syndrome is often characterized by the mother’s depression, delusions, and thoughts of harming either herself or her infant. Such ideation of suicide or infanticide must be carefully monitored; although rare, some mothers have acted on these ideas. Most available data suggest a close relation between postpartum psychosis and mood disorders, particularly bipolar disorder and major depressive disorder.
The incidence of postpartum psychosis is about 1 to 2 per 1,000 childbirths. About 50 to 60 percent of affected women have just had their first child, and about 50 percent of cases involve deliveries associated with nonpsychiatric perinatal complications. About 50 percent of the affected women have a family history of mood disorders.
The symptoms of postpartum psychosis can often begin within days of the delivery, although the mean time to onset is within 2 to 3 weeks and almost always within 8 weeks of delivery. Characteristically, patients begin to complain of fatigue, insomnia, and restlessness, and they may have episodes of tearfulness and emotional lability. Later, suspiciousness, confusion, incoherence, irrational statements, and obsessive concerns about the baby’s health and welfare may be present. Delusional material may involve the idea that the baby is dead or defective.
Patients may deny the birth and express thoughts of being unmarried, virginal, persecuted, influenced, or perverse. Hallucinations with similar content may involve voices telling the patient to kill the baby or herself. Complaints regarding the inability to move, stand, or walk are also common.
The onset of florid psychotic symptoms is usually preceded by prodromal signs such as insomnia, restlessness, agitation, lability of mood, and mild cognitive deficits. Once the psychosis occurs, the patient may be a danger to herself or to her newborn, depending on the content of her delusional system and her degree of agitation. In one study, 5 percent of patients committed suicide and 4 percent committed infanticide. A favorable outcome is associated with a good premorbid adjustment and a supportive family network. Subsequent pregnancies are associated with an increased risk of another episode, sometimes as high as 50 percent.
- Physical Investigations
- Social Investigations
In the first instance, the doctor must assess the extent of suicide risk and risk to the new baby in each case. This should be balanced against the degree of social support available.
Admission to a inpatient “mother and baby” unit where mentally ill mothers are nursed with their babies by nursing staff trained both in psychiatry and neonatology would be ideal.
In postnatal blues, usually no specific treatment is needed. The doctor needs to ensure adequate support for mother and baby at home by enlisting the help of relatives. Reassurance and education should be given. The condition is self-limiting and resolves spontaneously in two weeks.
In postnatal depression or psychoses, specific intervention is often required. If at risk, the patient should be admitted and closely supervised.
Postpartum psychosis is a psychiatric emergency. Antipsychotic medications and lithium, often in combination with an antidepressant, are the treatments of choice.
In mild to moderate cases, medication in the form of antidepressants or antipsychotics (e.g. haloperidol, chlorpromazine) need to be prescribed. In more severe cases, electroconvulsive therapy is the treatment of choice as it has been proven to be effective and rapidly enables the mother to resume the care of her new baby, enhancing the mother-child bond. Breastfeeding is contraindicated because of its stressful nature and because all psychotropic drugs are excreted in the breast milk.
Most patients do recover fully from a puerperal mental illness and prognosis is excellent if the illness is diagnosed early and treated adequately.
In postnatal blues, almost all cases resolve spontaneously with reassurance, emotional support and advice. The recurrence rate in subsequent pregnancies is up to 20%.
In postnatal depression, which is similar to major affective disorder, and postnatal psychosis, the response to drug treatment or electroconvulsive therapy is good. About 5% of cases committed suicide and 4% harmed their newborn when inadequately treated. Again, the recurrence rate in subsequent pregnancies is up to 20% and couples should be counselled about this risk before embarking on the next pregnancy so that adequate supervision can be arranged.
Comparison of Baby Blues and Postpartum Depression