Neighborhood socioeconomic environment and risk of postpartum psychosis

Mapping high-risk clusters and identifying place-based risk factors of mental health burden in pregnancy

Purpose

Despite affecting up to 20% of women and being the leading cause of preventable deaths during the perinatal and postpartum period, maternal mental health conditions are chronically understudied. This study is the first to identify spatial patterns in perinatal mental health conditions, and relate these patterns to place-based social and environmental factors that drive cluster development.

Methods

We performed spatial clustering analysis of emergency department (ED) visits for perinatal mood and anxiety disorders (PMAD), severe mental illness (SMI), and maternal mental disorders of pregnancy (MDP) using the Poisson model in SatScan from 2016 to 2019 in North Carolina. Logistic regression was used to examine the association between patient and community-level factors and high-risk clusters.

Results

The most significant spatial clustering for all three outcomes was concentrated in smaller urban areas in the western, central piedmont, and coastal plains regions of the state, with odds ratios greater than 3 for some cluster locations. Individual factors (e.g., age, race, ethnicity) and contextual factors (e.g., racial and socioeconomic segregation, urbanity) were associated with high risk clusters.

Conclusions

Results provide important contextual and spatial information concerning at-risk populations with a high burden of maternal mental health disorders and can better inform targeted locations for the expansion of maternal mental health services.

[Can men be included in the population subjected to puerperal psychosis? A case report]

INTRODUCTION

Puerperal psychosis (PP) is a psychiatric disorder that occurs in 1 out of 1000 pregnancies. Well known since antiquity, its symptoms have often been described in mothers, but few studies have successfully investigated a related disorder in fathers. The characteristic of this pathology is more related to its appearance than to its semiological description which is why its nosographic place is always discussed. The objective here is to focus on the definition of PP and to suggest an entity for both genders.

CASE REPORT

Our case report focused on the clinical description of an eighteen-year-old man suffering from an acute psychosis episode that occurred around the birth of his first child. Delusion followed a sudden decline in mood that lasted for a short period of time during the course of the third trimester of his wife's pregnancy. The delirium was rich with auditory and cenesthesic hallucinations, pregnancy and birth denial, feeling movements and hearing voices in his stomach. The symptoms disappeared after one month of treatment via an antipsychotic drug, risperidone.

CONCLUSION

We can confirm that the symptomatic description of the disorder in this patient fits the classical descriptions of PP. Two elements make the PP different from other acute psychoses: the context of pregnancy and delirium focused on the child which can lead to a child murder. The absence of a framework precisely defining the PP does not improve its prevention and can lead to legal attitudes rather than medical care. Men suffering from acute psychosis in a context of pregnancy are submitted to the same risks as women. It is necessary to emphasize descriptions of PP in men to redefine the disease and consider that this entity involves both men and women.

Admission to psychiatric hospital in the early and late postpartum periods: Scottish national linkage study

OBJECTIVE

To describe weekly admission rates for affective and non-affective psychosis, major depression and other psychiatric disorders in the early and late postpartum periods. To assess the impact of socioeconomic status, age and parity on admission rates.

METHODS

Scottish maternity records were linked to psychiatric hospital admissions. 3290 pregnancy-related psychiatric admissions were assessed. Weekly admission rates were calculated for the pregnancy period, early postpartum period (6 weeks after birth) and late postpartum period (up to 2 years after birth), and compared with pre-pregnancy rates (up to 2 years before pregnancy). Admission rates were generated by calculating the total number of admissions for each time period divided by the number of weeks in the period. Incidence rate ratios (IRRs) were generated for each time period, using deprivation, age, parity and record of previous psychiatric hospital care-adjusted Poisson regression models.

RESULTS

Women from more deprived social quintiles accounted for the largest proportion of admissions across all time periods. Compared with pre-pregnancy period, admission rates fell during pregnancy, increased markedly during the early postpartum period, and remained elevated for 2 years after childbirth. Within the most affluent quintile, admission IRRs were higher in the early postpartum period (IRR=1.29, 95% CI 1.02 to 1.59) than in the late postpartum period (IRR=0.87, 95% CI 0.74 to 0.98). For the late postpartum period, there was a positive association between higher maternal age and admission IRRs (ages 20-35 years, IRR=1.35, 95% CI 1.16 to 1.54 and age>40 years IRR=1.72, 95% CI 1.41 to 2.09).

CONCLUSIONS

Rates of psychiatric admission fell during pregnancy and increased in the early postpartum period (particularly during the first 2 weeks after birth), and remained elevated above baseline during the 2-year late postpartum period. An understanding of how social deprivation, age and parity might influence risk of psychiatric admission at different time points could help to target perinatal mental health services more effectively.

Obstetric Characteristics and Management of Patients with Postpartum Psychosis in a Tertiary Hospital Setting

Background. Postpartum psychosis is the most severe and uncommon form of postnatal affective illness. It constitutes a medical emergency. Acute management emphasizes hospitalization to ensure safety, antipsychotic medication adherence, and treatment of the underlying disorder. Objective. The aim of the study was to determine the obstetric characteristics and management of patients with postpartum psychosis in a tertiary centre in North-Western Nigeria. Methodology. This was a 10-year retrospective study. Records of the patients diagnosed with postpartum psychosis from January 1st, 2002, to December 31st, 2011, were retrieved and relevant data extracted and analyzed using the SPSS for Windows version 16.0. Results. There were 29 cases of postpartum psychosis giving an incidence of 1.1 per 1000 deliveries. The mean age of the patients was 20.6 ± 4 years. Twelve (55%) were primiparae, 16 (72.7%) were unbooked, and 13 (59%) delivered at home. All had vaginal deliveries at term. There were 12 (52.2%) live births, and 11 (47.8%) perinatal deaths and the fetal sex ratio was equal. The most common presentation was talking irrationally. Conclusion. There is need for risk factor evaluation for puerperal psychosis during the antenatal period especially in primigravidae and more advocacies to encourage women to book for antenatal care in our environment.

Realist identification of group-level latent variables for perinatal social epidemiology theory building

We have previously reported in this journal on an ecological study of perinatal depressive symptoms in South Western Sydney. In that article, we briefly reported on a factor analysis that was utilized to identify empirical indicators for analysis. In this article, we report on the mixed method approach that was used to identify those latent variables. Social epidemiology has been slow to embrace a latent variable approach to the study of social, political, economic, and cultural structures and mechanisms, partly for philosophical reasons. Critical realist ontology and epistemology have been advocated as an appropriate methodological approach to both theory building and theory testing in the health sciences. We describe here an emergent mixed method approach that uses qualitative methods to identify latent constructs followed by factor analysis using empirical indicators chosen to measure identified qualitative codes. Comparative analysis of the findings is reported together with a limited description of realist approaches to abstract reasoning.

Postpartum psychosis: risk factors identification

BACKGROUND

A better understanding of risk factors associated with postpartum psychosis may contribute to the better management.

AIMS

This study was to identify the risk factors contributing to postpartum psychosis.

MATERIALS AND METHODS

In this cross-sectional, case control study 100 patients of postpartum psychosis (PP) were compared with the healthy controls. Risk factors explored were sociodemographic factors (age, education, occupation, income, and family type); positive family history; pregnancy and perinatal factors (number of antenatal check-up, parity, and complications during pregnancy, perinatal phase or in newborn); and presence of husband during peripartum period. Data were analyzed by graph pad instat software using chi square test and Fisher's exact test.

RESULTS

Total of 64% patients and 42% controls were less than 25 years of age (P = 0.001). Among the patients, 62% were primiparae compared with 46% in the controls (P = 0.02). Per capita family income was less than 5000 INR in 72% patients and 56% controls (P = 0.01). Maternal complications during perinatal period were observed in 38% patients and 22% controls (P = 0.01), while the complications in newborns were seen in 21% patients and 8% controls (P = 0.009). Husband was present in 58% patients and 76% controls. (P = 0.006).

CONCLUSIONS

The risk factors related to PP were younger age, lower per capita income, perinatal and neonatal complications, and absence of husband in peripartum phase.

Bayesian hierarchical spatial regression of maternal depressive symptoms in South Western Sydney, Australia

Background

There is increasing interest in the role played by maternal depression in mediating the effects of adversity during pregnancy and poor infant outcomes. There is also increasing evidence from multilevel regression studies for an association of area-level economic deprivation and poor individual mental health. The purpose of the study reported here is to explore the spatial distribution of postnatal depressive symptoms in South Western Sydney, Australia, and to identify covariate associations that could inform subsequent multilevel studies.

Methods

Mothers (n = 15,389) delivering in 2002 and 2003 were assessed at 2–3 weeks after delivery for risk factors for depressive symptoms. The individual-level binary outcome variables were Edinburgh Depression Scale (EDS) >9 and >12. The association between social, demographic and ecological factors and aggregated outcome variables were investigated using exploratory factor analysis and multivariate hierarchical Bayesian spatial regression. Relative risks from the final EDS >12 regression model were mapped to visualise the contribution from explanatory covariates and residual components.

Results

The exploratory factor analysis identified six factors: neighbourhood adversity, social cohesion, health behaviours, housing quality, social services, and support networks. Variables associated with neighbourhood adversity, social cohesion, social networks, and ethnic diversity were consistently associated with aggregated depressive symptoms. Measures of social disadvantage, lack of social cohesion and lack of social capital were associated with increased depressive symptoms. The association with social disadvantage was not significant when controlling for ethnic diversity and social capital.

Conclusions

The findings support the theoretical proposition that neighbourhood adversity causes maternal psychological distress and depression within the context of social buffers including social networks, social cohesion, and social services. The finding have implications for the distribution of health services including early nurse home visiting which has recently been confirmed to be effective in preventing postnatal depression.

Electronic supplementary material

The online version of this article (doi:10.1186/2193-1801-3-55) contains supplementary material, which is available to authorized users.

Neighborhood adversity, ethnic diversity, and weak social cohesion and social networks predict high rates of maternal depressive symptoms: a critical realist ecological study in South Western Sydney, Australia

The aim of the study reported here is to explore ecological covariate and latent variable associations with perinatal depressive symptoms in South Western Sydney for the purpose of informing subsequent theory generation of perinatal context, depression, and the developmental origins of health and disease. Mothers (n = 15,389) delivering in 2002 and 2003 were assessed at two to three weeks after delivery for risk factors for depressive symptoms. The binary outcome variables were Edinburgh Postnatal Depression Scale (EPDS)> 9 and > 12. Aggregated EPDS > 9 was analyzed for 101 suburbs. Suburb-level variables were drawn from the 2001 Australian Census, New South Wales Crime Statistics, and aggregated individual-level risk factors. Analysis included exploratory factor analysis, univariate and multivariate likelihood, and Bayesian linear regression with conditional autoregressive components. The exploratory factor analysis identified six factors: neighborhood adversity, social cohesion, health behaviors, housing quality, social services, and support networks. Variables associated with neighborhood adversity, social cohesion, social networks, and ethnic diversity were consistently associated with aggregated depressive symptoms. The findings support the theoretical proposition that neighborhood adversity causes maternal psychological distress and depression within the context of social buffers including social networks, social cohesion, and social services.

The relationships between postpartum adaptation and postpartum depression symptoms of first pregnancy mothers in Taiwan

BACKGROUND

Motherhood is a critical situation characterized by role conflicts. These conflicts between the roles of mother, worker, and wife are the norm in the postpartum period and may jeopardize a mother's well-being. The purpose of this study was to explore the relationships between postpartum adaptation and depression among new mothers who live in northern Taiwan.

MATERIAL AND METHODS

A total of 186 first pregnancy mothers were recruited via convenience sampling methods and they completed mailed questionnaires between 1 week and 2 months after giving birth. Structured questionnaires including Demographic Inventory Scale, Postpartum Self-Evaluation Questionnaire, and Edinburgh Postnatal Depression Scale were used.

RESULTS

Ninety-four (50.5%) women exhibited depressive symptoms (EPDS > 10) and 73 (39.2%) women needed to consult the doctor (EPDS > 12). The risk factors for postpartum depression symptoms included unplanned birth, low socioeconomic status, and part-time employment. The correlation between women's different aspects of postpartum adaptation and depression ranged was from low to medium. The best predictors of postpartum depression were confidence in their own competence of motherhood tasks, satisfaction with life circumstances, and partner participating in child care. These three subsets explained 44.8% of the total variance.

CONCLUSION

This study shows that healthcare providers who work with primiparas during the first 2 months after giving birth should pay more attention to postpartum depression, keeping in mind associated risk factors. A new mother's confidence in her own abilities as a new mother may be particularly important in determining the likelihood of postpartum depression.

Immigrant maternal depression and social networks. A multilevel Bayesian spatial logistic regression in South Western Sydney, Australia

The purpose is to explore the multilevel spatial distribution of depressive symptoms among migrant mothers in South Western Sydney and to identify any group level associations that could inform subsequent theory building and local public health interventions. Migrant mothers (n=7256) delivering in 2002 and 2003 were assessed at 2-3 weeks after delivery for risk factors for depressive symptoms. The binary outcome variables were Edinburgh Postnatal Depression Scale scores (EPDS) of >9 and >12. Individual level variables included were: financial income, self-reported maternal health, social support network, emotional support, practical support, baby trouble sleeping, baby demanding and baby not content. The group level variable reported here is aggregated social support networks. We used Bayesian hierarchical multilevel spatial modelling with conditional autoregression. Migrant mothers were at higher risk of having depressive symptoms if they lived in a community with predominantly Australian-born mothers and strong social capital as measured by aggregated social networks. These findings suggest that migrant mothers are socially isolated and current home visiting services should be strengthened for migrant mothers living in communities where they may have poor social networks.

High lifelong relapse rate of psychiatric disorders among women with postpartum psychosis

BACKGROUND

The relapse rate for psychiatric disorders after postpartum psychosis is high. Apart from subsequent puerperal periods, previous studies have not examined when relapses in psychiatric disorders occur. In addition, little is known about the impact of certain individual factors on the risk of non-puerperal readmission among women with previous postpartum psychosis.

AIMS

The first aim was to examine the association between non-puerperal readmission due to psychiatric disorders and years of follow-up (in total, 30 years) in women with postpartum psychosis. The second aim was to examine the impact of age, type of psychosis, previous hospitalization for psychiatric disorders and level of education on the risk of non-puerperal readmission due to psychiatric disorders.

METHODS

All Swedish women aged 20-44 with postpartum psychosis (n =3140) were followed between 1975 and 2004 for non-puerperal readmission due to psychiatric disorders. A Cox frailty regression model was used to estimate hazard ratios for non-puerperal readmission.

RESULTS

The risk of non-puerperal readmission, although gradually decreasing with time, remained high many years after the postpartum psychosis. The risk of non-puerperal readmission was significantly higher among women with schizophrenia, lower levels of education and previous psychiatric hospitalization.

CONCLUSIONS

Postpartum psychosis is often part of a lifelong recurrent psychiatric disorder. Women with schizophrenia, lower levels of education and hospitalization due to a psychiatric disorder prior to postpartum psychosis have a higher risk of non-puerperal readmission.

CLINICAL IMPLICATIONS

The findings constitute important knowledge for all healthcare workers encountering women with a previous postpartum psychosis.

Clusters of maternal depressive symptoms in South Western Sydney, Australia

The purpose of this study is to explore the spatial distribution of perinatal depressive symptoms in South Western Sydney, Australia, and to identify any clusters that could inform subsequent qualitative, ecological and multilevel studies and local public health interventions. A routine survey of mothers with newborn infants was commenced in 2000. The survey included the Edinburgh Postnatal Depression Scale (EPDS). Mothers (n=15,389) delivering in 2002 and 2003 were assessed at 2-3 weeks after delivery for risk factors for depressive symptoms. The binary outcome variables were EPDS>9 and EPDS>12. EPDS>9 and EPDS>12 was mapped for 101 suburbs using likelihood standardised morbidity ratios (SMRs) and Bayesian log-normal models with conditional autoregressive (CAR) components. Open domain software SaTScan™ was used to test for the presence of clusters. The Bayesian methods identified clusters of depressive symptoms in north-east, north-west and southern areas of the study region. The northern clusters were statistically significant using SaTScan™. There were two high risk clusters of EPDS>9 (radius 4.3 and 5.6 km, both p<0.001) and two high risk clusters of EPDS>12 (radius 1.8 km p=0.003 and radius 3.97 km p=0.012). The clusters were in regions known to be socially disadvantaged and with high rates of non-English speaking migrants. The study findings will be used to inform future qualitative and epidemiological research, and to plan interagency early intervention services for women, children and their families.

Postnatal depression and socio-demographic risk: factors associated with Edinburgh Depression Scale scores in a metropolitan area of New South Wales, Australia

OBJECTIVE

The aim of this study was to determine the prevalence and risk factors for postnatal depressive symptoms in women living in metropolitan Sydney, Australia.

METHOD

A population-based cross-sectional study of mothers of newborn infants was undertaken during home and community clinic visits in South West Sydney from 2000 to 2004. A comprehensive 45 item survey questionnaire was completed by 29 405 mothers. A self-report Edinburgh Postnatal Depression Scale (EPDS) of depressive symptoms was completed by 25 455 mothers at the first child and family nurse visit. The primary study outcome measures were EPDS scores greater than 9 and greater than 12.

RESULTS

At a mean infant age of 2.16 weeks the prevalence of EPDS >9 was 12% and EPDS >12 was 6.2%. Results from multiple logistic regression revealed that EPDS >9 and EPDS > 2 were associated with a maternal country of birth other than Australia, difficult financial situation, living in the suburb one year or less, 'no regret leaving the suburb', unplanned pregnancy, not breastfeeding, and poor rating of mother's own health. Other social demographic factors such as marital status, maternal age, education of mother, or being Aboriginal or a Torres Strait Islander show no significant association with postnatal depressive symptoms.

CONCLUSIONS

The results confirm prevalence rates and maternal individual-level risk factors from previous studies. The study contributes to the limited number of studies of postnatal depression and socio-demographic factors. Neighbourhood and community group-level factors may be important and should be studied further.

Bipolar affective disorder in the postnatal period: investigating the role of sleep

OBJECTIVES

Psychotic disorders have a high rate of relapse in the postpartum period for reasons that are unclear, but may be related to changes in sleep patterns that occur during pregnancy and after birth. Understanding of the influence of sleep on postpartum psychosis presentation is limited. The aim of the current study was to investigate changes in sleep/wake activity during pregnancy and the postpartum period in women with a history of psychosis.

METHODS

Women with a history of bipolar disorder and/or postpartum psychosis (HxW) were recruited (n = 23) together with a control population (CtW) (n = 15). Data on demographic and psychosocial factors, mental health status, and sleep/wake activity were collected at seven timepoints-the last week of each trimester of pregnancy and four times during the postpartum (weeks 1, 4, and 8, and at month 6). Longitudinal data were analysed using an HLM version 6 repeated-measures multilevel model.

RESULTS

No significant differences were noted in sleep/wake activity between HxW and CtW. None of the HxW who were taking a mood stabilizer during their pregnancy, including at delivery, relapsed during the study. Of those taking an antidepressant or antipsychotic, or no medication, 3 relapsed within the first six months and 2 within the first two months. HxW were more likely to report a poor partner relationship than CtW.

CONCLUSION

Results suggest that during the perinatal period, there is no difference in sleep/wake activity in women with a history of a psychotic disorder. Use of mood stabilizer during pregnancy and at delivery appears important in preventing psychotic relapse in the postpartum.

Differentiation and clinical implications of postpartum depression and postpartum psychosis

Postpartum depression and postpartum psychosis are serious mood disorders encountered by nurses working in a variety of settings. Postpartum depression refers to a nonpsychotic depressive episode, while postpartum psychosis refers to a manic or affective psychotic episode linked temporally with childbirth. The nursing profession plays a crucial role in the early identification and treatment of these postpartum mood disorders. This article explains the classification, clinical presentation, epidemiology, management, and long-term outcomes of postpartum depression and postpartum psychosis.

Obstetric complications and postpartum psychosis: a follow-up study of 1.1 million first-time mothers between 1975 and 2003 in Sweden

OBJECTIVE

The severity of postpartum psychosis calls for further research on the association between obstetric variables and this psychiatric disorder.

METHOD

A total of 1,133368 Swedish first-time mothers were included during a 29-year period yielding 1413 hospitalized cases of postpartum psychosis. Several obstetric variables were analysed separately after adjustment for possible confounders.

RESULTS

Respiratory disorder in the neonate, severe birth asphyxia, preterm birth, caesarean section, perinatal death and SGA infant were associated with an increased risk of postpartum psychosis. After adjustment for previous hospitalization for psychiatric disorder only preterm birth and acute caesarean section remained significant risk factors for postpartum psychosis (relative risks were 1.20 and 1.31 respectively). The relative risk of postpartum psychosis among first-time mothers with previous hospitalization for psychiatric disorder was increased more than 100-fold.

CONCLUSION

Careful clinical risk assessments of postpartum psychosis are crucial among women with a history of psychiatric disorder whereas obstetric variables have a minor importance.