Mother-infant interactions in postpartum depression: an early intervention program

This paper examines the role of postnatal intervention in the prevention of the negative consequences of postpartum depression on developing mother-infant relationships. It is argued that, once difficulties in these interactions have been identified, direct attempts to modify the interactions must occur within a framework that includes maternal, paternal, partnership/marital and social variables. An intervention program that may be instituted by nurses is described. The Baby Happiness, Understanding, Giving and Sharing (HUGS) Programme is an attempt to integrate direct intervention in mother-infant interactions into a systemic framework which takes into account contextual variables such as cognitive style and social support.

Clinical clues to the aetiology of puerperal psychosis

Recent case reports of postpartum psychosis are reviewed, which suggest hypotheses for the aetiology of this disease. The main themes are: The relationship to manic depression. Premenstrual relapse. Prepartum onset. Onset after miscarriage or evacuation of a trophoblastic tumour. Onset after bromocriptine treatment. Attempts to treat this and related psychoses by progesterone. Apomorphine growth hormone challenge tests.

Descriptions of comfort by substance-using and nonusing postpartum women

OBJECTIVE

To compare definitions of comfort held by a group of postpartum substance users with those of a group of nonusers.

SETTING

The postpartum unit of a large university hospital.

PARTICIPANTS

The convenience sample constituted 36 postpartum women; half were substance users and half denied substance use. The nonusing participants were matched to the users according to age, race, type of delivery, and parity.

DESIGN

Qualitative, descriptive.

MAIN OUTCOME MEASURES

Data were collected through semistructured, individual interviews. Patients defined comfort and described the characteristics and patterns of comfort during the postpartum period.

RESULTS

Data were analyzed into three categories of themes. Attributes of comfort were resolution of pain, resolution of fatigue, satiation of hunger, resolution of individual irritants, and relaxation. Interventions for comfort were standard therapy, supportive presence, and caring nursing approach. Modifiers of comfort were individualized comfort patterns, environmental ease, and maternal concern.

CONCLUSIONS

Comfort is more than the absence of pain. A supportive presence and a caring nursing approach were the most helpful interventions.

Postnatal depression: a South Australian prospective survey

The purpose of this study was to determine the prevalence of postnatal depression (PND) and to assess self-esteem in the early postnatal period and at 6 weeks postpartum and PND at 6 months postpartum. Women giving birth to term babies over a 6-month period, completed an Edinburgh postnatal depression scale (EPDS) and a Rosenberg self-esteem scale in hospital, at 6 weeks postpartum and an EPDS only at 6 months postpartum. A total of 235 women participated in the study of which 222 (95%) returned their questionnaire at 6 weeks postpartum and 192 (82%) at 6 months postpartum. Characteristics of the women and their pregnancy outcome are presented. The EPDS identified a depressed mood in 9% of women in hospital and at 6 weeks postpartum (95% CI 5.3%-12.8%). At 6 months this had increased to 10% (95% CI 7.8%-12.2%).

Childbearing in women with and without a history of affective disorder. II. Electroencephalographic sleep

Electroencephalographic (EEG) sleep was examined longitudinally in 34 obstetrically healthy volunteers recruited early in pregnancy. All women were free of current psychiatric disorder. Fourteen women had a personal history of affective disorder, and 20 had no history of any psychiatric disorder. EEG sleep was recorded in subjects' homes at specified points from 12 weeks' gestation through 8 months' postpartum to examine the impact of childbearing on sleep and psychiatric symptoms in women with a history of affective disorder. EEG sleep measurements, as well as clinical ratings of sleep, indicated that sleep disturbances were most pronounced over the first 2 to 3 months' postpartum and were characterized primarily by interrupted sleep. The obstetrical course of these women was uneventful, and the outcome with respect to affective disturbances was highly favorable. Nevertheless, childbearing was associated with greater changes in total sleep time and with rapid eye movement (REM) latency reduction in women with a history of affective disorder, even in the absence of clinically significant mood changes. Findings suggest that the sleep system of women with a history of affective disorder may be more sensitive to the psychobiological changes associated with childbearing, as evidenced by earlier onset of sleep disruption over the childbearing course and a reduction in REM latency in the final trimester that persisted throughout the eighth postpartum month.

Social work practice with childbirth-injured women in Nigeria

Nigerian social workers in health care settings have been actively involved in the treatment of women in northern Nigeria who suffer from childbirth injury during obstructed labor. The patient population studied suffers from vesicovaginal fistula (VVF), a debilitating and chronic condition whereby a woman leaks urine uncontrollably and experiences grave social consequences. Crisis intervention, social rehabilitation, fighting stigma, and discharge planning similar to the American professional model were functions of the social workers in addressing the needs of this patient population. Implications for practice and the universality of social work skills are discussed.

[Postpartum depression]

Depression following childbirth (postpartum depression) is a common psychiatric illness of women, postpartum. We review Japanese and English literature on postpartum depression. Problems with definition, study design and validity of the diagnosis prevented comprehensive understanding whether postpartum depression is a distinct subtype of endogenous depression. In general, postpartum depression seems to be the same illness as depression at other times in life. The biological and psycho-social pathogenetic factors, unique to the puerperal period, are not yet known. Clinicians caring for women and infants should learn to screen their patients for this multifactorial (genetic, temperamental, and environmental) disorder, and try to integrate a multidisciplinary (pharmaco-, psycho-, socio-, familial) approach.

Childbearing in women with and without a history of affective disorder. I. Psychiatric symptomatology

Psychiatric symptoms and morbidity were examined prospectively in 34 obstetrically healthy volunteers recruited early in pregnancy. All women were free of current psychiatric disorder. Fourteen women had a history of affective disorder, and 20 had no lifetime history of any psychiatric disorder. Symptoms were assessed using both clinician- and self-administered ratings at specified points from 12 weeks of gestation through 8 months' postpartum. All women reported mild symptom elevation during pregnancy and the early puerperium, regardless of psychiatric history. The most frequently endorsed symptoms in both groups were somatic. However, women with a history of affective disorder reported more psychic and somatic distress than women with no psychiatric history. Onset of a psychiatric disorder did not occur during pregnancy in this sample, and only one woman, with both a personal and family history of affective disorder, met criteria for a new episode postpartum. Brief periods of symptom elevation occurred postpartum for 14.7% of the sample (five women, two with and three without a personal history of affective disorder) in the context of additional life stressors combining with the stress of new motherhood. These findings suggest that the impact of childbearing alone on psychiatric symptoms and morbidity is modest among women who are psychiatrically healthy at pregnancy onset and have sound social support networks.

Maternity blues and major endocrine changes: Cardiff puerperal mood and hormone study II

OBJECTIVES

To define relation between mood and concentrations of progesterone and cortisol during perinatal period to test hypothesis that rapid physiological withdrawal of steroid hormones after delivery is associated with depression.

DESIGN

Prospective study of primiparous women from two weeks before expected date of delivery to 35 days postpartum.

SETTING

Antenatal clinic in university hospital, obstetric inpatient unit, patients' homes.

SUBJECTS

120 of 156 primiparous women interviewed. Remainder excluded because of major marital, socioeconomic, or medical problems or because caesarean section required.

MAIN OUTCOME MEASURES

Concentrations of progesterone and cortisol in saliva samples; women's moods assessed by various scores for depression.

RESULTS

Changes in salivary progesterone and cortisol concentrations were similar to those already characterised for plasma. Peak mean score for maternity blues (5.3 on Stein scale) was on day five postpartum (P < 0.02 compared with mean scores on other postpartum days). High postpartum scores for maternity blues were associated with high antenatal progesterone concentrations on day before delivery (P < 0.05), with high rate of rise of antenatal progesterone concentrations (P < 0.05), with decreasing progesterone concentrations from day of delivery to day of peak blues score (P > or = 0.01), and with low progesterone concentrations on day of peak blues score (P < 0.01). Seventy eight women were designated as having maternity blues (peak score > or = 8 on Stein scale) while 39 had no blues. Women with blues had significantly higher antenatal progesterone concentrations and lower postnatal concentrations than women without blues (geometric mean progesterone concentrations: one day before delivery 3860 pmol/l v 3210 pmol/l respectively, P = 0.03; ten days postpartum 88 pmol/l v 114 pmol/l, P = 0.048). Cortisol concentrations were not significantly associated with mood.

CONCLUSION

Maternal mood in the days immediately after delivery is related to withdrawal of naturally occurring progesterone.

Mild hypomania (the highs) can be a feature of the first postpartum week. Association with later depression

About 10% of women show elation and associated features of hypomania in the first 5 days following childbirth. These symptoms can be detected using a self-rating scale (the 'Highs') based on SADS-L criteria. This phenomenon has been confirmed using the observer-rated Comprehensive Psychopathological Rating Scale, which also revealed a high degree of related irritability. Significantly more women scoring > or = 8 on the Highs scale at 3 days postpartum went on to manifest depression at 6 weeks than did subjects with no psychopathology in the early puerperium. It is suggested that the 'highs' followed by depression may be a mild and common form of bipolar disorder.

Bipolar affective puerperal psychosis associated with consanguinity

Most clinical and genetic evidence suggests that puerperal psychosis is closely related to bipolar affective disorder. During a linkage study of bipolar disorder we ascertained a British family in which puerperal psychosis was associated with consanguinity in three sisters. All three subjects had lifetime RDC diagnoses of bipolar I or manic disorder. An inbred brother also had bipolar I disorder. The only female member of the sibship to escape puerperal psychosis was outbred. These findings are consistent with several genetic models for bipolar disorder in this family. The most interesting possibility is a single major susceptibility locus of recessive effect. Under this assumption, the family could be used for homozygosity mapping to help localise the putative recessive locus. If other inbred families can be found in which the same putative recessive locus is operating, the power to localise the gene by homozygosity mapping would be greatly increased.

Postnatal depression in a community cohort

A community cohort of 206 European and Maori women completed a questionnaire screening for postnatal depression at 4 weeks postpartum. The prevalence of major depressive disorder amongst the women was 7.8% with a further 13.6% of women experiencing more minor depressive symptoms. Postnatal depression was more likely to occur in women who were single, were less than 20 years old at the birth of their first child, were unhappy with their relationship with their partner, had a history of previous psychiatric hospitalisation, and were Maori. Women who were depressed were more likely to show a lack of enjoyment of and less positive attitude towards their infant. The study highlights the value of screening for postnatal depression with a simple questionnaire, as few depressed women would have been otherwise recognised.

Postnatal depression in Singapore women

A longitudinal study of depressive symptomatology in 200 postnatal women using the Edinburgh Postnatal Depressive Scale showed that depressive symptomatology is mild but present in nearly all the postpartum women; however only one per cent of the women over a 6-month period had scores suggestive of a postnatal depression. None had experienced any depressive hallucinations or delusions during this period.

Postpartum blues: relationship between not-protein bound steroid hormones in plasma and postpartum mood changes

The relationship between non-bound steroid hormone levels in plasma and the occurrence of postpartum mood changes was investigated in 26 newly delivered mothers throughout the first 5 days postpartum. Studies with saliva samples had reported higher concentrations of 17 beta-estradiol and progesterone on the days of symptoms in women experiencing postpartum blues. As there had been a controversy as to how far saliva concentrations reflect free hormone levels in plasma, free hormone levels of 17 beta-estradiol and progesterone were determined in plasma using ultrafiltration. No significant difference concerning free hormone levels could be found between women with and without postpartum blues.

A pilot study of postnatal depression following caesarean section using two retrospective self-rating instruments

In a retrospective comparison study of rates of postnatal depression using two self-rating instruments, a significantly higher incidence of postnatal depression was found among subjects who had undergone Caesarean section than in those who had a vaginal delivery. The excess of cases of postnatal depression among the Caesarean subjects appeared to consist of a milder illness which started sooner after delivery. Following Caesarean section, there was a significant association between postnatal depression and general, but not regional, anaesthesia.

The invisible woman

This paper explores the meaning of experiences of invisibility in women. It was inspired in the course of psychotherapy with a woman who felt invisible in her feminine identity and who hid her feminine desire within an imaginary paper bag. Her visual imagery traces a pattern of pathological feminine development through a faulty sensory connection between her body, the external world, and her unconscious symbolic self-representation. Questions about her invisibility have evoked an exploration of two developmental models of visual thinking--a cognitive and a psychoanalytic model. A study of the myth of Persephone contributes a literary prototype for the understanding of the transmission of invisibility across the generations of mothers and daughters. Furthermore, the analysis of several literary passages from the work of Angela Carter serves the purpose of drawing the reader into the experiential world of femininity as it moves from the invisible to the visible. The paper blends together ideas from various, often contending, theorists in a way which highlights how theories can complement one another in explaining clinical phenomena.

Symptomatology of affective and psychotic illnesses related to childbearing

Symptom patterns in women with childbearing-related onset illnesses (CBROI) and nonchildbearing-related onset illnesses (NCBROI) were compared. Women with diagnoses of Affective Disorders and Psychoses (n = 762) were divided into four groups: CBROI with psychosis, CBROI with non-psychotic affective illnesses, NCBROI with psychosis, and NCBROI with non-psychotic affective illness. Principal components analysis of 64 symptoms revealed 9 factors. The most dramatic result was the high score for psychotic women with CBROI on the factor cognitive disorganization/psychosis. Psychotic women with CBROI also reported homicidal ideation more frequently. Symptoms of non-psychotic women with CBROI and NCBROI did not differ.

Follow-up and family study of postpartum psychoses. Part III: Characteristics of psychoses occurring exclusively in relation to childbirth

As part of a follow-up and family study of postpartum psychoses, this episode of illness being the first leading to psychiatric hospitalisation, patients with puerperal episodes (PE) and nonpuerperal episodes (NPE) of illness in the long-term course (n = 79) were compared to patients with PE only (n = 40). Few differences were found. Relatives of patients with PE only had a lower morbidity risk for functional psychoses than relatives of patients with PE and NPE. A favourable course of illness in the presence of a low genetic predisposition may be expected, according to the diathesis-stress model of functional psychoses.