No 'latent period' in the onset of bipolar affective puerperal psychosis

Posterior Reversible Encephalopathy Syndrome Presenting as Delirium With Psychosis and Agitation in the Postpartum Period

Posterior reversible encephalopathy syndrome (PRES), which was first described in 1996, is a neurologic condition characterized by a combination of clinical and neuroimaging findings. PRES may arise in the context of preeclampsia, eclampsia, renal failure, and sepsis, among other conditions. Neuropsychiatric symptoms of PRES include altered mental status, agitation, and in some cases psychosis. PRES occurring in the postpartum period is understudied, especially with regard to its psychiatric manifestations. We aim to add to the literature a case of PRES associated with psychosis and agitation in a postpartum woman, highlighting clinical implications and offering suggestions for practice. A female in her late 20s, with no significant psychiatric or medical history, presented to the hospital at 29 weeks and one day of gestation following a witnessed seizure. She was found to be hypertensive and hyponatremic, was diagnosed with eclampsia, and underwent an emergent cesarean section due to fetal malpresentation. The next day, the patient developed paranoia with acute agitation, and the psychiatry team diagnosed her with delirium with psychosis/agitation secondary to her underlying medical condition. She required intramuscular medications for agitation, was placed in restraints, and was transferred to the ICU for sedation. Subsequently, CT and MRI scans of her head both indicated that she had developed PRES. The patient's delirium and psychotic behavior resolved after appropriate treatment of her eclampsia. To our knowledge, this case report is the second documented case in the literature, of a patient who presented with PRES characterized by agitation and psychotic features in the postpartum period. Due to the significant overlap in symptoms between delirium and postpartum psychosis, this case highlights the crucial importance of interdisciplinary collaboration for accurate diagnosis and prompt treatment of PRES in the postpartum period. The case also speaks to the importance of differentiating postpartum psychosis associated with a primary psychiatric disorder from delirium arising in postpartum patients with or without a previous psychiatric history.

Establishment of the MGH Postpartum Psychosis Project: MGHP3

OBJECTIVE

Postpartum psychosis (PP) is a severe psychiatric disorder, with incomplete consensus on definition and diagnostic criteria. The Massachusetts General Hospital Postpartum Psychosis Project (MGHP3) was established to better ascertain the phenomenology of PP in a large cohort of diverse women spanning a wide geographical range (primarily in the US), including time of onset, symptom patterns, and associated comorbidities, psychiatric diagnoses pre- and post- the episode of PP, and also to identify genomic and clinical predictors of PP. This report describes the methods of MGHP3 and provides a status update.

METHOD

Data are collected from women who experienced PP within 6 months of childbirth and who provided this information within ten years of the study interview. Subject data are gathered during a one-time structured clinical interview conducted by phone, which includes administration of the Mini International Neuropsychiatric Interview for Psychotic Disorders Studies (Version 7.0.2), the MGHP3© Questionnaire, and other information including lifetime mental health history and use of psychiatric medications both prior to the episode of PP and during the subsequent time period prior to study interview. Subjects also provide a saliva sample to be processed for genomic analyses; a neuroimaging assessment is also conducted for a subset of participants.

RESULTS

As of July 1, 2022, 311 subjects from 44 states and 7 countries were enrolled in MGHP3. Recruitment sources include social media, online advertisements, physician referral, community outreach, and partnership with PP advocacy groups.

CONCLUSIONS

The rigorous phenotyping, genetic sampling, and neuroimaging studies in this sample of women with histories of PP will contribute to better understanding of this serious illness. Findings from MGHP3 can catalyze ongoing discussions in the field regarding proper nosologic classification of PP as well as relevant treatment implications.

Disparities in Emergency Department Utilization Among Women with Postpartum Mood Disorders (2006-2016)

INTRODUCTION

Postpartum mood disorders are associated with adverse outcomes for newborns and mothers and may require urgent evaluation. The emergency department is often a healthcare entry point, but factors associated with these emergency department visits are unknown.

METHODS

A longitudinal retrospective analysis using the Nationwide Emergency Department Sample to assess national estimates of emergency department visits by women ages 15-49 with primary diagnosis of a postpartum mood disorder between 2006 and 2016. Emergency department visit rates for postpartum mood disorders per 100,000 live births were calculated.

RESULTS

Emergency department visits related to postpartum mood disorders remained stable from 2006 to 2016 (5153 to 5390 respectively). Two-thirds of visits were by patients younger than 30. Approximately half of visits for postpartum mood disorders were funded by Medicaid (42.4-56.7%) compared to 27.4-41.2% funded by Medicaid for all other age-matched women. Of postpartum mood disorder visits 30.3% were by women from the lowest income quartile. The highest rate of emergency department visits occurred in the youngest patients (ages 15-19: 231 visits versus ages 35-49: 105 visits). Postpartum mood disorder admissions were higher than those for age-matched women with all other diagnoses (19.8% vs. 6.5%).

DISCUSSION

The high rate of women that are young and with public insurance visiting the emergency department for postpartum mood disorders demonstrates an increased risk for these disorders in these populations and an opportunity for targeted intervention by policymakers and providers. Higher admission rates for postpartum mood disorders compared to all other diagnoses reveals a chance to optimize outpatient screening and treatment.

Postpartum Relapse in Patients with Bipolar Disorder

Pregnancy and postpartum are vital times of greater vulnerability to suffer a decompensation of bipolar disorder (BD). Methods: A systematic literature search was performed on public electronic medical databases, following PRISMA guidelines. Studies were included if they reported postpartum relapse in patients diagnosed with BD according to Diagnosis Statistical Manual (DSM) or International Classification Disease (ICD) criteria. Results: Sixteen articles describing 6064 deliveries of 3977 women were included in the quantitative analyses. The overall risk of postpartum relapse was 36.77%. The methodology of the studies, the diagnostic criteria, the discrimination between BD type I and II, and the origin of the sample were very heterogeneous. Conclusions: the rate of postpartum bipolar relapse is very high, as it is considered to be a critical period. It is especially important to detect decompensation in this period and to evaluate mood-stabilizing treatment, given the high risk of relapse concentrated in a short period.

The role of the immune system in postpartum psychosis

Postpartum psychosis is the most severe psychiatric disorder associated with childbirth. The risk is particularly high for women with a history of bipolar disorder or schizoaffective disorder, or those who have suffered a previous episode of postpartum psychosis. However, the aetiology of the illness remains unclear. Pregnancy and the early postpartum are times of significant immunological change. Furthermore, alterations to the immune system have been implicated in the onset and course of various psychopathologies, both related and unrelated to childbirth. Emerging evidence, from studies on immune related disorders, immune cells and inflammatory markers, suggests that the immune system might also be involved in the pathophysiology of postpartum psychosis. Furthermore, recent research has also begun to explore the potential mechanisms underlying immune dysfunction in postpartum psychosis (e.g., disturbances in the Treg-CCN3 protein-(re)myelination axis). Nevertheless, more research is required to understand whether immune dysfunction is a cause or consequence of postpartum psychosis and to clarify the exact mechanisms involved. The aim of this short review is to present the current findings on immune system dysregulation in postpartum psychosis, discuss possible mechanisms underlying the association, highlight potential challenges and confounders and provide suggestions for future research.

Maternal perceived bonding towards the infant and parenting stress in women at risk of postpartum psychosis with and without a postpartum relapse

BACKGROUND

Postpartum psychosis (PP) is the most severe psychiatric disorder associated with childbirth. However, there is little research on maternal bonding towards the infant and parenting stress in this clinical population.

METHODS

We investigated maternal bonding during pregnancy and post-partum in 75 women: 46 at risk of PP (AR), because of a DSM-IV diagnosis of bipolar disorder, schizoaffective disorder or previous PP, and 29 healthy controls. Of the AR women, 19 developed a psychiatric relapse within 4 weeks' post-partum (AR-unwell), while 27 remained symptom-free (AR-well). We investigated childhood maltreatment, parenting stress and psychiatric symptoms as potential predictors of maternal bonding.

RESULTS

In pregnancy, AR-unwell women reported a more negative affective experience towards their infants than AR-well women (d = 0.87, p = .001), while postnatally there was no significant difference in bonding. In contrast, AR women as a group reported a more negative affective experience than HC postnatally (d = 0.69, p = .002; d = 0.70, p = .010), but not antenatally. Parenting stress and psychiatric symptoms significantly predicted less optimal postnatal bonding (b = -0.10, t = -4.29, p < .001; b = -0.37, t = -4.85, p < .001) but only psychiatric symptoms explained the difference in bonding between AR and HC (b = -1.18, 95% BCa CI [-2.70,-0.04]).

LIMITATIONS

A relatively small sample size precluded a more in-depth investigation of underlying pathways.

CONCLUSION

This study provides new information on maternal bonding in women at risk of PP, and particularly in those that do and do not develop a postpartum relapse. The results suggest that improving maternal symptoms and parenting stress in the perinatal period in women at risk of PP could also have positive effects on bonding.

Risk factors for postpartum relapse in women at risk of postpartum psychosis: The role of psychosocial stress and the biological stress system

BACKGROUND

Postpartum psychosis is the most severe psychiatric disorder associated with childbirth, and the risk is particularly high for women with a history of bipolar disorder, schizoaffective disorder or those who have suffered a previous episode of postpartum psychosis. Whilst there is a lot of evidence linking stress to psychosis unrelated to childbirth, the role of stress in the onset of postpartum psychosis has not been fully investigated.

METHODS

A prospective longitudinal study of 112 pregnant women, 51 at risk of postpartum psychosis because of a DSM-IV diagnosis of bipolar disorder (n = 41), schizoaffective disorder (n = 6) or a previous postpartum psychosis (n = 4) and 61 healthy women with no past or current DSM-IV diagnosis and no family history of postpartum psychosis. Women were followed up from the third trimester of pregnancy to 4 weeks' post partum. Women at risk who had a psychiatric relapse in the first 4 weeks' post partum (AR-unwell) (n = 22), were compared with those at risk who remained well (AR-well) (n = 29) on measures of psychosocial stress (severe childhood maltreatment and stressful life events) and biological stress (cortisol and inflammatory biomarkers).

RESULTS

Logistic regression analyses revealed that severe childhood maltreatment (OR = 4.9, 95% CI 0.5-49.2) and higher daily cortisol in the third trimester of pregnancy (OR=3.7, 95% CI 1.2-11.6) predicted psychiatric relapse in the first 4 weeks' post partum in women at risk of postpartum psychosis after adjusting for clinical and sociodemographic covariates.

CONCLUSION

The current study provides evidence for the role of psychosocial stress and the biological stress system in the risk of postpartum relapse in women at risk of postpartum psychosis.

Perinatal Mixed Affective State: Wherefore Art Thou?

Mixed states in patients with a perinatal mood episode is seldom encountered. Lack of appropriate assessment tools could be partly responsible for this observation. The authors conducted a selective review of studies dealing with the reporting of mixed symptoms in women during the perinatal period with the intention to quantify the phenomenon. In many instances of reported postpartum depression, either a first onset or an onset in the context of bipolar disorder, mixed states were identifiable. However, the strict application of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, mixed features specifier to these episodes risks misdiagnosis.

Puerperal psychosis: identifying and caring for women at risk

Puerperal (postpartum) psychosis – the acute onset of a manic or psychotic episode shortly after childbirth – most commonly occurs in women with a bipolar disorder diathesis who have a vulnerability to a specific childbirth-related trigger. Women with bipolar disorder are at particularly high risk of puerperal psychosis, with a severe affective episode following between 25 and 50% of deliveries. Suicide is a leading cause of maternal death in the UK and it is clear that we must do more to identify and better manage women at high risk of illness related to childbirth. The clinical picture of puerperal psychosis can vary dramatically from hour to hour and can escalate quickly to a true psychiatric emergency. It is vital that clinical services identify women who are unwell and can respond quickly to the severity of illness, delivering treatment in the most appropriate setting for the mother and her baby.

Perinatal depression and psychosis: an update

About 85% of women experience some type of postpartum mood disturbance. Generally, the symptoms are mild and short-lived, but a minority of women develop depressive illness or sudden psychosis. About half of episodes of apparently postnatal depression start during pregnancy and some seemingly postpartum psychoses start before delivery. Untreated antenatal depression can lead to poor obstetric outcomes, subsequent depression in the mother, and developmental disadvantage and depression later in life in the offspring. In this article we discuss the aetiology of perinatal depression and consider recommended pharmaceutical and psychosocial management of postpartum blues, perinatal depression and postpartum psychosis.

Mania triggered by sleep loss and risk of postpartum psychosis in women with bipolar disorder

BACKGROUND

Women with bipolar disorder are at high risk of affective psychoses following childbirth (i.e. "postpartum psychosis", PP) and there is a need to identify which factors underlie this increased risk. Vulnerability to mood dysregulation following sleep loss may influence risk of PP, as childbirth is typified by sleep disruption. We investigated whether a history of mood episodes triggered by sleep loss was associated with PP in women with bipolar disorder (BD).

METHODS

Participants were 870 parous women with BD recruited to the Bipolar Disorder Research Network. Lifetime diagnoses of BD and perinatal episodes were identified via interview and case notes. Information on whether mood episodes had been triggered by sleep loss was derived at interview. Rates of PP were compared between women who did and did not report mood episodes following sleep loss.

RESULTS

Women who reported sleep loss triggering episodes of mania were twice as likely to have experienced an episode of PP (OR = 2.09, 95% CI = 1.47-2.97, p < 0.001) compared to women who did not report this. There was no significant association between depression triggered by sleep loss and PP (p = 0.526).

LIMITATIONS

Data were cross-sectional therefore may be subject to recall bias. We also did not have objective data on sleep disruption that had occurred during the postpartum period or prior to mood episodes.

CONCLUSIONS

In clinical practice, a history of mania following sleep loss could be a marker of increased vulnerability to PP, and should be discussed with BD women who are pregnant or planning to conceive.

Pharmacological Management of Bipolar Disorder in Pregnancy

Bipolar disorder is associated with high morbidity and mortality. The management of bipolar disorder includes a broad approach involving psychoeducation, psychological therapies and psychotropic medication. The management of bipolar disorder in pregnancy is challenging; there is an increase in the rate of relapse of bipolar disorder in the perinatal period and treatment decisions are complex as clinicians are required to weigh up the risks of untreated illness versus unwanted treatment effects on both the mother and the developing fetus. Whilst depressive relapses are more common, women are also at an increased risk of postpartum psychosis, which is a psychiatric emergency that almost always requires inpatient treatment. This paper discusses the limited evidence base regarding the safety of psychotropic medication in the perinatal period, including challenges in perinatal mental health research and the lack of robust evidence. The general principles of prescribing in pregnancy, the importance of preconception counselling, and the risks and benefits associated with antipsychotics, mood stabilisers and antidepressants are addressed.

Use of primary health care prior to a postpartum psychiatric episode

OBJECTIVE

Childbirth is a strong trigger of psychiatric episodes. Nevertheless, use of primary care before these episodes is not quantified. The aim was to study the use of general practice in Denmark from two years before to one year after childbirth in women who developed postpartum psychiatric disorders.

DESIGN

A matched cohort study was conducted including women who gave birth in the period 1996-2010. Women were divided into four groups: (i) all mothers with postpartum psychiatric episodes 0-3 months after birth, n = 939; 2: All mothers with a postpartum psychiatric episode 3-12 months after birth, n = 1 436; and (iii) two comparison groups of mothers, total n = 6 630 among 320 620 eligible women.

SETTING

Denmark.

SUBJECTS

Women born in Denmark after 1 January 1960, restricting the cohort to women who gave birth to their first singleton child between 1 January 1996 and 20 October 2010.

MAIN OUTCOME MEASURES

The main outcome measures were consultation rates, consultation rate ratios, and rate differences.

RESULTS

Women who developed a psychiatric episode after childbirth had higher GP consultation rates before, during, and after the pregnancy. Women with a psychiatric episode 0-3 months postpartum had 6.89 (95% CI 6.60; 7.18) mean number of consultations during pregnancy, corresponding to 1.52 (95% CI 1.22; 1.82) more visits than the comparison group.

CONCLUSION

Women with a postpartum psychiatric episode had higher use of GP-based primary health care services years before the childbirth, and in this specific group of patients childbirth itself triggered a marked increase in the number of GP contacts postpartum.

Perinatal psychiatric disorders: an overview

Perinatal mental illness has a significant implication on maternal health, birth outcomes, and the offspring's development. Prevalence estimates of perinatal psychiatric illnesses range widely, with substantial heterogeneity in different population studies, with a lower prevalence rate in high- rather than low- or middle-income countries. Because of the potential negative impact on maternal and child outcomes and the potential lability of these disorders, the perinatal period is a critical time to identify psychiatric illnesses. Thus, obstetricians and midwives play a crucial role in assessing women's mental health needs and to refer identified women promptly for multidisciplinary specialist assessment. However, there is still limited evidence on best practice assessment and management policies during pregnancy and postpartum. This review focuses on the prevalence of common perinatal mental disorders and antenatal screening policies to identify women at risk. The effect of these conditions and their management on pregnancy, fetal outcomes, and child development are discussed.

Pharmacotherapy for mood disorders in pregnancy: a review of pharmacokinetic changes and clinical recommendations for therapeutic drug monitoring

OBJECTIVE

Pharmacotherapy for mood disorders during pregnancy is often complicated by pregnancy-related pharmacokinetic changes and the need for dose adjustments. The objectives of this review are to summarize the evidence for change in perinatal pharmacokinetics of commonly used pharmacotherapies for mood disorders, discuss the implications for clinical and therapeutic drug monitoring (TDM), and make clinical recommendations.

METHODS

The English-language literature indexed on MEDLINE/PubMed was searched for original observational studies (controlled and uncontrolled, prospective and retrospective), case reports, and case series that evaluated or described pharmacokinetic changes or TDM during pregnancy or the postpartum period.

RESULTS

Pregnancy-associated changes in absorption, distribution, metabolism, and elimination may result in lowered psychotropic drug levels and possible treatment effects, particularly in late pregnancy. Mechanisms include changes in both phase 1 hepatic cytochrome P450 and phase 2 uridine diphosphate glucuronosyltransferase enzyme activities, changes in hepatic and renal blood flow, and glomerular filtration rate. Therapeutic drug monitoring, in combination with clinical monitoring, is indicated for tricyclic antidepressants and mood stabilizers during the perinatal period.

CONCLUSIONS

Substantial pharmacokinetic changes can occur during pregnancy in a number of commonly used antidepressants and mood stabilizers. Dose increases may be indicated for antidepressants including citalopram, clomipramine, imipramine, fluoxetine, fluvoxamine, nortriptyline, paroxetine, and sertraline, especially late in pregnancy. Antenatal dose increases may also be needed for lithium, lamotrigine, and valproic acid because of perinatal changes in metabolism. Close clinical monitoring of perinatal mood disorders and TDM of tricyclic antidepressants and mood stabilizers are recommended.

Reproductive outcomes and risk of subsequent illness in women diagnosed with postpartum psychosis

OBJECTIVES

Women who experience postpartum psychosis (PP) seek guidance on further pregnancies and risk of illness; however, empirical data are limited. This study describes reproductive and mental health outcomes in women diagnosed with PP and examines clinical risk factors as predictors of further illness.

METHODS

A retrospective cohort design was used; 116 women who experienced episodes of mania or depression with psychotic features within six weeks of childbirth were recruited. All subjects underwent clinical diagnostic interviews and medical case notes were reviewed.

RESULTS

Only 33% of women had an antecedent history, of which 34% had bipolar disorder and 55% unipolar depression. Only 58% of those with PP in their first pregnancy had a subsequent pregnancy, and 18% of marriages ended following the PP episode. Clinical presentation at the time of initial episode did not influence the timing of the onset of symptoms, treatment, or recovery. Although 86% of patients received treatment within 30 days of onset, 26% of women reported ongoing symptoms at a year after delivery. The recurrence rate of PP was 54.4%; a longer duration of the index episode (p < 0.05) and longer latency between the index PP and next pregnancy predicted a subsequent PP. The rate of subsequent non-puerperal episodes was 69%, and all these episodes were bipolar.

CONCLUSIONS

Postpartum psychosis is difficult to predict in women with no antecedent history and is associated with a high rate of subsequent puerperal and non-puerperal illness. Risk of further illness needs to be conveyed in order to allow fully informed decisions to be made regarding future pregnancies.

Involving the family in the care and treatment of women with postpartum psychosis: Swedish psychiatrists' experiences

The aim of the study was to describe Swedish psychiatrists' experiences of involving the family in the treatment of women with postpartum psychosis. A qualitative design was used, and semistructured qualitative research interviews were conducted with nine psychiatrists from the south of Sweden. Data were analysed using qualitative content analysis. Four categories were found: the family as a resource, the family as coworkers, preparing the family for the future, and the family as a burden. The result showed that the psychiatrists considered the family to be a resource to which they devoted a great deal of care and effort. It was particularly important to involve the partner, informing about the course of the illness and the steps that need to be taken in the event of a relapse and reducing any guilt feelings. The psychiatrists instilled confidence and hope for a future of health and further child bearing. The family members' limited understanding of the treatment may impede the involvement of the family. Conclusion of the study was that the goal for family involvement was to facilitate the women's care and treatment. Further studies are needed to provide suggestions on how to develop family involvement in the care of women suffering from postpartum psychosis.

Should psychiatrists be prescribing oestrogen therapy to their female patients?

Some studies have indicated that oestrogen therapy may be beneficial in the treatment of a number of neuropsychiatric disorders. However, it has been suggested that psychiatrists fail to prescribe oestrogen therapy to their patients, as they are 'not aware of' or 'do not believe' studies supporting their use. This paper reappraises the putative role of hormone treatments, particularly oestrogen therapy, in psychiatry.

The management of bipolar disorder in the perinatal period and risk factors for postpartum relapse

Aims

The perinatal period is a time of high risk of relapse for women with a history of bipolar affective disorder (BPAD). We describe the pregnancy management of women with BPAD and identify risk factors for postpartum relapse.

Methods

The case records of 78 women with BPAD referred to perinatal mental health services before conception, during pregnancy or the postpartum period, between 1998 and 2009 in Birmingham UK, were screened. In women who were managed during pregnancy, those who relapsed in the postpartum were compared with those who remained well.

Results

Forty-seven percent of women with BPAD referred in pregnancy suffered postpartum relapse. Women who were unwell at referral, younger, with unplanned pregnancy, previous perinatal episodes or a family history of BPAD were more likely to suffer postpartum illness.

Conclusion

Identifying risk factors for postpartum relapse enables us to individualise the estimation of a woman's risk and modify care plans accordingly. Duration of wellness prior to pregnancy is not associated with a lower risk of postpartum illness and so it is imperative that all women with BPAD receive referral in pregnancy.

Interventions for the prevention and treatment of postpartum psychosis: a systematic review

Postpartum psychosis is a serious disorder that can cause negative consequences for the mother, infant, and entire family. While reports of this condition date back for centuries, little is known about what interventions are most effective for this population. The purpose of this systematic review was to examine the research evidence on interventions for the prevention and treatment of postpartum psychosis. Studies were searched using CINAHL, EMBASE, MEDLINE, PsycINFO, and PubMed databases. All primary research studies published in English since 1970 that explored interventions for the prevention or treatment of postpartum psychosis were included. The search resulted in 26 studies on interventions for postpartum psychosis, with 10 focusing on prevention and 17 focusing on treatment. Studies on the prevention of postpartum psychosis have examined the effects of mood stabilizers, antipsychotics, and hormone therapy, while those examining treatment have included electroconvulsive therapy, mood stabilizers, antipsychotics, hormones, and the beta blocker propranolol. Only preliminary evidence suggests which interventions may be effective strategies to prevent (e.g., lithium) and treat (e.g., electroconvulsive therapy) postpartum psychosis. Due to methodological limitations in the studies reviewed, extensive evidence-based recommendations for the prevention and treatment of postpartum psychosis cannot be made. The known risk factors and negative consequences of postpartum psychosis point to the importance of preventative and acute treatment measures. Well-designed prospective studies are needed to determine the efficacy of prevention and treatment interventions for women who experience postpartum psychosis.

Is sex important? Gender differences in bipolar disorder

Sex is clearly important in unipolar mood disorder with compelling evidence that depression is approximately twice as common in women than in men. In the case of bipolar disorder, however, it is widely perceived that the reported equal rate of illness in men and women reflects no important gender distinctions. In this paper we review the literature on gender differences in bipolar illness and attempt to summarize what is known and what requires further study. Despite the uncertainties that remain some conclusions can be drawn. Most studies, but not all, report an almost equal gender ratio in the prevalence of bipolar disorder but the majority of studies do report an increased risk in women of bipolar II/hypomania, rapid cycling and mixed episodes. Important gender distinctions are also found in patterns of co-morbidity. No consistent gender differences have been found in a number of variables including rates of depressive episodes, age and polarity of onset, symptoms, severity of the illness, response to treatment and suicidal behaviour. Unsurprisingly, however, perhaps the major distinction between men and women with bipolar disorder is the impact that reproductive life events, particularly childbirth, have on women with this diagnosis.

Swedish registered psychiatric nurses' descriptions of presence when caring for women with post-partum psychosis: an interview study

The concept of nursing presence has been widely used in nursing and is a significant component of nursing practice. In order to increase our understanding of nursing presence, it needs to be studied in different contexts. In this study, a secondary analysis of interviews with 10 registered psychiatric nurses (RPN) in Sweden was conducted to explore nurses' descriptions of presence when caring for women with post-partum psychosis (PPP). Based on the research question: 'How do RPN describe nursing presence in the context of caring for women with PPP?' content analysis was used to analyze the data. Three categories emerged: the use of presence to protect, the use of presence to facilitate recovery, and the use of presence for learning. The findings underscore the importance of recognizing nursing presence as a strategy to improve psychiatric nursing for the benefit of the woman and her child, and as an important part of psychiatric nursing when providing compassionate and effective nursing care to this population.

Nurses--psychiatrists' main collaborators when treating women with postpartum psychosis

The focus was to describe Swedish psychiatrists' experiences of collaboration with healthcare professionals when treating women with postpartum psychosis (PPP). A qualitative design was used, and semi-structured interviews were performed with nine psychiatrists working in psychiatric hospitals in Sweden. Data were analysed using manifest and latent content analysis. The results of these experiences were categorized in this study as: collaboration related to admission, collaboration during inpatient care and collaboration related to discharge. Collaboration with midwives and obstetricians was important in diagnosing the illness, as this often occurred on postnatal wards; and decisions about the form of care for the woman with PPP and for her baby demanded collaboration with various healthcare professionals. Collaboration with nurses was based on expectations and confidence in nurses' competence, and was exceedingly important during inpatient care. When the woman was to be discharged, collaboration with healthcare teams, e.g. outpatient clinic, child health clinic and community services, was required. The conclusions were that psychiatrists collaborate with different professionals in the various phases of the caring process. They rely extensively on nurses' competence when caring for women with PPP, and consider nurses to be their most important collaborators.

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.

Depression and Related Disorders during the Female Reproductive Cycle

For some women, times of reproductive transition represent times of high risk for the onset or exacerbation of depressive symptoms. In order to maintain emotional stability, the female brain must adapt to fluctuations in hormones that affect neurotransmitter functioning. Difficulty with this adaptation, along with stresses related to social role transitions, may confer heightened vulnerability to depression. In this review, we summarize data regarding the course, expression and risks of depression and related symptoms during puberty and menarche, the luteal phase of the menstrual cycle, the perinatal period and perimenopause. We note treatment strategies that have been found to be effective for depressive symptoms during specific phases of the female reproductive cycle.

A longitudinal study of hypomania and depression symptoms in pregnancy and the postpartum period

OBJECTIVES

Childbirth is a potent precipitant of severe episodes of bipolar disorder. We investigate mood longitudinally through pregnancy and the postpartum period, using the Highs Scale and the Edinburgh Postnatal Depression Scale (EPDS), to examine if the postpartum period is a time of increased risk for hypomanic symptoms in the general population.

METHODS

A total of 446 women were recruited at 12 weeks of pregnancy from the Birmingham Women's Hospital and four midwife-led community clinics. Women completed the Highs Scale and the Edinburgh Postnatal Depression Scale at 12 weeks of pregnancy, one week postpartum, and eight weeks postpartum.

RESULTS

Cases of probable depression, as defined by an EPDS score of 13 or greater, did not significantly increase from pregnancy to the postpartum period. The prevalence of 'the highs' was eightfold higher in the postpartum week than during pregnancy.

CONCLUSIONS

Consistent with the increased rates of severe manic illness following childbirth, we find that more minor hypomanic states are also increased. We consider the clinical relevance of postpartum hypomanic symptoms and the implications of these findings for research into postpartum-onset mood symptoms.

Dimensions of postpartum psychiatric distress: preliminary evidence for broadening clinical scope

BACKGROUND

Perinatal psychiatric disturbances afflict a significant number of women sometimes with tragic consequence. Yet, the range and characteristics of these disturbances are poorly understood. The goals of this research were to characterize a broader range of postpartum psychiatric symptoms and to identify their inherent structure using exploratory factor analysis (EFA).

METHODS

An Internet-based survey with 142 Likert-type questions, covering nine dimensions of postpartum mental health was constructed and posted on women's health websites. Data collected from 215 respondents was analyzed in three steps: (1) inter-item correlations were used to reduce the total number of variables by eliminating items that provided redundant information; (2) an EFA using a principal components extraction and VARIMAX rotation was performed and factors loading with Eigenvalues >1.0 were retained; (3) internal consistency was measured with Cronbach's alpha.

RESULTS

The 10 factors retained accounted for 58% of the variance and included: mental status (28%), psychoticism/morbid thoughts (6%), generalized anxiety (6%), panic (3%), guilt/self-criticism (3%), compulsive behavior (3%), hyper-vigilance (2%), contentment (2%), negative body-image (2%), and manic behavior (2%). There was strong (>0.8) internal consistency in all but the mania factor (0.6).

LIMITATIONS

The study was retrospective and respondent demographics were homogeneous.

CONCLUSION

Postpartum psychiatric disturbances are not limited to depressive symptoms. In the current study, cognitive difficulties, psychotic-morbid thoughts and anxiety symptoms accounted for the preponderance of variance while depressive symptoms did not form a cohesive factor and accounted for minimal variance. These results suggest postpartum screening tools should assess a broader array of symptoms.

Postpartum depression

Postpartum depression (PPD) affects up to 15% of mothers. Recent research has identified several psychosocial and biologic risk factors for PPD. The negative short-term and long-term effects on child development are well-established. PPD is under recognized and under treated. The obstetrician and pediatrician can serve important roles in screening for and treating PPD. Treatment options include psychotherapy and antidepressant medication. Obstacles to compliance with treatment recommendations include access to psychotherapists and concerns of breastfeeding mothers about exposure of the infant to antidepressant medication. Further research is needed to examine systematically the short-term and long-term effect of medication exposure through breastmilk on infant and child development.

Psychiatric nurses' descriptions of women with postpartum psychosis and nurses' responses--an exploratory study in Sweden

Postpartum psychosis is the most serious type of psychiatric illness related to childbirth. This interview study with nine psychiatric nurses in Sweden explored psychiatric nurses' descriptions of women with psychosis occurring in the postpartum period and nurses' responses when providing care to these women. Content analysis was used to analyze the data. The nurses described delusions, disconnection, aggression, changed personality, self-absorption, insomnia, chaos, quietness, suicidal ideation, and 'strange eyes.' The description of strange eyes noted by the nurses has not been found in the literature, warranting further investigation. When providing care, the nurses responded with sadness, sympathy, empathy and compassion, discomfort, anger, anxiety, and happiness. These findings underscore the importance of nurses recognizing their negatively charged emotions which could interfere with providing compassionate and effective nursing care to this population.