The purpose of this activity is to enable the learner to understand the risk factors, screening, and management of care of pregnancy and postpartum psychiatric illness
Course preview
Syllabus
Objectives
- Identify the risk factors for postpartum mental illness.
- Discuss screening tools for postpartum depression.
- Discuss the postpartum psychiatric illness categories.
- Compare and contrast symptoms of postpartum depression with postpartum psychosis.
- Discuss common treatment options for postpartum depression.
- Discuss resources for a woman with postpartum psychiatric illness.
Introduction
Perinatal mental health disorders are clinically defined, treatable, and amenable to support, education, and intervention. However, even with increasing awareness of the rates of perinatal mental health disorders and their potential negative consequences on mothers, infants, and families, perinatal mental health is often undiagnosed, under-treated, or not treated at all (Postpartum Support International, 2019).
The presence of maternal depression has gained a lot of attention not only because of the rising incidence or worldwide distribution, but also because of the negative impact on personal, family and child developmental outcomes (Shrivastava, Shrivastava, & Ramasamy, 2015). Worldwide, about 10% of pregnant women and 13% of women who have recently given birth experience a mental health disorder. In developing countries, the prevalence is 15.6% during pregnancy and 19.8% after childbirth. In severe cases, mothers may commit suicide or potentially harm the newborn. Affected mothers cannot function properly, and as a result, the child’s growth and development may be negatively affected (WHO, 2019).
Postpartum depression (PPD) was initially classified as a subtype of major depression in the Diagnostic and Statistical Manual of Mental Disorders (DSM) but is now classified as Major Depressive Disorder, with peripartum onset in the DSM-5. Diagnosis of major depression requires the presence of five or more of the following symptoms: depressed mood, diminished interest or pleasure in activities, more than 5% body weight change in one month, insomnia, psychomotor agitation, fatigue, feelings of worthlessness or excessive or inappropriate guilt, decreased ability to concentrate, or recurrent thoughts of death or suicidal ideation. The criteria for the peripartum specifier listed in the DSM-5 stipulates that symptom onset must occur during pregnancy or within the first four weeks following birth (Payne & Maguire, 2019).
Defining PPD
The etiology and pathophysiology of postpartum psychiatric illness are not clearly understood. Varying degrees of biological, social, genetic, and psychological factors contribute to the development of postpartum psychiatric illness (Langan & Goodbred, 2016). On analysis of all the elements, the most important contributor to the causation of antenatal/postnatal depression is the absence of family support (Shrivastava et al., 2015).
After childbirth, the levels of estrogen and progesterone in a woman’s body drop. This alteration in hormone levels can lead to chemical changes in the woman’s brain that may trigger mood swings. Many mothers may be unable to get the rest they need to recover fully from giving birth. Sleep deprivation, physical discomfort, and exhaustion can contribute to the symptoms of postpartum depression (National Institutes of Mental Health, n.d.). However, there is no consistent correlation between levels of estrogen, progesterone, cortisol, or thyroid hormones and the occurrence of postpartum mood disturbance (MGH Center for Women’s Health, 2018).
Postpartum psychiatric illness can be divided into three categories: (1) postpartum blues, (2) PPD, and (3) postpartum psychosis (MGH Center for Women’s Health, 2018).
Postpartum blues
It is estimated that anywhere from 50 to 85% of mothers experience postpartum blues during the first few weeks after delivery. Mothers with the postpartum blues more commonly report mood lability, tearfulness, anxiety, or irritability. These symptoms peak on the fourth or fifth day after delivery and may last for a few hours or a few days. The symptoms usually resolve about two weeks after childbirth and do not interfere with the mother’s ability to function or care for her child. No specific treatment is required. If symptoms of depression persist for longer than two weeks, the mother should be evaluated to rule out a more serious mood disorder (MGH Center for Women’s Health, 2018).
Postpartum depression (PPD)
PPD usually begins during the first two to three months after delivery but may occur at any point after childbirth. The symptoms of PPD include:
- Appetite changes,
- Depressed or sad mood,
- Fatigue,
- Feelings of guilt,
- Feelings of worthlessness or incompetence,
- Hypochondriasis,
- Loss of interest in usual activities,
- Poor concentration,
- Severe anxiety,
- Sleep disturbances,
- Suicidal thoughts,
- Tearfulness (MGH Center for Women’s Health, 2018).
Postpartum psychosis
“Postpartum psychosis is the most severe form of postpartum psychiatric illness” (MGH Center for Women’s Health, 2018, para 5). It affects about 1 to 2 per 1000 women after childbirth. The onset of symptoms can appear as early as the first 48 to 72 hours after delivery, and most mothers develop symptoms within the first two postpartum weeks (MGH Center for Women’s Health, 2018).
The signs of postpartum psychosis are:
- Auditory hallucinations to harm herself or her infant,
- Delusional beliefs,
- Irritability,
- Insomnia,
- Mood swings ranging from depression and disorientation to erratic and disorganized behavior,
- Restlessness (MGH Center for Women’s Health, 2018).
Risk/protective factors
Any woman can develop mental disorders during pregnancy and in the first year after delivery, but poverty, migration, extreme stress, exposure to violence (domestic, sexual, and gender-based), emergency and conflict situations, natural disasters, and low social support can increase the risk (WHO, 2019).
Certain risk factors for PPD have been identified:
- Depression during pregnancy,
- History of depression or bipolar disorder,
- Inadequate social supports,
- Marital problems,
- A previous episode of PPD,
- Recent stressful life events (MGH Center for Women’s Health, 2018).
Management of Care
Screening
The American Academy of Pediatrics (AAP) Mental Health Task Force recommends incorporating screening for peripartum depression into the prenatal visit and the well-child visits at one, two, four, and six months. However, there is not one preferred screening tool for peripartum depression (Langan & Goodbred, 2016). Two commonly used tools are the Edinburgh Postnatal Depression Scale and the Patient Health Questionnaire-9. Each questionnaire has advantages and disadvantages. The Edinburgh Postnatal Depression Scale is a 10-item questionnaire that is used to identify women who have PPD. On this scale, a score of 12 or higher or answering yes to question 10 (presence of suicidal thoughts) raises concern and indicates a need for a more thorough evaluation (MGH Center for Women’s Health, 2018). The Patient Health Questionnaire-9 is a nine-item questionnaire used to identify major depression in patients. A score of 10 or above may indicate a possible major depression (Levis, Benedetti, & Thombs, 2019).
Prevention
The U.S. Preventative Services Task Force recommends that “clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions” (U.S. Preventative S
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ervices Task Force [USPSTF], 2019, p. 581). The Task Force recommends counseling for women with one or more of these risk factors:
- Current signs and symptoms of depression,
- History of depression or other mental health condition,
- Being pregnant as a teenager or being a single mom,
- Having stressful life circumstances,
- Being a victim of intimate partner violence (March of Dimes, 2019)
Studies on counseling interventions to prevent perinatal depression focused on cognitive behavioral therapy and interpersonal therapy (IPT). With cognitive behavioral therapy, positive changes in mood and behavior are achieved by addressing and managing negative thoughts, beliefs, and attitudes and by increasing positive events and activities. Common techniques include patient education, goal setting, interventions to identify and modify maladaptive thought patterns, and behavioral activation. IPT treats interpersonal issues thought to contribute to psychological disorders. Standard techniques include the use of exploratory questions, role-playing, decision analysis, and communication analysis. There is no data on the ideal time recommendation for offering or referral to counseling interventions. In studies, most women started during the second trimester of pregnancy. Counseling sessions reviewed for this recommendation ranged from 4 to 20 meetings, lasting for 4 to 70 weeks. Counseling consisted of both group and individual sessions, with the majority involving in-person visits (USPSTF, 2019).
Treatment
Treatment of PPD is generally holistic and includes reassurance, family and social support, education, and in some cases, psychotherapy, and/or pharmacologic treatment (Rai, Pathak, & Sharma, 2015). Without treatment, PPD can last for months or years, adversely affecting the mother’s and child’s health (National Institute of Mental Health, n.d.).
Education about postpartum mental illness and emotional support for the partner and family members is essential. Respite care services may be recommended to minimize the mother’s sleep disruption. In some cases, IPT might be beneficial. IPT can result in a reduction in depressive symptoms and improvement in social adjustment. In cases of postpartum psychosis, separation from the infant might be necessary to prevent harm. The mother needs reassurance and emotional support to boost her self-esteem and confidence. Group psychotherapy may also be beneficial (Rai et al., 2015).
Psychotropic medication may become necessary to treat PPD and postpartum psychosis. The use of psychotropic medications during lactation should be addressed. The amount of medication to which an infant is exposed depends on the maternal dosage of medication, timing and frequency of dosing, rate of maternal drug metabolism, and metabolism of the ingested drug in the infant. In premature infants or infants with compromised hepatic metabolism, breastfeeding should be deferred if the mother is taking psychotropic medications. Peak concentrations in breast milk are attained 6 to 8 hours after ingestion of the medication. Breastfeeding can be restricted to times when the breast milk drug concentration is lowest, either just before or after taking the medication (Rai et al., 2015).
Two classifications of antidepressants used in the treatment of PPD are selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). SSRIs are ideal first-line medications as they are anxiolytic, non-sedating, and well-tolerated (MGH Center for Women’s Health, 2018). Fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), and venlafaxine (Effexor) have shown efficacy in the treatment of PPD (MGH Center for Women’s Health, 2018).
Antidepressants influence the production and function of neurotransmitters in the brain. Neurotransmitters control mood, emotions, and behavior. In postpartum depression, there are chemical imbalances of serotonin and norepinephrine. Serotonin helps control mood and emotions, whereas norepinephrine is produced in response to tense situations. Antidepressants help to regulate these imbalances over time. It may take several weeks for the body to build up its production of neurotransmitters to levels that will improve mood, emotions, and behavior (Postpartum Depression, 2019).
Electroconvulsive therapy (ECT) can also be used for severe PPD and psychosis (MGH Center for Women’s Health, 2018). Research has shown high response rates of PPD and postpartum psychosis to ECT; the most significant predictor of response was the severity of symptoms (the more severe the symptoms, the higher the probability of response to ECT) (Rundgren et al., 2018).
In the 1980s, National Institutes of Mental Health Intramural Research Program researchers discovered that metabolites of the steroid hormones progesterone and deoxycorticosterone bound to and acted upon receptors for gamma-aminobutyric acid (GABA) — a major inhibitory neurotransmitter in the brain. These steroid hormones were found to amplify GABA-activated chloride ion currents, thereby impacting neuronal excitability. Research indicated that the concentration of one of these metabolites, specifically allopregnanolone, increases during pregnancy. After childbirth, the concentration drops, which then potentially triggers the development of depression and anxiety (National Institutes of Mental Health, 2019).
In 2019, the Food and Drug Administration (FDA) approved brexanolone (Zulresso), an analog of the endogenous human hormone allopregnanolone and the first drug specifically designed to treat PPD (National Institutes of Mental Health, 2019). Brexanolone (Zulresso) is given intravenously over 60 hours, and due to the risk of side effects, this medicine can only be administered in a clinic setting under the supervision of a health care provider. Brexanolone (Zulresso) may be unsafe to take while pregnant or breastfeeding (USDHHS, 2019).
Implications for Evidence-based Nursing
Nurses need to be aware of the resources available to new or expecting mothers for support. Postpartum Support International offers weekly online support meetings. Emergency hotlines are available 24 hours a day. Some examples of hotlines include:
- National Alliance on Mental Health: 800-950-NAMI (6264)
- National Crisis text line: Text HOME to 741741
- National Suicide Prevention Hotline: 800-273-TALK (8255) or see website
- Postpartum Support International helpline: 800-944-4PPD (4773)
Family and friends may be the first ones to notice that there is a problem, so education about the signs and symptoms of PPD is critical. Nurses can also educate the mother and family about things they can do to help:
- Refrain from drinking alcohol and drug use,
- Exercise to stay healthy,
- Eat well-balanced, nutritious meals regularly,
- Keep in touch with people who care,
- Take time for yourself,
- Ask and accept help,
- Reduce stress (March of Dimes, 2019).
Future research/directions
Further research is needed to address gaps in several areas. There is a lack of good-quality evidence on how to best identify high-risk women who could potentially benefit from preventive interventions. Larger-scale trials are needed for depression prevention interventions, such as physical activity, infant sleep education, in-hospital perinatal education, and peer counseling. Depression symptoms are useful in predicting future instances of perinatal depression, but more research is needed on how to incorporate perinatal risk factors into postpartum depression screening tools. Larger-scale trials of cognitive behavioral therapy and interpersonal therapy are needed to demonstrate whether these strategies are scalable and applicable to women at lower risk. Data is lacking on the benefits and harms of antidepressant medications for the prevention of perinatal depression. Dietary supplements, such as selenium and vitamin D, have shown potential, but more research is needed (USPSTF, 2019).
Placentophagy is a growing trend in Western societies, however there is no empirical evidence to support the benefits or risks. A convenience sample of women’s beliefs about their experience with ingesting the placenta found mothers perceived mostly positive effects such as an improvement in mood, energy, lactation, and bleeding. There needs to be a better understanding of the placenta’s properties including how the placenta affects mood and lactation (Marraccini & Gorman, 2015). A 2016 study found 17 different hormones in placenta capsule samples, including a level of estrogen and progesterone that researchers felt could have a physiologic effect (Young, Gryder, Zava, Kimball, & Benyshek, 2016). The CDC (Buser et al., 2017) reported on a case in Oregon where a mother’s encapsulated placenta was found to be infected with group B Streptococcus (GBS), which led to critical illness in her infant. Benyshek, Cheyney, Brown, and Bovbjerg (2018) assimilated data from over 7,000 mothers who engaged in placentophagy within a larger study including the medical records of over 23,000 women who planned a community birth. The vast majority ingested the placenta in uncooked, encapsulated form, and 73% reported they were attempting to avoid postpartum depression. The study found no reported adverse neonatal outcomes (Benyshek et al., 2018).
References
American College of Obstetrics and Gynecology. (2015). Screening for perinatal depression. Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Screening-for-Perinatal-Depression
Benyshek, D. C., Cheyney, M., Brown, J., & Bovbjerg, M. L. (2018). Placentophagy among women planning community births in the United States: Frequency, rationale, and associated neonatal outcomes. Birth, 45(4), 459–468. doi: 10.1111/birt.12354
Buser, G. L., Mató, S., Zhang, A. Y., Metcalf, B. J., Beall, B., & Thomas, A. R. (2017). Notes from the Field: Late-Onset Infant Group B Streptococcus Infection Associated with Maternal Consumption of Capsules Containing Dehydrated Placenta — Oregon, 2016. MMWR. Morbidity and Mortality Weekly Report, 66(25), 677–678. doi: 10.15585/mmwr.mm6625a4
Langan, R. C. & Goodbred, A. J. (2016). Identification and management of peripartum depression. American Family Physician, 93(10), 852-858.
Levis, B., Benedetti, A., Thombs, B. D. (2019). Accuracy of Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression: Individual participant data meta-analyses. BMJ, 365. doi: 10.1136/bmj.l1476.
March of Dimes. (2019). Postpartum depression. Retrieved from https://www.marchofdimes.org/pregnancy/postpartum-depression.aspx
Marraccini, M. E. & Gorman, K. S. (2015). Exploring placentophagy in humans: Problems and recommendations. Journal of Midwifery & Women’s Health, 60(4), 371-379. https://doi.org/10.1111/jmwh.12309
MGH Center for Women’s Mental Health. (2018). Postpartum psychiatric disorders. Retrieved from https://womensmentalhealth.org/specialty-clinics/postpartum-psychiatric-disorders/
National Institute of Mental Health. (n.d.). Postpartum depression facts. Retrieved from https://www.nimh.nih.gov/health/publications/postpartum-depression-facts/index.shtml
National Institute of Mental Health. (2019). Bench-to-Bedside: NIMH research leading to brexanolone, first-ever drug specifically for postpartum depression. Retrieved from https://www.nimh.nih.gov/news/science-news/2019/bench-to-bedside-nimh-research-leading-to-brexanolone-first-ever-drug-specifically-for-postpartum-depression.shtml
Payne, J. L. & Maguire, J. (2019). Pathophysiological mechanisms implicated in postpartum depression. Frontiers in Neuroendocrinology, 52, 165-180. Doi: 10.1016/j.yfrne.2018.12.001
Postpartum Depression. (2019). Postpartum depression antidepressants. Retrieved from https://www.postpartumdepression.org/treatment/postpartum-depression-medication/antidepressants/
Postpartum Support International. (2019). Screening recommendations. Retrieved from https://www.postpartum.net/professionals/screening/
Rai, S., Pathak, A., & Sharma, I. (2015). Postpartum psychiatric disorders: Early diagnosis and management. Indian Journal of Psychiatry, 57(Suppl 2), S216–S221. doi: 10.4103/0019-5545.161481
Rundgre, S., Brus, O., Bave, U., Landen, M., Lumdberg, J., Nordanskog, P., & Nordenskjold, A. (2018). Improvement of postpartum depression and psychosis after electroconvulsive therapy: A population-based study with a match comparison group. Journal of Affective Disorders, 235, 258-264.
Shrivastava, S. R., Shrivastava, P. S., and Ramasamy, J. (2015). Antenatal and postnatal depression: A public health perspective. Journal of Neurosciences in Rural Practice, 6(1), 116-119. doi: 10.4103/0976-3147.143218
U.S. Department of Human and Health Services (USDHHS). Office on Women’s Health. (2019). Postpartum depression. Retrieved from https://www.womenshealth.gov/mental-health/mental-health-conditions/postpartum-depression
U.S. Preventative Services Task Force (2019). Interventions to prevent perinatal depression. JAMA, 321(6), 580-587. doi:10.1001/jama.2019.0007
World Health Organization (WHO). (2019). Mental health. Retrieved from https://www.who.int/mental_health/maternal-child/maternal_mental_health/en/
Young, S. M., Gryder, L. K., Zava, D., Kimball, D. W., & Benyshek, D. C. (2016). Presence and concentration of 17 hormones in human placenta processed for encapsulation and consumption. Placenta, 43, 86–89. doi: 10.1016/j.placenta.2016.05.005