Early postpartum symptoms in puerperal psychosis

The lived experiences of individuals with postpartum psychosis: A qualitative analysis

Postpartum psychosis (PP) is a severe psychiatric illness that occurs in about 1 to 2 per 1000 people in the perinatal period. To date, qualitative research investigating PP has focused on specific topics, such as treatment experiences or the impact of the illness on patients' lives and families. These studies have included small samples of women with histories of PP, often limited to certain geographical areas or treatment centers. Given the heterogeneity in presentations of PP and access to care, larger and geographically diverse samples are needed to broadly understand this complex illness. Initiated in 2018, the Massachusetts General Hospital Postpartum Psychosis Project (MGHP3) consists of a large, international sample of those who have experienced PP. In addition to the specific aims of MGHP3, which include to better understand the phenomenology and potential genetic underpinnings of PP, this investigation invites participants to qualitatively describe their narratives of postpartum psychosis. This analysis included 130 participants who reported on 133 episodes of PP. Participants' responses to the PP narrative prompt fell under several overarching categories: 1) broad psychosocial experiences surrounding postpartum psychosis, 2) impact on the mother-baby dyad, 3) treatment experiences, and 4) recovery experiences. Our findings shed light on a range of ways in which individuals' lives are impacted by this illness, and point to areas for future research and clinical directions to improve the support and care for individuals with PP and their families.

"It kind of strips down your relationship to its defining features……it just kind of shone a light on what was already there": A grounded theory of the impact of postpartum psychosis on the couple's relationship

BACKGROUND

Postpartum psychosis is a severe mental health illness following childbirth. Studies to date have developed from initial focus on experiences of women to address the role and experiences of partners, and recently to touch on the effect on their relationship. This study aimed to build on this work, by focussing directly on the impact of postpartum psychosis on the couple's relationship, from the perspectives of both the woman and her partner.

METHOD

A constructivist grounded theory approach was utilised to generate a theory that explained the impact of postpartum psychosis on the couple's relationship. In-depth semi-structured interviews were completed with a sample of eight women and six partners.

RESULTS

Four stages and five general categories described the processes that the couple experienced, and the impact postpartum psychosis had on their relationship.

DISCUSSION

The grounded theory adds to current evidence and helps increase understanding of factors that play a role in adjustment and outcomes. New insights were identified, including postpartum psychosis amplifying existing relational patterns; and the mediating role of the pre-existing relationship and couplehood. Clinical implications and areas for further research are considered.

Prophylactic Management of Women With Bipolar Disorder During Pregnancy and the Perinatal Period: Clinical Scenario-Based Practical Recommendations From A Group of Perinatal Psychiatry Authors

ABSTRACT

Many women with bipolar disorder experience episodes of illness or relapses over the perinatal period, especially in the immediate postpartum period. Risks associated with treated/untreated psychopathologies and fetal exposure to bipolar medications make the management of bipolar disorder during these periods challenging for clinicians and patients. In light of the available effectiveness and reproductive safety data, the current clinical update based on the opinions of a group of international perinatal psychiatry authors recommends general considerations and specific management strategies for each possible clinical scenario, including mixed features, predominant polarity, diagnosis of subtypes of bipolar disorder, severity of previous episodes, and risk of recurrence of mood episodes.

Experiences of Mental Health Care Among Women Treated for Postpartum Psychosis in England: A Qualitative Study

Postpartum psychosis has been found to affect 0.89-2.6 per 1000 women. Onset is typically rapid and severe. Early recognition and appropriate treatment are crucial for a good prognosis. Our aim in this study was to understand women's experiences of mental health care and services for psychosis in the postnatal period. Semi-structured interviews were conducted with 12 women who reported being treated for postpartum psychosis. Findings were analysed thematically. Women reported that healthcare professionals across maternity and mental health services often lacked awareness and knowledge of postpartum psychosis and did not always keep them or their partners/families informed, supported, and involved. Women wanted better collaboration between and within services, and more efficient, appropriate, and timely care. They valued inpatient services that could meet their needs, favouring Mother and Baby Units over general psychiatric wards. Early Intervention in Psychosis services and specialist perinatal community mental health teams were also well liked.

Postpartum Psychosis: The Role of Women's Health Care Providers and the Health Care System

Importance

The postpartum period is a time of high risk for serious psychiatric symptoms and hospitalization. Postpartum psychosis (PPP) is the most severe disorder that emerges during this time, with significant and wide-ranging consequences that can include suicide and infanticide.

Evidence Acquisition

A PubMed, MEDLINE, and PsycINFO search was completed for English-language publications about PPP, including subtopics (eg, infanticide, maternal suicide). Citations in these articles were also reviewed for relevant references.

Results

Although it is clear that the triggering event for PPP is childbirth, the processes by which this occurs are not fully understood, which is a critical need for being able to predict, prevent, and manage PPP. There are risk factors that contribute to PPP, and specific groups of women may be at increased risk (eg, women with bipolar disorder). Many questions and challenges remain related to the phenomenology, nosology, prevention, and treatment of PPP. However, there are changes that women's health care providers and systems can take to improve the care of women at risk of and experiencing PPP.

Results

Of the 1382 articles reviewed, 8 met eligibility criteria, representing 6 distinct cohorts and 726 subjects. Synthetic slings available for review were either tension-free vaginal tape (TVT) or minisling. The vast majority of studies demonstrated similar short- and long-term success rates of AFS and SS procedures utilizing a range of outcome measures. Both AFS and TVT sling had low recurrence rates in short- and long-term follow-up. However, AFS had significantly longer operative time, and longer hospital stay. Bladder perforation, on the other hand, occurred more commonly in TVT sling. Health-related quality-of-life scores, including sexual function, were similar between groups.

Conclusions and Relevance

Postpartum psychosis is a rare but serious condition. However, recovery is possible. Women's health care providers and systems can improve the care by better understanding the needs of women and families, offering patient-centered discussions and options for care, particularly those that promote recovery, minimize risk, and limit the interruption of the maternal-infant bond. Improving the prevention and treatment of PPP can have a broad impact for women, children, and families.

It's About Time: The Circadian Network as Time-Keeper for Cognitive Functioning, Locomotor Activity and Mental Health

A variety of organisms including mammals have evolved a 24h, self-sustained timekeeping machinery known as the circadian clock (biological clock), which enables to anticipate, respond, and adapt to environmental influences such as the daily light and dark cycles. Proper functioning of the clock plays a pivotal role in the temporal regulation of a wide range of cellular, physiological, and behavioural processes. The disruption of circadian rhythms was found to be associated with the onset and progression of several pathologies including sleep and mental disorders, cancer, and neurodegeneration. Thus, the role of the circadian clock in health and disease, and its clinical applications, have gained increasing attention, but the exact mechanisms underlying temporal regulation require further work and the integration of evidence from different research fields. In this review, we address the current knowledge regarding the functioning of molecular circuits as generators of circadian rhythms and the essential role of circadian synchrony in a healthy organism. In particular, we discuss the role of circadian regulation in the context of behaviour and cognitive functioning, delineating how the loss of this tight interplay is linked to pathological development with a focus on mental disorders and neurodegeneration. We further describe emerging new aspects on the link between the circadian clock and physical exercise-induced cognitive functioning, and its current usage as circadian activator with a positive impact in delaying the progression of certain pathologies including neurodegeneration and brain-related disorders. Finally, we discuss recent epidemiological evidence pointing to an important role of the circadian clock in mental health.

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.

Diseases and complications of the puerperium

BACKGROUND

In terms of maternal morbidity and mortality, the puerperium is just as significant as pregnancy and childbirth. Nearly half of all maternal deaths occur in the time after delivery.

METHODS

This review is based on pertinent articles in English and German from the years 2000- 2020 that were retrieved by a selective search in MEDLINE and EMBASE, as well as on the available guidelines in English and German and on German-language textbooks of obstetrics.

RESULTS

The most common and severe complications are, in the post-placental phase, bleeding and disturbances of uterine involution; in the first seven days after delivery, infection (e.g., endomyometritis, which occurs after 1.6% [0.9; 2.5] of all births) and hypertension-related conditions. Thromboembolism, incontinence and disorders of the pelvic floor, mental disease, and endocrine disturbances can arise at any time during the puerperium. In an Australian study, the incidence of embolism was 0.45 per 1000 births, with 61.3% arising exclusively after delivery.

CONCLUSION

Basic familiarity with the most common and severe diseases in the puerperium is important for non-gynecologists as well, among other things because highly acute, lifethreatening complications can arise that demand urgent intervention.

Postpartum Psychosis after Traumatic Cesarean Delivery

An emergency cesarean delivery can be a traumatic childbirth experience for a woman and a risk factor for postpartum psychosis, especially in a patient with a history of bipolar disorder. This article describes the case of a pregnant woman with an unknown history of bipolar disorder who developed an acute psychotic reaction during the procedure of an emergency caesarian section and switched to mania. The purpose of this case study is for perinatal health care professionals to identify suspicious symptoms and promptly refer to psychiatric services so as to ensure the mother's and the newborn's safety. This case study highlights the importance of assessing women with bipolar disorder or a previous psychotic episode for the risk of psychiatric complications in pregnancy and after childbirth. Midwifery education on perinatal mental health is crucial for the detection of suspicious symptoms and early referral to a specialist.

A closer look at the nosological status of the highs (hypomanic symptoms) in the postpartum period

Studies from several countries have reported occurrence of the highs (hypomanic symptoms) immediately after childbirth; however, questions remain about the relationship of the highs with mood disorders. This systematic review aims to clarify this relationship, critically review important aspects of the highs, and make treatment recommendations and suggestions for future research. The electronic databases of MEDLINE/PubMed, PsycINFO, CINAHL, Cochrane Database of Systematic Reviews, and Evidence-Based Medicine Reviews (EBMR) were searched using the keywords and their combinations: postpartum, euphoria, hypomania, and baby pinks. Reference lists of articles identified were also searched. Using the Highs scale, studies have found that 9.6-49.1% of postpartum women have hypomanic symptoms. Some but not all of the studies found an association of the highs with later depression. Symptoms of hypomania or mania are also common among women referred to specialized perinatal clinics for mood disorders. Depending on the instrument used, 12-30% of these women have symptoms of hypomania or mania after childbirth. The methodological limitations of current studies do not permit any definitive conclusions about the nosology of the highs. The discrepancy between the reported prevalence of the highs in non-clinical populations and the prevalence rates of bipolar disorder in the general population implies that the highs may be analogous to the baby blues in some women. Longitudinal studies are needed to investigate whether the highs are limited to the postpartum period or whether there are some women who continue to have recurrences of the highs outside of the postpartum period.

Postpartum Depression: Identification and Treatment in the Clinic Setting

Perinatal care, including the management of mental health issues, often falls under the auspices of primary care providers. Postpartum depression (PPD) is a common problem that affects up to 15% of women. Most women at risk can be identified before delivery based on psychiatric history, symptoms during pregnancy, and recent psychosocial stressors. Fortunately, there have been a variety of treatment studies using antidepressants, nonpharmacologic interactions, and most recently, allopregnanolone (Brexanolone) infusion that have shown benefits. The most commonly used screening scale, Edinburgh Postnatal Depression Scale, a 10-item self-rated scale, has been translated into a variety of languages.

Recovery from postpartum psychosis: a systematic review and metasynthesis of women's and families' experiences

Postpartum psychosis is a serious disorder that can result in adverse consequences for the mother and baby. It is important that we understand the experiences of women, to develop effective interventions during this critical period. The aim of this systematic review was to conduct a metasynthesis of qualitative research exploring women's experiences of postpartum psychosis and factors involved in recovery from the perspective of women and family members. A comprehensive literature search of five databases was conducted and the findings were appraised and synthesised, following a thematic synthesis approach. Fifteen studies, capturing the views of 103 women and 42 family members, met the inclusion criteria. Four main themes incorporating 13 subthemes were identified following synthesis: (1) Experiencing the unspeakable, (2) Loss and disruption, (3) Realigning old self and new self and the integrative theme of (4) Social context. The findings offer new insight into the unique experience of postpartum psychosis and demonstrate that recovery does not follow a linear path. To improve clinical outcomes, a more integrative and individualised approach is needed which incorporates long-term psychological and psychosocial support, and considers the needs of the family. Further areas for staff training, service development and future research are highlighted.

Maternal and child delivery charges, postpartum charges, and utilization of care among women with bipolar disorder: a cohort study

Bipolar disorder (BD) during pregnancy is known to be a morbid condition associated with poor outcomes for both the mother and her infant. We aimed to determine if women with BD and their children have higher charges and health service utilization than mother-infant dyads with and without other mental health (MH) diagnoses. The International Classification of Diseases, Ninth Revision (ICD9) codes were used to identify mutually exclusive groups of women who gave birth between January 1, 2011, and December 31, 2012, coding first for BD, then diagnoses that comprised an "other MH diagnoses group" that included post-traumatic stress disorder, anxiety, and depression. Health service utilization and related charges were obtained for the dyad for delivery and for 2 years post-delivery at a single tertiary care center. Analyses included 4440 dyads. A BD diagnosis occurred in 1.8% of medical record codes, other MH diagnoses in 10%, and no known MH diagnosis in 88%. Compared with women with both other MH and no known MH diagnoses, women with BD had higher delivery charges (p < 0.001), higher cumulative charges in the 2 years postpartum (p < 0.001), higher preterm birth and low birthweight rates (15.5% v. 6.9% and 20.8% v. 6.4%, p < 0.001, BD v. no known MH, respectively), and greater utilization of inpatient and emergency psychiatric care services (p < 0.001). Compared with women with and without other mental health diagnoses, women with BD have the highest care utilization and charges. They also have higher preterm birth and low birthweight infant rates, two clinically relevant predictors of long-term health for the child. Given the low prevalence of BD and severity of the disease versus the magnitude of systems costs, women with BD, and their children, deserve the heightened attention afforded to other high-risk perinatal conditions.

Psychological interventions for managing postpartum psychosis: a qualitative analysis of women's and family members' experiences and preferences

BACKGROUND

Postpartum psychosis is a rare, yet severe disorder, in which early identification and immediate intervention are crucial. Despite recommendations for psychological input, little is known about the types of psychological intervention reported to be helpful. The aim of this study was to explore the experiences, needs and preferences for psychological intervention from the perspective of women with postpartum psychosis and from the perspective of family members.

METHODS

Thirteen women and eight family members, including partners were interviewed. The data from these semi-structured interviews were audio-recorded, transcribed and inductively analysed using thematic analysis.

RESULTS

Twelve subthemes were identified and then organised around three main themes: 1) Seeking safety and containment, 2) Recognising and responding to the psychological impact and 3) Planning for the future. These themes highlight the temporal element of recovery from postpartum psychosis, because women's psychological needs and preferences changed over time. Emphasis was initially placed on ensuring safety, followed by a need to connect, process and adjust to their experiences. Additional needs were reported by women and family when planning for the future, including managing the fear of relapse and help to reach a decision about future pregnancies.

CONCLUSION

The results illustrate a range of areas in which psychological intervention could be delivered to facilitate and enhance recovery. Further research is needed to develop meaningful and effective psychological interventions and to investigate the most appropriate timing for this to be offered.

Auricular Treatment of Maternal Depressive Disorders

The birth of a child is one of the greatest moments in the life of a parent. It brings joy, bliss, and exhilaration. However, for a variety of reasons, childbirth may also promote fear and anxiety. In some cases, childbearing can even cause considerable emotional distress that can ruthlessly influence the dynamics of the family. Perinatal depressive disorders are mood disorders that can affect mothers, and are considered one of the most common complications during and after pregnancy. Perinatal depressive disorders can have profound negative effects on personal and family life. These disorders can also have serious childrearing consequences. The auricular acupuncture microsystem has been used for a long time to treat emotional problems in both animals and humans. This system offers a safe approach to treat depressive states without side-effects or complications.

Childbirth and prevention of bipolar disorder: an opportunity for change

The recent conceptualisation of bipolar disorder as a neuroprogressive illness has highlighted the potential importance of prevention and early intervention in high-risk populations. Undiagnosed bipolar disorder early in the disease course is associated with adverse clinical outcomes and impaired functioning for patients, which in turn has economic consequences. Despite the mounting evidence that childbirth is one of the most potent and specific triggers of manic symptoms, studies are not available on the effectiveness of targeted interventions in the prevention of bipolar disorder in women who have recently given birth. In this Personal View, we describe the clinical characteristics of women at risk of developing bipolar disorder after childbirth, before discussing opportunities for prevention and early intervention and outlining challenges in the assessment and management of women at risk of transitioning to bipolar disorder after childbirth. Existing evidence, although scarce, supports a clinical staging model by which at-risk women are managed with a variety of behavioural and pharmacological interventions aimed at preventing bipolar disorder. Close monitoring and early intervention might reduce the risk of hypomanic or manic symptoms in women at risk of developing bipolar disorder after childbirth; however, the potential benefits of early identification and intervention need to be carefully balanced against the additional risks for affected women.

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.

The Prevalence of Anxiety Disorders During Pregnancy and the Postpartum Period: A Multivariate Bayesian Meta-Analysis

OBJECTIVE

To estimate the prevalence of anxiety disorders in pregnant and postpartum women and identify predictors accounting for variability across estimates.

DATA SOURCES

An electronic search of PsycINFO and PubMed was conducted from inception until July 2016, without date or language restrictions, and supplemented by articles referenced in the obtained sources. A Boolean search phrase utilized a combination of keywords related to pregnancy, postpartum, prevalence, and specific anxiety disorders.

STUDY SELECTION

Articles reporting the prevalence of 1 or more of 8 common anxiety disorders in pregnant or postpartum women were included. A total of 2,613 records were retrieved, with 26 studies ultimately included.

DATA EXTRACTION

Anxiety disorder prevalence and potential predictor variables (eg, parity) were extracted from each study. A Bayesian multivariate modeling approach estimated the prevalence and between-study heterogeneity of each disorder and the prevalence of having 1 or more anxiety disorder.

RESULTS

Individual disorder prevalence estimates ranged from 1.1% for posttraumatic stress disorder to 4.8% for specific phobia, with the prevalence of having at least 1 or more anxiety disorder estimated to be 20.7% (95% highest density interval [16.7% to 25.4%]). Substantial between-study heterogeneity was observed, suggesting that "true" prevalence varies broadly across samples. There was evidence of a small (3.1%) tendency for pregnant women to be more susceptible to anxiety disorders than postpartum women.

CONCLUSIONS

Peripartum anxiety disorders are more prevalent than previously thought, with 1 in 5 women in a typical sample meeting diagnostic criteria for at least 1 disorder. These findings highlight the need for anxiety screening, education, and referral in obstetrics and gynecology settings.

The psychopathology of NMDAR-antibody encephalitis in adults: a systematic review and phenotypic analysis of individual patient data

BACKGROUND

Early immunotherapy administration improves outcomes in patients with N-methyl-D-aspartate receptor (NMDAR)-antibody encephalitis. As most patients with NMDAR-antibody encephalitis present to psychiatrists, the psychopathology of NMDAR-antibody encephalitis needs to be clearly defined to encourage accurate clinical identification and prompt treatment.

METHODS

For this systematic review, we searched PubMed for all studies published in English between Jan 1, 2005, and Oct 7, 2017, to identify individually reported adult patients (≥18 years) who satisfied consensus criteria for definite NMDAR-antibody encephalitis. After generating a list of 50 fine-grained, lower-level features, we extracted psychopathological data in addition to demographic and aetiological data. The lower-level features were later ordered within higher-level categories. As a means of quality control, we filtered the data according to proxy markers of psychiatric involvement in their description. Subsequently, we compared lower-level features from individual patient data with operationalised psychiatric syndromes using a constrained combination approach and principal component analysis, and did a network analysis to explore the inter-relationships between multiple lower-level features. The review protocol was prospectively registered with PROSPERO, number CRD42017068981.

FINDINGS

Of 1096 records identified in PubMed, 333 satisfied inclusion criteria and described 1100 patients in total with NMDAR-antibody encephalitis. The psychopathology of 505 (46%) patients with reported psychiatric symptoms was described in more detailed terms than only psychiatric or behavioural. 464 (91%) of the 505 patients were from papers in which patient data were reported individually. The remainder of the analyses focused exclusively on these 464 patients. Median age was 27 years (IQR 22-34), 368 (79%) of 464 patients were female and in 147 (32%), NMDAR-antibody encephalitis was associated with ovarian teratoma. The five higher-level categories into which the 464 patients most frequently grouped were behaviour (316 [68%]), psychosis (310 [67%]), mood (219 [47%]), catatonia (137 [30%]), and sleep disturbance (97 [21%]). The overall pattern of lower-level features was statistically stable across subgroups classified by age, sex, pregnancy association, presence of ovarian teratoma, prior herpes simplex virus encephalitis, and isolated psychiatric presentations (two-way ANOVA p=0·6-0·9). Constrained combination and principal component analyses found that mixtures of mood and psychosis syndromes fit each patient better than any single diagnosis alone, particularly for the patients in the psychiatric-described subgroup (mean ΔAkaike information criterion -0·04 in non-psychiatric-described subgroup vs 0·61 in psychiatric-described subgroup). The overlapping nature of the higher-level features was also enriched upon analysis of the psychiatric-described data (221 [67%] of 329 overlaps in non-psychiatric-described subgroup vs 96 [81%] of 118 overlaps in psychiatric-described subgroup, p=0·0052). Network analysis confirmed that the features were closely related and consistent between individual patients; the psychiatric-described subgroup had a markedly high and narrow range of closeness centralities (92% above 0·93 in psychiatric-described subgroup vs 51% above 0·93 in the non-psychiatric group).

INTERPRETATION

The distinctive aspect of NMDAR-antibody encephalitis psychopathology is complexity; core aspects of mood and psychotic disorders consistently coexist within individual patients. Alongside the predominant young female demographic, these psychopathological features could help psychiatrists identify patients who would benefit from cerebrospinal fluid testing and immunotherapies. Well-controlled prospective studies with bespoke inventories are needed to advance this clinically grounded approach.

FUNDING

Wellcome Trust, NIHR Oxford Biomedical Research Centre, NIHR Oxford Health Biomedical Research Centre, British Medical Association Foundation for Medical Research.

The impact of postpartum psychosis on partners

Background

Postpartum Psychosis is a severe mental health condition following childbirth, with a psychosis and associated mood disturbance. Research to date has primarily focused on mothers’ experiences, and on identifying risk factors, aetiology, and intervention efficacy. Within both research and clinical communities, there has been little acknowledgement of partners’ experiences of Postpartum Psychosis, nor the important support role that partners can provide. The aim of this study was to consider the lived experiences of partners of women who have had Postpartum Psychosis, and the impact that it has had on their lives and relationships.

Methods

Participants (N = 8) were partners recruited through the charity Action on Postpartum Psychosis. Partners completed an in-depth, semi-structured interview regarding their experiences of Postpartum Psychosis. Interpretative Phenomenological Analysis was used to analyse the interview transcripts.

Results

Seven superordinate themes emerged from the interview data: loss; powerlessness; united vs. individual coping; hypothesising and hindsight; barriers to accessing care and unmet needs; managing multiple roles; and positive changes from Postpartum Psychosis.

Conclusions

These findings provide a rich illustration of the experiences of partners, including some previously unidentified findings relating to partner hypervigilance to signs of relapse and positive changes in their attitudes and relationships. Areas where support could be provided for partners are also highlighted.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-2055-z) contains supplementary material, which is available to authorized users.

Women's views and experiences of having their mental health needs considered in the perinatal period

OBJECTIVE

To explore women's views and experiences of having their mental health needs considered in the perinatal period in an Irish maternity hospital setting.

DESIGN

A qualitative design using semi-structured interviews was used to explore women's views and experiences. Data were analysed using Thematic Analysis (Braun and Clarke, 2006).

SETTING

A voluntary maternity hospital in Dublin, Ireland which had access to a perinatal mental health team.

PARTICIPANTS

In total 8 women who met the inclusion criteria were recruited and participated in this study. The women were interviewed in the early postpartum period.

FINDINGS

The study offers important insights into how women feel about having their mental health needs considered in the perinatal period. Women reported pregnancy was an emotional time, feeling expected to be happy, and women with significant mental health histories preferred not to be referred to available services unless they asked for help. Women reported barriers to disclosure including stigma/shame, lack of time. Screening tools were viewed with mixed opinions. In getting help, the baby was a motivator for some women, attitudes of healthcare professionals and lack of time affected this.

KEY CONCLUSIONS

Women appreciated all methods of enquiry about their mental health and being given time to discuss concerns with healthcare professionals. Perceived busy staff workloads was a barrier in asking for help, as was lack of continuity of care. Screening tools were viewed as a tick box exercise, but also as a 'modality' to assist detection of women at risk. Mental health enquiry focused on depression and anxiety, with little or no enquiry about less common disorders. Women with significant histories were less likely to engage or accept referral to perinatal mental health services, preferring to access help if they felt they needed to.

IMPLICATIONS FOR PRACTICE

HCPs should enquire regularly about women's emotional wellbeing at every antenatal and postnatal contact, offering support where required. Detailed enquiry about mental health should encompass the broad spectrum of perinatal mental health problems, including but not limited to depression and anxiety. Screening tools can assist in the identification of women at risk of developing perinatal mental health problems. A specialist mental health midwife should link with high-risk women at the first antenatal booking visit and provide information on early intervention and access to services.

Postpartum psychiatric disorders

Pregnancy is a complex and vulnerable period that presents a number of challenges to women, including the development of postpartum psychiatric disorders (PPDs). These disorders can include postpartum depression and anxiety, which are relatively common, and the rare but more severe postpartum psychosis. In addition, other PPDs can include obsessive-compulsive disorder, post-traumatic stress disorder and eating disorders. The aetiology of PPDs is a complex interaction of psychological, social and biological factors, in addition to genetic and environmental factors. The goals of treating postpartum mental illness are reducing maternal symptoms and supporting maternal-child and family functioning. Women and their families should receive psychoeducation about the illness, including evidence-based discussions about the risks and benefits of each treatment option. Developing effective strategies in global settings that allow the delivery of targeted therapies to women with different clinical phenotypes and severities of PPDs is essential.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third- line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment-emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second- line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence-based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first-line treatments for acute mania. First-line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first-line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.

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.

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.

Homeopathic Treatment for Postpartum Depression: A Case Report

Postpartum psychosis has long-lasting consequences for mother and child. Beside depression, sleep and eating disturbances, exhaustion, social withdrawal, and anxiety, postpartum depression can also interfere with normal maternal-infant bonding and adversely affect child development. Recent reports show that most affected pregnant women are hesitant about taking antidepressant drugs, with a high percentage discontinuing their use. Some authors suggest that the reluctance of pregnant women to take antidepressant drugs should encourage clinicians to discuss with their patients the use of psychological interventions or alternative forms of treatment. In this article, a case of severe postpartum depression, treated successfully with homeopathic therapy, is presented. Considering the high noncompliance of women suffering from postpartum depression with conventional antidepressant medication, research in safe complementary medical methods is justified. One of these methods should be homeopathy.

Risk of postpartum psychosis after IVF treatment: a nationwide case-control study

STUDY QUESTION

Is the risk of postpartum psychosis (PPP) increased in women who give birth after IVF treatment compared to after spontaneous conception?

SUMMARY ANSWER

The risk of PPP is not higher in the group of women who give birth after IVF treatment compared with women who give birth after spontaneous conception.

WHAT IS KNOWN ALREADY

Women who conceive using IVF treatment can experience higher levels of pregnancy-specific distress and are at increased risk of pre-eclampsia, an immune-related condition which in turn has been linked to PPP, as well as other pregnancy and delivery complications, which also serve as PPP risk factors. It is not known whether the risk of PPP is increased in women who have conceived using IVF treatment.

STUDY DESIGN, SIZE, DURATION

A nationwide, register-based, case-control study of all primiparous women who had given birth after IVF treatment between 1988 and 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Information about 10 412 women was collected from the Swedish IVF register. A control group of women who had given birth after spontaneous conception was selected from the Swedish Medical Birth Register (n = 18 624). PPP diagnoses, identified using ICD-10 diagnostic codes F20-31 and F531 the first year postpartum, were collected from the National Patient Register. Associations between PPP and IVF/spontaneous conception were evaluated using chi-square tests and logistic regression analyses while controlling for known risk factors of PPP.

MAIN RESULTS AND THE ROLE OF CHANCE

There were no differences in PPP prevalence between the IVF group and the control group (0.3%, n = 29 versus 0.4%, n = 77) in the chi-square analysis (P = 0.169) or the multiple logistic regression analyses (P = 0.646; odds ratio (OR): 1.178; 95% CI: 586-2.365). No associations between pregnancy or delivery complications and PPP were found. A history of any psychiatric disorder (P < 0.001; OR = 40.7; 95% CI = 23.9-69.5), or specifically a psychotic (P < 0.001; OR = 324.1; 95% CI = 131.3-800.0), bipolar (P < 0.001; OR = 516.1; 95% CI = 264.3-1008.1), depressive (P < 0.001; OR = 27.5; 95% CI = 16.2-46.5), anxiety (P < 0.001; OR = 12.9; 95% CI = 7.4-22.6) or personality disorder (P < 0.001; OR = 27.3; CI = 11.8-63.0), all significantly increased the risk of PPP.

LIMITATIONS REASONS FOR CAUTION

PPP is a rare condition, hence the number of individuals was small. Since all women for whom information was available from all registers were included, it was not possible to further increase the power of the study using this design.

WIDER IMPLICATIONS OF THE FINDINGS

Since this study is the first to examine risk of PPP after IVF treatment, more studies are needed to verify these results. The generalizability is restricted to primiparous women in western countries. This study confirms the results of previous studies in showing a history of mental illness to be the major risk factor for PPP.

STUDY FUNDING/COMPETING INTERESTS

None.

TRIAL REGISTRATION NUMBER

Not applicable.

Is sleep disruption a trigger for postpartum psychosis?

An episode of postpartum psychosis can be devastating for a woman and her family, and it is vital we understand the factors involved in the aetiology of this condition. Sleep and circadian rhythm disruption is a plausible candidate but further research is needed that builds on the latest advances in chronobiology and neuroscience.

Optimizing the treatment of mood disorders in the perinatal period

The perinatal period is a time of high risk for women with unipolar and bipolar mood disorders. We discuss treatment considerations for perinatal mood disorders, including unipolar and bipolar depression as well as postpartum psychosis. We further explore the unique issues faced by women and their families across the full trajectory of the perinatal period from preconception planning through pregnancy and following childbirth. Treatment of perinatal mood disorders requires a collaborative care approach between obstetrics practitioners and mental health providers, to ensure that a thoughtful risk : benefit analysis is conducted. It is vital to consider the risks of the underlying illness versus risks of medication exposure during pregnancy or lactation. When considering medication treatment, attention must be paid to prior medication trials that were most efficacious and best tolerated. Lastly, it is important to assess the impact of individual psychosocial stressors and lifestyle factors on treatment response.

Historical perspectives: a snapshot of women admitted to psychiatric facilities with psychosis or mania after childbirth in the late Victorian and inter-war periods

AIM

This study analysed historical healthcare records to investigate how women diagnosed with mania or psychosis and admitted to two mental health facilities in Australia following childbirth, were described in the late Victorian (1885-1895) and inter-war period (1925-1935).

BACKGROUND

Although historians have examined the history of mental health systems in Australia, there is no published scholarship that considers the healthcare records of these women. This was a unique opportunity to explore these documents.

DESIGN

An historical study examining healthcare records. The data collection occurred in 2012.

METHODS

Women admitted to mental health facilities with a diagnosis of psychosis or mania were identified in the admission registers found in the State Record Office of New South Wales and, if available, their healthcare record was transcribed verbatim. The records were imported into NVivo 10 for content analysis to determine the range and scope of information. A further textual analysis was conducted to see if the woman's diagnosis was congruent with the outcome of her admission.

RESULTS/FINDINGS

155 cases were identified across the two periods. Although, demographic data and the description of the women on admission were remarkably similar, 17% of women were physically, rather than mentally, ill and died soon after admission. The findings demonstrate the importance of current practices such as taking a comprehensive healthcare assessment and the use of antibiotics and sanitary measures during labour and in the postnatal period.

CONCLUSION

Historical investigations of healthcare records provide legitimacy for current healthcare practices.

DOES SCREENING WITH THE MDQ AND EPDS IMPROVE IDENTIFICATION OF BIPOLAR DISORDER IN AN OBSTETRICAL SAMPLE?

BACKGROUND

Women with bipolar disorder (BD) are at high risk for postpartum affective episodes and psychosis. Although validated screening tools are available for postpartum unipolar depression, few screening tools for hypomania/mania exist. Screening tools for BD in the postpartum period are essential for improving detection and planning appropriate treatment. We evaluated whether adding the Mood Disorders Questionnaire (MDQ) to the Edinburgh Postnatal Depression Scale (EPDS) increased the identification of BD in the early postpartum period.

METHODS

Women (N = 1,279) who delivered a live infant and screened positive on the EPDS and/or MDQ at 4-6 weeks postbirth were invited to undergo an in-home Structured Clinical Interview for DSM-IV (SCID).

RESULTS

Positive EPDS and/or MDQ screens occurred in 12% of the sample (n = 155). In home SCID diagnostic interviews were completed in 93 (60%) of the mothers with positive screens. BD was the primary diagnosis in 37% (n = 34). Women with BD screened positive on the EPDS and/or MDQ as follows: EPDS+/MDQ+ (n = 14), EPDS+/MDQ- (n = 17), and EPDS-/MDQ+ (n = 3). The MDQ identified 50% (17/34) of the women with BD and 6 additional cases of BD when the MDQ question regarding how impaired the mother perceived herself was excluded from the screen criterion.

CONCLUSION

Addition of the MDQ to the EPDS improved the distinction of unipolar depression from bipolar depression at the level of screening in 50% of women with traditional MDQ scoring and by nearly 70% when the MDQ was scored without the impairment criterion.

Bipolar disorder in women

Bipolar affective disorder in women is a challenging disorder to treat. It is unique in its presentation in women and characterized by later age of onset, seasonality, atypical presentation, and a higher degree of mixed episodes. Medical and psychiatric co-morbidity adversely affects recovery from the bipolar disorder (BD) more often in women. Co-morbidity, particularly thyroid disease, migraine, obesity, and anxiety disorders occur more frequently in women while substance use disorders are more common in men. Treatment of women during pregnancy and lactation is challenging. Pregnancy neither protects nor exacerbates BD, and many women require continuation of medication during the pregnancy. The postpartum period is a time of high risk for onset and recurrence of BD in women. Prophylaxis with mood stabilizers might be needed. Individualized risk/benefits assessments of pregnant and postpartum women with BD are required to promote the health of the women and to avoid or limit exposure of the fetus or infant to potential adverse effects of medication.

The relationship between sleep and postpartum mental disorders: A systematic review

BACKGROUND

Postpartum mental disorders (e.g., anxiety, depression, psychosis) are serious conditions that affect approximately 10-15% of women after childbirth, and up to 40% of women at risk for these disorders. Research reveals an association between poor sleep quality/quantity and symptoms of anxiety, depression and psychosis. The aim of this systematic review was to evaluate the available evidence for the relationship between sleep and postpartum mental disorders.

METHODS

Searches included MEDLINE, EMBASE, and EBM Reviews - Cochrane Central Register of Controlled Trials, PsycINFO and EBSCOHost CINAHL through June 30, 2014. Manual searching was performed on reference lists of included articles. Published primary research in any language was included.

RESULTS

There were 3187 unique titles/abstracts and 44 full-text articles reviewed. Thirty-one studies were included. Evidence was found for the impact of self-reported poor sleep during pregnancy and the postpartum on the development of postpartum depression, with not enough evidence for either postpartum anxiety or psychosis. The evidence for objectively assessed sleep and the development of postpartum disorders was mixed. Among the 31 studies included, 1 was strong, 13 were moderate and 17 were weak.

LIMITATIONS

Research design, method of assessment, timing of assessment, recruitment strategies, representative adequacy of the samples and inclusion/exclusion criteria all varied widely. Many studies did not use tools validated for the perinatal population and had small sample sizes without power analysis.

CONCLUSIONS

Sleep interventions represent a potential low-cost, non-pharmacological prevention and treatment strategy for postpartum mental illness. Further high-quality research is needed on this topic area.

Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period

The perinatal period is associated with an increased risk of severe mental disorders. We summarise the evidence regarding the epidemiology, risk factors, and treatment of severe mental illness in relation to childbirth, focusing on bipolar disorder, affective psychosis, and schizophrenia. We discuss women with ongoing chronic conditions and those with the onset of new episodes of post-partum psychosis. Despite the importance of perinatal episodes, with suicide a leading cause of maternal death, few studies are available to guide the management of women with severe mental disorders in pregnancy and the post-partum period. However, general principles of management are discussed, including the need for an individual risk-benefit analysis for each woman.

A narratology of postpartum psychosis in an Orthodox Jewish woman

PURPOSE

The purpose of this study was to understand the experience of postpartum psychosis in an Orthodox Jewish woman.

DESIGN AND METHODS

A case-based narratology using an unstructured interview was conducted to facilitate the telling of her story.

FINDINGS

While the nurses were unable to recognize her symptoms in the hospital, her family members were also unable to recognize escalating symptoms once she returned home, until she became a danger to herself.

PRACTICE IMPLICATIONS

Better recognition of symptoms, empathetic connections, cultural appreciation of faith-based rituals and their effect on patient isolation, and education of families and nursing staff may be vital components to successful recovery from postpartum psychosis.

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.

Experiences of the first days of postpartum psychosis: an interview study with women and next of kin in Sweden

The aim of this study was to explore accounts of the first days of postpartum psychosis from different perspectives, that is, that of the women and their next of kin. Interviews were conducted with seven women with postpartum psychosis and six interviews were done with the next of kin. The overall theme was Shades of Black with A Ray of Light, revealing a difficult experience of darkness, despair, and suffering. For the women, the experience cannot be shared fully other than with those who have lived through it themselves. For the next of kin, the illness is incomprehensible and it proved difficult to express in words what these relatives believe the women were going through. The women and their next of kin spoke about loss of sleep, being in an unreal world, thoughts that moved from having a wanted to an unwanted baby, being infanticidal, and having suicidal ideation. The women and their next of kin described the situations in different ways. The women gave an account of their illness in the strongest of terms, while the language used by the next of kin was much milder. The findings underscore the importance of recognizing the next of kin as key sources in early recognition of the disorder, which would make early treatment possible and support recovery.

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.

A review of postpartum depression, preterm birth, and culture

Postpartum depression (PPD) varies worldwide and is considered a serious issue because of its devastating effects on mothers, families, and infants or children. Preterm birth may be a risk factor for PPD. In 2005, the global incidence of preterm birth was estimated to be 9.6%, and of these births, 85% occurred in Africa and Asia. Among Asian countries, Pakistan has a preterm birth rate of 15.7% and the highest prevalence rate of PPD (63.3%). A literature review was therefore undertaken to better understand the potential contribution of preterm birth to PPD and to identify gaps in the scientific literature. Limited studies compare prevalence rates of PPD in mothers of full-term infants and mothers of preterm infants. Furthermore, meta-analyses examining predictors of PPD have not included preterm birth as a variable. The interrelationship between preterm birth and PPD may be explained by early parental stress and mother-infant interaction among mothers of preterm infants. Culture plays an important role in shaping communication between mothers and their infants and defines social support rituals that may or may not mediate PPD. More research is needed to provide evidence for practice.

Information and support needs during recovery from postpartum psychosis

Postpartum Psychosis (PP) is a severe and debilitating psychiatric illness with acute onset in the days following childbirth. Recovering from an episode can be a long and difficult process. The aim of this study was to gain an understanding of the difficulties faced by recovering women and to inform the planning of post-discharge information and support services. A study was designed collaboratively by service user and academic researchers. Women with experience of PP were trained in qualitative research methodology. Service user researchers (SURs) led in-depth interviews into women's experiences of recovery. PP is a life-changing experience that challenges women's sense of personal and social identity. Recovery themes are organised around ruminating and rationalising, rebuilding social confidence, gaining appropriate health service support, the facilitation of family functioning, obtaining appropriate information, and understanding that recovery will take time. Women suffering from PP must be adequately supported following discharge from psychiatric hospital if we are to address maternal suicide rates. We describe a successful collaboration between academics and service users exploring the needs of women and their families.

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.