Dopamine supersensitivity and hormonal status in puerperal psychosis

Hormones, psychotic disorders, and cognition in perinatal women: a mini review

Previous scientific evidence has shown a relationship between hormones and the onset and relapse of perinatal psychotic disorders (PPD) in women during pregnancy, childbirth, and the postpartum period. In healthy women the interaction between hormones and cognitive changes has been confirmed mainly in memory, attention, and executive function during pregnancy and postpartum, which respond to adaptive demands related to parenting tasks. In women with psychotic episodes there is a significant impairment in several cognitive functions, but studies of the perinatal period are limited. The objective of this mini review is to analyze the main findings to identify whether hormonal changes interact with the onset of PPD and cognitive impairment in perinatal women. The studies included samples of women with psychosis, risk of developing psychosis, bipolar psychosis, schizoaffective psychosis, and psychotic symptoms, during pregnancy and postpartum. Findings contributed to knowledge about five hypotheses regarding the relationship between hormones in the perinatal period and the appearance of PPD. Nevertheless, this review did not find reports of evidence of a relationship between hormonal production and cognitive function among women with clinically diagnosed PPD, suggesting a research gap. Clinical implications of assessing hormonal production and cognitive function in PPD are discussed. Although the evidence identified is scarce and heterogeneous, the findings call for further research with clinical samples on the role of hormones in perinatal psychotic disorders, especially as they relate to the study of cognition. This will promote more consistent evidence and understanding of PPD etiopathology that can guide early and effective multidisciplinary interventions.

The association between hormones and antipsychotic use: a focus on postpartum and menopausal women

During the postpartum and menopausal periods of women's lives, there is a well-established and significant drop of circulating estrogens. This may be the reason why both these periods are associated with an increased risk for onset or exacerbation of psychiatric disorders. Whether symptoms are mainly affective or mainly psychotic, these disorders are frequently treated with antipsychotic medications, which calls for an examination of the relationship between hormone replacement and antipsychotic agents at these time periods. The aim of this narrative review is to summarize what is known about the association of hormones and antipsychotics in the postnatal period and at menopause. In the review, we focus on estrogen and oxytocin hormones and include, for the most part, only papers published within the last 10 years. Both estradiol and oxytocin have at various times been implicated in the etiology of postpartum disorders, and estrogens, sometimes combined with progesterone, have been tested as potential treatments for these conditions. The role of estradiol as an adjunct to antipsychotics in the prevention of postpartum relapses is currently controversial. With respect to oxytocin, studies are lacking. Psychosis in menopausal and postmenopausal women has been successfully treated with estrogens and selective estrogen-receptor modulators, mainly raloxifene, in addition to antipsychotics. Some symptoms appear to respond better than others. No oxytocin study has specifically targeted postmenopausal women. Because of feedback mechanisms, there is a theoretical danger of therapy with exogenous hormones interfering with endogenous secretion and disturbing the balance among inter-related hormones. When used with antipsychotics, hormones may also affect the metabolism and, hence, the brain level of specific antipsychotics. This makes treatment with antipsychotics plus hormones complicated. Dose, timing and route of intervention may all prove critical to efficacy. While much remains unknown, this literature review indicates that, within standard dose ranges, the combination of hormones and antipsychotics for postnatal and menopausal women suffering severe mental distress can be beneficial, and is safe.

Relapses of bipolar/cycloid psychosis related to childbearing

It was observed nearly 200 years ago that mothers with puerperal psychosis may recover, then relapse, sometimes repeatedly. This phenomenon seems to be better recognized in the American and French literature, where it has been reported in a large minority, or even majority, of cases. It offers an opportunity to study the pathogenesis of psychosis.

Recurrent episodes associated with childbearing: a matrix of associations

A study of several hundred recurrent puerperal psychoses shows that about half of those with known onset recur in the same phase of reproduction, and half have onsets in different phases. Onsets in the same phase are especially a feature of prepartum psychosis and are the strongest indication of a specific trigger operating during pregnancy. Onsets in different phases provide a prima facie case for links between 'puerperal psychosis' and other reproductive onsets. They suggest that the 'picture puzzle' is not just about early onset puerperal psychosis, but a group of related reproductive triggers.

Diagnosis, pathophysiology, and management of mood disorders in pregnant and postpartum women

Mood disorders disproportionately affect women across the lifespan. Mood disorders in pregnancy and the postpartum period are common and have profound implications for women and their children. These include obstetric and neonatal complications, impaired mother-infant interactions, and, at the extreme, maternal suicide and infanticide. Because obstetrician-gynecologists are often the first (and sometimes the only) point of contact for young women in the health care system, familiarity with the presentation and treatment of depressive illness in the perinatal period is imperative. The goal of this review is to synthesize essential information on depressive illness in the perinatal period with a focus on its most common and severe presentations, major depressive disorder and bipolar disorder. Accurate diagnosis of unipolar major depressive disorder from bipolar disorder can facilitate the selection of the best possible treatment alternatives. Counseling may be sufficient for perinatal women who have mild to moderate depression, but women who are severely depressed are likely to require antidepressant treatment. Women with bipolar disorder are at high risk for relapse if mood stabilizer medication is discontinued, and they are vulnerable to relapse near the time of delivery. Comanagement of their care with psychiatrists will increase their chances of avoiding a recurrence of illness.

Amphetamine sensitization in reproductively experienced female rats

Recent studies have supported the hypothesis that pregnancy and parturition are associated with altered sensitivity of brain dopamine systems. An increased behavioral sensitivity to a direct-acting D1/D2 receptor agonist (apomorphine) has also been observed several weeks after lactation, suggesting that these adaptations are long-lasting. To further characterize this phenomenon, the effects of reproductive experience on behavioral sensitization to an indirect-acting dopamine agonist (amphetamine) in female rats were studied. In two separate experiments, nulliparous and primiparous (12-16 weeks post-weaning) female rats were pretreated with amphetamine (1.0 or 5.0mg/kg) or vehicle (saline) once daily for 5 consecutive days. After 10 days of withdrawal, all animals were challenged with a low dose of amphetamine (25% of pretreatment dose). Locomotor activity was measured following each drug or vehicle administration. Locomotor sensitization to amphetamine challenge was observed in all animals pretreated with 1mg/kg, regardless of reproductive experience. In contrast, primiparous animals pretreated with 5mg/kg amphetamine displayed a significantly larger locomotor response to the challenge compared to nulliparous controls. The findings indicate enhanced behavioral sensitization to amphetamine in reproductively experienced rats, and confirm previous reports of lasting adaptations of dopamine systems following pregnancy and lactation.

Sensorimotor gating and dopamine function in postpartum rats

There is much speculation regarding the effects of estrogen withdrawal at the end of pregnancy on forebrain dopamine, however, few studies have directly examine changes in this system postpartum. The present work sought to determine what changes in forebrain dopamine function occur in the postpartum rat. Specifically, prepulse inhibition of the acoustic startle response (PPI) was measured in primiparous female rats on postpartum day 2 (PPD2) or 14 (PPD14) following treatment with saline or the dopamine D2 agonist, quinpirole. Diestrus (DI) females served as controls. Dopamine content and turnover as well as cyclic AMP (cAMP) accumulation were determined within the nucleus accumbens and dorsal striatum in these same females. In addition, circulating levels of plasma corticosterone, estradiol and progesterone were measured. PPI was significantly disrupted in both postpartum groups. This effect was associated with decreased cAMP content within the nucleus accumbens. Quinpirole treatment (0.1 and 0.5 mg/kg) dose-dependently disrupted PPI in DI controls while PPD2 and PPD14 animals demonstrated reduced sensitivity to the D2 agonist. PPD14 animals demonstrated increased startle amplitude, an effect that was attenuated by quinpirole treatment. PPD14 females were also less sensitive to quinpirole-mediated reductions in DA turnover within the nucleus accumbens and both PPD2 and PPD14 females had an attenuated response to the stimulatory effects of quinpirole on corticosterone secretion. Collectively these findings suggest that the postpartum period is associated with reduced sensorimotor gating and altered forebrain DA systems, which may be related to shifts in circulating hormones.

The HPA axis and perinatal depression: a hypothesis

Episodes of depression and anxiety are as common during pregnancy as postpartum. Some start in pregnancy and resolve postpartum, others are triggered by parturition and some are maintained throughout. In order to determine any biological basis it is important to delineate these different subtypes. During pregnancy, as well as the rise in plasma oestrogen and progesterone there is a very large increase in plasma corticotropin releasing hormone (CRH), and an increase in cortisol. The latter reaches levels found in Cushing's syndrome and major melancholic depression. Levels of all these hormones drop rapidly on parturition.We here suggest that the symptoms of antenatal and postnatal depression may be different, and linked in part with differences in the function of the hypothalamic pituitary adrenal (HPA) axis. There are two subtypes of major depression, melancholic and atypical, with some differences in symptom profile, and these subtypes are associated with opposite changes in the HPA axis. Antenatal depression may be more melancholic and associated with the raised cortisol of pregnancy, whereas postnatal depression may be more atypical, triggered by cortisol withdrawal and associated with reduced cortisol levels. There is evidence that after delivery some women experience mild bipolar II depression, and others experience post traumatic stress disorder. Both of these are associated with atypical depression. It may also be that some women are genetically predisposed to depression of the melancholic type and some to depression of the atypical type. These women may be more or less vulnerable to depression at the different stages of the perinatal period.

Role of sleep loss in the causation of puerperal psychosis

Puerperal psychosis is a rare but serious psychiatric disorder following delivery. Although controversy continues to surround its nosological status, puerperal psychosis is generally considered a mood episode with psychotic features occurring in the context of bipolar disorder or schizoaffective disorder. Due to the close temporal association with childbirth, the etiological role of gonadal steroids, particularly estrogen, has been considered. Familial factors have also been implicated in the triggering of episodes of puerperal psychosis. Sleep deprivation arising from an array of diverse factors is a common occurrence surrounding parturition. The author suggests that sleep loss plays a pivotal role in the causation of puerperal psychosis. Clinical implications of this hypothesis are discussed. Studies on the aetiology and pathogenesis of puerperal psychosis are urgently needed not only for prevention and better treatment strategies of puerperal psychosis but also for understanding the biological underpinnings of bipolar disorder.

Postpartum mood disorders

Depression is a common disorder in women of childbearing age. Many women experience depressive symptoms during the postpartum period, ranging from mild postpartum blues to significant mood disorders such as postpartum depression and postpartum psychosis. The 'baby blues' are extremely common, affecting 30-75% of new mothers. This form of postpartum mood change is self-limited and requires no specific treatment other than education and support. While less common, occurring in 10-15% of births, postpartum depression has the potential for significant impact on both the health of the mother and baby. Unfortunately, affective illness in women frequently goes unrecognized and untreated. While there are effective pharmacological treatments for postpartum depression, the treatments for postpartum depression are often not utilized due to concerns about lactation. Postpartum psychosis is extremely rare, affecting one to two women per 1000 births; each case represents a true psychiatric emergency. Identifying and treating postpartum affective illness in women is critical to the health of both mother and infant. This paper reviews the literature on the diagnosis and treatment of mood disorders in the postpartum period: postpartum blues, postpartum depression and postpartum psychosis.

Menstrual cycle effects on hypothalamic dopamine receptor function in women with a history of puerperal bipolar disorder

Neuroendocrine challenge tests of hypothalamic dopamine receptor function in the early postpartum period suggest that the sensitivity of these receptors is increased in women with a history of bipolar disorder after childbirth. We tested the hypothesis that, in women predisposed to bipolar disorder in the puerperium, hypothalamic dopamine receptor function is more sensitive to changes in circulating ovarian hormone concentrations than in women without such histories. Eight fully recovered and drug-free women who had had at least one episode of bipolar illness following childbirth were compared with nine normal controls. Growth hormone (GH) responses to apomorphine (APO 0.005 mg s.c.) were measured in the early follicular phase, when plasma concentrations of ovarian hormones are low, and in the mid-luteal phase, when they are relatively high. The recovered bipolar subjects and the controls did not differ from each other in their follicular and midluteal oestrogen and progesterone concentrations. In the midluteal phase, both groups had increased oestrogen and progesterone levels. The recovered bipolar subjects did not differ from controls in baseline concentrations of GH in either of the menstrual phases. The APO-GH responses of the two groups did not differ in the follicular phase, but in the midluteal phase, when female sex steroids are relatively increased, the recovered group had significantly enhanced APO-GH responses [MANOVA for repeated measures: (i) area under the curve, group by phase effect: p < 0.04; (ii) GH peak rise after APO, group by phase effect: p < 0.056] and the responses were not related to concurrent measures of mood. The results of this small study of women predisposed to bipolar disorder in the puerperium shows an increased dopaminergic receptor sensitivity in the luteal phase of the menstrual cycle. It suggests that their dopaminergic systems have increased sensitivity to changes in circulating female sex steroids. This may be aetiologically relevant to the pathogenesis of puerperal bipolar disorder.

Endocrine factors in the etiology of postpartum depression

This article reviews the literature regarding endocrine factors postulated or presumed to be relevant in postpartum depression (PPD), a condition affecting at least 10% of childbearing women. The phenomenology and epidemiology of PPD are also described. Data suggest that parturition-related endocrine changes are causally implicated in PPD in a vulnerable subgroup of women. More specifically, studies by our group and others suggest a role for changes in estradiol and progesterone in precipitating mood symptoms among women with PPD. The mechanisms underlying such differential sensitivities remain undetermined. Future directions for research are explored.

Sleep loss and postpartum psychosis

Postpartum psychosis is a rare but severe psychiatric disorder. Its diagnostic status remains controversial, but several studies have shown that the majority of patients who develop psychosis immediately following childbirth suffer from bipolar disorder. The pathophysiology of postpartum psychosis is poorly understood, but factors such as primiparity, difficult labor, genetic predisposition, and hormonal changes have been suggested as etiological factors. This paper reviews the literature on the relationship of sleep disruption and postpartum psychosis. It is argued that sleep loss resulting from the interaction of various putative causal factors may be the final common pathway in the development of psychosis in susceptible women. Clinical significance of these findings, including strategies to prevent postpartum psychosis, are discussed and suggestions are made for future research directions.

Molecular genetic approaches to puerperal psychosis

Puerperal psychosis, an episode of mania or psychosis precipitated by childbirth follows approximately one in 1000 deliveries. The evidence of clinical, outcome and genetic studies supports the hypothesis that the majority of puerperal psychotic episodes are manifestations of an affective disorder diathesis with a puerperal trigger. Furthermore the available evidence supports the hypothesis that genes are involved in susceptibility to both diathesis and trigger. For complex genetic disorders such as affective illness there are marked benefits in focussing on a homogeneous subtype which allows a subset of hypotheses to be tested. Molecular genetic studies of puerperal psychosis provide an excellent example of this strategy, allowing a hierarchy of hypotheses concerning the involvement of neurosteroid pathways in pathophysiology to be tested. Puerperal psychosis results in considerable suffering to a woman and her family. Elucidating the pathophysiological basis of this disorder will lead to better prevention and treatment and, it is anticipated, inform research on affective disorders more generally.

The maternal brain as a model for investigating mental illness

The idea that a particular type of severe mental illness, puerperal or post-partum psychosis, is a disease entity and that its causes lie in some kind of physiological disturbance of the reproductive process, can be traced back to antiquity. Epidemiological studies provide strong support for such an hypothesis, but, despite the powerful methodological attractions of using childbirth as a model for research, there has been surprisingly little neuroendocrine research into this subject. There have been preliminary reports of prospective research into women with histories of affective psychosis who are pregnant and who are at particularly high risk of recurrence of illness. This work suggests that it may be very fruitful to investigate interactions between the massive changes that occur in sex hormones around parturition and the activity of selected neurotransmitter systems. Because of the prospective research paradigm, it becomes possible to test whether the measures can predict who will become ill and who will stay well.

Increased sensitivity of dopamine systems following reproductive experience in rats

Several studies have suggested that alterations in forebrain dopamine activity during the postpartum period may result in the onset of postpartum psychosis in women [J. Psychosom. Obstet. Gynecol. 19 (1998) 104; Prog. Neuro-Psychopharmacol. Biol. Psychiatry 17 (1993) 571; J. Clin. Psychiatry 51 (1990) 365.]. The present study investigated whether increased dopamine activity in these forebrain regions is a normal consequence of reproductive experience in rodents. Both intact and ovariectomized parous and nulliparous females were tested for their responses to the dopamine agonist apomorphine using two behavioral measures, prepulse inhibition (PPI) and oral stereotypy. In addition, dopamine and DOPAC levels were measured in tissue from the striatum and nucleus accumbens together with circulating plasma prolactin levels. The results of the behavioral studies demonstrate an increased response to apomorphine in parous females. Parous subjects also had increased levels of dopamine and DOPAC in striatal tissue and lower levels of circulating prolactin. Ovariectomy in nulliparous females resulted in a potentiated response to apomorphine with regard to the disruption of PPI, as well as a significant decrease in the plasma prolactin levels, as compared with intact nulliparous females. These data suggest that increased dopamine activity in forebrain regions occurs as a consequence of parity, which persists for a minimum of several weeks postpartum. These findings support the hypothesis that increased dopamine sensitivity in forebrain dopamine regions may be one potential mechanism underlying the development of postpartum psychosis in women.

Dopaminergic sensitivity and prediction of antidepressant response

This study was designed to examine neuroendocrine predictors of antidepressant response to the selective serotonin reuptake inhibitor (SSRI) paroxetine. We assessed the prognostic utility of the apomorphine stimulation test by examining the relationship between pretreatment change in growth hormone (GH) following apomorphine and acute response to paroxetine treatment. We hypothesized that those subjects with most marked pretreatment dopaminergic supersensitivity, as manifested by greatest change in GH, would be most likely to show an early antidepressant response and would also be more likely to develop manic or hypomanic symptoms on paroxetine. Contrary to our hypothesis, greater dopamine postsynaptic sensitivity was associated with greater resistance to paroxetine treatment. In our sample of 13 subjects with a major depressive episode, pretreatment GH response to apomorphine per unit weight was inversely correlated with change in Hamilton depression rating scale following 6 weeks of paroxetine. Within the group of subjects who showed mood elevation on paroxetine, there was a trend towards greater GH response being associated with slower antidepressant response. With regard to the development of manic or hypomanic symptoms on paroxetine, change in GH per unit weight not did distinguish the two subjects who subsequently developed paroxetine-induced hypomania from other subjects. The seven subjects with previous antidepressant-induced hypomania did not differ from the other subjects in change in GH response per unit weight. The finding that subjects who had low dopamine receptor responsivity pretreatment were more likely to have an antidepressant response with paroxetine is consistent with recent suggestions that the therapeutic effect of SSRIs may be mediated through increased dopamine receptor sensitivity in the mesolimbic system. Further work assessing pretreatment and post-treatment GH response to apomorphine will help to test the hypothesis that low dopamine receptor responsivity predicts antidepressant response to SSRIs.

Childhood abuse, postpartum depression and parenting difficulties: a literature review of associations

OBJECTIVE

The aim of this paper is to obtain an understanding of the links between maternal postpartum depression, poor parenting and childhood abuse, and the subsequent development of adult psychopathology in children from these families.

METHOD

A literature review was undertaken of studies on postpartum depression looking at parental childhood abuse, parenting and child outcomes, as well as childhood abuse and its association with adult depression and parenting difficulties.

RESULTS

Considerable overlap is noted in predisposing factors for major depression, postpartum depression, inadequate parenting and childhood abuse. Links appear to begin in early infancy, suggesting postpartum depression as a possible mechanism for intergenerational transmission of psychopathology.

CONCLUSIONS

Further research is required to look at the outcome of children of women who are at high risk of chronic or recurrent depression and of difficulties parenting; the postpartum period is the optimum time for identification and intervention.

Puerperal and menstrual psychoses: the proposal of a unitary etiological hypothesis

Puerperal and menstrual psychoses are both uncommon disorders and the occurrence of both in individual patients suggests the possibility of a common underlying pathogenesis. In this paper two cases are reported, the literature is reviewed and a unifying etiological hypothesis is postulated in which precipitous reductions in the brain estrogen environment precipitate episodes of psychosis in predisposed individuals. In the case of puerperal psychosis, estrogen cascade follows a lengthy period of sustained high brain estrogen environment; in menstrual psychosis, it is postulated that the occurrence in at least some cases of anovulatory menstrual cycles, wherein high levels of relatively unopposed estrogens are maintained until the next ovulatory cycle, play a role in priming the central nervous system prior to premenstrual estrogen cascade. Further research in this area using more sensitive techniques to follow hormonal fluctuation and mental state is called for.

Aspects of perinatal psychiatric illness

BACKGROUND

In view of the current changes in the National Health Service, it was considered an opportune time to review the literature on perinatal psychiatric illness.

METHOD

A systematic review was undertaken of relevant articles on MEDLINE, ClinPsych and Excerpta Medica Psychiatry.

RESULTS

Sixty-eight articles were used in the review.

CONCLUSIONS

Developments in the field of perinatal psychiatry include a greater understanding of the nosology and aetiology of the conditions, the effect of maternal illness on the child, as well as transcultural factors. The perspective of the individual sufferer has been somewhat ignored. New treatments with both pharmacotherapy and hormones are emerging, but perhaps the greatest current challenge is to adapt our management strategies to community care.

The growth hormone response to apomorphine at 4 days postpartum in women with a history of major depression

We have examined the responsiveness of dopamine sensitive neurones in the postpartum period in woman with a history of major depression who are at high risk of experiencing a recurrence of illness in the postpartum period. Fourteen women were assessed at 36 weeks of pregnancy and during the 3 months following delivery, using the Schedule for Affective Disorders and Schizophrenia, including its change version. They were not depressed at initial assessment. Five of the 14 women went on to experience a postpartum relapse (2 major depressive disorder, 2 generalised anxiety disorder, 1 panic disorder). On the fourth day postpartum, i.e., before relapse, the growth hormone response to the dopamine agonist apomorphine was measured as an index of the functional state of hypothalamic dopamine D2 receptors. Women who subsequently relapsed had a significantly greater growth hormone response to apomorphine than those who remained well. This was particularly marked in women with anxiety/panic. The development of increased sensitivity of hypothalamic dopamine D2 receptors in the postpartum period appears to predict the onset of depressive and anxiety disorders.