Mental health problems are relatively common in pregnancy and the postpartum period. Early diagnosis, appropriate management and prompt referral to specialist services (if required) are essential.
Depression during or after pregnancy is significantly more common than in the general population. Postpartum psychosis is a rapidly developing severe mental illness that can occur in women with no previous psychiatric history. It can have significant consequences if not recognised quickly and treated correctly.
It is also important to note that patients with a previous diagnosis of a mental health problem, including schizophrenia, bipolar disorder, OCD or an eating disorder, may suffer from a relapse during pregnancy.
Depression during pregnancy, postnatal depression and postpartum (puerperal) psychosis will be discussed in this article.
Depression During Pregnancy
10 to 15% of pregnant women will suffer from depression and/or anxiety during pregnancy. This presents in a similar manner to depression outside of pregnancy, with the core symptoms being low mood, lethargy, anhedonia and additional biological symptoms, such as poor sleep and appetite. There may be added worries or ruminations about childbirth and caring for the baby, especially if there is a lack of support available.
Urgent referral to specialist mental health services should be made if the patient is severely depressed, there is a risk of self harm or suicide, evidence of self neglect, psychotic symptoms, manic features or behaviour, previous definite or possible diagnosis of bipolar disorder or any other severe mental illness. Referral should also be considered if there is a family history of severe mental illness or suicide. Specialist advice may also be considered if medication changes are necessary (including starting antidepressant therapy) or if the patient is not responding appropriately to medication.
The management of a patient with newly-diagnosed depression in pregnancy should be carefully considered. Social support and psychological treatments are recommended. When considering antidepressant treatment, it is important to acknowledge that no antidepressant is without risks in pregnancy. Published guidelines recommend different antidepressants for use in pregnancy, so it may be best to seek advice from pharmacy colleagues or specialist Perinatal Psychiatry Services. The patient should make an informed decision with her doctor, after considering the risks of medications versus the risks of untreated depression.
The UK Teratology Information Service can provide detailed information about risks of antidepressant medication.
Postnatal depression is defined as a depressive episode within the first twelve months postpartum. The peak incidence appears to be during the first two months after childbirth. It should be distinguished from, the ‘Baby Blues’ (a period of low mood and irritability) which normally starts three to four days after birth, lasts for about seven days and doesn’t require treatment.
Symptoms are very similar to those of depression, but may include negative cognitions about motherhood and coping skills. There may also be anxiety which can focus around baby, including worries that the baby is becoming ill, not being able to care for them adequately or that they may harm them, and hopelessness about the future.
Again, urgent referral to specialist mental health services should be made if the patient is severely depressed, there is a risk of self-harm or suicide, evidence of self-neglect, psychotic symptoms, manic features or behaviour, previous definite or possible diagnosis of bipolar disorder or any other severe mental illness. Referral should also be considered if there is a family history of severe mental illness or suicide.
Only social support and psychological treatments may be appropriate, depending on the severity of the depressive episode. If there is a need for medication, (in individuals who have moderate depression where there are risks or non response to other treatments, or in individuals with severe depression), consideration needs to be given to whether the patient is breastfeeding. If not, recommended management of depression will be the same as in a non-breastfeeding woman. If breastfeeding, the risk benefit ratio of different antidepressants needs to be discussed with the patient, so they can make their own choice about treatment. Again published guidelines recommend different antidepressants for use in breastfeeding women, so it may be best to seek advice from pharmacy colleagues or specialist Perinatal Psychiatry Services.
Postpartum (Puerperal) Psychosis
Postpartum psychosis is an extremely severe form of mental illness that needs to be recognised early to avoid harm to either mother or baby. It can develop rapidly (over the course of a few hours), and starts within days to weeks of delivery, affecting about 1 in 1000 women. Postpartum psychosis can develop in women with no previous mental health problems, but is more common in patients with a previous diagnosis of bipolar disorder or a psychotic illness. A history of postpartum psychosis in the patient’s mother or sister also increases the risk. Women who have had a previous episode of postpartum psychosis have a 50% chance of it recurring in their next pregnancy.
The presentation of postpartum psychosis can be very variable. Patients are often noted to appear confused and distracted. Relatives may report they have become quiet and withdrawn, or the opposite; that they appear agitated and distressed. They may express bizarre ideas, for example paranoid or grandiose delusions, or report or respond to auditory hallucinations. They may also appear manic, with behaviour that is out of character such as talking rapidly and being more active. Sleep disturbance is very common. Family and friends may not recognise that the patient needs urgent medical attention, especially if the patient has no history of mental health problems.
A patient presenting to health services with postpartum psychosis needs prompt assessment by Specialist Mental Health services. It is crucial to conduct a very thorough risk assessment, including suicidal ideation, thoughts of harm to or bizarre ideas about the baby, self-neglect and ability to provide care for the baby. Most women suffering from postpartum psychosis need to be treated as an inpatient, possibly under the Mental Health Act. Specialist Mother and Baby units are available, or the patient may be admitted to a general psychiatric ward. Pharmacological treatment usually involves the use of an antipsychotic and/or mood stabiliser.
Prognosis is generally good. Most women have severe symptoms for two to twelve weeks, and take six to twelve months to recovery fully. Earlier diagnosis after childbirth appears to reduce the likelihood of long term difficulties.
It is important to remember the risk of having another episode is 50%, and these patients will require very close monitoring during future pregnancies and after delivery.