Mood and Anxiety Disorders during the postpartum period
Gerald Hurowitz, M.D.·Published 14 May 2010·9 min read
Key points
The months following childbirth are a time of heightened vulnerability to depressive mood changes.
The postpartum period is a time of exceptionally high risk for episodes of depression, mania, or psychosis in women with manic depressive illness.
In a prospective study of 10 pregnant women with previous histories of panic disorder,32 7 (70%) of 10 subjects continued to meet DSM-III-R criteria for panic disorder at all trimester visits.
The postpartum period marks a time of increased vulnerability to OCD, even if attempts at medication discontinuation are successful during pregnancy.
Depression
The months following childbirth are a time of heightened vulnerability to depressive mood changes. Postpartum depression is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) 40(p386) as a major depressive episode that occurs within 4 weeks of delivery. However, inconsistencies in the postpartum time frame (up to 6 months after delivery) make the literature on the epidemiology of postpartum depression difficult to interpret. Furthermore, reluctance on the part of women to endorse depressive symptoms at a time when they feel pressure to fit the stereotype of happy, fulfilled mothers may lead to reporting bias.
Compared with depression occurring at other times in women's lives, postpartum depression is frequently complicated by prominent anxious features. 41 Large and carefully controlled studies in the 6 to 12 weeks after delivery report rates of maternal depression at 12% to 16%. 42–44
The overlap of depressive symptoms with those of normal childbirth sequelae can confound the clinical identification of postpartum depression. Changes in sleep, appetite, libido, fatigue, and worry are characteristic of both postpartum depression and a normal postpartum period.
Risk factors that help to identify postpartum mood disorder include prior episodes of postpartum depression, which is associated with a 50% to 62% risk of subsequent postpartum episode. 45,46 Depressive symptomatology during pregnancy 25,42,47 and family or personal history of major depression 42,43,47 also appear to increase the risk for postpartum depression.
Marital discord, stressful life events, and ambivalence about the pregnancy are risk factors not only for depression during pregnancy but also for postpartum depression. 25,42,47–50
Stressful newborn events, such as health problems and infant irritability, have also been associated with greater risk for postpartum depression. 25,44,51 Two prospective cohorts 52 were analyzed to determine whether women who frequently brought their neonates for (problem-oriented) primary care or emergency department visits were at an elevated risk of having depressive symptoms.
Findings revealed that neonatal health care use-patterns predicted maternal risk for postpartum depression; mothers were more likely to have high levels of depressive symptoms if their infants had even 1 emergency department visit.
The father's emotional state may also influence the risk for maternal postpartum mood changes. Depression 53 and high levels of expressed emotion in a woman's partner 54 have been associated with greater likelihood of maternal depression in the 6 to 12 months after delivery. Finally, cultural factors may contribute to postpartum mood disturbances.
Written and revised by
Gerald Hurowitz, M.D.
Our doctors write and review articles for accuracy and keep them up to date.
health.am provides general information, not medical advice. Always consult a qualified health professional about your own health.
Attention to the new social role as a mother and social structuring of postpartum events plus assistance in the development of mothering skills have been suggested as possible factors that may protect against depressed mood after childbirth.55
{pagebreak}
The etiology of postpartum depression remains unclear. Changes in the reproductive hormonal milieu associated with pregnancy and the postpartum period have been postulated to play a role in mood regulation.56 It has been hypothesized that the precipitous fall in estrogen concentration after delivery may contribute to the onset of depressive symptoms. Thyroid dysfunction may also contribute to postpartum mood disturbances.
In the 6 months after delivery, women experience thyroid dysfunction at a rate of up to 7%57–59 compared with a rate of 3% to 4%60 in the general population. In a prospective study61 of 303 pregnant euthyroid women, 21 (7%) developed postpartum thyroid disorders. Depression was identified in 8 (38%) of the 21 mothers and resolved with treatment of the thyroid dysfunction.
Thyroid dysfunction, however, does not appear to account for the majority of cases of postpartum depression. While certain hormones, such as estradiol and corticotropin, merit further exploration, studies have been negative or contradictory for most biological variables thought to be etiologic for postpartum mood disturbance.56 Data on the extent to which breast-feeding or weaning may affect mood are similarly inconclusive. Blood sampling in many studies does not control for breast-feeding. Lactation not only influences levels of prolactin, progesterone, estrogen, oxytocin, and cortisol, but also has been associated with both positive and negative mood states.
Prophylactic antidepressant treatment administered immediately after delivery has been noted to dramatically reduce the recurrence of postpartum major depression.
A total of 23 pregnant women with histories of at least one previous postpartum episode that fit the DSM-III-R criteria for nonbipolar major depression without psychotic features were evaluated in an open clinical trial.62
Patients who began antidepressant treatment within 24 hours after delivery relapsed at a rate of 6.7% compared with a rate of 62.5% in women who deferred antidepressant prophylaxis.
Manic Depression (Bipolar Disorder)
The postpartum period is a time of exceptionally high risk for episodes of depression, mania, or psychosis in women with manic depressive illness. The rate of postpartum relapse in women with manic depressive illness varies but has been estimated at 20% to 50%.63–65 Women with manic depression have a 100-fold greater risk than women with no previous psychiatric history for developing a postpartum psychosis.
66 Although postpartum psychosis can present with features that distinguish it from a typical manic episode (i.e., delirium-like symptoms and confusion),67 several follow-up studies of women with postpartum psychosis demonstrate recurrence of episodes of manic depression68,69 or schizoaffective illness,70 an illness characterized by chronic psychotic symptoms and recurrent manic and depressive episodes.
A few studies have addressed the role of moodstabilizing medications in preventing a postpartum relapse of manic depressive illness. In a retrospective comparison of recurrence rates and survival functions after lithium discontinuation4 in 101 women with manic depression, symptoms increased sharply during the postpartum period. Among subjects who remained stable during the first 40 weeks after lithium discontinuation (i.e., during pregnancy), postpartum recurrences (70%) were 2.9 times more frequent than recurrences in non-childbearing women (24%) during weeks 41 through 64.
Stewart et al.71 studied 21 women with a prior history of postpartum psychosis who were treated with lithium either during the third trimester or immediately after delivery of a subsequent pregnancy. Only 2 women (10%) had a recurrence of psychotic illness while on prophylactic lithium. A retrospective study63 of 27 women with manic depressive disorder found that only 1 (7%) of 14 women taking prophylactic mood-stabilizing agents during the acute puerperium experienced a postpartum relapse compared with 8 (61%) of 13 women who received no antimanic drugs and showed evidence of recurrent affective instability during the 3-month postpartum period. All of these studies underscore the significant morbidity associated with the natural course of manic depressive disorder in new mothers who are not treated prophylactically.
{pagebreak}
Panic Disorder
The postpartum period appears to be a time of increased vulnerability to recurrent panic symptoms.31,72,73
In a prospective study of 10 pregnant women with previous histories of panic disorder,32 7 (70%) of 10 subjects continued to meet DSM-III-R criteria for panic disorder at all trimester visits. A total of 9 women (90%) with panic disorder—some of whom had experienced a reduction in symptoms during pregnancy—were actively symptomatic in the 1 to 3 months postpartum; the remaining patient who stayed well was also on antipanic medications. Some investigators have hypothesized that the sharp fall in progesterone concentration after delivery may increase vulnerability to panic symptoms.
74 Elevated progesterone during pregnancy produces hyperventilation and a subsequent reduction in PCO2 levels. One theory posits that the rise in PCO2 levels after delivery corresponds with the decline in progesterone and may predispose postpartum women to panic attacks.30
The onset of panic disorder during the postpartum period has recently been reported. In the computerized search of 215 pregnancies in 8 relevant studies reported by Hertzberg and Wahlbeck,33 83 (38%) of the 215 reviewed pregnancies exhibited onset or exacerbation of panic disorder in the postpartum period. As a consequence of these latest findings, clinicians are urged to differentiate presentations of the more widely known postpartum depression and the newly reported postpartum panic disorder.
Obsessive-Compulsive Disorder
The postpartum period marks a time of increased vulnerability to OCD, even if attempts at medication discontinuation are successful during pregnancy.
Buttolph and Holland37 reported that OCD symptoms in 39 women increased in the postpartum period in 4 women (10%) after the birth of a first child and in 2 women (5%) after the birth of a subsequent child. Another study76 assessed the occurrence of potentially traumatizing life events among patients with OCD. When examining types of stressful life events, women with OCD were found to be more likely than normal women subjects to report exposure to postpartum events, and high rates of obstetric complications were observed in these patients.
Subjects with postpartum OCD also had significantly higher rates of aggressive obsessions to harm their newborn infants. These findings confirm that the postpartum period represents a risk factor for OCD in some individuals and suggest that obstetric complications may be relevant to the development of OCD.
{pagebreak}
CONCLUSION
Mood and anxiety disorders frequently begin during the childbearing years, and management of women with these disorders poses a substantial challenge to clinicians, especially during pregnancy and the postpartum period.
Depressive relapse during pregnancy is of particular concern because of an increased risk of inadequate prenatal care, poor maternal/fetal nutrition, obstetric complications, and postpartum depression. The etiology of postpartum depression remains unclear, but the disorder affects approximately 12% to 16% of new mothers. Recent data suggest that pregnancy is not protective against the risk for relapse after lithium discontinuation in women with bipolar illness.
The course of panic disorder during pregnancy and the postpartum period is variable. Some women do poorly when attempts are made to discontinue their medications during pregnancy. Other women experience a diminution of symptoms that allows them to tolerate medication discontinuation. For reasons that are unclear, pregnancy and the puerperium may precipitate or exacerbate symptoms of obsessive-compulsive disorder.
Future prospective studies of women during pregnancy and the postpartum period should begin prior to conception and end several weeks after delivery of the infant.
Although the use of psychotropic medications is appropriate in many clinical situations, pharmacologic treatment should include thoughtful weighing by the clinician of the risk of prenatal exposure to psychotropic drugs versus the risk of relapse following drug discontinuation. Decisions regarding medication discontinuation during pregnancy should be made carefully and should take into account the previous psychiatric history and its severity as well as chronicity of the illness as measured by the number of previous episodes of illness.
---- Received Aug. 25, 2000; accepted Sept. 1, 2000. From the UCLA Neuropsychiatric Institute and Hospital (Drs. Altshuler and Hendrick) and West L.A. Veterans Administration Medical Center (Dr. Altshuler), Los Angeles; and Massachusetts General Hospital, Boston (Dr. Cohen).
Financial disclosure: Dr. Altshuler has received research support from Abbott, Eli Lilly, Forest, Glaxo Wellcome, SmithKline Beecham, and Solvay; is on the speakers' bureau of Abbott, Glaxo Wellcome, and Solvay; is a consultant for Abbott, Eli Lilly, Forest, Janssen, Parke-Davis, Solvay, and Bristol-Myers Squibb; and is an advisory board member with Abbott, Eli Lilly, and Forest. Dr. Cohen has received grant/research support from Eli Lilly, Glaxo Wellcome, Organon, Pfizer, and SmithKline Beecham; is a consultant for Eli Lilly, Janssen, Pfizer, Solvay, and Wyeth-Ayerst; and is on the speakers' bureau of Eli Lilly, Janssen, Pfizer, SmithKline Beecham, Solvay, and Wyeth-Ayerst.
Reprint requests to: Lori L. Altshuler, M.D., VA Medical Center, West Los Angeles, B116AA, Bldg. 158, Room 104, 11301 Wilshire Blvd., Los Angeles, CA 90073.
Lori L. Altshuler, M.D.; Victoria Hendrick, M.D.; and Lee S. Cohen, M.D.
Guide
News
News
