Introduction:
During the postpartum period, up to 85% of women experience some type of mood disturbance. For most women the symptoms are transient and relatively mild, however some may experience a more disabling and persistent form of a mood disturbance. Although postpartum mood disorders are relatively common, patients and their caregivers frequently overlook depressive symptoms that emerge during the postpartum period. Puerperal affective illness places both the mother and the infant at risk and has been associated with significant long-term effects on child development and behavior. Therefore, prompt recognition and treatment of puerperal mood disorders are essential.
History:
Although Hippocrates is often acknowledged as the first to have recognized postpartum illness, it was not until the 1700s and 1800s that case reports of ‘puerperal insanity' appeared in French and German literature. Pitt in 1960 first described ‘atypical depression' which was later called as ‘maternity blue'.
Classification:
Postpartum psychiatric disorders have not been listed separately in the DSM-IV, and no specific criteria for their diagnosis have been provided. However, according to DSM-IV, postpartum psychiatric illnesses may be indicated with a postpartum onset specifier. With postpartum onset specifier can be applied to the current or most recent major depressive, manic, or mixed episode in major depressive disorder, bipolar I or bipolar II, or brief psychotic disorder.
The Marce Society, an International Scientific Organization dedicated to the study of postpartum psychiatric disorders, defines postpartum psychiatric illness as any episode occurring within the first year after childbirth.
Inwood has classified postpartum psychiatric disorders into 3 types;
- Type 1: Postpartum psychosis (puerperal psychosis or brief reactive psychosis)
- Type 2: Adjustment reaction with depressed mood (also called as postpartum blues/ maternal blues or postpartum perplexity syndrome)
- Type 3: Postpartum major mood disorder (also called as postpartum neurosis or neurotic reaction)
It is helpful to classify these disorders as existing along a continuum as there may be a significant overlap between these three diagnostic subtypes.
Etiology:
The impact of the physiological transition in the hormonal system, biological vulnerability to psychiatric illness, and psychosocial factors include the multiplicity of factors and complexity of their interactions that contribute to the etiopathogenis of postpartum mood disturbances.
Screening:
Since it is difficult to reliably predict which women in the general population are likely to develop puerperal illness, it is advisable to screen all women for depression during the postpartum period. The standard postpartum obstetrical visit at 6 weeks and subsequent visits to the pediatrician are the ideal times for screening. Screening may be difficult at times as many of the neurovegetative symptoms that are characteristic of depression (e.g. sleep and appetite disturbances, low energy, low libido) are also seen in non-depressed women during acute puerperium. The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item, self-rated questionnaire that has been extensively used and has a satisfactory sensitivity and specificity.
Clinical Features:
- Postpartum Blues:
Many women experience mild depressive symptoms during the first week after delivery, which are commonly known as 'maternity blues' or 'baby blues'. As there are no definite criteria, depending on the criteria used, prevalence estimates range from 30 to 85 percent. A variety of symptoms are reported which include irritability, insomnia, dysphoria, mood lability, and tearfulness. These symptoms that are transient, typically peak on the 4 th or 5 th day after delivery and remit spontaneously by the 10th day. These symptoms are relatively benign and are by definition time-limited. Although the symptoms may be distressing, they do not affect the mother's ability to care for the infant. While these symptoms do not necessarily reflect a psychopathology in the mother, some women with blues go on to develop postpartum depression. Women, whose symptoms persist beyond the second week, require further evaluation for a more serious affective illness. Women with a past history of a mood disorder require close monitoring, as the symptoms of the blues may herald the onset of a major depressive episode.
- Postpartum Depression:
Major depressive disorder is relatively common in the postpartum period. The prevalence estimates range from 10-15 percent, which are similar to the general population of women. This depression commonly develops insidiously over the first 6 months postpartum. The symptoms are similar to those seen in major depressive mood disorder and include; dysphoric mood, anhedonia, fatigue, insomnia, irritability and a range of somatic symptoms. Ambivalent or negative feelings towards the child, and expressing of doubts or concerns regarding her ability to care for the child are also commonly noted. Although suicidal ideation is frequently expressed, the rates of suicide are reported to be low. Occasionally women with postpartum depression also report co morbid disorders such as obsessive-compulsive disorder, generalized anxiety disorder, panic disorder. Hypothyroidism, which is relatively common in the postpartum period, and Sheehan's syndrome are differential diagnoses that should be ruled out. In general, the prognosis is good. While in most cases this represents the first episode of psychiatric illness, in some of the cases, they might have only puerperal episodes of symptoms, but a large majority of women go on to have nonpuerperal episodes of psychiatric illness. Data suggests that that those who receive early treatment have a better outcome. The effect on the child also appears to be significant with attachment difficulties, behavioral problems. Child abuse and neglect have also been reported.
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