PsychoTropical Research - Dr Ken Gillman, Serotonin Syndrome, Mirtazapine, Dual Action Drugs.Depression - Post natal

PsychoTropicalResearch, serotonin and serotonin syndrome research.

Depression - Post natal

Depression - Post natal

Date Created: 14/03/1995   Last Modified: 15/12/2002   Last Checked: 02/10/2003

Summary

  1. Post-natal depressive illness is affective disorder; that is either endogenous depression, or manic-depressive illness, presenting around the puerperium.
  2. Post-natal depressive illness meeting criteria for major ('endogenous') depressive illness occurs in about 10% of women (althought at least 25% will, in due course, be revealed to be Bipolar Disorder).
  3. The death by suicide risk, in the first post-natal year, is increased 70-fold.
  4. Recurrence rates in those with previous episodes of affective disorder range from 30% up to 75%.
  5. The genetic predisposition to affective disorder is specifically triggered by puerperal factors.
  6. Symptoms may start before delivery.
  7. Screening for symptoms peri-natally is worthwhile.
  8. Specialist psychiatric assessment before delivery may be appropriate.
  9. In a majority of cases symptoms manifest themselves within one month post-partum.
  10. Post-partum affective disorder is a valuable piece of family history information and is a strong indicator of illness type in other family members.

Introduction

New symptoms in the peri-natal period represent the first manifestation of the diathesis (predisposition) for affective disorder (ie both major, or 'endogenous', depressive illness and manic-depressive illness / Bipolar Disorder). This trigger is specific for affective illnesses; the incidence of schizophrenic psychosis is not elevated post-natally. Since the illness may affect people over a lifetime this is a unique and valuable opportunity to establish accurate diagnosis and early, effective, and life-saving medical intervention.

It is wise to regard anxiety symptoms arising 'de novo' post-partum as affective illness until (if ever) proved otherwise. They indicate the need for close follow up and referral because they herald the onset of major affective disorder. Likewise, if you find a patient who has been diagnosed as suffering from schizophrenia when the illness definitely started de novo post-partum, then that diagnosis of schizophrenia is almost certainly wrong.

It is a time when screening for depressive symptoms is particularly important and I strongly recommend an attempt to be especially alert for symptoms at this time. Try using the computer aid / rating scale "Depression diagnosis assistant" (DDAssist or DDA)* to help. The latest evidence strongly supports the use in general practice of simple depression questionaires in screening for illness. So place printed sheets for patients to fill out themselves in the waiting room (the DDA will print these for you).

Doing the DDA on every patient for a trial period may help by highlighting patients with significant symptoms that may otherwise have passed un-noted. To obtain the DDA, and set it up to run on your own computer, follow the link "Available programs" on the www.psychotropical.com home page. You can use it as a self rating scale that patients do before they see you, or rate it yourself whilst seeing them.

The illness can severe and chronic. Early consideration of specialist referral is indicated. It is particularly rewarding to recognise and treat these illnesses.

Definition

So-called "post-natal depression" is the medical illness of "affective disorder" (ie endogenous depression / uni-polar depression or manic-depressive illness / Bipolar Disorder), that presents peri-natally. The term "puerperal psychosis" may be considered synonymous with the more severe manifestations of this continuum of illnesses; viz psychotic depression or manic illness (in this somewhat confused terminology manic is paired with hypo-manic, where manic is synonymous with psychotic).

The terms ""postpartum blues", "maternity blues" etc have little usefulness and probably no validity** (see footnote).

The terminology of "post-natal / post-partum, depression" has had one negative consequence of insinuating into people's minds the notion that depression is a natural and understandable reaction to the stresses of birth. In my opinion a mass of accumulating evidence indicates that is incorrect and misleading.

The brief comment below (from another update note) is worth repeating here: "The concept of reactive depression is both difficult and also of uncertain validity or usefulness. When we think we understand why a patient is depressed we are less likely to treat the illness with drugs. I have dubbed this ‘the danger of understandability’ because it leads to a failure to treat the illness. The lesson is:-- if the symptoms justify a diagnosis of depressive illness then apparent precipitating factors (be they social, psychological or biological) are largely irrelevant in relation to the need for drug treatment."

The genetic predisposition to affective disorder is specifically triggered by puerperal factors and these appear to be the most powerful triggering factors for depressive illness a female ever encounters in her lifetime. Thus, there is a tendency for those whose first episode is puerperal to have less subsequent relapses. Picturing genetic vulnerability as a 'threshold' model may aid understanding of this observation, which may at first seem contradictory. ie the later in life the onset, and the more potent the trigger needed, the weaker is the diathesis.

This genetic predisposition, marked by post-partum affective disorder, is a valuable piece of family history information. It may help by clarifying the illness status in not only that patient, but also close relatives.

Therefore, if there is a definite post-partum first illness or definite relapse / exacerbation that fact constitutes the most powerful and reliable evidence of a familial genetic diathesis, for either major ('endogenous') depressive illness or Bipolar Disorder. On that basis alone it may be possible to state with confidence, for instance, that a sibling is bi-polar even though they have only ever had depressive episodes.

The incidence of schizophrenic psychosis is not significantly elevated peri- or post- natally.

Incidence

I summarise some recent (2000 - 2002) figures here, because they add to our understanding, as well as reviewing some older less well remembered ones.

Significant post-natal depressive illness (ie of a degree that requires drug treatment) occurs in at least 5% of women, 10% may be a better estimate. This suggests that routine assessment of depressive symptoms is worthwhile in all patients, and well advised in at risk groups.

If you do not perceive at least one in twenty of your post-natal ladies as being clinically depressed it may be beneficial to readjust your criteria and threshold for diagnosis. The frequency, according to the some recent studies, varies little between different countries, cultures or economic circumstances. That suggests a predominant medical (biological) etiology.

Childbirth is a major risk factor for first admission with "psychosis" (ie severe depression / mania), the risk being increased at least x 3 over non-puerperal case controls.

A recent study of the occurrence of puerperal psychosis in families with several members affected with bipolar disorder, who were participating in a study of the molecular genetics of bipolar disorder in siblings, found:--

Episodes of puerperal psychosis (in those with a personal history of bipolar disorder):--

  1. Total of 152 women, =26% (81 episodes out of the 313 deliveries)
  2. 38% had two or more puerperal psychotic episodes.
  3. In women with a personal history of bipolar disorder who also had a family history of puerperal psychosis in a first-degree relative =75%
  4. In women with with a personal history of bipolar disorder but with no family history =30%

In a longitudinal study of 1,558 consecutively registered pregnant women in Sweden depressive symptoms (rated with a recognised depression rating scale) were assessed at four time points:--

  1. in gestational week 35-36: depressive symptoms, 17%
  2. in the maternity ward: 18%
  3. 6-8 weeks postpartum: 13%
  4. 6 months postpartum: 13%

These results require cautious interpretation and reinforce the problems of screening for depression. Rating scales overinflate the impression of illness frequency because the number and (especially self-rated) severity of symptoms does not equate with clinical illness as diagnosed at interview by a specialist. It may be that the 17% at 35 weeks is a quite different population from the 13% at 6-8 weeks.

A prospective study of 465 women (who were not depressed at 1 month post-partum) found 5.8% became clinically depressed after 1 month, and before 4 months, postpartum. I am not clear why they choose 1 month postpartum as the starting point when (from figures in the paper) 13.5% were already clinically depressed before one month postpartum. So their total with significant post-partum depression was 19%, or one in five. It is probably fair to say that US thresholds for a diagnosis of major ('endogenous') depressive illness are lower than those in UK and perhaps Australia: so 19% may be an upper limit. Nevertheless, this is a prospective study (so inherently more reliable than a retrospective one) with a large sample size; so it deserves serious attention. Also they found breast-feeding, mode of delivery, family income, parity and mother's education did not predict depression.

The harmfully naive notion that depression is a natural and understandable reaction to the stresses of birth is betrayed, again, by recent research confirmation that "Postpartum blues" is significantly predictive of the subsequent development of postnatal depressive illness. Re-stated as:- "mild symptoms tend to develop into more severe symptoms" that seems a banal observation.

Recurrence

The risk of recurrence for affective disorder generally is ~ 30% in subsequent pregnancies. During a follow-up period of 17-28 years in one study 75% had further episodes, mostly unrelated to childbirth; 37% had at least three further episodes.

Rates of recurrence after lithium discontinuation in patients with established Bipolar Disorder (in pregnant vs non pregnant control group). Postpartum recurrences were 3 times more frequent (in pregnant vs non pregnant) during weeks 41-64 (70% vs 24%); having been similar during the first 40 weeks after lithium discontinuation.

Bipolar disorder was followed during pregnancy and the post-partum period in 27 women. Only one of the 14 patients taking prophylactic agents relapsed within the first 3 months postpartum, eight of the 13 who did not receive anti-manic drugs had symptoms. And in another study, 21 women at high risk for puerperal psychosis were given prophylactic lithium late in the third trimester of pregnancy or immediately after delivery. Only two had a recurrence of their psychotic illness which is much less than expected (even though there was no control group, that looks convincing).

Kendell found that those with first episode puerperal onset (vs first episode non-puerperal onset) had significantly fewer relapses in the follow-up period and fewer committed suicide. This better outcome was marked in those with major depressions; those with Bipolar Disorder were similar to the controls.

Mortality

A recent study of 1567 women who were admitted to hospital for psychiatric illness post-partum found that 6.8% had died in the first year after childbirth.

The standardised mortality ratios- SMRs (100) were:--

  • SMR for suicide within one year was 7216
  • 1329 for all unnatural causes
  • 238 for natural causes.

ie The suicide risk in the first postnatal year is increased 70-fold

and

for those illnesses (of "mandating-hospital-admission" level of severity)
the mortality rate in the first post-natal year is more than one out of each twenty individuals.

General

Professor Robert Kendell's work indicates that any illness occurring truly 'de novo' within the puerperium is an affective illness, not a schizophrenic one. I suggest it is wise to regard any new symptoms of anxiety or depression as indicating the need for close follow up and referral, because they probably herald the onset of significant affective disorder, often depressive illness.

As Kendell observed, 'Childbirth is a uniquely potent precipitant of affective illness, some of those who develop puerperal episodes have a lesser genetic predisposition to affective illness than the generality of women with affective disorders'. Kendell's research seems not to have received as much attention as it merits, perhaps because so many wish to "understand" the supposed "psycho-social" dimension. Another facet of the insidious "danger of understandability" perhaps?

Specialist psychiatric assessment before delivery is especially appropriate when:

  1. Any previous post-natal depressive episode. Previous episodes of severe, treatment refractory, recurrent or suicidal depression.
  2. Symptoms start before delivery (this is not uncommon in the last trimester, see above).
  3. A family history
  4. General considerations about referral are detailed in the note "Depression When to refer Note ref number: 352"

Points to observe

  1. When referring for ante-natal care, or assessing: note any possible family / personal history of depression / Bipolar Disorder
  2. Use the DDA to screen for symptoms peri-natally
  3. Focus on significant changes from usual abilities in functional capacity for work / social / leisure activities as well as on anergia and anhedonia as key features
  4. Anxiety symptoms arising de novo post-partum, even in complete absence of 'depression', may be taken as presumptive evidence of depressive illness
  5. In a great majority of cases clear symptoms manifest themselves within one month, often one week, post-partum; if sought by an alert and informed clinician.

Summary of Kendell's seminal 1987 paper

Computer linkage (I think the first such study) of an obstetric and psychiatric case register-- investigation of the temporal relationship between childbirth and psychiatric contact in a population of 470 000 people over a 12-year period.

54 087 births resulted in 120 psychiatric admissions within 90 days of parturition (2.2 per 1000) ***

Women with a history of manic depressive illness, manic or depressive, had a much higher risk of psychiatric admission in the puerperium than those with a history of schizophrenia or depressive neuroses. A majority of puerperal admissions met Research Diagnostic Criteria for manic or depressive disorder. Probably, therefore, puerperal psychoses are manic depressive illnesses and unrelated to schizophrenia.

Footnotes

* "Depression diagnosis assistant" (DDAssist or DDA)

This program is a cross between a rating scale and a clinical interview guide / assistant. It is autonomous and runs on a PC or Mac. A short piece about it has been published on a peer-reviewed web site in Europe.

** The term ""postpartum blues" etc seems to have been coined by the notorious psychotherapist Yalom in 1968. It has never been subjected to any proper critical validation or assessment. Despite widespread casual usage it has only been used in the peer-reviewed literature infrequently, usually by nurses, social workers or psychotherapists.

*** This figure of 2.2 admissions per 1000 within 90 days (per 1000, not per 100) suggests the probability of a staggering under-diagnosis and under-treatment of illness. For those who have a true appreciation of the awfulness and suffering that can result from depression, that is a nightmarish thing to contemplate.

References

  • Albers, L. & Williams, D. (2002) Lessons for US postpartum care. Lancet, 359, 370-371.
  • Altshuler, L. L., Cohen, L. S., Moline, M. L., et al (2001) The Expert Consensus Guideline Series. Treatment of depression in women. Postgrad Med, 1-107.
  • Georgiopoulos, A. M., Bryan, T. L., Wollan, P., et al (2001) Routine screening for postpartum depression. J Fam Pract, 50, 117-122.
  • Jones, I. & Craddock, N. (2001) Familiality of the puerperal trigger in bipolar disorder: results of a family study. Am J Psychiatry, 158, 913-917.
  • Josefsson, A., Angelsioo, L., Berg, G., et al (2002) Obstetric, somatic, and demographic risk factors for postpartum depressive symptoms. Obstet Gynecol, 99, 223-228.
  • Moline, M. L., Kahn, D. A., Ross, R. W., et al (2001) Postpartum depression: a guide for patients and families. Postgrad Med, 112-113.
  • Steiner, M. (1998) Perinatal mood disorders: position paper. Psychopharmacol Bull, 34, 301-306.
  • Stocky, A. & Lynch, J. (2000) Acute psychiatric disturbance in pregnancy and the puerperium. Baillieres Best Pract Res Clin Obstet Gynaecol, 14, 73-87.
  • Webster, J. & Pritchard, M. (2001) Postnatal depression and health care use. Aust Fam Physician, 30, 1024.
  • Yonkers, K. A., Ramin, S. M., Rush, A. J., et al (2001) Onset and persistence of postpartum depression in an inner-city maternal health clinic system. Am J Psychiatry, 158, 1856-1863.
  • Wisner, K. L., Perel, J. M., Peindl, K. S., et al (2001) Prevention of recurrent postpartum depression: a randomized clinical trial. J Clin Psychiatry, 62, 82-86.