Differentiation and Clinical Implications of Postpartum Depression and Postpartum Psychosis

doi:10.1111/j.1552-6909.2009.01019.x

Journal of Obstetric, Gynecologic & Neonatal Nursing

Volume 38, Issue 3, May–June 2009, Pages 269-279

https://doi.org/10.1111/j.1552-6909.2009.01019.x Get rights and content

ABSTRACT

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.

Section snippets

Classification and Clinical Presentation

The classification of postpartum mood disorders has been a source of contention for many years. The argument concerns whether these disorders should be classified as distinct entities or be considered as part of existing conditions (Brockington, 1996). Most experts agree that PPD and PP are not distinct diagnostic entities. The current psychiatric classification systems, the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV-TR) (American Psychiatric

Epidemiology

Epidemiologic studies demonstrate that women are more likely to be admitted to a psychiatric unit after giving birth than at any other time in their lives (Kendell et al., 1987, Munk-Olsen et al., 2006). There has long been debate as to whether the postpartum period is a time of increased risk for mood disorders. Although the overall prevalence of depression does not appear to be higher in women after delivery as compared with age-matched comparison women (Cox, Murray, & Chapman, 1993), serious

Prevention and Treatment

Both PPD and PP are highly treatable disorders, and given that they are not considered to be qualitatively different than depression and mania or affective psychosis outside the postpartum period, there is no evidence to suggest that interventions outside the postpartum period would not be as effective postnatally. Prevention and treatment interventions for women experiencing postpartum mood disorders are guided by severity of symptoms, underlying mental illness, past response to treatment,

Postpartum Depression

Numerous studies have examined the long-term outcomes of PPD. Most women who receive treatment recover within 12 weeks (Cooper & Murray, 1995), while up to 15% of women will continue to experience depressive symptoms for greater than 24 weeks (Cooper, Campbell, Day, Kennerley, & Bond, 1988). The course of PPD is often prolonged because of a delay in diagnosis or inadequate treatment (Scottish Intercollegiate Guidelines Network, 2002). Stigma and shame frequently prevent women from obtaining the

Comparing PPD and PP

Table 1 outlines the principle differences between PPD and PP with respect to the prevalence, risk factors, onset, symptoms, management, and long-term outcomes of these disorders. A noticeable difference is the prevalence and onset times. The risk factors for both PPD and PP are complex and multifactorial. While PPD is often predicted by psychosocial factors, PP is generally predicted by biological factors. The approach to treatment also differs. Postpartum depression is most commonly managed

Nursing Implications

Childbearing women encounter nurses working in a variety of settings. Accordingly, nurses are ideally placed to screen, assess, and treat women experiencing postpartum mood disorders.

Improved recognition of at-risk women and early detection of postpartum mood disorders is essential, considering the high prevalence and potential adverse consequences.

Conclusion

Postpartum depression and PP are severe and debilitating disorders that affect women at a crucial time. Given that women are often in contact with health care services throughout the perinatal period, this represents an excellent window of opportunity for nurses to screen for PPD and PP and to assist in implementing preventative and treatment measures. Early identification and appropriate and timely treatment are critical to the well-being of the affected woman and her family. Collaboration

REFERENCES (105)

C.T. Beck
The effects of postpartum depression on child development
Archives of Psychiatric Nursing
(1998)
N. Coyle et al.
Variation at the serotonin transporter gene influences susceptibility to bipolar affective puerperal psychosis
Lancet
(2000)
J. Goodman
Postpartum depression beyond the early postpartum period
Journal of Obstetric, Gynecologic, & Neonatal Nursing
(2004)
A.J.P. Gregoire et al.
Transdermal oestrogen for treatment of severe postnatal depression
Lancet
(1996)
M.W. Groer et al.
Cytokines, infections, stress, and dysphoric moods in breastfeeders and formula feeders
Journal of Obstetric, Gynecologic, & Neonatal Nursing
(2006)
J.A. Horowitz et al.
Identifying and treating postpartum depression
Journal of Obstetric, Gynecologic & Neonatal Nursing
(2005)
C. MacArthur et al.
‘Effects of redesigned community postnatal care on womens’ health 4 months after birth
Lancet
(2002)
S.A. Madsen et al.
Paternal depression in the postnatal period assessed with traditional and male depression scales
Journal of Men's Health and Gender
(2007)
K. McQueen et al.
Evidence-based recommendations for depressive symptoms in postpartum women
Journal of Obstetric, Gynecologic, & Neonatal Nursing
(2008)
C.J. Miller et al.
Sensitivity and specificity of the Mood Disorder Questionnaire for detecting bipolar disorder
Journal of Affective Disorders
(2004)

E. Robertson et al.

Antenatal risk factors for postpartum depression

General Hospital Psychiatry

(2004)

D.A. Sichel et al.

Prophylactic estrogen in recurrent postpartum affective disorder

Biological Psychiatry

(1995)

P. Agrawal et al.

Post partum psychosis

International Journal of Social Psychiatry

(1997)

A. Ahokas et al.

Estrogen deficiency in severe postpartum depression

Journal of Clinical Psychiatry

(2001)

Diagnostic and statistical manual of mental disorders, text revision

(2000)

L. Appleby et al.

Suicide and other causes of mortality after post-partum psychiatric admission

British Journal of Psychiatry

(1998)

K.L. Armstrong et al.

A randomized controlled trial of nurse home visiting to vulnerable families with newborns

Journal of Pediatrics and Child Health

(1999)

J. Baker et al.

Treating postpartum depression

Physician Assistant

(2002)

C.G. Ballard et al.

Prevalence of postnatal psychiatric morbidity in mothers and fathers

British Journal of Psychiatry

(1994)

C.T. Beck

The effects of postpartum depression on maternal-infant interaction

Nursing Research

(1995)

C.T. Beck

Maternal depression and child behaviour problems

Journal of Advanced Nursing

(1999)

C.T. Beck

Predictors of postpartum depression

Nursing Research

(2001)

C.T. Beck

Postpartum depression

Qualitative Health Research

(2002)

C.T. Beck et al.

Postpartum depression screening scale manual

(2002)

M. Bloch et al.

Effects of gonadal steroids in women with a history of postpartum depression

American Journal of Psychiatry

(2000)

I.F. Brockington

Motherhood and mental health

(1996)

I.F. Brockington et al.

Puerperal psychosis

Archives of General Psychiatry

(1981)

K. Chung et al.

Validation of the Chinese version of the Mood Disorder Questionnaire in a psychiatric population in Hong Kong

Psychiatry and Clinical Neurosciences

(2008)

L.S. Cohen et al.

Postpartum prophylaxis for women with bipolar disorder

American Journal of Psychiatry

(1995)

P.J. Cooper et al.

Non-psychotic psychiatric disorder after childbirth

British Journal of Psychiatry

(1988)

P.J. Cooper et al.

The course and recurrence of postnatal depression

British Journal of Psychiatry

(1995)

J.L. Cox et al.

Detection of postnatal depression

British Journal of Psychiatry

(1987)

J.L. Cox et al.

A controlled study of the onset, duration, and prevalence of postnatal depression

British Journal of Psychiatry

(1993)

C. Dean et al.

Is puerperal psychosis the same as bipolar manic-depressive disorder? A family study

Psychological Medicine

(1989)

C.-L. Dennis

The effect of peer support on postpartum depression

Canadian Journal of Psychiatry

(2003)

C.-L. Dennis

Treatment of postpartum depression part 2

Journal of Clinical Psychiatry

(2004)

C.-L. Dennis et al.

Postpartum depression help-seeking barriers and maternal treatment preferences

Birth

(2006)

C.-L. Dennis et al.

Psychosocial and psychological interventions for preventing postpartum depression

(2004)

C.-L. Dennis et al.

Psychosocial and psychological interventions for treating postpartum depression

(2007)

C.L. Dennis et al.

Global and relationship-specific perceptions of support and the development of postpartum depressive symptomatology

Social Psychiatry and Psychiatric Epidemiology

(2007)

C.-L. Dennis et al.

Relationships among infant sleep patterns, maternal fatigue, and the development of depressive symptomatology

Birth

(2005)

C.-L. Dennis et al.

Women's perceptions of partner support and conflict in the development of postpartum depressive symptoms

Journal of Advanced Nursing

(2006)

N. DeRosa et al.

A comparison of screening instruments for depression in postpartum adolescents

Journal of Child and Adolescent Psychiatric Nursing

(2006)

A. Forray et al.

The use of electroconvulsive therapy in postpartum affective disorders

Journal of ECT

(2007)

P. Garfield et al.

Outcome of postpartum disorders

Acta Psychiatrica Scandinavica

(2004)

B.N. Gaynes et al.

Perinatal depression: Prevalence, screening accuracy, and screening outcomes (AHRQ publication no. 05-E006-2)

(2005)

S. Gentile

The role of estrogen therapy in postpartum psychiatric disorders

CNS Spectrum

(2005)

V. Glover et al.

Mild hypomania (the highs) can be a feature of the first postpartum week

British Journal of Psychiatry

(1994)

S.L. Grace et al.

The effect of postpartum depression on child cognitive development and behavior

Archives of Women's Mental Health

(2003)

M. Grube

Inpatient treatment of women with postpartum psychiatric disorders

Archives of Women's Mental Health

(2005)

Cited by (44)

The lived experiences of individuals with postpartum psychosis: A qualitative analysis
2024, Journal of Affective Disorders
Postpartum psychosis (PP) is a severe psychiatric illness that occurs in about 1 to 2 per 1000 people in the perinatal period. To date, qualitative research investigating PP has focused on specific topics, such as treatment experiences or the impact of the illness on patients' lives and families. These studies have included small samples of women with histories of PP, often limited to certain geographical areas or treatment centers. Given the heterogeneity in presentations of PP and access to care, larger and geographically diverse samples are needed to broadly understand this complex illness. Initiated in 2018, the Massachusetts General Hospital Postpartum Psychosis Project (MGHP3) consists of a large, international sample of those who have experienced PP. In addition to the specific aims of MGHP3, which include to better understand the phenomenology and potential genetic underpinnings of PP, this investigation invites participants to qualitatively describe their narratives of postpartum psychosis. This analysis included 130 participants who reported on 133 episodes of PP. Participants' responses to the PP narrative prompt fell under several overarching categories: 1) broad psychosocial experiences surrounding postpartum psychosis, 2) impact on the mother-baby dyad, 3) treatment experiences, and 4) recovery experiences. Our findings shed light on a range of ways in which individuals' lives are impacted by this illness, and point to areas for future research and clinical directions to improve the support and care for individuals with PP and their families.
The river of postnatal psychosis: A qualitative study of women's experiences and meanings
2021, Midwifery
Citation Excerpt :
PP can also disrupt the developing bond between the mother and her child and this can have severe and long term consequences for the wellbeing of the mother, her child, and family (Jones et al., 2014). Being able to recognise the early symptoms of PP enables treatment and care to begin before the illness has reached its most severe form (Doucet et al., 2009; Posmontier, 2010; Royal College of Psychiatrists, 2015; Wicks et al., 2019). Assisting midwives to understand how women describe their experience of PP is important because it has been identified that women feel most comfortable in disclosing symptoms of mental ill health in the peripartum period to midwives (Russell et al., 2017).
This paper reports findings from a study about women's experience of postpartum psychosis which affects 1-2 women in 1000 in the first four to six weeks following childbirth. Previous research reports many women are relucent to disclose symptoms of mental ill health to healthcare professionals, although they are most likely to discuss symptoms and concerns with a health professional known to them.
A qualitative interpretive study using semi-structured interviews.
Ten women in Australia who had recovered from postpartum psychosis in the last ten years were interviewed.
Data were analysed thematically by three researchers to enhance trustworthiness.
The women described their overall experience as traumatic and described what they saw as contributing factors such as a previous history of mental illness or a significant life event that was present before or during pregnancy; the women described how they made meaning of the symptoms they experienced, such as a lack of sleep or changes in their thoughts or behaviours; and the difficulties they experienced during recovery. The women also identified novel ways to support themselves and each other as they recovered.
Midwives require further education to recognise the symptoms of postpartum psychosis, to ask further probing questions to identify postpartum psychosis in its early stages and to support women as they recover from this illness.
Maternal perceived bonding towards the infant and parenting stress in women at risk of postpartum psychosis with and without a postpartum relapse
2021, Journal of Affective Disorders
Citation Excerpt :
As detailed in the Methods section, women at risk of PP were recruited from specialist perinatal mental health services and were closely monitored by them; this probably contributed to the fact that a relatively low proportion of them developed an episode of full-blown psychosis. Although we used a broader definition of PP to capture relapse of affective symptoms in the immediate postpartum, which included symptoms of depression, we are confident that we are not measuring typical postnatal depression, which often has a later onset (Doucet et al., 2009; Gavin et al., 2005; Hazelgrove et al., 2021). Lastly, our groups were different in some socio-demographic variables.
Postpartum psychosis (PP) is the most severe psychiatric disorder associated with childbirth. However, there is little research on maternal bonding towards the infant and parenting stress in this clinical population.
We investigated maternal bonding during pregnancy and post-partum in 75 women: 46 at risk of PP (AR), because of a DSM-IV diagnosis of bipolar disorder, schizoaffective disorder or previous PP, and 29 healthy controls. Of the AR women, 19 developed a psychiatric relapse within 4 weeks’ post-partum (AR-unwell), while 27 remained symptom-free (AR-well). We investigated childhood maltreatment, parenting stress and psychiatric symptoms as potential predictors of maternal bonding.
In pregnancy, AR-unwell women reported a more negative affective experience towards their infants than AR-well women (d = 0.87, p = .001), while postnatally there was no significant difference in bonding. In contrast, AR women as a group reported a more negative affective experience than HC postnatally (d = 0.69, p = .002; d = 0.70, p = .010), but not antenatally. Parenting stress and psychiatric symptoms significantly predicted less optimal postnatal bonding (b = -0.10, t = -4.29, p < .001; b = -0.37, t = -4.85, p < .001) but only psychiatric symptoms explained the difference in bonding between AR and HC (b = -1.18, 95% BCa CI [-2.70,-0.04]).
A relatively small sample size precluded a more in-depth investigation of underlying pathways.
This study provides new information on maternal bonding in women at risk of PP, and particularly in those that do and do not develop a postpartum relapse. The results suggest that improving maternal symptoms and parenting stress in the perinatal period in women at risk of PP could also have positive effects on bonding.
Perinatal depression: a review on diagnosis and treatment strategies
2020, Revista Medica Clinica Las Condes
Para las mujeres, experimentar cambios emocionales durante el embarazo y hasta un año posterior al parto puede ser parte del proceso de adaptación a los cambios fisiológicos y emocionales de esta nueva etapa, siendo por lo general manejable por ellas mismas. Diferente es el desarrollo de síntomas depresivos durante este período perinatal que comprende el embarazo y hasta doce meses posterior al parto. La depresión perinatal constituye un trastorno de alta prevalencia que puede tener efectos negativos tanto para la salud de la madre, del hijo y de otros miembros de la familia.
For women it is natural to experience changes in mood and feelings during pregnancy and after twelve months after childbirth, these shifting moods are often manageable by themselves, it differs with depressive symptoms that appear during these period. Perinatal depression constitutes a high prevalence disorder that might have a negative effect not only in the mother, but the child and other familiy members.
Perinatal mental illness
2015, Medicine (Spain)
La enfermedad mental durante el periodo perinatal es frecuente y es una de las principales causas de morbimortalidad para las madres y sus hijos. Es recomendable que los profesionales en contac-to con las madres tengan conocimientos básicos sobre la psicopatología del periodo perinatal, y desarrollen habilidades y protocolos que permitan evaluar la salud mental de la madre y su historia psiquiátrica previa. Aquellas mujeres cuyo embarazo o postparto se complica con una enfermedad mental deberían tener acceso a equipos de salud mental perinatal especializados. Se ha demostra-do la importancia del diagnóstico y tratamiento precoz de estas patologías, para mejorar el pronóstico y promover un vínculo seguro de la madre con su bebé, que es absolutamente necesario para su desarrollo físico y psicológico.
Mental illness during the perinatal period is quite frequent and is a major cause of morbidity and mortality for mothers and their children. It is recommended that professionals in contact with obstetric process have basic knowledge of psychopathology, and develop skills to assess the mental health of the mother with special attention to her previous psychiatric history. Women whose pregnancy or postpartum is complicated by a mental disease should have access to mental health care. It is importance the early diagnosis and treatment of these diseases, to improve prognosis and to promote a safety link between the mother with her baby, which is absolutely necessary for their physical and psychological development.
Mother-infant interaction and infant development in women at risk of postpartum psychosis with and without a postpartum relapse
2023, Psychological Medicine

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Principles & PracticeDifferentiation and Clinical Implications of Postpartum Depression and Postpartum Psychosis

ABSTRACT

Section snippets

Classification and Clinical Presentation

Epidemiology

Prevention and Treatment

Postpartum Depression

Comparing PPD and PP

Nursing Implications

Conclusion

Archives of Psychiatric Nursing

Lancet

Journal of Obstetric, Gynecologic, & Neonatal Nursing

Lancet

Journal of Obstetric, Gynecologic, & Neonatal Nursing

Journal of Obstetric, Gynecologic & Neonatal Nursing

Lancet

Journal of Men's Health and Gender

Journal of Obstetric, Gynecologic, & Neonatal Nursing

Journal of Affective Disorders

General Hospital Psychiatry

Biological Psychiatry

Post partum psychosis

International Journal of Social Psychiatry

Estrogen deficiency in severe postpartum depression

Journal of Clinical Psychiatry

Diagnostic and statistical manual of mental disorders, text revision

Suicide and other causes of mortality after post-partum psychiatric admission

British Journal of Psychiatry

A randomized controlled trial of nurse home visiting to vulnerable families with newborns

Journal of Pediatrics and Child Health

Treating postpartum depression

Physician Assistant

Prevalence of postnatal psychiatric morbidity in mothers and fathers

British Journal of Psychiatry

The effects of postpartum depression on maternal-infant interaction

Nursing Research

Maternal depression and child behaviour problems

Journal of Advanced Nursing

Predictors of postpartum depression

Nursing Research

Postpartum depression

Qualitative Health Research

Postpartum depression screening scale manual

Effects of gonadal steroids in women with a history of postpartum depression

American Journal of Psychiatry

Motherhood and mental health

Puerperal psychosis

Archives of General Psychiatry

Validation of the Chinese version of the Mood Disorder Questionnaire in a psychiatric population in Hong Kong

Psychiatry and Clinical Neurosciences

Postpartum prophylaxis for women with bipolar disorder

American Journal of Psychiatry

Non-psychotic psychiatric disorder after childbirth

British Journal of Psychiatry

The course and recurrence of postnatal depression

British Journal of Psychiatry

Detection of postnatal depression

British Journal of Psychiatry

A controlled study of the onset, duration, and prevalence of postnatal depression

British Journal of Psychiatry

Is puerperal psychosis the same as bipolar manic-depressive disorder? A family study

Psychological Medicine

The effect of peer support on postpartum depression

Canadian Journal of Psychiatry

Treatment of postpartum depression part 2

Journal of Clinical Psychiatry

Postpartum depression help-seeking barriers and maternal treatment preferences

Birth

Psychosocial and psychological interventions for preventing postpartum depression

Psychosocial and psychological interventions for treating postpartum depression

Global and relationship-specific perceptions of support and the development of postpartum depressive symptomatology

Social Psychiatry and Psychiatric Epidemiology

Relationships among infant sleep patterns, maternal fatigue, and the development of depressive symptomatology

Birth

Women's perceptions of partner support and conflict in the development of postpartum depressive symptoms

Journal of Advanced Nursing

A comparison of screening instruments for depression in postpartum adolescents

Journal of Child and Adolescent Psychiatric Nursing

The use of electroconvulsive therapy in postpartum affective disorders

Principles & Practice
Differentiation and Clinical Implications of Postpartum Depression and Postpartum Psychosis