Aspects of perinatal psychiatric illness

Inpatient mother-and-child postpartum psychiatric care: Factors associated with improvement in maternal mental health

Purpose

This study assessed the underexplored factors associated with significant improvement in mothers’ mental health during postpartum inpatient psychiatric care.

Methods

This study analyzed clinical improvement in a prospective cohort of 869 women jointly admitted with their infant to 13 psychiatric Mother-Baby Units (MBUs) in France between 2001 and 2007. Predictive variables tested were: maternal mental illness (ICD-10), sociodemographic characteristics, mental illness and childhood abuse history, acute or chronic disorder, pregnancy and birth data, characteristics and mental health of the mother's partner, and MBU characteristics.

Results

Two thirds of the women improved significantly by discharge. Admission for 25% was for a first acute episode very early after childbirth. Independent factors associated with marked improvement at discharge were bipolar or depressive disorder, a first acute episode or relapse of such an episode. Schizophrenia, a personality disorder, and poor social integration (as measured by occupational status) were all related to poor clinical outcomes.

Discussion

Most women improved significantly while under care in MBUs. Our results emphasize the importance of the type of disease but also its chronicity and the social integration when providing postpartum psychiatric care.

Untargeted screening for novel autoantibodies with prognostic value in first-episode psychosis

Immunological and inflammatory reactions have been suggested to have a role in the development of schizophrenia, a hypothesis that has recently been supported by genetic data. The aim of our study was to perform an unbiased search for autoantibodies in patients with a first psychotic episode, and to explore the association between any seroreactivity and the development of a Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) disorder characterized by chronic or relapsing psychotic symptoms. We collected plasma samples from 53 patients when they were treated for their first-episode psychosis, and 41 non-psychotic controls, after which the patients were followed for a mean duration of 7 years. Thirty patients were diagnosed with schizophrenia, delusional disorder, schizoaffective disorder, bipolar disorder or a long-term unspecified nonorganic psychosis during follow-up, whereas 23 patients achieved complete remission. At the end of follow-up, plasma samples were analyzed for IgG reactivity to 2304 fragments of human proteins using a multiplexed affinity proteomic technique. Eight patient samples showed autoreactivity to the N-terminal fragment of the PAGE (P antigen) protein family (PAGE2B/PAGE2/PAGE5), whereas no such autoreactivity was seen among the controls. PAGE autoreactivity was associated with a significantly increased risk of being diagnosed with schizophrenia during follow-up (odds ratio 6.7, relative risk 4.6). An immunohistochemistry analysis using antisera raised against the N-terminal fragment stained an unknown extracellular target in human cortical brain tissue. Our findings suggest that autoreactivity to the N-terminal portion of the PAGE protein family is associated with schizophrenia in a subset of patients with first-episode psychosis.

Outcome of infants exposed to olanzapine during breastfeeding

OBJECTIVE

This study evaluated the outcome of infants exposed to olanzapine during lactation.

METHODS

A prospective, controlled observational study design was used. Mothers who contacted Beilinson Teratology Information Service regarding use of olanzapine while breastfeeding were followed by phone interview. Data on lactation, neonatal symptoms, and outcome at the age of 1-2 years were obtained. Mother-infant groups were compared. Mothers breastfeeding while taking olanzapine (n = 22) were compared to two control groups of mothers who continued to take olanzapine but did not breastfeed (n = 15) and to breastfeeding mothers using a drug known to be safe during lactation (n = 51).

RESULTS

Follow-up was obtained for 37 of 70 women. Comparison of olanzapine-exposed breastfed versus control breastfed infants showed a similar duration of breastfeeding; however, early discontinuation of breastfeeding was more common in the olanzapine-exposed breastfed group (five of 22 vs. none of 51, p = 0.02). The rate of adverse outcomes in olanzapine-exposed breastfed infants did not differ from those of the control groups. Among the 30 newborns exposed in utero to olanzapine, no congenital birth defects were found. Neonatal symptoms were seen in six of 30 of olanzapine-exposed infants versus two of 51 of nonexposed infants (p < 0.05). A withdrawal syndrome was seen in three of 30 (10%) infants.

CONCLUSIONS

No increase in adverse long-term outcomes in olanzapine-exposed breastfed infants were found. Our data in conjunction with previous estimates of very low drug exposure support continuation of breastfeeding in women treated with olanzapine. However, until additional long-term studies are available, infants exposed to olanzapine through breastmilk should be followed up.

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.

Postnatal depression: A global public health perspective

The aim of this paper is to discuss whether or not postnatal depression is a global public health concern. Public health is the study of the morbidity, mortality and the cause and course of disease, at a population rather than an individual level. Public health is also concerned with examining factors that cause health inequalities. Postnatal depression is a mental and emotional condition that can affect women during the first postnatal year. Since the effects of postnatal depression are known to go beyond the mother in that it also affects the partner and the child, it can be deemed a public health problem. Additionally, severe postnatal depression can lead to infanticide as well as maternal death, often by suicide. Furthermore, evidence demonstrates that all countries are faced with the challenge of postnatal depression, but low- to middle-income countries face the greatest burden. The literature revealed various treatment options for this complex condition. However, it also uncovered that not all women are assessed for postnatal depression, nor do all women receive treatment. The emerging picture is that postnatal depression is indeed a public health problem, particularly as the incidence is much higher than the quoted rate of 10%—15%. This paper recommends direction for public health-orientated perinatal mental health research and suggests that service providers should consider the routine assessment of all postnatal women.

Olanzapine treatment during breast feeding: a case report

Postpartum psychosis constitutes a severe complication that entails risk for both mother and child. Little is known about the use of olanzapine in the treatment of postpartum psychosis. In previous studies, it has been reported on mothers receiving relatively low doses of olanzapine. We report a 38-year-old patient who was admitted to the hospital for an acute psychotic exacerbation. She was breast feeding her 5-month-old child, and she wished to continue breast feeding. Olanzapine treatment was started with a daily dosage of 15 mg. The weight-corrected maternal dose was 270 mug/kg. The olanzapine concentration in the mother's plasma was 24 ng/mL. The analysis of olanzapine in breast milk applying two different high-performance liquid chromatography procedures revealed similar results: 12.2 ng/g without and 11.5 ng/g with additional hydrochloric acid extraction, respectively. In addition, breast milk of an unmedicated mother was used for establishing the analytical procedure so that the validity of the results was better confirmed. The milk-plasma ratio arising from our data was 0.5, and the relative infant dose was 0.3%. The olanzapine concentration was below the limit of detection (<5 ng/mL) in the infant's plasma sample. No adverse effects were noticed, and the mother experienced a rapid improvement in her psychopathology during her hospital stay. In future studies, long-term follow-up of both mother and child would be useful.

Detecting depressive disorder with a 19-item local instrument in Tanzania

BACKGROUND

Based on experience with the Hopkins Symptom Checklist-25 (HSCL-25) in a Tanzanian population, this study attempted to develop a locally specific screen that employs indigenous expressions.

AIM AND METHOD

Thirty ethnographically derived local idioms were added and the final 47-item questionnaire administered to 787 randomly selected antenatal clinic attendees.

RESULTS

Logistic regression identified 19 items for the Dar-es-Salaam Symptom Questionnaire (DSQ), which demonstrated good internal consistency (Cronbach's alpha = 0.84), interrater reliability (intraclass r = 0.89), and test-retest reliability (intraclass r = 0.82). Positive endorsement overall increased only slightly, but the report of mild symptoms was more frequent with the DSQ (15.0%) than the HSCL-25 (10.8%). Content and discriminant validation of the local scale conformed to expectation, but depressed affect failed to emerge as an important feature.

CONCLUSION

Locally derived expressions may aid in the reporting of illness and illness severity. Further studies are recommended to uncover universal aspects and culturally specific manifestations of illness expression.

DECLARATION OF INTEREST

None to report.

Detecting depressive disorder with the Hopkins Symptom Checklist-25 in Tanzania

BACKGROUND

Assessment of the growing prevalence of depression in developing countries is hampered by a lack of valid diagnostic instruments for the local settings.

AIM AND METHOD

This study attempted to examine the validity of the 25-item Hopkins Symptom Checklist (HSCL-25) in a special primary care population in Dar es Salaam, Tanzania.

RESULTS

787 antenatal participants were recruited, and their responses revealed good internal consistency, interrater reliability, and test-retest reliability, and the scale was validated using content, construct, and discriminant validation methods. Factor analysis of the depression subscale, however, confirmed the need for a locally developed scale.

CONCLUSIONS

Integrating universalist and relativist approaches, through the validation and modification of scales, may help in the detection of depression in cross-cultural settings.

Orbitofrontal dysfunction in a monozygotic twin discordant for postpartum affective psychosis: a functional magnetic resonance imaging study

BACKGROUND

Incomplete concordance for psychosis in monozygotic (MZ) twins has been interpreted as indicative of non-genetic cofactors in transmission of the illness. In this case study, we consider childbirth a landmark in the onset of psychotic symptoms, leading to the diagnosis of puerperal psychosis and then to bipolar/schizoaffective disorder. At the end of the third trimester, there is a sudden drop in estrogen, which exerts prominent effects on the serotonergic system in the orbitofrontal cortex (OFC).

OBJECTIVES

The purpose of the present study was to investigate OFC activation during emotional processing in MZ twins discordant for affective psychosis.

METHODS

Blood-oxygen-level-dependent activation using functional magnetic resonance imaging was measured during the passive viewing of emotional film excerpts.

RESULTS

Consistent with our hypothesis, a significant locus of activation was found in the left OFC in the normal MZ twin, but not in the psychosis MZ twin.

CONCLUSIONS

The personality changes noted in the psychosis MZ twin (postpartum psychosis) may be related to dysfunctional OFC. Ms J's childbirth may have triggered the onset of psychotic symptoms, leading to the diagnosis of bipolar or schizoaffective disorder.

Postnatal depression in primary care populations in Nigeria

OBJECTIVE

The purpose of this study is to determine the prevalence and associated factors for postnatal depression in primary health care (PHC) centers of a developing society.

METHOD

A two-stage screening procedure involving the 10-item self-report Edinburgh Postnatal Depression Scale (EPDS) and the Present State Examination Schedule was employed.

RESULTS

The prevalence of postnatal depression in the primary care populations studied was 18.6%. Postnatal depression was found on logistic regression to be independently predicted by younger age (OR, 5.42; 95% CI, 2.61-10.32; P<.05), by being primigravida (OR, 2.73; 95% CI, 1.44-4.24; P<.05), by not having the desired gender for their babies (OR, 2.86; 95% CI, 1.62-5.93; P<.05) and by in-law relationship problems (OR, 3.64; 95% CI, 1.84-7.22; P<.05). The EPDS was shown to be a feasible screening instrument for postnatal depression in the PHC centers (sensitivity, 88.1%; specificity, 84.3%; minimum misclassification rate, 15.0%).

CONCLUSION

The EPDS should be incorporated into the maternal and child health care programs of PHC centers in developing countries in order to ensure early detection and appropriate therapeutic intervention in cases of postnatal depression.

Postnatal depression: a review of current literature

The print and other forms of media offer significant amounts of information to women about pregnancy, parenthood and the birth process, but much less information exists about postnatal depression and how to cope with the frequently painful realities involved in childbirth and parenting--especially when debilitated by postnatal depression (PND). Even less information exists about such women's reactions to interventions by health professionals, which is the subject of my Ph.D study in progress. This article reviews current literature about the clinical presentation of postnatal depression, the three major types of mood disorders following childbirth, the risk factors for postnatal depression, detection and treatment of postnatal depression and the need for further research on treatment outcomes for women with PND.

Considering a simple strategy for detection of women at risk of psychological distress after childbirth

BACKGROUND

Postpartum depression is a common, severe, yet often undetected condition. Between 10 and 15 percent of new mothers suffer from depressive disorders in the first year after childbirth. The objective of this study was to investigate whether asking women questions about their daily life constituted a useful strategy to detect women at risk of developing psychological distress after childbirth.

METHODS

A prospective study of 330 first- and second-time mothers was conducted. Structured interviews with women were performed at the maternity unit 1 to 2 days after childbirth, and postal questionnaires were sent to participants 5 months later. An interviewer wrote down her perception of the mood of participants, in the form of three short statements, immediately after the interview. This perception was compared with the score of the woman on the General Health Questionnaire scale, which was included in the 5 months' questionnaire.

RESULTS

The interviewer's perception of women's mood was significantly associated with the score on the General Health Questionnaire scale 5 months later. Multivariate analysis showed that the interviewer's perception of anxiety was a better predictor of postpartum psychological distress at 5 months than women's answers to questions about their mood before pregnancy and 1 to 2 days after delivery.

CONCLUSIONS

Asking the new mother questions about her private and occupational life can be considered as one of many possible ways to improve the identification of women at risk of developing postpartum depression.

In the shadow of maternal depressed mood: experiences of parenthood during the first year after childbirth

To study the period and point prevalence of maternal depressive mood at three occasions before and after childbirth, and the relationship to the parents' psychosocial conditions and experiences of parenthood during the first year after childbirth. In a longitudinal community-based study, 434 pregnant women were invited to complete the Edinburgh Postnatal Depression Scale (EPDS) (cut-off score 9/10) at three time points. The parents' psychosocial conditions and experiences of parenthood were enquired at two months and at one year after childbirth, when the form Experience of Motherhood/Fatherhood Questionnaire (EMQ/EFQ) was applied. Three times measurement responses from both men and women were analyzed using non-parametric statistical methods and path-analysis. About 75% of the parents responded to the questionnaires. The period prevalence was 28%, and the point prevalence found on the three time points was EPDS I 21%, EPDS II 17% and EPDS III 12%. Correlations between antenatal and postnatal depressive symptoms were found, r = 0.61 and r = 0.45, respectively. Women, who experienced financial worries, lack of social support and losses and strains after childbirth showed more symptoms of depressed mood. The maternal depressive mood influenced negatively on breastfeeding and experiences of motherhood, but not on experiences of fatherhood. The partners of depressed women were neither more involved in childcare nor did they utilize paternal leave more than the other men. Both men and women reported the sexual life as negatively influenced by the women's depressed mood.

Does pain relief during delivery decrease the risk of postnatal depression?

BACKGROUND

To test the hypothesis that sufficient pain relief during delivery decreases the risk of postnatal depression.

METHODS

As part of a prospective follow-up study of the risk factors for postnatal depression and its impact on the mother-infant interaction and child development, 185 parturients filled in the Edinburgh Postnatal Depression Scale (EPDS), first during the first postpartum week and again (n = 162) 4 months later. The incidence and the risk of high EPDS scores was calculated according to the mode of delivery and the mode of pain relief during vaginal delivery, also after adjusting for the length of labor.

RESULTS

Mothers who received epidural/paracervical blockade during their delivery spent less time in the delivery room than mothers in the nitrous oxide/acupuncture group (p = 0.033) or mothers with no pain relief (p = 0.026) and had shorter length of labor than mothers without pain relief (p = 0.04). The adjusted risk of depressive scores at the first postnatal week was decreased in the epidural/paracervical group when compared with no analgesia group (OR: 0.25, 95% CI: 0.09-0.72). This difference was not shown at 4 months postpartum. Elective or emergency cesarean section did not increase the risk of high EPDS scores at the first week or at 4 months postpartum.

CONCLUSION

The mode of pain relief during vaginal delivery seems to be associated with the incidence of postpartum depression, especially immediately after delivery.

Breast-feeding and maternal health in online mothers

Self-reports of mothers currently breast-feeding (n = 561) and mothers who had breast-fed in the past (n = 452) were compared for perceived stress, self-reports of upper respiratory infection symptoms, and physician visits for psychological illnesses. Possible demographic confounds were controlled statistically. In analyses examining breast-feeding status as a dichotomous variable (current vs. past), breast-feeding was negatively associated with perceived stress and upper respiratory symptoms (the latter association dissolved when controlling for perceived stress), but not with physician visits for psychological illnesses. However, analyses of the continuous variables of frequency of breast-feeding and cumulative amount of breast-feeding revealed negative associations, and analyses of times since last nursing revealed positive associations with likelihood for physician visits for psychological illnesses. Frequency of bottle-feeding was positively associated with perceived stress. The results support the interrelatedness of breast-feeding and maternal health in online mothers.

Dimensions of depression and perfectionism in pregnant and nonpregnant women: their levels and interrelationships and their relationship to marital satisfaction

The authors studied S. J. Blatt's (1974) 2 dimensions of depression (anaclitic and introjective), P. L. Hewitt and G. L. Flett's (1991b) 3 dimensions of perfectionism (socially prescribed, self-oriented, and other-oriented), and the relationship between these and marital satisfaction in 100 married women in the last trimester of their first pregnancy and in 50 married women who had not yet experienced pregnancy. The measures used were the Depressive Experiences Questionnaire (S. J. Blatt, J. P. D'Afflitti, & D. M. Quinlan. 1976a, 1976b), the Multidimensional Perfectionism Scale (P. L. Hewitt & G. L. Flett, 1989), and G. B. Spanier's (1976) Dyadic Adjustment Scale. Pregnant and nonpregnant women did not differ in anaclitic depression, but the level of introjective depression of pregnant women was lower than that of nonpregnant women. The two groups did not differ in level of marital satisfaction or in any of the dimensions of perfectionism. For both groups, introjective depression was positively correlated with socially prescribed perfectionism and negatively correlated with marital satisfaction. Self-oriented perfectionism was positively related to introjective depression and negatively related to marital satisfaction for nonpregnant women. For the pregnant women, there was a negative relationship between socially prescribed perfectionism and marital satisfaction. Anaclitic depression and other-oriented perfectionism were unrelated to any of the other variables studied.

Care in a mother-baby psychiatric unit: analysis of separation at discharge

Joint psychiatric admission to a Mother-Baby Unit (MBU) enables a mother to obtain care for psychiatric disorders and simultaneously receive support in developing her identity as a mother. This care is meant to prevent attachment disorders and mother-baby separation. Outcome at discharge, however, may differ according to the mother's admission diagnosis. Demographic data, clinical features of parent and child, and clinical outcome of 92 consecutive admissions of mothers and their children to a MBU in Marseille were collected over a period of eight years (1991-1998). Separations occurred in 23% of the joint admissions. Women with acute postpartum psychoses and major depressive disorders had better outcomes than those with chronic psychoses: at discharge, the latter were more often separated from their children. In those cases, however, MBU admission provided time to arrange the best placement for the child. Outcome was less predictable for non-psychotic personality disorders and depended not only on the mother's disease but also on her family and social context.

Pregnancy and post partum: changes in cognition and mood

Steroidal hormones are increasingly recognized as highly relevant in multiple aspects of brain functioning. While basic science has actively worked to advance understanding of fundamental steroid mechanisms within the brain, investigation of the neurobehavioral outcomes of reproductive hormone actions on the human brain has received less attention. We argue that the dramatic steroidal hormone changes seen in human reproduction must be systematically studied and may provide novel explanations of cognitive and mood disorders associated with reproductive events. This chapter provides a review of current literature establishing a role for a variety of steroids on neuroactivity, and evidence from a variety of observational and experimental paradigms linking hormones and clinical aspects of cognition and mood in humans. The specific hormonal changes of pregnancy are described and discussed in relation to concomitant alterations in cognition and mood across the peri-natal period. A review of studies that have systematically observed cognitive and affective changes both during pregnancy and the post-partum period is presented, as well as new data that follow a small cohort of women for an extended period of time after delivery. We conclude that women may show specific areas of cognitive changes during and after pregnancy, notably deficits in verbal learning and memory. Mood appears to be impacted as well. While steroidal hormones show a pattern of associations with mood during and after pregnancy, no such pattern is evident for cognition. The embryonic state of our knowledge regarding reproductive hormones and neurobehavioral functioning is evident, as are the scientific and public health reasons to redress this lacuna.

Correlation between serum testosterone levels and peripartal mood states

BACKGROUND

We conducted a prospective study at the Department of Obstetrics and Gynecology, University Hospital of Vienna to investigate associations between serum testosterone levels and maternal peripartal mood states.

METHODS

Two hundred and fifty-two pregnant women at term (38 to 40 weeks' gestation) took part in the study. Blood samples for plasma testosterone levels and other biochemicals were obtained prepartum, and on the 1st and 3rd day postpartum. Mood was assessed with the McNair Profile of Mood States (POMS) at term pregnancy and daily from the first day after delivery until discharge from the hospital.

RESULTS

The final study population consisted of 193 women. Serum testosterone levels correlated significantly with maternal depression scores, both pre- and post partum (at term r=0.148, p=0.04; 1st day postpartum r=0.156, p=0.03; and 2nd day postpartum r=0.186, p=0.02, respectively). Testosterone concentrations also correlated with anger prepartum (r=0.164, p=0.02) and on the third day after delivery (r=0.188, p=0.02). No significant correlation between testosterone concentration and fatigue and vigor both pre- and post partum, respectively were found.

CONCLUSION

Serum testosterone levels correlate with depression and anger in the first postpartum days.

Review of the role of progesterone in the management of postnatal mood disorders

Postnatal mood disorders (maternity blues, postnatal depression and puerperal psychosis) are cross-cultural symptoms that are commonly seen in primary care by general practitioners and midwives, by gynecologists and obstetricians, and within the psychiatric services. One of several hypotheses for their causation is falling progesterone levels in the postpartum period. Progesterone supplements are therefore currently used in the treatment of postnatal mood disorders, both in primary and secondary health care settings. The evidence for this is reviewed. The MEDLINE and PSYCHLIT databases from 1966 to 1999 were searched. References reporting observational data on progesterone levels around delivery or therapeutic studies using progesterone were retrieved. Additional references were identified by citation tracking from these and direct contact with available authors. Eight papers were identified. Although there is some weak evidence for its role in maternity blues and some theoretical justification for its use, there is no robust primary research to support the use of progesterone in the treatment of postnatal mood disorders. Progesterone is being used to prevent recurrence of postnatal depression but the evidence supporting its efficacy is lacking. Its use in the treatment of postnatal mood disorders cannot be recommended on the basis of current evidence. Randomized controlled trials are needed to decide if it has a role in the treatment and prevention of postnatal mood disorders.

Pregnancy, the postpartum, and steroid hormones: effects on cognition and mood

The effects of pregnancy on cognition and mood were examined using a repeated-measures design. Nineteen women, average age 33, were tested with a comprehensive neuropsychological battery during their last 2 months of pregnancy and again within 2 months of delivery. Blood samples were obtained from all subjects and assayed for a variety of steroid hormones implicated in cognitive and mood functioning. Most participants also completed several self-report measures of mood. In comparison with performance after delivery, women showed significantly more impairment in aspects of verbal memory during pregnancy and also tended to report more negative mood states. Memory deficits were not explained by mood disturbances. No hormone assayed consistently related to cognitive performance during pregnancy. During pregnancy, higher levels of progesterone (P) were associated with greater mood disturbances and higher levels of dehydroepiandrosterone (DHEA) with better mood. After delivery, testosterone (T) was strongly and consistently associated with greater reported mood disturbances. Our results confirm a peripartal memory deficit, which cannot be explained by the dramatic rise in circulating steroid hormones, or by mood status during pregnancy. Steroidal hormones, namely P, DHEA and T, appear to play a role in mood disturbances during, and after, pregnancy. Studies beginning earlier in pregnancy and continuing for an extended period of time after delivery are needed to confirm and expand these observations.

Postpartum psychosis and postpartum thyroiditis

The term postpartum psychosis refers to a group of severe and heterogeneous disorders with psychotic symptoms that occur most frequently in the context of a mood disorder during the postpartum period. We report a case of 'postpartum psychosis' possibly associated with postpartum thyroiditis in a 29 year-old woman. The appearance of psychotic symptoms was chronologically related to the onset of postpartum thyroiditis and resolution of psychosis synchronized with the achievement of biochemical euthyroidism. The patient had typical symptoms of 'classic postpartum psychosis' (a historical term not included in DSM-IV, but used frequently by many physicians to describe diagnostic and therapeutic challenges posed by puerperal psychoses). Three months postpartum, the patient began to believe that she was pregnant with the Christ child, although she was not pregnant. Her delusions resolved around the 'pregnancy' and harm to her 'unborn' child. She also believed that her child (Jesus) was going to be killed. Other key symptoms included hallucinations, mixed mood symptoms, agitation and transient disorientation. Her DSM-IV diagnosis on admission was major depression with psychotic features and her discharge diagnosis (most likely diagnosis) was psychotic disorder due to thyrotoxicosis caused by postpartum thyroiditis. The differential diagnosis of co-occurring psychosis and postpartum thyroiditis can be examined relative to four possibilities: (1) psychosis due to thyrotoxicosis caused by postpartum thyroiditis; (2) a coincidence (no association between psychosis and postpartum thyroiditis); (3) precipitation of psychotic symptoms and disorientation related to a postpartum thyroiditis in a woman with a pre-existing mood disorder; or (4) both psychosis and thyroiditis caused by a pre-existing defect in autoimmunity. The authors stress the importance of early diagnosis and prompt treatment of postpartum psychosis. They discuss the indications for thyroid screening in postpartum psychoses. Further research is needed to clarify the nosology and mechanisms of severe postpartum disorders and to elucidate treatment-relevant and etiologically-distinct subsets of postpartum psychosis.