Infanticidal ideas and infanticidal behavior in Indian women with severe postpartum psychiatric disorders

Postpartum Psychosis: A Proposed Treatment Algorithm

Background

Postpartum psychosis (PPP) is a psychiatric emergency that generally warrants acute inpatient care. PPP is marked by the sudden onset of affective and psychotic symptoms with a rapid deterioration in mental state. Evidence suggests that PPP is a discrete disorder on the bipolar disorder spectrum with a distinct treatment profile and prognosis.

Methods

We conducted a PubMed database search for various terms involving PPP and its treatment and included peer-reviewed articles published in English.

Objective

To provide a treatment algorithm for the management of PPP based on available evidence.

Results

Pharmacological therapy is the mainstay of PPP management in the acute phase. Evidence points to a combination of antipsychotics and lithium in the acute treatment of PPP. Electroconvulsive therapy can offer a rapid treatment response where required. Lithium appears to have the best evidence for relapse prevention and prophylaxis in PPP. Psychoeducation is essential and psychosocial interventions used in bipolar disorder may be effective in PPP.

Conclusion

Early detection and prompt treatment with antipsychotics and lithium, followed by maintenance treatment with lithium, is associated with a favourable prognosis in PPP.Reprinted from J Psychopharmacol 2023; 37:960-970, with permission from Sage Journals. Copyright © 2023.

Postpartum psychosis: A proposed treatment algorithm

BACKGROUND

Postpartum psychosis (PPP) is a psychiatric emergency that generally warrants acute inpatient care. PPP is marked by the sudden onset of affective and psychotic symptoms with a rapid deterioration in mental state. Evidence suggests that PPP is a discrete disorder on the bipolar disorder spectrum with a distinct treatment profile and prognosis.

METHODS

We conducted a PubMed database search for various terms involving PPP and its treatment and included peer-reviewed articles published in English.

OBJECTIVE

To provide a treatment algorithm for the management of PPP based on available evidence.

RESULTS

Pharmacological therapy is the mainstay of PPP management in the acute phase. Evidence points to a combination of antipsychotics and lithium in the acute treatment of PPP. Electroconvulsive therapy can offer a rapid treatment response where required. Lithium appears to have the best evidence for relapse prevention and prophylaxis in PPP. Psychoeducation is essential and psychosocial interventions used in bipolar disorder may be effective in PPP.

CONCLUSION

Early detection and prompt treatment with antipsychotics and lithium, followed by maintenance treatment with lithium, is associated with a favourable prognosis in PPP.

Adverse effects and short-term developmental outcomes of infants exposed to atypical antipsychotics during breastfeeding

BACKGROUND

Postpartum period in women is vulnerable to the occurrence and exacerbation of psychiatric disorders. Mothers with postpartum psychosis or bipolar disorder need treatment with psychotropic medications, especially atypical antipsychotics. However, many mothers and families will have reservations about the use of psychotropics during the perinatal period, particularly during breastfeeding because of its presumed side effects and adverse developmental outcomes of the child. Since there are limited data in this area, the present study aimed to examine the adverse effects, if any, and the short-term developmental outcome of infants exposed to atypical antipsychotics during breastfeeding.

METHODS

The study involved infants of postpartum women (n = 28) who were admitted in the mother and baby inpatient psychiatry unit of a tertiary care center in India. The medication side effects were checked every alternate day for 1-2 weeks using a checklist based on common side effects that infants may experience due to lactation exposure of atypical antipsychotics. Developmental assessments of the infants were done using the Developmental Assessment Scales for Indian Infants and through anthropometric measurements such as weight, length, head circumference, and chest circumference in follow-up when they came as an outpatient after 1-3 month interval.

RESULTS

The occurrence of adverse side effects was quite low (17.85%). The main side effects directly attributable to atypical antipsychotics were constipation and sedation. Of the 17 infants who attended follow-up, 52.9% (n = 9) showed some form of developmental delay at the time of the first follow-up. However, low birth weight, higher maternal age (>35 years), and exposure to medications (quetiapine and phenytoin) during pregnancy may be confounding risk factors.

CONCLUSIONS

The acute adverse effects of atypical antipsychotics such as sedation and constipation in the infant through breast milk were seen in less than a fourth of the sample. Developmental delay was noted in a proportion of infants; however, this may be due to other risk factors.

The NIMHANS (National Institute of Mental Health and Neuro Sciences) Maternal Behaviour Scale (NIMBUS): Development and validation of a scale for assessment of maternal behaviour among mothers with postpartum severe mental illness in low resource settings

PURPOSE

A mother's behaviour towards her infant is an important aspect of assessment in postpartum severe mental illness (SMI). The existing tools for this purpose need formal training, require time and do not include certain aspects of maternal behaviour. Hence, there is a need for a tool that may overcome some of the above problems and be simple to use, especially in limited resource low and middle income countries (LAMIC) settings. The NIMHANS Maternal Behaviour Scale was constructed for this purpose.

METHODS

The 16 items were compiled based on 100 detailed assessments of mother-infant dyads. The NIMBUS is rated based on observations and information from caregivers, health assistants and nurses. The scale which has six domains was administered to 51 mother-infant dyads admitted to an MBU to establish construct validity and internal consistency. Inter-rater, and test retest reliability were also established. External validity was established using the Bethlem Mother infant Interaction Scale (BMIS) and the Postpartum Bonding Questionnaire (PBQ).

RESULTS

The scale was found to have adequate inter-rater and test retest reliability (Cohen's kappa > 0.81). The Cronbach's alpha for internal consistency was 0.94 and it showed adequate external validity when used with the BMIS (R = 0.947, p = 0.000) and PBQ.

CONCLUSION

The NIMBUS appears to be a useful tool to assess maternal behaviour among mothers with SMI in the postpartum especially in LAMIC situations where observations are often made by family members and health assistants rather than trained perinatal nurses.

Perinatal mental health and risk of child maltreatment: A systematic review and meta-analysis

BACKGROUND

Mental health problems in parents have been identified as a risk factor for child maltreatment. The perinatal period (from conception to 1 year) is a critical period but it is unclear whether perinatal mental health problems are also associated with increased risk.

OBJECTIVE

To review evidence on perinatal mental health and risk of child maltreatment.

METHODS

Searches were conducted on six databases and 24 studies reported in 30 papers identified. Studies were conducted in seven countries, mainly the USA (n = 14). Sample sizes ranged from 48-14,893 and most examined mothers (n = 17). Studies were conducted in community (n = 17) or high-risk (n = 7) samples.

RESULTS

The majority of studies found a relationship between parental perinatal mental health problems and risk of child maltreatment, but inconsistent findings were observed between and within studies. The few studies that examined fathers (n = 6) all found a relationship between fathers' mental health and risk of child maltreatment. Meta-analysis of 17 studies (n = 22,042) showed perinatal mental health problems increased risk of child maltreatment by OR 3.04 (95% CI 2.29-4.03). This relationship was moderated by type of sample, with larger effects for risk of child maltreatment in high-risk samples. The relationship was not moderated by type of mental illness, child maltreatment; methodological or measurement factors.

CONCLUSION

The association between perinatal mental health and risk of child maltreatment is similar to that observed at other times during childhood. Methodological heterogeneity and inconsistent findings mean conclusions are tentative and need to be considered alongside other individual, family and social/cultural risk factors.

Understanding the lived experiences of severe postnatal psychiatric illnesses in English speaking South Asian women, living in the UK: a qualitative study protocol

INTRODUCTION

The South Asian population is the UK's largest and fastest growing minority ethnic group. There is evidence to suggest the lay understanding of postnatal psychiatric illnesses of this group may fall outside the purview of Western biomedical perspectives. Alternative explanations include psychosocial, cultural and spiritual factors. Approaching psychiatric illnesses through a social perspective includes gaining insight to the patient's subjective experiences and understandings via qualitative inquiry. The objectives of this qualitative study are to explore South Asian women's narrative of living with a severe postnatal psychiatric illness and experiences of Perinatal Mental Health Services, care and support.

METHODS AND ANALYSIS

Data collection is ongoing and will continue until 31 December 2018. Participants will be identified and recruited from Perinatal Mental Health Services in Birmingham and London. Eligible participants will be English speaking South Asian females aged 18 years or above with the capacity to give written informed consent. Participants are clinically diagnosed with a severe postnatal psychiatric illness. This qualitative study uses individual in-depth face-to-face interviews that aim to last 1 hour. Interviews will be audio recorded with participants' permission. Interview audio recordings will be transcribed verbatim and analysed using interpretative phenomenological analysis (IPA). The primary goal of IPA is for the researcher to closely study and interpret how individuals make sense of their life experiences in a particular context by drawing on the fundamental principles of phenomenology, hermeneutics and idiography.

ETHICS AND DISSEMINATION

The University of Birmingham, the South Birmingham Research Ethics Committee and the Health Research Authority have approved this study (approvals date: 18-12-2017 ref: 17/WM/0350). Local capability and capacity have been confirmed from Trust Research and Development departments. The researchers plan to publish the results from this study in journals and present findings at academic conferences.

Life events and depressive symptoms among pregnant women in India: Moderating role of resilience and social support

BACKGROUND

Recent life events may be significant risk factors for depression during pregnancy. However, its association with the individual's resilience and social support is not clear.

AIMS

To understand the association between life events and depression during pregnancy and whether the association is moderated by resilience and social support.

METHODS

This study is part of a prospective cohort study on perinatal mental health in an urban antenatal clinic, which included 589 women recruited in the first and early second trimester. Participants were administered the Life Events Checklist adapted from the Social Readjustment Rating Scale by the authors to assess life events; Edinburgh Postnatal Depression Scale (EPDS) and Connor-Davidson Resilience Scale-10 to assess depression and resilience, respectively. The relationship between life events (12 months prior to the time of assessment) and antenatal depression and the moderating role of resilience and social support was analysed.

RESULTS

Thirty-eight women (6.5%) who had depression (EPDS score ⩾ 11) had significantly higher number of life events (i.e. on average three; U = 3,826; p < .01), lower resilience scores ( U = 4,053; p < .01) and lower perceived social support ( U = 2,423; p < .01) as compared to those who were negative for depression on EPDS. Life events predicted depression during pregnancy; however, the relationship was moderated by social support but not by resilience.

CONCLUSION

The pregnant women who experienced life events may experience depression during the first trimester of pregnancy, but the effect could possibly be reduced by enhancing the social support.

Self-reported violent ideation and its link to interpersonal violence among offenders with mental disorders and general psychiatric patients

This study aims at comparing mentally disordered offenders and general psychiatric patients regarding violent ideation and at exploring its association with interpersonal violence. We recruited 200 detainees undergoing forensic psychiatric evaluation and 390 general psychiatric patients at discharge. At baseline, they were asked about violent ideation; at the 20-week follow-up, information about violent acts was gathered from crime conviction registry, interviews, and records. The lifetime prevalence of violent ideation was 32.5% for offenders and 35.6% for patients; the corresponding two-month prevalence was 22.5% and 21.0%, respectively. For the both samples combined, those with violent ideation in their lifetime were significantly more prone to commit violent acts during follow-up than those without such ideation, OR = 2.65. The same applied to the patient sample, OR = 3.41. In terms of positive predictive values, fewer than 25% of those with violent ideation committed violent acts. Contrary to our hypothesis, the prevalence of violent ideation did not differ significantly between offenders and patients. However, there was support for the hypothesized association between violent ideation and violent acts on a group level. On an individual level, the clinician should consider additional factors when assessing the risk for violent acts.

Cross-National Differences in Psychosocial Factors of Perinatal Depression: A Systematic Review of India and Japan

Perinatal depression is prevalent worldwide. However, there are few available studies that discuss the different cultural factors affecting perinatal depression within Asian countries. This study aims to compare the literature regarding related factors relating to perinatal depression in India and Japan, and to synthesize the evidence common to both countries in addition to the country-specific evidence. We conducted a systematic review using several databases (CINAHL, MEDLINE, Pubmed, Ovid, SCOPUS, IndMED, and ICHUSI). Keywords were “antenatal depression” or “postpartum depression”, and “India” or “Japan”. Both Japanese and English language papers were reviewed. The identified evidence was compared between the two countries, as well as with non-Asian countries based on previous reports. In total, 15 articles on India and 35 on Japan were reviewed. Although several factors were shared between the two countries as well as with other non-Asian countries (vulnerable personality, being abused, age, marital conflict, and lower socio-demographic status), some differing factors were identified between India and Japan and non-Asian countries; India: poor socioeconomic status, living only with the husband, pregnancy not welcomed by the husband, a female baby, and poor relationship with in-laws; Japan: infertility treatment, conflict with work–life balance, poor relationships with biological mother or in-laws, and concerns about social relations with the other mother’s friends. To conclude, involving the family and community may be important for implementing both global standardized and culture-specific interventions. In India, treatment involving the in-laws may be effective because large family structure is a significant predictor of perinatal depression. In Japan, a family/community approach involving not only the mother’s family of origin but also the working environment is essential.

Phenotypical characteristics of postpartum psychosis: A clinical cohort study

OBJECTIVES

Postpartum psychosis (PP) is known for its clear onset but its phenotype has never been clearly described in a cohort. The aim of this study was to describe PP symptomatology, and to identify subgroups of patients based on symptom profiles.

METHODS

We prospectively assessed a wide range of symptoms in cases of PP in a cohort of women (N=130) admitted to the Mother-Baby inpatient unit. Using a person-centered analytic approach, we distinguished mutually exclusive subgroups of women. Subgroups were related to demographic and clinical characteristics.

RESULTS

The most prevalent symptoms of PP were irritability (73%), abnormal thought content (72%), and anxiety (71%). Suicidal and infanticidal ideation was present in 19% and 8% of patients, respectively. Delusions and hallucinations often had a negative content. Latent class analysis revealed three symptom profiles, a manic (34%), depressive (41%) and atypical (25%) profile, respectively. The manic profile is characterized by manic symptoms and agitation, the depressive profile by depressive and anxiety symptoms, and the atypical profile by disturbance of consciousness and disorientation. In women with a depressive profile, treatment was started 2 weeks later (P=.049), and more often voluntarily, than in manic and atypical women (P=.037).

CONCLUSIONS

We distinguished subgroups of PP patients with a manic, depressive, and atypical profile. Disturbance of consciousness, disorientation, and depersonalization/derealization were less prevalent than previously suggested in the literature. Instead, the depressive profile was the most prevalent, but the depressive profile can easily remain undetected, which could lead to treatment delay and risk of suicide/infanticide. Within the manic profile, irritability was highly prevalent and occurred more often than elevated mood.

Homicide in the western family and background factors of a perpetrator

AIMS

Familicide is a multiple-victim homicide incident in which the killer's spouse and one or more children are slain. A systematic review was conducted to reveal the background factors of western homicide perpetrators.

METHODS

The systematic search was performed in the Arto, Medic, Cinahl, Medline, EBSCOhost Academic Search Premier and Social Services abstracts databases. The keywords were familicide, family homicide, familicide-suicide, filicide-suicide, extended suicide, child, murder, family, filicide and infanticide. The searches revealed 4139 references from the databases. The references were filtered and 32 peer-reviewed research articles revealed in years 2004-2014 were selected as data. The articles were analysed using inductive content analysis, by finding all possible background factors related to homicide.

RESULTS

The factors were described as percentages of the range. The background factors of familicide perpetrators were categorised as follows: perpetrators who had committed homicide of a child and intimate partner and possibly committed suicide; a father had who killed a child; a mother who had killed a child; a father who had committed a filicide-suicide; and a mother who had committed a filicide-suicide.

CONCLUSIONS

Psychological instability, violence and crime were found in all these categories of familicides. Perpetrators who had committed a suicide in addition to the familicide had more often been diagnosed with depression, but they sought treatment for mental health problems less often and had violence and self-destructiveness less often in their background than in other familicide categories. Social and healthcare professionals should be more sensitive to emerging family problems and be prepared for intervention.

Filicide in the United States

In the United States the Accreditation Council of Graduate Medical Education determines the curriculum required for fellows in forensic psychiatry to become board certified as a subspecialist. Areas that must be covered during the one year fellowship include criminal issues, such as insanity; civil issues, such as tort law and Workers' Compensation; legal regulation of psychiatry, such as confidentiality and involuntary hospitalization; and correctional psychiatry issues, such as dual agency and prisoner's rights. Fellows are also expected to have knowledge about juvenile courts, the structure of the legal system, and child custody issues. In addition, fellows are required to analyze complex cases and write forensic reports which are well reasoned. Teaching methods include lectures, storytelling, use of video vignettes, and mock trials. Additional teaching methodologies include group supervision of fellows in their report writing and direct observation of giving testimony. During the year we see fellows evolve and shift their orientation from being an advocate for patients to perceiving their role as serving justice.

Selective serotonin reuptake inhibitors (SSRIs) for post-partum depression (PPD): a systematic review of randomized clinical trials

BACKGROUND

The treatment of postpartum depression with selective serotonin reuptake inhibitors (SSRIs) has been claimed to be both efficacious and well tolerated, but no recent systematic reviews have been conducted.

METHODS

A qualitative systematic review of randomized clinical trials on women with postpartum depression comparing SSRIs to placebo and/or other treatments was performed. A comprehensive literature search of online databases, the bibliographies of published articles and grey literature were conducted. Data on efficacy, acceptability and tolerability were extracted and the quality of the trials was assessed.

RESULTS

Six randomised clinical trials, comprising 595 patients, met quality criteria for inclusion in the analysis. Cognitive-behavioural intervention, psychosocial community-based intervention, psychodynamic therapy, cognitive behavioural therapy, a second-generation tricyclic antidepressant and placebo were used as comparisons. All studies demonstrated higher response and remission rates among those treated with SSRIs and greater mean changes on depression scales, although findings were not always statistically significant. Dropout rates were high in three of the trials but similar among treatment and comparison groups. In general, SSRIs were well tolerated and trial quality was good.

LIMITATIONS

There are few trials, patients included in the trials were not representative of all patients with postpartum depression, dropout rates in three trials were high, and long-term efficacy and tolerability were assessed in only two trials.

CONCLUSIONS

SSRIs appear to be efficacious and well tolerated in the treatment of postpartum depression, but the available evidence fails to demonstrate a clear superiority over other treatments.

Breastfeeding, retinoids, and postpartum depression: a new theory

Postpartum depression (PPD) is an international public health problem affecting at least 1 in 8 mothers. Known risk factors include: giving birth to a preterm or low birth weight infant, babies with greater symptoms of illness at age 4-6 weeks, formula feeding, younger maternal age, smoking, and fatigue. Prolonged breastfeeding is associated with a reduced risk of PPD but the mechanisms are not well understood. Interventions for PPD focusing on psychosocial risk factors have been largely unsuccessful, suggesting that the condition has a mainly biological basis. The hypothesis proposed for consideration is that breastfeeding protects against PPD by maintaining endogenous retinoids (vitamin A-related compounds) below a threshold concentration. In fact, breast milk is rich in retinoids; pregnant women accumulate retinoids in liver and breast in preparation for lactation; there is increasing evidence that retinoids in higher concentration are associated with cognitive disturbances and mood disorders, including depression and suicide; and prolonged lactation reduces maternal stores of retinoids. Consistent with this hypothesis, it is estimated that an amount of vitamin A is transferred from mother to infant during the first six months of exclusive breastfeeding equivalent to 76% of a dose known to cause acute vitamin A poisoning in an adult. Breastfeeding may thus have evolutionary-adaptive functions for both mother and infant, transferring vital nutrients to an infant unable to feed itself, yet at the same time providing a natural means of reducing potentially toxic concentrations of retinoids in the mother.

A comparative study of psychopathology, symptom severity, and short-term outcome of postpartum and nonpostpartum mania

OBJECTIVES

Most studies acknowledge that postpartum psychosis is a variant of bipolar disorder with certain unique clinical features. There have been several descriptions of similarities and differences between postpartum psychosis and postpartum mania to support this conclusion. However, not many studies have compared postpartum-onset and nonpostpartum-onset mania. This study compared short-term outcome, clinical features, and severity of symptoms between these two groups.

METHODS

Two groups of women (n = 30 each) matching the study criteria were recruited from psychiatric inpatient units in India during the period from April 2007 to August 2008. They had been systematically assessed for psychiatric symptoms and symptom severity using the Comprehensive Psychopathology Rating Scale (CPRS), Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HDRS), and Global Assessment of Functioning Scale (GAF). To evaluate short-term outcome, all assessments were conducted within a week of admission and were repeated at six weeks.

RESULTS

Women with postpartum-onset mania had higher scores on the HDRS, indicating more depressive symptoms. The score on the anxiety factor of the HDRS was also higher in the postpartum group. Based on CPRS ratings, perplexity, muscle tension, worrying, inner tension, lability of mood, lassitude, and disorientation were more common in the postpartum group, while typical manic symptoms were more common in the nonpostpartum group. Duration of hospital stay and short-term outcome were, however, similar in the two groups.

CONCLUSIONS

Symptoms of depression and anxiety are more common and more severe in mania of postpartum onset and typical manic symptoms are fewer. However, six-week outcomes appear similar to those of nonpostpartum mania.

Preventive interventions for postnatal psychosis

BACKGROUND

Postnatal psychosis is a worldwide life-threatening condition that affects one to two in every 1000 new mothers. It has an abrupt onset within a month of childbirth. Affected new mothers rapidly develop frank psychosis, cognitive impairment, and disorganised behaviours. Factors that increase the risk of postnatal psychosis include primiparous mothers who are single, women who are older, or with a past psychiatric history and family history of affective psychosis, prenatal depression and autoimmune thyroid dysfunction. The risk of a future postnatal recurrence is 25% to 57%. Preventive interventions for postnatal psychosis aim at identifying women with risk factors, early recognition of imminent psychosis through screening, and preventive drug therapy. Mood stabilisers, antipsychotic drugs and hormone therapy may be beneficial in the prevention of postnatal psychotic episodes in women at risk.

OBJECTIVES

To investigate the best available evidence for interventions aimed at preventing postnatal psychosis.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register and the Cochrane Central Register of Controlled Trials (CENTRAL) in October 2012 using the search strategy of the Cochrane Schizophrenia Group.

SELECTION CRITERIA

All randomised controlled trials relevant to the prevention of postnatal psychosis.

DATA COLLECTION AND ANALYSIS

Two review authors inspected all citations to ensure reliable selection. If we had included relevant trials, we planned to assess the methodological quality of identified trials using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions. Two review authors would have independently extracted data. For homogenous dichotomous data, we planned to calculate the risk ratio (RR), 95% confidence interval (CI), and the number needed to treat to benefit/harm (NNTB/NNTH) on an intention-to-treat basis.

MAIN RESULTS

There are no included studies in this review. The electronic search produced three relevant references, among which we identified two old planned trials that seem never to have started, and one which we excluded a study because it was a report of a case series.

AUTHORS' CONCLUSIONS

This is not an empty review - it is a review full of unanswered questions. Despite growing interest in women's mental health, the literature in the area of postnatal psychosis is still very limited. It seems that clinicians have no choice but to continue with their current practices guided solely by varied clinical judgement. Women at risk of postnatal psychosis and their relatives are justified to be disappointed in the medical/research fraternity. A post hoc PubMed topic (not methodology-specific) search identified mainly case series. Policy makers have no trial-based evidence upon which to base their guidelines. Certainly, preventive interventions for postnatal psychosis are difficult to justify with confidence without well-designed, well-conducted, and well-reported randomised studies. Available publications suggest that such studies are possible and funders of research may wish to make this work a priority.

Child murder by parents and evolutionary psychology

This article explores the contribution of evolutionary theory to the understanding of causation and motive in filicide cases and also reviews special issues in the forensic evaluation of alleged perpetrators of filicide. Evolutionary social psychology seeks to understand the context in which our brains evolved, to understand human behaviors. The authors propose evolutionary theory as a framework theory to meaningfully appreciate research about filicide. Using evolutionary psychology as a theoretical lens, this article reviews the research on filicide over the past 40 years, and describes epidemiologic and typologic studies of filicide, and theoretical analyses from a range of disciplines.

[Peripartum depression and grief after pregnancy loss: special problem areas in obstetrics]

There is evidence that postpartum depression increases the risk of premature birth and developmental disabilities of the child. Risk factors include a history of depression, prenatal anxiety, lack of social support, intimate partner violence, low socioeconomic status and lack of a relationship. For women in high risk groups antenatal interventions could reveal positive effects to prevent postpartum depression. In the peripartum period routine screening is recommended to detect women at risk of developing depression. Furthermore, prenatal losses during pregnancy, specifically occurring during the first weeks of pregnancy may result in complicated grief disorders. Only very few controlled and randomized intervention studies for the treatment after prenatal loss have been conducted; however, aimed at specific high-risk groups these bereavement interventions demonstrated a high treatment efficacy.

[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.

Recognizing and treating peripartum depression

BACKGROUND

In this article, we review current data on the prevalence of, risk factors for, and treatment of peripartum depression.

METHOD

Pertinent publications were retrieved by searches in Medline and the Cochrane Library using the key words "peri/pre/post", "partum/partal/natal", "maternal/motherhood/pregnancy", and "depression/affective disorder".

RESULTS

Depression is the most common peripartal disease: The prevalence of depressive disorders is 18.4% during pregnancy and 19.2% in the puerperium. Prepartum depression is associated with preterm birth, low birth weight, and an abnormal fetal heart rate. In the long run, children of depressed mothers have been found to have impaired cognitive and emotional abilities. Risk factors for peripartal depression include prior depression, poor social support, poor quality of intimate relationship, and negative live events. Peripartum depression can be treated effectively with psychotherapy or drug therapy. Current data support the use of antidepressants during pregnancy and breastfeeding. In many places, pregnancy counseling centers offer low-threshold psychosocial assistance. Nonetheless, no more than 20% of the affected women are identified, even though rapid screening would be possible with instruments such as the Edinburgh Postnatal Depression Scale (EPDS) and the two Whooley questions.

CONCLUSION

Peripartum depression is both common and treatable. Screening for depression should become a routine part of both prepartum care by gynecologists and postpartum care by midwives. This will only be possible, however, with expanded availability of ambulatory and inpatient psychotherapy and psychiatric care for the affected women and their children.

Women's experience of postpartum psychotic episodes--analyses of narratives from the internet

The aim of this study was to gain an insight into women's experiences of postpartum psychosis (PPP). Ten narratives taken from the Internet, which met the definition of PPP, were analyzed using cross-case and content analyses. The results revealed women's experience of having unfulfilled dreams, being enveloped by darkness, having disabling symptoms, and being abandoned. The women's experiences point to the importance of further education of nurses and doctors concerning PPP. It is vital not only for those working in psychiatric health care but also midwives and nurses who are working in maternity wards and child welfare centers. This would facilitate early recognition of signs and symptoms of the disorder, which, in turn, would make early treatment possible, thus supporting recovery. Furthermore, greater knowledge could contribute to providing more effective and compassionate care for these women.

State of Consultation-Liaison Psychiatry in India: Current status and vision for future

Over the years Consultation-Liaison (C-L) psychiatry has contributed significantly to the growth of the psychiatry and has brought psychiatry very close to the advances in the medicine. It has also led to changes in the medical education and in the providing comprehensive management to the physically ill. In India, although the General Hospital Psychiatric units were established in 1930s, C-L Psychiatry has never been the main focus of training and research. Hence there is an urgent need to improve C-L Psychiatry services and training to provide best and optimal care to the patients and provide best education to the trainees.

Postpartum mental health screening and diagnosis by obstetrician-gynecologists

Postpartum depression (PPD) and postpartum psychosis (PPP) can impact mother, infant, and family. Obstetrician-gynecologists (ob-gyns) are often the most frequent medical contact for postpartum women, and so are in a position to identify women needing psychological care. This study assessed ob-gyns' knowledge, attitudes, and practices regarding diagnosing PPD/PPP. A survey was sent to 400 members of the American College of Obstetricians and Gynecologists who have volunteered to participate in research. Response rate was 56%. Routine screening for PPD and PPP is conducted by 72% and 30% of respondents, respectively. Personal experience (through friend, family, or self) was associated with increased screening. Perceived PPP screening barriers are similar to those found in the PPD literature: time constraints, lack of training, and lack of knowledge of diagnostic criteria. In responding to standardised vignettes, physicians were more likely to over-diagnose, than under diagnose PPD/PPP. This study is the first to provide exploratory data of ob-gyns' knowledge, attitudes, and practice regarding PPD and PPP. Ob-gyns are screening for PPD/PPP, though not universally so. Future research should identify ways to mitigate screening barriers.

Maternal Filicide and Mental Illness in Italy: A Comparative Study

This retrospective records review study of maternal filicide in Italy compared the demographic, historical, clinical, victim, and offense/forensic characteristics of mothers with (MI) and without (NMI) severe mental illness. MI mothers were found to be older, married, more intelligent, and unemployed at the time of their crime. They were more likely to be in psychiatric outpatient treatment and to have a history of suicide attempts. NMI mothers were more likely to have given birth in a nonhospital setting and to have a younger-aged victim. MI mothers were more likely to have confessed to their crime, but at trial almost all were acquitted by reason of insanity. Implications of the data for treatment planning and prevention are discussed.

Prevalence and correlates of suicidality among Indian women with post-partum psychosis in an inpatient setting

OBJECTIVE

The aims of the present study were twofold: first, to determine the prevalence of suicidal ideation and suicide attempts among women inpatients with post-partum-onset psychosis; and second, to describe the clinical, childbirth-related and demographic correlates of suicidal ideation in this group.

METHOD

A total of 82 post-partum women consecutively admitted to the psychiatric unit of the National Institute of Mental Health and Neurosciences, India during 18 months were assessed using the Comprehensive Psychopathology Rating Scale (CPRS) for psychopathology and suicidality.

RESULTS

Thirty-one women (38%) reported suicidal ideation, of whom 15 (18%) had attempted suicide in the current episode. Suicidal ideation and suicide attempts were more frequent in women with depression, an insidious onset of the current illness and those with higher scores on the depressive dimension. On logistic regression analysis, however, only higher scores on the depressive symptom dimension of CPRS, irrespective of diagnosis, emerged as significant (p<0.001). Suicidal ideation was also significantly associated with ideas of harm to the infant (p<0.05).

CONCLUSIONS

There is a high prevalence of suicidal ideation and suicide attempts in this group of patients. Depressive symptoms in post-partum psychosis appear to be the most important risk factor predicting suicidal ideation and attempts.

From Mental Illness to Disability

This article traces the critical engagement of the women's movement with psychiatry, mental health and disability in India over the past two decades. Three phases can be discerned in this history. The first was a phase of radical intellectual disbelief about the very existence of mental illness as a valid knowledge category. In the second phase the experiential reality of women, who had to engage with their own emotional states, found expression in a variety of discourses about women and mental health. The marginalisation of women by the mainstream medical sciences was addressed, and the right to care was redefined as the creation of gender-sensitive sciences. In the third and present phase I interrogate the paths we have taken in the creation of such gender-sensitive mental health practices. A mental illness language has been exhausted of any positive content. The rights orientation to mental health can be developed from disability thinking, which is providing an alternative vision for the world, as well for persons labelled mentally ill.

[Children murdered by their mothers in the postpartum period]

The parental killing of children constitutes a complex phenomenon which has been reported across numerous cultures and throughout history. Children in the 1st year of life are at the highest risk of filicide. Types of filicide in the postpartum period include altruistic filicide, extended suicide, fatal child maltreatment, and neonaticide. Babies are murdered more frequently by mothers who are psychiatrically disturbed. With high frequency, depressive and psychotic symptoms are related to the newborn or to the maternity itself. The knowledge about maternal factors associated with filicide is not homogeneous. Sociodemographic characteristics are presented in relation to the different types of filicide. Risk constellations that may lead to a child's murder are described.

Psychiatrists' knowledge about maternal filicidal thoughts

OBJECTIVE

Child murder by mentally ill mothers is an important public health and psychiatric concern. However, the authors' clinical and forensic experience has been that psychiatrists often do not inquire about maternal thoughts of harming their children. This study sought to elucidate the perceptions of psychiatrists and psychiatric residents regarding the frequency of such thoughts, and to clarify whether they inquire specifically about maternal filicidal thoughts. Psychiatrists were expected to underestimate the prevalence maternal thoughts of harming their children. It was hypothesized that psychiatrists often do not ask their patients about these thoughts.

METHODS

This study surveyed psychiatrists and psychiatric residents at 2 academic institutions. Respondents were asked whether they routinely query women about motherhood, to estimate the frequency of thoughts of child harm, and whether they inquire about filicidal thoughts in psychotic or suicidal mothers.

RESULTS

Two hundred twenty surveys (67%) were returned. Most psychiatrists underestimated the frequency of depressed mothers who experienced thoughts of harming their young children. Almost one half indicated that they do not ask specifically about filicidal ideation but rather ask about general homicidal thoughts only.

CONCLUSIONS

Psychiatrists should have further education about the prevalence of filicidal thoughts and more frequently inquire about them.

Judgments of culpability in a filicide scenario

Previous research has indicated that potential jurors are likely to use personal biases, such as those based on gender and ethnicity, in their judgments of culpability of criminal defendants in addition to, or instead of, the facts of the crime. The present paper seeks to extend this literature to the crime of filicide; to examine whether male defendants are judged more harshly than female defendants, as is the case for domestic violence and sexual abuse. 214 participants were provided with a scenario of filicide in which the gender of the perpetrator, the gender of the child, and the family's social class were randomly assigned. Participants were asked to rate the culpability of the defendant in the case. Results indicated that, unlike for other violent crimes, participants did not use gender or social class biases in their judgments of criminal culpability.

[Infanticide in the postpartum period: about a clinical case]

BACKGROUND

Infanticide is an extremely traumatic criminal act, which has psychopathologic repercussions and severe sociofamilial consequences. It is marked by its plurality of forms, the variety of its aspects and the frequency of its hidden cases. Circumstances and modes of completion of the infanticide act are variable according to the nature of the author and the sociocultural context. Infanticide is often situated within the framework of an acute and a chronic structured psychiatric pathology (puerperal psychosis, maniacodepressive psychosis, schizophrenia, epilepsy, substance abuse, etc.). Sometimes, it is connected to sociocultural constraints and confusions of adaptation of the postpartum stage. The psychopathologic justifications evoke a profound dysfunction of the mother-child interactions, fears of division and the infantile and regressive characteristics of the mother. The medicolegal issue of responsibility of the author of infanticide is complex. Treatment depends on the mental pathology of the author; psychotherapeutic efforts are required in parallel with pharmacological treatment. The role of psychiatrists in preventing the act of infanticide is crucial. This consists in detecting the populations at risk, identifying the psychiatric complications of the postpartum stage and ensuring an adequate coordination of the maternity team and the social services.

CASE-REPORT

The infanticide acts reported in the literature are situated in diverse contexts and are motivated by various circumstances. We report a case of a young woman without any personal or family psychiatric history; she is married and has a stable matrimonial life. She was hospitalised following a suicide attempt and subsequently killed her child by strangulation; this occurred ten days after giving birth. The murder took place during a first psychotic episode that arose brutally one week after delivery and essentially included persecution mania, inconsistent comments, auditive hallucinations, indifference and emotional coolness. This symptomatology lasted four months and totally regressed with antipsychotics. The diagnosis of a puerperal psychosis was evoked at first, having eliminated major melancholic depression and any organic affection.

CONCLUSION

The illustration of our clinical case shows to what extent the role of the psychiatrist is essential in preventing and ensuring the therapeutic stage of such psychiatric disorders arising during the postpartum stage, which would complicate infanticide acts at any time.

Delusions related to infant and their association with mother-infant interactions in postpartum psychotic disorders

The relationship between mother infant interactions and psychopathology in postpartum psychotic disorders has been recognised as being clinically important, however data in the field is sparse. The current study had two aims--firstly, to study the prevalence and nature of delusions towards the infant among mothers with postpartum onset severe mental illness and secondly, to study the association between delusional symptoms towards the infant and mother infant interactions. 108 consecutive women with onset of severe mental illness in the postpartum, who were admitted to an inpatient psychiatric unit in South India over a two-year period, were systematically assessed for presence of delusions related to the infant, using the Kannada version of the Birmingham Interview for Maternal Mental Health. Fifty-three percent of subjects reported delusions related to the infant, with 34% reporting more than one delusion. Mothers with infant related persecutory delusions were more likely to show affectionate behaviour and had normal competence and caring for baby's basic needs; however, they were more likely to get disturbed and agitated if separated from the baby. Mothers who had delusions that the baby was a devil or ill fated or someone else's baby, were more likely to have significant abusive incidents towards the baby. Overall, the mothers who had delusions related to the infant were seen to have more significant abusive incidents and were more likely to be considered unsafe in looking after the baby alone. The study emphasises the need for systematic clinical assessment of psychopathology in mothers with postpartum psychosis.

Interactive regulation of affect in postpartum depressed mothers and their infants: an overview

Specific patterns of interaction emerging in the first months of life are related to processes regulating mutual affects in the mother-child dyad. Particularly important for the dyad are the matching and interactive repair processes. The interaction between postpartum depressed mothers and their children is characterized by a lack of responsiveness, by passivity or intrusiveness, withdrawal and avoidance, as well as a low level of positive expression of affect. Thus, an impaired capability to regulate the child's affect has been demonstrated in depressed mothers. Maternal aggression, neglect toward infants, infanticidal thoughts, as well as infanticidal behavior are mainly linked to severe postpartum depression, especially with psychotic symptoms. The findings on mother-child interaction reported in this paper are based on mothers with mild to moderate depressive disorders without psychotic symptoms. Considering the stability of interaction patterns in the course of depressive illness as well as the long-term consequences of these interactions, it seems surprising that there are still few systematic studies of depressed mothers interacting with their infants. In connection with an overview on these issues, treatment models for parent-infant psychotherapy are discussed.

Focus on psychiatry in India

India is a country with a population of over 1 billion, and immense diversity in the languages spoken, levels of literacy, and social and cultural practices. Organising mental health services for this predominantly rural population is indeed a daunting task. Compounding this problem are low budgetary resources, the presence of competing and conflicting healing systems, scarcity of mental health personnel, ‘brain drain’, and the stigma of seeking help for problems related to the mind. This paper looks at the mental health scene in India with respect to services and research. It deals with conditions such as schizophrenia, acute psychoses, minor mental morbidity and drug misuse, highlighting aspects unique to the Indian scene. Indian families exhibit great tenacity in caring for relatives who are ill, and are a great resource in treatment and rehabilitation.

Predicting Infant Maltreatment in Low-Income Families: The Interactive Effects of Maternal Attributions and Child Status at Birth

Maternal attributions and child neonatal status at birth were assessed as predictors of infant maltreatment (harsh parenting and safety neglect). The population included low-income, low-education families who were primarily Hispanic. Child maltreatment during the 1st year of life (N = 73) was predicted by neonatal status (low Apgar scores, preterm status), as moderated by mothers' attributions. The highest levels of maltreatment were shown within dyads that included a mother with low perceived power and an at-risk infant. Partial support was found for maternal depressive symptoms as mediators of harsh parenting among at-risk infants. It is suggested that lack of perceived parental power constrains investment in protective relationships and fosters sensitization to potential threat.