Elsevier

The Lancet

Volume 363, Issue 9405, 24 January 2004, Pages 303-310
The Lancet

Seminar
Postpartum psychiatric disorders

https://doi.org/10.1016/S0140-6736(03)15390-1Get rights and content

Summary

This review summarises the psychiatry of the puerperium, in the light of publications during the past 5 years. A wide variety of disorders are seen. Recognition of disorders of the mother–infant relationship is important, because these have pernicious long-term effects but generally respond to treatment. Psychoses complicate about one in 1000 deliveries. The most common is related to manic depression, in which neuroleptic drugs should be used with caution. Post-traumatic stress disorder, obsessions of child harm, and a range of anxiety disorders all require specific psychological treatments. Postpartum depression necessitates thorough exploration. Cessation of breastfeeding is not necessary, because most antidepressant drugs seem not to affect the infant. Controlled trials have shown the benefit of involving the child's father in therapy and of interventions promoting interaction between mother and infant. Owing to its complexity, multidisciplinary specialist teams have an important place in postpartum psychiatry.

Section snippets

Postpartum psychoses

The sudden onset of psychosis after childbirth has intrigued medical practitioners for centuries. More than 2000 papers have been published. This group of disorders is diverse, including psychogenic and organic psychoses.1 Only one form is commonly seen in countries with modern obstetric services. This form is generally called puerperal psychosis and takes the form of mania, severe depression (with delusions, confusion, or stupor), or acute polymorphic (cycloid) psychosis. Record-linkage studies

Disorders of the mother-infant relationship

Childbirth presents many challenges to the mother: trauma, sleep deprivation, breastfeeding, adjustments in conjugal and other relationships, and social isolation. However, the central and most important psychological process is development of the relationship with the infant. Disturbances in this process were recognised long ago, when hatred of children12, 13 and child abuse14 were described. Various terms have been used for these disturbances. “Bonding” is a useful lay term, but neither

Depression

Although puerperal melancholia has been recognised for centuries, American research in the 1950s drew attention to the prevalence of milder postpartum depression.31 A concept of postnatal depression emerged, which has been useful as a lay term. It reduces stigma and enables mothers with various postpartum psychiatric disorders to recognise that they are ill and to seek help. It is a focus for self-help groups and lobbying to improve services.

As a medical concept, however, it is less useful.

Post-traumatic stress disorder (PTSD)

Bydlowski and Raoul-Duval93 described PTSD after childbirth in 1978. Long ordeals during labour led to secondary tocophobia, and the recurrence of tension, nightmares, and flashbacks towards the end of the next pregnancy. There are now about 40 publications on this disorder, which has been called the fourth postpartum mental disorder.94 The stressful experience is pain in most cases, but loss of control and fear of death can be the focus.95, 96 There have been eight quantitative studies (Table 3

Various morbid preoccupations

Distress about the bodily changes resulting from pregnancy and childbirth are common. Such women complain of weight gain, stretch marks, or scars. They are reluctant to undress in front of their partners, avoid looking at themselves naked, and can even avoid being seen in public. In an unpublished prospective interview study of over 200 patients in the UK and New Zealand, this distress amounted to dysmorphophobia in 14% of clinic patients.

Conjugal jealousy is another disorder sometimes linked

Anxiety disorders specific to the puerperium

Several studies have reported the effect of pregnancy on panic disorder. A review of eight studies showed no overall effect: in 41% pregnancy brought an improvement, but in 44% there was an exacerbation in the postpartum period and in 10% new onset in the puerperium.107 Recent studies suggest that postpartum anxiety disorders are underemphasised and are more common than depression.108, 109 There could be a biological basis for some postpartum anxiety. McIvor and colleagues110 studied the

Obsessions of child harm

Obsessions of infanticide were one of the first postpartum disorders to be described,117 and several recent series have been published.118, 119, 120 The central symptom is of impulses to attack the child, but the setting is different from the pathological anger that precedes child abuse. The mother is gentle and devoted. She experiences extravagant infanticidal impulses, together with fantasies of the family's horror and grief, causing intense distress and leading to reduced contact with the

Specialist teams

Given the diversity of postpartum mental illness and its risks for infants, there is a case for setting up specialist services for pregnant and puerperal women. In the UK, after the pioneering initiative of Main 50 years ago,127 a wealth of experience has been gained, through the concentration of severe cases in mother and baby units. However, in the absence of service evaluation, good clinical practice is based on ideas and innovation, rather than rigorous outcome data. The essence of these

Search strategy

Motherhood and Mental Health reviewed published work up to the end of 1995, citing over 2000 articles on postpartum disorders. For this review, I used PubMed to screen articles published in the past 7 years, under the headings “postpartum depression” (760 articles since 1995), “mother-infant relationship disorders” (290 articles), “postpartum anxiety” (370 articles, overlapping considerably with postpartum depression), “postpartum post-traumatic stress disorder” (26 articles), and

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