Post partum psychosis: a clinical study

ECT in the Postpartum Period: A Retrospective Case Series from a Tertiary Health Care Center in India

OBJECTIVE

To evaluate the clinical profile and effectiveness of ECT in females with postpartum onset psychiatric syndromes or worsening of psychiatric disorder during the postpartum period.

MATERIALS AND METHODS

A retrospective chart review was carried out to identify females who had received ECT during their postpartum period from January2004 to April 2017.

RESULTS

During the study period, 13 females in their postpartum period received ECT, which accounted for 2.24% of the total females (n = 578) who had received ECT and 1% of total patients who were administered ECT during this period. The most common clinical diagnosis was postpartum depression (n = 7; 53.86%). Three (23.1%) patients were diagnosed with bipolar disorder and had experienced a relapse during the postpartum period. Two (15.4%) patients were diagnosed with schizophrenia and 1 (7.7%) patient was diagnosed with postpartum psychosis/acute and transient psychotic disorder. ECT was considered as a treatment of choice in 9 (69.2%) patients. All the patients with depression or mania achieved clinical remission, and patients with psychotic disorders also had significant reduction in their symptoms. Cognitive complaints were reported by 4 (30.8%) patients, and aches and pains after ECT were reported by 7 (53.8%).

CONCLUSION

ECT is a safe and effective treatment option in postpartum onset psychiatric syndromes or patients experiencing relapse or exacerbation of severe mental disorders during the postpartum period and is associated with a very good response rate with minimal or no complications.

Improvement of postpartum depression and psychosis after electroconvulsive therapy: A population-based study with a matched comparison group

INTRODUCTION

Electroconvulsive therapy (ECT) is used to treat postpartum depression and psychosis based on clinical experience and small observational studies.

AIMS

The primary aim was to test the hypothesis that the response rate to ECT for depression and psychosis is higher during the postpartum period than outside this period. The secondary aim was to identify predictors of a response to ECT during the postpartum period.

MATERIALS AND METHODS

Cases with postpartum depression and/or psychosis received ECT within 6 months of delivery. A matched comparison group with depression and/or psychosis (not within the postpartum period) was identified from the Swedish National Quality Register for ECT. The improvement 1 week after ECT was classified according to the Clinical Global Impressions Scale - Improvement scale (CGI-I) as responder (CGI-I score 1-2) or non-responder (CGI-I score 3-7).

RESULTS

185 cases and 185 comparison group subjects were included (46% with psychosis in each groups). More cases (87.0%) than comparison group subjects (73.5%) responded to ECT (p = 0.001). Adjusted binary regression analysis revealed that more severe symptoms prior to treatment were the only statistically significant predictor of response.

LIMITATIONS

There was no control group without ECT treatment.

CONCLUSION

The response rate of those with postpartum depression and/or psychosis to ECT was high. The response rate of patients with psychosis or depression was higher during the postpartum period than outside it. This study supports the use of ECT for severe forms of postpartum depression and/or psychosis.

Postpartum electroconvulsive therapy: a systematic review and case report

OBJECTIVE

Postpartum depression can have devastating consequences on the mother and child. Prompt treatment is challenging. Whereas electroconvulsive therapy (ECT) is considered to be an effective treatment modality in severe depression and brings about rapid clinical improvement, little is known about ECT during the postpartum period.

METHOD

We systematically reviewed the literature on the use of ECT during the postpartum period using PubMed, Institute for Scientific Information Web of Knowledge and PsycINFO databases until September 2014, using the search terms "electroconvulsive therapy" or "ECT" and "postpartum". Then, we described the successful treatment with ECT and the joint mother-baby hospitalization of a woman with severe depression.

RESULTS

Eight case reports and 8 studies were identified. All of the studies reported that ECT is effective in the postpartum period. It is well tolerated, provides a fast response and allows for breastfeeding. In addition, our case report showed the benefits of the hospitalization of the mother-baby unit.

CONCLUSIONS

Combined ECT and joint mother-baby hospitalization could be a valuable treatment by targeting both the mother-infant relationship and the maternal depressive symptoms.

Clinical and Socio-Demographic Profile of Women with Post-Partum Psychiatric Conditions at a Federal Neuropsychiatric Hospital in Southeast Nigeria between 2009 and 2011

Background:

Pregnancy and labor in areas with high maternal morbidities as in Nigeria could be sufficiently stressful to precipitate mental disorders in women after delivery, which may be a new or a relapse of previously existing one, or an exacerbation of an attenuated mental illness in the nursing mother. Mental illness in a nursing mother, if not treated may result in impaired mother-infant relationship.

Aim:

To determine the clinical and socio-demographic characteristics of women diagnosed with postpartum psychiatric conditions in a tertiary mental health facility of a developing country.

Subjects and Methods:

A retrospective case note reviews of 76 women diagnosed with postpartum psychiatric conditions for the first time in the Federal Neuropsychiatric Hospital Enugu between January 2009 and December 2011.

Results:

The mean age of the women was 27.76 years, with 63% (48/76) of them coming from the rural areas. 93% (71/76) of them had at least a secondary education and 78% (59/76) of the women had a family history of psychiatric disorders. Schizophrenia was commonest, 48.7% (37/76) followed by depression, 22% (17/76) and mania, 15% (11/76). Those presenting with schizophrenia were younger when compared with other diagnostic groups, had a lower level of education and presented earlier for treatment. The husbands were the primary caregivers in 48% of them.

Conclusion:

With 63% (48/76) of them being rural dwellers, policy changes become imperative that would encourage establishment of psychiatric services in rural areas to ensure early detection and prompt treatment of postpartum women with a need for psychiatric services.

Psychotic-like experiences in pregnant and postpartum women without a history of psychosis

OBJECTIVES

This study investigated whether psychotic-like experiences (PLEs) are prevalent amongst women in pregnancy and/or in the early postnatal phase, and whether the predictors identified in the literature for non-puerperal psychosis apply in a general sample of perinatal women.

METHOD

101 women in their third trimester of pregnancy completed questionnaire measures of mood, subjective well-being, sleep, expectations about labour, and PLEs. 66 of these participants also completed questionnaires shortly after giving birth. The main outcome measures were scores on the Peters Delusions Inventory (PDI) and the Launay-Slade Hallucination Scale-Revised (LSHS-R).

RESULTS

During pregnancy, 80% of the samples endorsed at least one item on the PDI, and 76% endorsed at least one item on the LSHS-R. Endorsement rates were lower postnatally, with rates of 59% and 52% for the PDI and LSHS-R, respectively. Mean scores on the PDI were 3.07 during pregnancy and 1.61 postnatally. Mean scores on the LSHS-R were 8.38 during pregnancy and 5.24 postnatally. Hierarchical multiPLEs regression analyses revealed that ratings of depressive symptomatology significantly predicted PDI total score during pregnancy and LSHS-R total score postnatally, whilst postnatally, scores obtained on the PDI and LSHS-R postnatally were significantly predicted by scores on these measures during pregnancy. Fear in childbirth, but not in pregnancy, showed associations with PLEs but these associations were not maintained once multivariate analyses were conducted.

CONCLUSIONS

The results of this study support the continuum model of psychosis, by illustrating that PLEs occur frequently in perinatal individuals without a diagnosis of severe mental illness.

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.

Use of electroconvulsive therapy (ECT) in postpartum psychosis--a naturalistic prospective study

Postpartum psychosis (PPP) is a severe psychiatric condition requiring rapid restoration of health in view of significant risks to both mother and the infant. Electroconvulsive therapy (ECT) is often used for treatment of severe PPP. The aims of the study were to describe the indications for ECT among women admitted with PPP to a psychiatric hospital in India. It also aimed at assessing whether women with PPP who received ECT differed in their clinical history, diagnosis, severity of illness, psychopathology, drug dosage, and duration of hospital stay, compared to women who did not receive ECT. Infants of mothers who were breast-feeding their infants while receiving ECT were assessed for adverse effects. This was a naturalistic prospective study of 78 women admitted with PPP, 34 (43.6 %) of whom received ECT. Presence of catatonia, augmentation of medications, and suicidality were common indications for ECT. Catatonic symptoms were significantly higher among women who received ECT. There was no significant difference in duration of hospitalization or severity of psychopathology between women who did and did not receive ECT. Transient side effects to ECT were observed in few women, with no adverse effects noted in infants who were breast-fed. The current study supports the use of ECT as an effective and safe treatment for women with severe PPP.

Behavioral emergencies in India: would psychiatric emergency services help?

INTRODUCTION

Behavioral emergencies constitute an important component of emergencies worldwide. Yet, research on behavioral emergencies in India has been scarce. This article discusses the burden, types, and epidemiology of behavioral emergencies in India.

METHODS

A computerized search of Medline, Psychinfo, and Cochrane from 1975 to 2009 was performed, and all articles were evaluated and collated. The results were summarized.

RESULTS AND CONCLUSIONS

There is an acute need for psychiatric emergency services in India. Suicides, acute psychoses, and substance-related problems form the major portion of behavioral emergencies, while current trends show a rise in disaster- and terrorism-related emergencies.

Lactational exposure to atypical antipsychotic drugs disrupts the pituitary-testicular axis in mice neonates during post-natal development

Olanzapine (OLNZ) and risperidone (RISP), two widely prescribed drugs for post-partum psychosis, transfer through milk to the neonates. Hence, neonates are susceptible to their adverse side effects. In the present study, the pituitary-testicular axis of lactationally exposed mice neonates (PND 28) was examined to evaluate the reproductive adverse effects. Testicular histopathology, immunocytochemistry and morphometric analysis of pituitary PRL (prolactin) and LH (luteinizing hormone) cells and plasma hormonal (PRL, LH and testosterone) levels were the various end points studied. Significantly regressed testes, reduced seminiferous tubules with disrupted germ-cell alignment, spermatogonial exfoliation into the tubule lumens and sparse sperms in the lumens were observed. PRL-immunointensity and plasma levels were elevated, whereas immunoreactivity and plasma levels of LH were decreased. Plasma testosterone levels were also decreased. The hypogonadism thus observed might be mediated by drug-induced hyperprolactinemia, which further inhibited secretions of LH and testosterone. Age may be the factor which made the neonates vulnerable to the PRL elevation by OLNZ which otherwise causes transient elevation in adults and is considered safe. The adverse impact was persistent until adulthood with higher doses of both of the drugs as evident by the analysis of testicular weight, histology and hormonal profiles of post-pubertal mice (PND 63) lactationally exposed as neonates.

Effect of lactational exposure of olanzapine on body weight of mice: a comparative study on neonates of both the sexes during post-natal development

Adverse impact of atypical antipsychotic drugs on body weight of adult and juvenile groups has been well-documented both at clinical and preclinical investigations. However, studies on impact of drug on body weight during fetal or neonatal development received little attention. The present study is the first-ever preclinical investigation demonstrating the effect of lactational exposure of olanzapine (4, 8, and 10 mg/kg) and risperidone (1 and 2 mg/kg), two widely prescribed antipsychotics, on body weight of mice neonates. Body weight gain was observed with both the drugs, although a sex-related differential response was noted. In olanzapine-exposed female neonates, the weight gain was more with the highest dose. Male neonates showed a reverse trend, i.e. the highest gain with the lowest dose. Female neonates exposed to risperidone also showed significant, but less gain as compared to their olanzapine-exposed counterparts. Risperidone-exposed male neonates showed little body weight gain. Waist-to-hip ratio and plasma prolactin level were measured to explain the reason behind the body weight gain, but there were deviations with respect to drug and sex. The body weight gain may be the overall manifestations of drug-induced endocrine and metabolic dysregulations.

Differentiation and clinical implications of postpartum depression and postpartum psychosis

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

Postpartum major depression at six weeks in primary health care: prevalence and associated factors

BACKGROUND

Major depression is a common and disabling complication of the postpartum period in women. It is thought to occur three times more commonly in the developing than in developed countries.

OBJECTIVES

The objectives of this study were to determine the prevalence of and factors associated with major depression among women attending a peri-urban primary health care unit in Kampala, Uganda, at six weeks postpartum.

METHOD

Five hundred and fourty four women attending a peri-urban health centre were investigated in a cross-sectional study. These women were screened using the twenty five-item Self Reporting Questionnaire (SRQ-25), while major depression was confirmed using the Mini International Neuro-psychiatric Interview (MINI). Associations were sought between major depression and the respondents' demographics and various psychological, social and obstetric factors.

RESULTS

The point prevalence of major depression at six weeks postpartum was 6.1%. Psychiatric disorder was significantly associated with young age, being single, negative life events, unplanned pregnancy, unwanted sex of baby and current physical illness in both mother and newborn.

CONCLUSION

There is indication for routine screening of at risk women in the peri-natal period to avoid, recognize and manage postpartum psychiatric morbidity and its consequence on mothers and their developing children.

Immigrant Asian Indian women and postpartum depression

OBJECTIVE

To determine the incidence of postpartum depressive symptomatology in a sample of immigrant Asian Indian women and to establish whether cultural factors such as arranged marriage or gender of the newborn are associated with differences in depression scores.

DESIGN

Quantitative, descriptive study.

SETTING

Ten private obstetric and pediatric offices in Northern California.

PARTICIPANTS

A convenience sample of 58 self-selected immigrant Asian Indian women between 2 weeks and 12 months postpartum.

MAIN OUTCOME MEASURE

Depressive symptomatology as measured by the 35-item self-report Postpartum Depression Screening Scale.

RESULTS

There was a minor depressive symptomatology rate of 28% and an additional major depressive symptomatology rate of 24%. No differences in depression scores were found with regard to arranged marriage or the gender of the newborn.

CONCLUSIONS

Findings suggest that Asian Indian women living in the United States are just as likely to experience postpartum depressive symptomatology as White women. Therefore, it is critical to identify and refer women at risk for postpartum depression to ensure they do not become part of the 50% who remain undiagnosed. Health care providers need to become cognizant of the potential for postpartum depression and become skilled in the detection of this mood disorder.

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.