The genetics of puerperal psychosis

This paper examines the role of familial factors in the aetiology of puerperal psychosis. It reviews diagnostic issues associated with puerperal psychosis and the aetiology of the disorder in general before considering genetic studies in more detail. Owing to methodological difficulties, uncertainty over the importance of genetic factors persists.

Follow-up and family study of postpartum psychoses. Part IV: Schizophreniform psychoses and brief reactive psychoses: lack of nosological relation to schizophrenia

Among 30 women suffering from a postpartum psychosis without affective syndrome, and for whom this episode of illness was the first leading to psychiatric hospitalisation, 19 fulfilled in the long-term course the DSM-III-R criteria for schizophreniform psychosis (SCHF) or brief reactive psychosis (BRP), and 11 fulfilled the criteria for schizophrenia (SCH). The two groups were compared in order to investigate their nosological relation. Patients with SCHF or BRP more often had the symptomatology of cycloid psychoses and signs of confusion, the onset of illness was more frequently abrupt and the age at the index delivery tended to be lower (p < 0.07) than in patients with SCH. No case of SCHF or BRP was observed at the index episode that later developed into SCH. These findings, together with the different liability to puerperal decompensations, suggest that SCHF and BRP beginning in the postpartum period are nosologically distinct from SCH.

Follow-up and family study of postpartum psychoses. Part II: Early versus late onset postpartum psychoses

Patients suffering from a severe psychiatric postpartum disorder (n = 119) were classified according to early onset (EO) of symptoms, i.e. onset within 2 weeks postpartum, versus late onset (LO) in the 3-month period following delivery. The patients were admitted for the first time in their life to a psychiatric hospital. The EO cases more often had a manic syndrome, the symptomatology of cycloid psychoses, signs of confusion and an abrupt onset of illness. They were also younger at the index delivery and at the first episode of illness. No important difference in the distribution of diagnoses considering the long-term course was found in the two groups. The global psychopathological outcome was also similar. There is no definite evidence that different diseases are provoked in the early and later postpartum period.

[Emotional and psychiatric postpartum complications]

The three emotional and psychiatric complications of post-partum are: puerperal psychoses; post-natal depressions; and post-partum blues. Puerperal psychoses (prevalence = 0.2%) are now well known in their clinical and therapeutic aspects. Much less known are the post-natal depressions, in spite of their high incidence (10 to 20% of women). The consequences upon the life of patients and mother-child bond are still ignored. These depressions are too rarely adequately treated. Finally, post-partum blues is to be recognized for a preventive purpose, its intensity being a predictive factor of post-natal depression.

Follow-up and family study of postpartum psychoses. Part I: Overview

A group of 119 patients suffering from a severe psychiatric postpartum disorder who were admitted for the first time in their life to a psychiatric hospital has been investigated. The onset of illness occurred within 3 months following delivery. The patients represented 92% of the total sample fulfilling the inclusion criteria. A follow-up investigation was performed after a mean of 21 years (range 2-35 years). Of the patients 66% had nonpuerperal psychotic episodes in later life. The diagnosis, taking into account the long-term course, was affective psychosis in 57%, schizoaffective psychosis in 18%, schizophreniform psychosis in 12%, brief reactive psychosis in 4% and schizophrenia in 9%. A bipolar psychosis was found in 31%. The relation of unipolar to bipolar psychoses corresponded to that in a control group of affectively ill women without puerperal onset. The frequency of a manic syndrome in bipolar psychoses at the index episode was the same as in nonpuerperal episodes, which does not suggest a mania-provoking pathoplastic effect of the puerperium. The comparison with female nonpuerperal controls matched for age and diagnosis revealed evidence of a better long-term course in the index patients. The risk of a puerperal relapse for further pregnancies was 35%. The global morbidity risk for functional psychoses in first-degree relatives was 11%, with affective psychoses representing the majority of secondary cases (6.8%). The index patients showed a nonsignificant lower morbidity risk in relatives than a control group of psychotically ill women without puerperal onset. The major aetiological factor found for postpartum psychoses is the relation of these disorders to functional psychoses. There is strong evidence that the postpartum period tends to provoke affective psychoses and other nonschizophrenic psychoses, but not, or only to a lesser degree, narrowly defined schizophrenias. The liability to puerperal decompensations suggests some common pathophysiological mechanism, the nature of which remains unknown.

[Psychiatric disorders during maternity. 16 cases]

This study, originally intended to identify the status of puerperal psychoses, has revealed today, on the basis of a review of 16 requests for psychiatric opinions coming from departments of gynecology and obstetrics in Limoges, that this acute psychiatric situation plays only a tiny role in psychiatric psychology associated with pregnancy. Post-partum disorders, with the exception of "baby-blues", were seen infrequently, the majority of cases involving psychological difficulties with or without behavioural disturbances or somatic decompensation, but the onset of which could have been predictable if it had been possible to identify the risk factors of psychological decompensation which our study was able to demonstrate.

Social support in pregnancy: psychosocial correlates of birth outcomes and postpartum depression

This prospective study examined the effects of prenatal social support on maternal and infant health and well-being in a sample of low-income pregnant women (N = 129). Three aspects of support (amount received, quality of support received, and network resources) and four outcomes (birth weight, Apgar scores, labor progress, and postpartum depression) were studied. Results indicated that women who received more support had better labor progress and babies with higher Apgar scores. Women with higher quality support had babies with higher Apgar scores and experienced less postpartum depression. Also, women with larger networks had babies of higher birth weight. Further analyses indicated that the outcomes as a whole were more consistently predicted by instrumental rather than emotional forms of support. Finally, although there was some evidence for stress-buffering effects of support, the overall findings were more consistent with a main effect model.

The tyramine test is not a marker for postnatal depression: early postpartum euphoria may be

Abnormally low tyramine test values are known to be markers for vulnerability to unipolar, but not bipolar, endogenous depression. In the present study, 37 women with recent postnatal depression (25 major, 12 minor) and 22 puerperal controls with no depressive disorder, all assessed by Schedule for Affective Disorder and Schizophrenia (SADS-L) interview, together with 17 other controls, underwent the test. No significant differences in tyramine sulfate output were demonstrated between the different groups. Those subjects with endogenous features according to Newcastle score (n = 7) or Research Diagnostic Criteria (RDC) (n = 6) also had normal output. Thus, the tyramine test does not appear to be a useful marker for vulnerability to postnatal depression. Over half the subjects recalled that their postnatal depression had started in the first 2 weeks postpartum. Of the total of 62 postpartum subjects interviewed with the SADS-L, ten recalled a period of euphoria in the first postpartum week, which met RDC for hypomania and eight of them went on to become depressed postnatally. An additional patient from the total group was hospitalized with mania.

Women and mood disorders. Menarche to menopause

Considering the multiple issues affecting women and their experiences with mood disorders, several clinical observations may be pertinent: Because women are very vulnerable to depression, physicians in all patient care related specialties need to be familiar with the diagnosis of depression and related mood syndromes. Early intervention may be far more critical than previously considered in preventing chronic, tragic outcomes for major depression, bipolar disorder, and even severe premenstrual depression. Both dysphoric mania (because of its poor prognosis) and rapid cycling bipolar disorder (because the majority of cases involve women) distinguish bipolar illness in women. In these situations, anticonvulsants such as carbamazepine or valproic acid may offer treatment advantages over lithium. Premenstrual depression is very strongly linked to traditional psychiatric mood syndromes and is likely to benefit from appropriate antidepressant therapy. The serotonin-specific reuptake inhibitors are especially attractive in this situation because of their low side effect profiles (including low weight gain percentages) and safety in overdoses. Previous experience with psychiatric illness, especially bipolar disorder, is often predictive of postpartum mood episodes. Aggressive early treatment is critical to prevent or successfully manage postpartum episodes. Menopause cannot yet be linked to a specific or unique mood syndrome.

Postnatal emotional disorders in Nigerian women. A study of antecedents and associations

One hundred and sixty-two women were evaluated for psychiatric morbidity in the second trimester of pregnancy and also six to eight weeks postnatally. A sizeable proportion of the women also had a second prenatal assessment in their third trimester and in the lying-in ward shortly after giving birth. Assessments were conducted with the 28-item GHQ. This was initially validated using a subsample of 106 women, taken from the original group, who were interviewed with the PAS. Thirty per cent of the women were 'cases' at the first prenatal assessment, while only 14% were 'cases' six to eight weeks postnatally. Thus, even though there was an overlap between prenatal and postnatal morbidity, there was also substantial difference between the groups that were symptomatic at both periods. This observation was reinforced by the low correlation between the mean GHQ scores at both periods. Both prenatal and postnatal morbidities were associated with recent adverse life events, with the latter more likely to be associated with marital and family events. This observation is in support of the view that neurotic problems, prenatally or postnatally, are caused mainly by psychosocial factors.

[Postpartum depression and the illusion of symbiosis]

Post-partum depression is an important clinical phenomenon that has been neglected in psychoanalytic research. The author's approach to the problem proceeds on the basis of the postulation of a cross-generational constellation, a specific, pathological relation between the mother and the daughter who has herself become a mother. This relation is termed the "illusion of symbiosis". The central factor here is the mother's fantasy that her baby can fulfill for her all the desires that she herself was denied in childhood by her own mother. In order to sustain this illusion of symbiosis, frustration and anger are split off and frequently projected onto the father, who thus becomes the object of those hostile fantasies. To elucidate this constellation, Halberstadt-Freud draws upon a highly suggestive and impressive case history.

[Psychoses in puerperium: symptoms, course and long-term prognosis]

86 women who suffered from a psychotic disorder for the first time in their life within 6 weeks after parturition, were investigated regarding sociodemographic and gynaecological parameters, time of onset and initial symptomatology, psychopathological symptoms during hospitalisation, treatment and short-term outcome of the illness. The majority of patients became ill after the first (75%), full-term normal (63%) delivery and within the first two postpartum weeks (78%). The most frequent initial symptoms were anxiety, restlessness, depressive mood, sleep disturbances, behaviour disturbances, catatonic excitement, delusions and hallucinations. By the time of follow-up investigation, 16 women had died; 61 women were investigated on average 25.6 years after onset (minimum 12, maximum 41 years), using standardised instruments of evaluation. Nearly two-thirds of the patients had suffered re-manifestation of psychotic disorder during a long-term course (64%). The frequency of re-manifestations of illness after additional pregnancies and deliveries was found to be 1:4, which is also known to be the expected frequency during the course of other psychotic disorders. These results do not justify the global recommendation to avoid additional pregnancies or carry out an interruption of pregnancy, if the patient has a history of postpartum psychosis. The climacteric period also seems to be a vulnerable phase for the re-manifestation of illness. Nearly 3/4 of the investigated women displayed no disturbances in any of the evaluated dimensions (psychopathological, psychological, psychosocial status) at the time of follow-up.

Early detection of postnatal depression

Although postnatal depression is considered a relatively common problem, it is particularly difficult to detect in the early months following childbirth. The author describes how she and her colleagues examined what action could be taken to increase the detection of postnatal depression in the early stages, and benefited from the use of the Edinburgh Postnatal Depression Scale. While she concedes that the project would need to be developed into a wider study before definitive conclusions could be drawn, the article demonstrates how different parts of the primary health care team can work together to improve services to patients.

[Depressed mothers: the impact of depression on early interactions. An analysis of Anglo-Saxon studies]

Maternal depression remains a public health problem as indicated by many studies focusing on depression in mothers of young children. Although the high prevalence of depression in mothers of infants and young children is now a recognized fact, the detection and management of maternal depression in everyday practice still raises significant problems. This initial review centers on studies providing diagnostic guidelines. The problem of maternal depression and of its impact on the offspring is relevant to the issue of how qualities, abilities, and vulnerabilities are transmitted from one generation to the next. Psychoanalysts, infant psychiatrists, and developmental psychologists show great interest in this field. The current review was restricted to recent Anglo-Saxon studies on depression-related changes in early maternal behavior. The most striking findings are as follows: although depression affects maternal behavior overall, there is considerable variation across mothers; timing alterations (in terms of micro and macro sequences) in mother-child interactions occur in every case and are among the obstacles to harmony and synchronization; subtle alterations in the mother's response to her baby's signals preclude flexibility and anticipation.

Crying and motor behavior of six-week-old infants and postpartum maternal mood

OBJECTIVE

To determine whether prepartum and postpartum emotional distress in first-time mothers is associated with crying and fussing behavior and activity level in 6-week-old infants, after eliminating potential biases.

DESIGN

Observational study examining predictive and concurrent associations between maternal emotions and infant behaviors.

SETTING

General community.

PARTICIPANTS

Expectant primiparas attending obstetricians' offices for routine prenatal care were recruited in the third trimester. Mothers and babies were required to be free of medical complications to complete the study. Of 113 mothers who enrolled, complete crying/fussing data were obtained in 88 dyads. Activity data were obtained in a designated subgroup of 50 infants.

MEASUREMENTS

Mothers completed a self-report scale of emotional distress, the 28-item General Health Questionnaire, at 34 weeks of gestation and at 6 weeks postpartum. Crying/fussing data were obtained using a previously validated parent diary of infant behavior during the sixth week of life. Motor activity was measured objectively in the home setting with actometers.

RESULTS

Third-trimester distress was not related to either infant crying/fussing or activity. Postpartum distress was significantly related to crying/fussing duration and bout frequency (r[88] = .45 and .28, respectively; both P < .01). These relations were not diminished after controlling statistically for background and/or potential mediating variables, nor could they be accounted for by different diary-recording styles in the mothers. Postpartum distress was not, however, related to activity level (r[50] = -.09; not significant). Furthermore, the pattern of maternal distress was associated differentially with crying levels. Distress levels increased from prepartum to postpartum among mothers of infants who met predefined clinical criteria for "colic," while decreasing in the others ("colic" status x period interaction: F(1,86) = 8.2; P < .01). Also, infant crying varied among four groups of mothers who differed according to presence and timing of clinically significant emotional disturbance (one-way analysis of variance, F (3,86) = 9.4; P < .001). Infants of mothers who became significantly distressed postpartum ("reactive") cried more than those in the other groups, even mothers who had been distressed both prepartum and postpartum ("depressed") (3.7 vs 2.7 h/d; P = .05, post hoc Tukey).

CONCLUSIONS

Maternal emotional distress and infant crying behavior are associated in the postpartum period independent of reporting or referral biases. Clinically significant levels of crying (or "colic") are differentially associated with different patterns of clinically significant maternal distress. Reported concern about either maternal mood or infant crying behavior should be taken seriously as a possible indicator of a stressed mother-infant relationship.

Thyroid and adrenal measures during late pregnancy and the puerperium in women who have been major depressed or who become dysphoric postpartum

Prior studies of thyroid, adrenal and mood measures during pregnancy and the puerperium, which we review, have not examined hormone-mood relationships over the full peripartum period during which hormone levels change nor have they compared prior depression history with hormone changes. In a pilot study we measured thyroid and adrenal hormones as well as mood at 38 weeks of pregnancy, and 1, 3, 6, 9 and 12 weeks postpartum in 12 women with major depression history and 14 women with negative psychiatric history. Subjects with prior depressions had significantly higher T3, T4, TSH and cortisol levels during the puerperium. Subjects with higher levels of postpartum dysphoria had lower T4 and free T4 levels as well as higher T3 uptake at 38 weeks of pregnancy and higher cortisol levels during the puerperium. The pathophysiological implications of these findings are discussed.

["Psychologic marital unfitness" in cyclothymia? A case report on the topic of the annullment procedure in canon law]

According to the Canon Law (CIC) of the catholic church a marriage can be annulled because of psychological inability under certain conditions. We present the case report of a married woman, who fell ill with cyclothymia after her first childbirth. Her marriage was annulled under canon 1095 (n.3 CIC) because of psychological inability to fulfill martial obligations. The authors believe that this represents a clear cut case of discrimination against patients with mental disorders: on the one hand the catholic church claims that every martial bond is principally indissoluble; on the other hand they do not eschew invalidating a marriage due to an affective psychosis. This poses special problems which are also discussed.

The Edinburgh Postnatal Depression Scale: validation for an Australian sample

One hundred and three post-partum women completed the Edinburgh Postnatal Depression Scale (EPDS) and were interviewed using the Diagnostic Interview Schedule. A cut-off score of 12.5 on the Edinburgh Postnatal Depression Scale identified all nine women who reached criteria for major depression. At this threshold the sensitivity (the percentage of true "cases" identified) of the EPDS was 100%, its specificity (the percentage of true "non-cases" identified as such) 95.7% and its positive predictive value (the percentage of all those tested as positive who were correctly identified as such) 69.2%. Although this study supported the validity of the EPDS, a replication of this study on a larger sample is suggested.

The psychiatrist in an obstetric/gynaecology hospital: establishing a consultation-liaison service

The establishment and first six months of a psychiatric consultation-liaison service to an Australian obstetric and gynaecology hospital is described. Referrals, diagnoses and follow-up of patients are discussed, with case reports used to illustrate the types of patients seen. Evaluation of the findings and possible future directions for the service are discussed.

An exploratory study of the effectiveness of a relaxation with guided imagery protocol

An exploratory study was done to examine the effectiveness of a relaxation with guided imagery protocol in reducing anxiety and depression and increasing self-esteem in new mothers during the first 4 weeks postpartum. The results indicate that anxiety and depression declined and self-esteem increased in subjects in both the experimental and control groups over the 4-week period. However, the decline in anxiety and the increase in self-esteem was greater in the experimental group than in the control group. The decline in depression was about the same in both groups. Further study, using more precise methodology and instrumentation, needs to be done to verify the results.