Peripartum mood disturbances overview

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sunita Kumawat, M.B.B.S[2]

Overview

Childbirth is a life changing event in a woman's life. Her body undergoes many physiological and psychological changes during pregnancy and childbirth; a causal relationship between hormone changes and mood shifts has been proposed. During the postpartum period, women face many depressive symptoms which varies in severity from mild postpartum blues to serious mood disorders like postpartum depression and postpartum psychosis. Identification and treatment of these mood disorders is critical to both child and mother's health.

Historical Perspective

In 460 B.C., Hippocrates was the first to mention about postpartum fever, mania, delirium and agitation. His writings reflected how postpartum depression is described today.
In 11th century, a professor of medicine, Trotula of Salerno, first recognized postpartum depression.
In 1547, a Portuguese physician, Joao Rodrigues de Castello Branco(Amatus Lusitanus), briefly described postpartum depression.

Between 16th and 18th centuries about 50 brief reports about Psychosis were published stating that these psychoses were recurrent and could be seen in both non-lactating and lactating females.
In 1797, Osiander, an obstetrician, wrote about 2 cases in detail, that are among the treasures for postpartum psychosis.
In 1819, Esquiro evaluated inpatients in the Salpêtrière, which paved the way for long term research.

Classification

Puerperal psychiatric illnesses may be classified according to Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) into 3 types:

• postpartum blues,
• postpartum depression, and
• postpartum psychosis.

During the postpartum period there is also increased susceptibility to anxiety disorders such as obsessive-compulsive disorder and panic disorder.

Pathophysiology

Many pathological mechanisms are involved in postpartum depression which interact with one another.

• Genetics of postpartum depression
  Estrogen receptor alpha gene, polymorphisms in the serotonin transporter gene, 5-HTT, and the gene encoding for MAOA and the gene encoding for Catechol-O-methyltransferase (COMT), Genetic variants for the TPH2 gene, a SNP in OXT was predictive of both variation in breastfeeding duration and postpartum depression scores, an interaction between a SNP in the OXTR gene and methylation state was detected in association with postpartum depression. In a genome-wide linkage and association study, the Hemicentin 1 gene (HMNC1) had the strongest association with postpartum depression.

• Epigenetic mechanisms of postpartum depression
  In women with postpartum depression, there was a substantial interaction between OXTR DNA methylation, estradiol, and the ratio of allopregnanolone to progesterone. Alterations in DNA methylation of the OXTR gene are adversely linked with blood estradiol levels in women with postpartum depression. As a result, epigenetic alterations can affect metabolic processes linked to postpartum depression.

• Neuroendocrine mechanisms of postpartum depression
  In postpartum depression, there is an interaction between the Hypothalamus-pituitary-gonadal (HPG) and Hypothalamus-Pituitary-Adrenal(HPA) axis. HPA axis function has been found to be influenced by reproductive hormones and vice versa. As a result, any change in reproductive hormones may cause stress hormone levels to fluctuate, resulting in postpartum depression. Alterations of the HPA axis' function may also affect reproductive hormone levels, contributing to postpartum depression.

• Neurotransmitters and postpartum depression
  GABA-GABA which is an inhibitory neurotransmitter in the brain, its level is inversely related with the depression symptoms in the postpartum period.
  

Glutamate-Glutamate is the excitatory neurotransmitter in the brain. In women with postpartum depression its level are increased in the medial prefrontal cortex and decreased in the dorsolateral prefrontal cortex.
Serotonin-The binding of Serotonin to 5HT1A receptors is decreased in the mesiotemporal and anterior cingulate cortices.
Dopamine-Mutations in DR1 is related to the behaviour of mother paying less attention to the baby.

• Neuroinflammatory mechanisms in postpartum depression
  There is a negative relationship between T-cell number and postpartum depression symptoms, whereas IL-6 and IL-1β have a significant positive relationship with it.

It is thought that in postpartum psychosis, immunoneuroendocrine set point is dysregulated with overactivation of the immune system's macrophage and monocyte arm.

Causes

Postpartum depression: drop in estrogen, progesterone and thyroid hormones after the birth of the child, anxiety, lack of sleep , distorted self image :
postpartum psychosis: sleep disruptions, genetics, immune system dysregulation, family history of mental health conditions, presence of other underlying mental health conditions, extreme hormone fluctuations, thyroid gland dysfunction
Postpartum blues: are caused mainly by a drop in estrogen and progesterone post delivery, decrease in thyroid hormone, sleep deprivation, not eating properly, emotional issues, anxiety about the care of the newborn and not finding time for oneself.

Differentiating POstpartum depression from Other Diseases

• Postpartum anxiety : The onset is anywhere between child birth to one year. Presents with feelings of dread, worry, lack of concentration, sleeping and eating problems, nausea, palpitations, dizziness. The condition does not subside on its own. The patient has to seek medical advice.
• Postpartum blues: They usually occur within a few days after child birth and improve within a week or two. The new mother has low mood, frequent crying, change in appetite and sleep, feeling of inadequacy. This does not impact day to day functioning or the capacity to look after the baby.
• Hyperthyroidism or Hypothyroidism: These pathologies can cause mood diorders along with other physiologic symptoms. These can be differentiated by evaluating free T4 and TSH levels.
• Postpartum Psychosis: This presents within days or weeks post delivery. This is acute in onset and an emergency situation with the risks of suicide and harm to the baby. The mother experiences agitation, delusions, hallucinations, sleep deprivation for several nights and change in behaviour.

Epidemiology and Demographics

Up to 85% of women have some form of mood disorder during the postpartum period.
The most widespread is postpartum blues with prevalence ranging from 30%-75%. It exists in a number of nations and cultures, although there is a difference in the prevalence rates.
According to the reports, it ranges from 15% in Japan to 60% in Iran. The disparity in prevalence is because of underreporting of the condition because of cultural beliefs.

The second most common is postpartum depression which affects 10%-15% of new mothers. The average age at presentation is 27 with majority being married and being Akans. On grading them on severity scale, 39% has minimal depression, 22% are affected by moderate depression and mild depression, 6% have moderately severe depression, and 11% are affected by severe depression. There is significant reduction in the symptoms with psychosocial support.
Postpartum psychosis is relatively uncommon which affects 0.1%-0.2% women.

Risk Factors

Postpartum blues: History of mood changes during menstrual cycles or pregnancy, multiple pregnancies during lifetime, personal history of major depression or dysthymia or family history of postpartum depression.

Postpartum depression: Prior history of anxiety and depression, family history of depression, severe premenstrual syndrome, low social support, difficulty to conceive, stressful life events, teenage pregnancy, pregnancy and labor complications, preterm labor (before 37 weeks) and delivery, multiple babies like twins or triplets, hospitalisation of baby after birth.

Postpartum psychosis: Family history of postpartum psychosis or bipolar disorder, history of bipolar disorder, postpartum psychosis in a previous pregnancy or schizoaffective disorder or schizophrenia, first pregnancy, discontinuation of psychiatric medication for pregnancy and sometimes even without a risk factor.

Screening

There are no specific guidelines for screening of postpartum blues.

Woman at-risk for postpartum psychosis should see a psychiatrist even before delivery to discuss treatment options to prevent illness during the delivery and postpartum period. In the first 2-4 weeks postpartum, the woman and her family should contact a physician if they find any of these symptoms, that is, confusion, strange beliefs, mood swings, and hallucinations in the new mother. At the 6-week obstetrical follow-up appointment, it is highly recommended that physicians should inquire about symptoms of postpartum psychosis. If the patient expresses red flags like difficulty caring for her child, confusion, poor self-care or threats to harm herself or others, a psychiatric referral should be made as soon as possible.

A variety of depression screening tools are available, their specificity ranges from 77% to 100%, but sensitivity varies and is the deciding factor in choosing the depression screening tool. The most sensitive tools are Edinburgh Postnatal Depression Scale, Postpartum Depression Screening Scale, and Patient Health Questionnaire-9. Other screening tools are given in the table below

Caption text

Screening tool	Sensitivity/Specificity
Edinburgh postnatal depression scale	Sensitivity:59-100%, Specificity:49-100%
Postpartum Depression Screening Scale	Sensitivity:91-94%, Specificity:72-98%
Patient Health Questionnaire-9	Sensitivity:75%, Specificity:90%
Beck Depression Inventory	Sensitivity:47.6-82%, Specificity:85.9-89%
Beck Depression Inventory-II	Sensitivity:56-57%, Specificity:97-100%
Center for Epidemiologic Studies Deppression Scale	Sensitivity:60%, Specificity:92%
Zung Self Rating Depression Scale	Sensitivity:45-89%, Specificity:77-88%

References

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