[Suicidal and infanticidal risks in puerperal psychosis of an early onset]

OBJECTIVE

A sample of patients with a puerperal psychosis of an early manifestation is investigated in respect of special risks of suicide and infanticide.

METHODS

During a 20-year period 96 patients who had been fallen ill with a puerperal psychosis within four weeks after delivery were admitted to a psychiatric university hospital. Patients with an acute exacerbation of a known schizophrenic disorder were excluded. In a subgroup of 37 patients states of a previous (affective, bipolar affective) psychotic illness were recorded already before the puerperal index episode, in a subgroup of 59 patients puerperal psychosis was the first manifestation of a psychotic illness. Suicide- and infanticide-relevant psychopathological symptoms were analysed (suicidal ideas/behaviour before/during inpatient treatment, general disorganized aggression, psychotic anxieties related to baby, infanticidal obsessions, aggressive ideas/behaviour towards baby, neglect, infanticidal impulses).

RESULTS

Puerperal psychoses were distributed to the diagnostic categories of psychotic depressive disorder, bipolar affective disorder, and schizoaffective disorder. Six patients died due to suicide, tragically already some few days till weeks after discharge from psychiatric hospital, despite a pronounced or even complete remission of puerperal psychotic symptoms at the time of discharge. Three patients committed an extended suicide attempt that resulted in two infanticides. All isolated and extended suicides were committed in a state of depressive mood and presumably synthymic delusion.

CONCLUSIONS

Suicidal ideas and behaviour play a major role in patients with puerperal psychosis before and during inpatient treatment. An increased risk for mothers and babies may persist, however, even after a seemingly good symptomatic remission. Besides the clinical challenge of general prevention of puerperal psychosis the request of adequate models of inpatient treatment, carefully prepared discharge, close afterdischarge follow up, and continuous outpatient care have to be stressed.

Identifying patients at risk of perinatal mood disorders

Perinatal mental illness influences obstetric outcomes, mother-baby interactions and longer term emotional and cognitive development of the child. Psychiatric disorders have consistently been found to be one of the leading causes of maternal deaths, often through suicide. Postnatal depression and puerperal psychosis are two disorders most commonly associated with the perinatal period. The most efficient strategy to identify patients at risk relies on focussing on clinically vulnerable subgroups: enquiries about depressive symptoms should be made at the usual screening visits. Attention should be paid to any sign of poor self-care, avoidance of eye contact, overactivity or underactivity, or abnormalities in the rate of speech. Particular care should be taken to ask about suicidal ideation and thoughts of harming others, including the baby. One of the most important risk factors is a previous history of depression. The degree of risk is directly correlated with severity of past episodes. Both antenatal and postnatal depression are being increasingly recognised in men. Puerperal psychosis is rare (1 to 2 per 1,000). Sixty per cent of women with puerperal psychosis already have a diagnosis of bipolar disorder or schizoaffective disorder. Women with a personal history of postpartum psychosis or bipolar affective disorder should be considered as high risk for postpartum psychosis. All pregnant women who are identified as being at high risk should have a shared care plan for their late pregnancy and early postnatal psychiatric management. Women with current mood disorder of mild or moderate severity who have a first-degree relative with a history of bipolar disorder or postpartum psychosis should be referred for psychiatric assessment.

Commentary: postpartum psychosis, infanticide, and insanity--implications for forensic psychiatry

Two dozen nations have infanticide laws that decrease the penalty for mothers who kill their children of up to one year of age. The United States does not have such a law, but mentally ill mothers may plead not guilty by reason of insanity. As in other crimes, in addition to the diagnosis of a mental disorder, other factors, such as knowledge of wrongfulness and motive, are critical to the assessment. Postpartum psychosis has been described for 2,000 years and modern science supports a genetic component to the risk. Yet, the Diagnostic and Statistical Manual of Mental Disorders does not include it as a diagnosis, leading to difficulty in testimony. In this article, we discuss postpartum psychosis, infanticide law, and research regarding mothers who kill, and we make recommendations to forensic psychiatrists.

Postpartum psychosis and the courts

Although mental state defenses frequently are raised in cases of infanticide, legal criteria for these defenses vary across jurisdictions. We reviewed outcomes of such cases in states using M'Naughten or model penal code (MPC) standards for insanity, and the factors considered by the courts in reaching these decisions. LexisNexis and Westlaw searches were conducted of case law, legal precedent, and law review articles related to infanticide. Google and other Internet search engines were used to identify unpublished cases. Despite the differing legal standards for insanity among states, the outcomes of infanticide cases do not appear to be dependent solely on which standard is used. The presence of psychosis was important in the successful mental state defenses. This case series suggests that states that use the stricter M'Naughten standard have not been less likely than states with an MPC standard to adjudicate women who have committed infanticide as not guilty by reason of insanity.

Bonding in women with postnatal anaemia: a pilot case control study looking at postnatal bonding in women who have been diagnosed with anaemia at a University Hospital in the East of England

PURPOSE

Anaemia is common postpartum; however, the effect of anaemia on mother-infant bonding is presently unknown. This case controlled study was designed to evaluate the effects of anaemia on mother and baby bonding in the first month following delivery.

METHODS

945 consecutive postpartum women who gave birth at home or in the obstetric unit at a university hospital in the East of England were identified from the hospital computer records. Blood counts had been performed on 279 of these women within 48 h of delivery, entirely at the discretion of the clinical team. The women with available blood count data were sent a self-reporting questionnaire which included a validated postpartum bonding questionnaire (PBQ). Data were collected from the 115 (41%) responses and analysed for the evidence of an effect of anaemia on bonding.

RESULTS

57 (50%) of women responding to the questionnaire were anaemic (haemoglobin < 10 g/dL). There was no evidence of a difference between maternal, age, parity, mode of delivery, gestational age, baby weight or baby age at the time of completing questionnaire between the anaemic and non-anaemic groups. Moreover, there was no evidence of a difference in maternal perception of mother-infant bonding between the anaemic and non-anaemic groups.

CONCLUSION

Our study suggested no evidence of an association between postnatal anaemia and the mother's ability to bond with the baby; however a small but significant effect may still exist which we were not able to detect due to a possible lack of power, hence we suggest, further larger studies to be conducted.

Maternal neonaticide following traumatic childbirth: a case study

Recent work has documented the relatively high incidence of Posttraumatic Stress Disorder (PTSD) symptoms in women during the birth delivery process and afterwards, even in uncomplicated births. This phenomenon, however, has yet to be linked with cases of neonaticide (child homicide in the first 24 hr of life) or infanticide (child homicide within the 1st year of life). Women are more likely to experience mental disorder after childbirth than at any other time in their lives, and the intentional killing of an offspring by a mentally ill mother is likely underreported. The immediate postpartum period is a time of heightened vigilance by health providers and, when the tragic death of an infant occurs, forensic professionals should specifically assess for PTSD. As an illustration, the authors present a case of maternal neonaticide that was directly linked to PTSD without any other concomitant mental disorder. PTSD is a viable mitigating factor to be examined in legal defenses of infanticide either in isolation or in conjunction with other factors.

Feeling cooped up after childbirth--the need to go out and about

It is well known that recovering from childbirth can be a real challenge for many women. New mothers are, mostly, left to self care and manage their own recovery process. In seeking to feel like their old selves again mothers in this ethnographic study took longer than the traditional six weeks and needed to manage their feelings around being cooped up after childbirth. This article highlights an aspect of self care such as getting out and about, with or without the baby--a process that is pivotal to good recuperation and a sense of wellbeing after childbirth.

Invariance of SCL-90-R dimensions of symptom distress in patients with peri partum pelvic pain (PPPP) syndrome

OBJECTIVES

There are no studies available that have examined the factorial invariance of dimensions underlying the Symptom Checklist-90-Revised (SCL-90-R) across at least three distinct samples. In the following study, we wished to determine whether a dimensional model comprising eight primary factors previously identified in psychiatric out-patients, phobics and the general population (Arrindell & Ettema, 2003) could be extended to a homogeneous sample of pain patients comprising females suffering from peri partum pelvic pain (PPPP) syndrome (N = 413). The internal consistency and discriminant validity of the dimensions were also examined.

METHOD

The SCL-90-R and measures of disability, pain-related fear, pain intensity and fatigue were administered to the participants. The multiple group method was used to determine factorial invariance. Pearson correlations were determined between the SCL-90-R and aforementioned measures.

RESULTS

The factorial invariance of an 8-dimensional model of primary factors underlying the SCL-90-R, namely, agoraphobia, anxiety, depression, somatization, cognitive-performance deficits, interpersonal sensitivity-mistrust, acting-out hostility and sleep difficulties, was extended with success to the present sample of PPPP patients. In spite of substantial correlations between the internally consistent SCL-90-R symptom dimensions, some evidence of discriminant validity was reported in that specific subscales showed different patterns of correlations with measures of disability, pain-related fear, pain intensity and fatigue.

CONCLUSIONS

The 8-dimensional system based on the work of Arrindell and Ettema (2003) was invariant across psychiatric patients, phobics, the general population and pain patients. The invariance of the SCL-90-R hostility dimensions may have implications for a re-formulation of Watson and Clark's tripartite model of general distress, specific anxiety and specific depression.

Validation of the Arabic version of the Cohen Perceived Stress Scale (PSS-10) among pregnant and postpartum women

BACKGROUND

This study was conducted to evaluate the validity of the Arabic translation of the Cohen Perceived Stress Scale (PSS-10) in pregnant and postpartum women.

METHODS

A sample of 268 women participated. These included 113 women in their third trimester of pregnancy, 97 in the postpartum period and 58 healthy female university students. GHQ-12 and EPDS were also administered to the participants. Internal consistency reliability, assessed using Cronbach's α, was 0.74.

RESULTS

PSS-10 significantly correlated with both EPDS and GHQ12 (ρ = 0.58 and ρ = 0.48 respectively), and significantly increased with higher scores on stressful life events. PSS-10 scores were higher among university students who also recorded higher stressful life events scores.

CONCLUSION

The Arabic translated version of the PSS-10 showed reasonably adequate psychometric properties.

Domestic abuse before, during and after pregnancy in Jahrom, Islamic Republic of Iran

We conducted a cross-sectional study among 300 women with a child aged 6 to 18 months, to determine the prevalence and determinants of domestic abuse against women in Jahrom; before, during and after pregnancy. The prevalence of abuse during pregnancy (42%) was lower than during the 1 year before pregnancy (51.7%) and after delivery (53.5%). The overall prevalence of emotional abuse, sexual abuse and physical abuse was 53.5%, 34.7% and 26.7% respectively. Abuse during any previous period was a strong risk factor for subsequent abuse. Other risk factors associated with abuse were: woman previously witnessing domestic violence, opium use by husband, woman's education < or = 12 years, age at marriage of woman < 18 years, husband's education < or = 12 years, woman's economic dependency and living in an extended family. Routine screening of abuse in maternity clinics should be considered.

A systematic review of the effects of postnatal maternal anxiety on children

Several decades of research have focused on the impact of exposure to postnatal depression on children, while anxiety has been largely overlooked. Estimates of the prevalence of postnatal maternal anxiety (PMA) range from 3% to 43%, suggesting PMA may be an important risk factor for adverse outcomes in children. This review summarizes what is known about the effects of PMA exposure on children and makes recommendations for future research. A systematic search of Ovid MEDLINE and PsychINFO through 2008 identified 18 studies that evaluated child outcomes associated with PMA exposure. Identified studies covered three domains: somatic, developmental, and psychological outcomes. The strongest evidence for an adverse effect of PMA exposure is in somatic and psychological outcomes; the evidence for an effect of PMA on child development is inconclusive. Methodological differences among the studies make comparisons difficult and there are a number of common limitations that challenge the validity of these studies.

[The treatment of bipolar disorder during pregnancy and the postpartum period]

The prevalence of bipolar disorder (BD) in males and females is almost equal. The onset of BD in females typically occurs during the reproductive years, complicating its treatment. Although it was once believed that pregnancy prevents recurrence, studies have shown that recurrence is common and severe during pregnancy. On the other hand, the effects of pharmacological treatment on obstetrical outcome are not well known and some of these agents are considered teratogenic. Thus, the decision to treat pregnant patients with psychotropic agents requires solving an ethical dilemma. Risk-benefit decisions should be made while considering both the risk of relapse of BD and its morbidity, and the risk of fetal exposure to psychotropic medications. Moreover, the risk of recurrence increases dramatically in the postpartum period. It is well known that all of the psychotropic medications studied enter the breast milk. Thus, their effects on infants should be considered while prescribing for a breastfeeding mother. The aim of this review was to discuss the safety profiles of the treatment options for pregnant and breastfeeding BD patients. Firstly, each medication's effects on organ dysgenesis, neonatal toxicity, and neurobehavioral development, and their associated adverse events during pregnancy and the postpartum period are discussed, with a focus on the emerging literature. Given this background, practical suggestions on tailoring treatment in BD patients, from preconception to breastfeeding are highlighted.

[Suicidal crises at the time of motherhood]

In collective imagination, motherhood cannot be but a source of joy and self-fulfilment for a woman. Nevertheless, we are reminded by the frequency and/or the severity of some psychic troubles during pregnancy and postpartum that such a phase, so specific in the psycho-affective development of the woman, can be a challenge for the woman going through it, some women will go as far as contemplating death after having given life. In the 2000 consensus conference on the suicidal crisis, there is not a single chapter though devoted to suicide problems amongst women becoming mothers, It is true that suicide at motherhood is not so frequent as during other times in a woman's life. Nevertheless, it is a not so negligible contributor to mothers' mortality at the times of pregnancy and post delivery, being even, according to some authors, the main cause of mothers' mortality. A better knowledge of epidemiology of suicidal crisis at the time of motherhood, of its precipitating and preparing factors, seems to be required so that preventive measures can be taken for the benefit of the personnel--either psychiatrists, obstetricians or midwives--in charge of those suicidal women. The British and Australian authors seem to be particularly involved in the prevention of such an event "above all dramatic" which, as unfrequent as it may be, cannot leave us indifferent.

Service satisfaction on discharge from a psychiatric mother and baby unit: a representative patient survey

In this representative survey of 57 women before discharge from a psychiatric mother and baby unit satisfaction levels were high for most aspects of the service. However, the qualitative part of the study highlighted issues that were not captured by completion of the satisfaction questionnaire. These included a need for greater support from nursing staff and a high level of distress about interactions with children's social workers in some patients. The latter aspect requires further exploration. For future surveys we recommend to use quantitative as well as qualitative methodology.

Measuring hypomania in the postpartum: a comparison of the Highs Scale and the Altman Mania Rating Scale

We examine the prevalence of hypomania on day 3 postpartum using two self-report mania scales: The Highs Scale and Altman Mania Rating Scale (AMRS). 279 women were recruited from postnatal wards and completed the questionnaires on day 3 postpartum. The scales show good correlation, however, 11% of women meet the suggested threshold for caseness on the Highs Scale and 44% on the AMRS. Hypomanic symptoms are commonly experienced in the early postpartum. Although there is some evidence that the Highs Scale might be conservative, the AMRS likely overestimates hypomania in the postpartum. The definition of what constitutes 'a case' of postnatal hypomania requires further validation against clinical interview and ability to predict variables of clinical importance. Mania scales developed in bipolar disorder populations must be specifically validated for postpartum use.

Sleep and depression in postpartum women: a population-based study

STUDY OBJECTIVES

(1) To describe the prevalence of and risk factors for postpartum maternal sleep problems and depressive symptoms simultaneously, (2) identify factors independently associated with either condition, and (3) explore associations between specific postpartum sleep components and depression.

DESIGN

Cross-sectional.

SETTING

Population-based.

PARTICIPANTS

All women (n = 4191) who had delivered at Stavanger University Hospital from October 2005 to September 2006 were mailed a questionnaire seven weeks postpartum. The response rate was 68% (n = 2830).

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Sleep was measured using the Pittsburgh Sleep Quality Index (PSQI), and depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS). The prevalence of sleep problems, defined as PSQI > 5, was 57.7%, and the prevalence of depression, defined as EPDS > or = 10, was 16.5%. The mean self-reported nightly sleep duration was 6.5 hours and sleep efficiency 73%. Depression, previous sleep problems, being primiparous, not exclusively breastfeeding, or having a younger or male infant were factors associated with poor postpartum sleep quality. Poor sleep was also associated with depression when adjusted for other significant risk factors for depression, such as poor partner relationship, previous depression, depression during pregnancy and stressful life events. Sleep disturbances and subjective sleep quality were the aspects of sleep most strongly associated with depression.

CONCLUSIONS

Poor sleep was associated with depression independently of other risk factors. Poor sleep may increase the risk of depression in some women, but as previously known risk factors were also associated, mothers diagnosed with postpartum depression are not merely reporting symptoms of chronic sleep deprivation.

[Epidural anesthesia in labor and conversion disorder]

A 37-year-old woman came to our hospital at the beginning of labor. She reported a history of depression with attempted suicide some years earlier and had also undergone dilation and curettage following an abortion; on admission to our hospital, she was euthymic and not receiving treatment. The patient requested epidural analgesia. Several hours later, she reported dorsal foot numbness and difficulty performing dorsal flexion. After an organic cause had been ruled out, a diagnosis of conversion disorder was considered. The incidence of this psychiatric disorder is high, though it is usually underdiagnosed. Conversion disorder involves at least 1 neurologic symptom suggestive of organic disease. Symptoms are not feigned and cannot be ascribed to a medical disease, the effects of a toxic substance, or culturally normal behavior, yet there is significant clinical, social, and occupational deterioration.

Maternal anxiety: course and antecedents during the early postpartum period

The early course and antecedents of postpartum anxiety are unknown. This study sought to determine the course and antecedents of maternal anxiety during the first month postpartum and to develop a model to predict 1-month anxiety using information obtainable before perinatal hospital discharge. Two hundred and ninety-six mothers were screened before discharge with the State (SS) and Trait (TS) Scales of the State Trait Anxiety Inventory (STAI). Demographic characteristics were assessed by questionnaire and medical record review, and psychiatric history, measures of perinatal stress, and resilient factors were determined by focused questions and formal instruments. At 1-month postpartum, the SS was repeated. Scores on the SS were significantly higher at 1 month than immediately postpartum (35.30+/-0.68 versus 33.38+/-0.60, mean+/-standard error, P=.004), but only 58.6% of mothers with high pre-discharge anxiety had high anxiety at 1 month. One-month anxiety correlated with pre-discharge SS and TS scores, a history of psychiatric problems including depressed mood, medical and negative social life events, lack of pregnancy planning and prenatal class attendance, perceived peripartum stress, and duration of postpartum hospital stay. Inverse correlations were observed with education, household income, and resiliency factors. In multivariate modeling, anxiety trait, education, history >or=2 years of depression, and perception of peripartum stress accounted for 50% of the variance in the 1-month SS score. Maternal anxiety increases during the first postpartum month. Women with high trait anxiety, low education, a history of depressed mood, and a perception of high peripartum stress are at risk for experiencing anxiety at this time.