Postnatal Mental Disturbance
Dr. Alyx Taylor, Bernhard Baron Building, Queen Charlotte's Hospital, Goldhawk Road, London W6 OXG, 1997, for the Marce` Society
Reports of mental illness in the postpartum period have been found in the most ancient written records (Hippocrates c460 - 370 BC)(Lloyd, 1983), but the scientific study of the subject is generally regarded to have begun with the publication of the treatise by Louis Victor Marce`: "Traite` de la folie des femmes enceintes, des nouvelles accouche`s et des nourrices" (Marce`, 1858). Marce` regarded postpartum psychiatric illness as a distinct nosological group with unique psychopathology and outcome. This view was highly controversial, Kraepelin argued that postpartum psychosis was affective disorder triggered by childbirth (Kraepelin, 1913). Concerted modern research began in the 1960s. Pitt followed approximately 300 women through to the late puerperium, reporting the incidence of depression as 10.8% (Pitt, 1968).
Postpartum mental disturbance is generally subdivided into the blues, postnatal depression and postnatal psychosis (O'Hara, 1987). The blues are a brief period of mild lability or depression that start on the third to fifth day postpartum, affecting approximately 50% of all mothers (Yalom, et al., 1968; Pitt, 1973).
Postnatal depression (PND), occurs after about 10% of births, often starts within the first two weeks and can last for as much as twelve months. The majority of women recover within three months (Cooper, et al., 1988), however postnatal depression is frequently unrecognised and untreated (Steiner, 1990). Some women have no idea they need medical help, added to which is the difficulty that some primary healthcare workers do not recognise PND or deny the existence of the illness (Taylor, et al., 1994). At the other extreme puerperal psychosis is an incapacitating disorder that usually requires hospitalisation and thus rarely missed by the families and healthcare workers. This affects only 1 of every 500 women postpartum and is frequently of the manic depressive type (Brockington, et al., 1981).
In a recent study of women in the early puerperium (Hannah, eel al., 1992), employing the Schedule for Affective Disorders and Schizophrenia - Lifetime Version (SADS-L), (Endicott and Spitzer, 1978), interviewed women who had recently suffered from postnatal depression, and noted that approximately one quarter of them described symptoms, occurring during the first postpartum week, which met the criteria for hypomania. Such symptoms have been referred to elsewhere in the literature, (Handley, et al., 1977; Ballinger, et al., 1982; Brinsmead, et al., 1985), but never focused upon.
The postpartum blues is a mild, transient psychological disturbance, usually starting day 3 or 4 after parturition and lasting approximately 48 hours (Pitt, 1973). Symptoms include emotional lability with episodes of tearfulness, anxiety, confusion, irritability, restlessness, and exhaustion (Handley, et al., 1980. O'Hara, 1987). Estimates of the incidence vary, due to different criteria chosen by the different research group, from 30 to 80% (Kendell, et al., 1981; Harding, 1989). There is no evidence that the blues have any lasting effect on the mother or the child (Dinan, 1990). However, severe blues have been shown to be linked with later postnatal depression (Paykel, et al., 1980; Glover, et al., 1994).
Symptoms of PND can include feeling lethargic, weeping, anxiety, guilt, depression, irritability, confusion, disturbed sleep and excessive exhaustion (Pitt, 1968, Cox, 1989). The depression may be overlooked when symptoms are confused with normal postpartum experience, including fatigue, weight loss, and sleep disturbance in caring for the infant (Pitt, 1968). There is continuing controversy over recognition of PND as a separate illness from depression arising at other times (O'Hara, 1987). Puerperal psychosis, was removed from the Ninth Revision of the International Classification of Diseases (IDC-9), primarily on the grounds that psychoses beginning after childbirth can not be distinguished clinically from psychoses occurring at other times (VMO, 1978). 'Postpartum onset' is an atypical feature which can be applied to the 'current or most recent major depressive, manic or mixed episode of major depressive disorder, bipolar 1, 11 disorder or brief psychotic disorder' (APA, 1994). The Marce` Society was set up in 1980 as an international forum for the understanding, prevention and treatment of mental illness associated with childbirth. Members of this organisation have pursued research to provide nosological evidence for PND as a separate classification.
A prospective study of the course and recurrence of PND and other depression in primiparous women was carried out over a period of five years (Cooper and Murray, 1995). Three groups of primiparous women were included; those for whom the mood disorder had arisen de novo, those for whom it was a recurrence of previous affective disorder and a control group. The results after three and a half years, showed that women who had suffered non-puerperal depression at any time before their index pregnancy had an increased risk of further non-puerperal episodes but not PND. Conversely women for whom the index episode had arisen de novo were at increased risk of further episodes of PND and not non-puerperal depression. A strict definition of postnatal depression was used throughout, including only that which arose within 12 weeks of the birth. This provides some evidence for a difference in vulnerability to PND from depression which occurs at other times.
The literature on the incidence, precipitating factors, prevalence and family traits of postnatal depression shows a huge variation in almost all parameters. This is due largely to the different ways in which the postnatal depression has been defined, the time periods chosen and methods of identification used by different research groups. At any time point the percentage of women postpartum recorded as depressed, ranges widely, for example 6.8% (Gotlib, 1989), to 20% (Paykel et al., 1980) at 6 to 8 weeks. Some studies use self rating psychometric scales alone while others incorporate structured or unstructured psychiatric interviews. At least eleven different psychometric scales have been used, creating difficulties when comparing study results (Richards, 1990). The Edinburgh Postnatal Depression Scale (EPDS) was developed specifically for use in the puerperium, approximately six weeks after the birth. The EPDS is the most appropriate choice for research because the other more general scales contain items not easily applicable to these patients (Cox, et al., 1987). It is increasingly used by primary health care workers in the identification of potential patients and by research workers in this field. In studies using the EPDS at a cut-off of 13 points and measuring at 6 weeks postpartum, a rate of approximately 10% is found.
Watson found the prevalence of depression 6 weeks postpartum at 12% to be very similar when compared with data from non-pregnant women (14.9%), (Watson, et al., 1984). Other groups have reported similar findings lending support to the view that depression in the puerperium is coincidental with this life event, not as a result of the birth and in no way distinguishable from depression arising at other times. Kumar and Robson, on the other hand conclude that 'childbearing per se has a particular and deleterious effect on the mental health of women' (Kumar and Robson, 1984). In support of this Cox and co-workers, have shown in a study of 232 women, that while there was no difference in the point prevalence of depression at six months between the postnatal group of women (9. 1%) and the control group (8.2%), nor in the 6 month period prevalence (13.8% and 13.4% respectively), a threefold higher rate of onset of depression was found within five weeks of childbirth compared with the controls (Cox, et al., 1993). Other researchers have found that the age of onset of depression is lower in the postpartum group than in the whole population of women (Frank, et al., 1987).
Sleep patterns of women with postpartum depression were found by electroencephalogram to have longer and more active rapid eye movement periods than control women, with no psychopathology. This difference was almost entirely accounted for by women with a history of only pregnancy related affective episodes (Frank et al., 1987). Martin et al. studied women on a psychiatric mother and baby unit and women in the community and found that only 16% of the cases of depression in the puerperium had a psychosocial provoking cause compared with 88% of the cases of depression in pregnancy and 73% of the cases in the general population (Martin, et al., 1989). This points to a biological component in the development of at least some of the cases of depression in the postpartum period, which is likely to be a multifactoral disorder, with different women showing greater influence from different factors.
The time of onset varies also (Richards, 1990; Hannah, et al., 1993), supporting the idea that the patients suffering from postnatal depression could be divided into subgroups. The identification of such subgroups could be of great benefit in the understanding of the biochemical mechanisms and in the treatment of patients.
Postnatal Affective Disorders in Different Cultures
It has been suggested that postnatal affective disorders are a problem exclusive to Western culture and associated with the change in the r61e of women in these societies (Shaw, 1974; Arms, 1975).
A study of the psychiatric state of women in the puerperium in two very different cultures has revealed similar rates of depression in semi-rural Ugandan women (10%), and Scottish women (13%), suggesting an element not related to the environment was common to both groups of women (Cox, 1979; Cox, 1982a). In a recent study of women in a rural area in the United States a rate of 19.9% was recorded as potentially suffering from postnatal depression (Reighard and Evans, 1995), which the authors note as higher than the results reported in the literature (range of 7% - 15%). They do not discuss that the threshold for the EPDS used (1 1/12), was one point lower than that of 12/13 which was originally validated by Cox and co-workers (Cox et al., 1987). A re-analysis of the data Reighard and Evans present, including only those women scoring >13 on the EPDS, gives 28 out of 181 (15.5%). The EPDS was recently translated into Portuguese and used in an urban area of Portugal in a study of 352 women between 2 and 5 months after childbirth (Augusto, et al., 1996). The usual EPDS cut-off score of 13 or more was used and 13.1% of the women were identified by this as likely to be suffering from postnatal depression. Similar results have been obtained in Japan (Okano and Nomura, 1995), although the Japanese women expressed more somatic symptoms than psychological symptoms, and in Chile (Jadresic, et al., 1992). From these studies it would appear that despite great differences in numerous factors (for example: the environment, social customs, financial status and medical support), approximately the same percentage of women are identified as probably having postnatal depression throughout the world.
In a study employing the Schedule for Affective Disorders and Schizophrenia Lifetime Version (SADS - L), women who had recently suffered from postnatal depression 'were interviewed (Hannah et al., 1993). It was noted that about 25% of them described symptoms occurring during the first postpartum week which met the criteria for hypomania. To study this phenomenon prospectively, a questionnaire, based on the SADS - L, was developed. It was revealed that 10% of women in the first postpartum week show symptoms that meet the SADS-L criteria for hypomania (Glover et al., 1994). These symptoms appear to be present each day, for at least the first five days in the women that experience them, but they have usually disappeared by week 6.
It could be argued that the highs simply reflect happiness at having a baby rather than any psychopathology. However, clinical interviews using the Comprehensive Psychopathological Rating Scale (CPRS), confirmed the presence of mild mania or hypomania with a high prevalence of irritability in these women. It could also be argued that the symptoms described for the highs are simply another aspect of the blues. Elation or euphoric symptoms have been noted in other studies of the blues (Stein, 1982; Kennerley and Gath, 1989). Five of the women, in the study by Glover and co-workers, did have high scores on the highs scale and the EPDS or blues scale simultaneously. Thus it is possible for elation or euphoria to coexist with anxiety or depression. The highs have also been found to be a risk factor for later postnatal depression (Glover et al., 1994).
Clinical Significance of Early Postnatal Mental-Disturbance
The possibility of identifying those women who are at greater risk of developing postnatal depression has important clinical implications not only for the patient and her family during the depression but potentially permanently. The latest evidence suggests that this is particularly true for the development of the index child (O'Hara and Zekoski, 1988). It has been found that children of women who suffer depression in their first year of life show cognitive and behavioural problems at school age, while children whose mother becomes depressed after their first year of life do not show the same effects later (Cogill, et al., 1986).
Most women will recover spontaneously from postnatal depression within one month unaided, but some continue to suffer for many months (Dinan, 1990). The lasting effects on the family are just beginning to be understood. There is also evidence that dysfunctional parenting is associated with failure in relationships in adulthood (Rodriguez Vega, et al., 1993).
It has been suggested that disturbed family relationships, brought about by psychiatric illness in the parents could have lasting effects on the mental development of the child (Rutter and Quinton, 1984; Tarullo, et al., 1994). There is some evidence that the immediate postpartum period is particularly sensitive for the formation of bonding between mother and baby (Klaus, et al., 1972). A failure in the mother-infant bonding may cause a positive feedback mechanism exacerbating the woman's depressed mood, such circular patterns have been noted in a study of two month old infants and their mothers (Whiffen and Gotlib, 1989).
Behaviour and temperament problems of children have been found to be related to PND in the mother, as a result and also a contributing factor (Whiffen, 1988). Children of postnatally depressed mothers performed less well at object concept tasks, showed greater insecurity with regard to their mothers and more behavioural difficulties up to 18 months, compared with children of women either with a previous history of depression or those who had never suffered mental illness (Murray, 1992). In another study mother-child dyads showed, at 19 months, a reduced quality of interaction. the mothers showing less facilitaion of their children and the children exhibiting less affective sharing and less initial sociability with strangers (Stein, 1991). In this study it was noted that the children whose mothers had recovered from depression by 19 months showed similar but reduced effects. Wrate and co-workers contacted women who had taken part in a PND study, three years previously. It was found that children whose mothers had had episodes of PIND lasting up to six months showed more behavioural disturbance at three years than the children of women who were not depressed (Wrate, et al., 1985). Other researchers have made similar findings; the children of women who had been depressed during the first postnatal year showed significant deficits in cognitive development and behavioural adjustment (Cogill et al., 1986; Murray, 1992). More on Motherhood.
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