Download POSTPATUM PSYCHIATRIC SYNDROMES

POSTPATUM PSYCHIATRIC
SYNDROMES
H.Amini M.D.
Roozbeh Hospital
TUMS
History
• Hippocrates: a mania related to lactation
• Case reports of “puerpral insanity” in 1700-1800
in the French& German medical literature
• Jean Esquirol,1818: quantitative data on 92 cases
of puerperal psychosis
• Victor Louis Marce,1856: foundation for modern
conceptualizations of mental illness related to
pregnancy & postpartum period
• B. Pitt, 1960: an atypical depression ( later called
:maternity blue”)
History
• Large, population-based studies, 1970s:
high rates of mild to moderate depression in
women during the first 6 months after
delivery
• Recent studies: a sharp peak in the number
of psychiatric admissions during the first 3
months after delivery
Definition
• Postpartum blues:
30-85%, within 1th week
• Nonpsychotin postpartum depression:
10-15%, within first 2-3 months
• Puerperal psychosis:
0.1-0.2%, within first 2-4 weeks
Etiology
• Demographic variable:
- high rates(26%) of PP depression in
adolescent mothers ??
- primiparous women are more
vulnerable to PP psychosis than
multiparous women
• Psychosocial factors:
- stressful life events during pregnancy or near
the time of delivery
- marital dissatisfaction or inadequate social
support
Etiology
• History of psychiatric illness:
- 70% risk of relapse at future pregnancy
for PP psychosis
- 50% risk of relapse at future pregnancy
for PP depression
- 20-50% risk of relapse at future
pregnancy for BID
- 30% risk of relapse at future pregnancy
for MDD
Etiology
• Hormonal factors:
- declining progestrone??
- declining estrogen??
- rapid decreasing cortisol??
- thyroid dysfunction??
Diagnosis & Clinical Features
• DSM-IV have no specific criteria for Dx of
PP psychiatric illness
• According DSM-IV, PP psychiatric illnesses
may be indicated with a postpartum onset
specifier
• Marce society: any episode occuring within
the first year after delivery
Diagnosis & Clinical Features…
• Often overlooked or ignored by both patients and
caregivers
• <1/3 of women with PP ilness seek professional
help
• Untreated depression may contribute to the
development of chronic and refractory depression
in the mother
• Adverse effects of maternal depression on the
cognitive, emotional, and social development of
the child
Postpartum Blues
• Baby blues
• 30-85%
• Mild depressive symptoms:
dysphoria, mood lability, irritability,
tearfulness, anxiety, and insomnia
• Peak on 4th or 5th day after delivery
• Remit spontaneously by the 10th day
• Relatively benign, time-limited
• Some women with blues will go on to develop PP
depression
Postpartum Depression
• 10-15% PP minor or major depression
• More commonly develops insidiously over the
first 6 postpartum months
• A significant proportion of women experience the
onset of depressive symptoms during pregnancy
• Indistinguishable from those characteristic of
nonpsychotic MDD
• Somatic complaints are common
Postpartum Depression…
• Ambivalent or negative feelings toward the
infant
• suicidal ideation is frequent, but suicide
rates appear to be relatively low
• Generalized anxiety, panic disorder, and
OCD are often observed
Puerpral Psychosis
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1-2/1000 women after childbirth
Onset as early as the first 48-72 hours
Within the first 2-4 weeks after delivery
Disorganized behavior is prominent
A rapidly evolving affective psychosis with
manic, depressive, or mixed features
• The earliest signs are restlessness,
irritability, and insomnia
Puerpral Psychosis…
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A rapidly shifting depressed or elated mood
Disorientation or depersonalization
Delusional beliefs often center on the infant
Auditory hallucinations that instruct the
mother to harm or kill herself or her infant
• Distinct in that it is more commonly
associated with confusion and delirium than
nonpuerperal psychotic mood disorder
Screening
• It is advisable to screen all women for depression
during the PP period
• Clinicians fail to inquire about affective symptoms
• The standard PP obstetrical visit at 6 weeks and
subsequent pediatric appointments are ideal times
• Edinburgh Postnatal Depression Scale(EPDS) is a
10-item, self-rated questionaire that has
satisfactory sensitivity and specificity
Differential Diagnosis
• Various medical illnesses
• Schizophrenia or schizoaffective disorder
• Anxiety disorders
Course & Prognosis
• Often relatively short-lived(< 3months)
• Depressive episodes tend to be longer and more
severe in those with histories of MDD
• Duration may be related to the severity of
depression
• In general, women with PP mood disorders have a
good prognosis
• In about half of the cases, PP depression or
psychosis represents the first onset of psychiatric
illness
Course & Prognosis
• Rates of recurrence appeare to be high in women
with BMD
• Outcome is better in those that receive treatment
early during the course of illness
• Attachment and behavioral difficulties are
common in new depressed or psychotic mothers
• Child abuse and neglect
• Infanticide
Treatment
• Postpartum blues:
- no specific treatment
- support & reassurance
- monitoring
Treatment
• Postpartum Depression:
- Nonpharmacological Therapy:
* there are limitted data: for milder forms, for those who are
reluctant to use medications, ideally performe in the home
* interpersonal psychotherapy:
role transition, disruption of relationships with
the spouse,and interaction with the infant
* CBT:
inability to cope with the demands of caring for the
child, perceived lack of support, absence of
enjoyable activities
Treatment…
• Pharmacological Therapy:
- few studies have assessed the efficacy
of Ads in PP depression
- standard dosage
- patient’s prior response
- SSRIs are ideal first-line agents
- TCAs are frequently used
- BZDs as an adjunctive
Treatment…
• Pharmacological Therapy:
- women who plan to breastfeed must be
informed
- ADs secretion into the breast milk
- concentrations in the breast milk appeare to
vary widely
- one ADs is not safer than another
- severe complications are rare
- long-term effects on brain development are
not known
- hormonal therapy??
Treatment…
• Inpatient Hospitalization:
- in severe cases
- who are at risk for suicide or
infanticide
- mother-infant unit
- ECT is safe and highly effective
Puerpral Psychosis
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An emergency
Systematically derived guidelines are lacking
Should be treated like a manic psychosis?
An antipsychotic + a mood stabilizer(lithium)
Breastfeeding should be avoided
Bilateral ECT is well-tolerated and rapidly
effective
Puerpral Psychosis
• Treatment duration is cotroversial
• Prolonged neuroleptic use should be
minimized
• A mood stabilizer should be maintained
(up to 1 year?)
Prevention
• Identification of women at greatest risk
• Women with Hx of BMD or PP psychosis benefit
from prophilactic lithium therapy
• Just prior to delivery (at 36 weeks gestation) or no
later than the first 48 hours PP
• Ads??
• Psychosocial interventions?
• “wait and see” approach is appropriate for women
with PP blues or without Hx of psychiatric illness