Postpartum psychosis: Wikis

  
  

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Incidence of psychoses among Swedish first-time mothers

Postpartum (or puerperal) psychosis is a term that covers a group of mental illnesses with the sudden onset of psychotic symptoms following childbirth. In this group there are at least a dozen organic psychoses, which are described under another heading - organic pre- and postpartum psychoses [1]. The relatively common non-organic form, still prevalent in Europe, North America and throughout the world, is sometimes called puerperal bipolar disorder, because of its close link with manic depressive (bipolar) disorder [2]; but some of these mothers have atypical symptoms (see below), which come under the heading of acute polymorphic (cycloid) psychosis (schizophreniform in USA) [3]. Puerperal mania was first clearly described by the German obstetrician Osiander in 1797 [4] , and a literature of over 2,000 works has accumulated since then. These psychoses are endogenous, heritable illnesses with acute onset, benign episodic course and response to mood-normalising and mood-stabilising treatments. The inclusion of severe postpartum depression under postpartum psychosis is controversial: many clinicians would allow this only if depression was accompanied by psychotic features (see below).

The onset is abrupt, and symptoms rapidly reach a climax of severity. Manic and acute polymorphic forms almost always start within the first fortnight, but depressive psychosis may develop somewhat later.

Contents

Symptoms

Some patients have typical manic symptoms, such as euphoria, overactivity, decreased sleep requirement, loquaciousness, flight of ideas, increased sociability, disinhibition, irritability, violence and delusions, which are usually grandiose or religious in content; on the whole these symptoms are more severe than in mania occurring at other times, with highly disorganised speech and extreme excitement. Others have severe depression with delusions, verbal hallucinations, mutism, stupor or transient swings into hypomania. Some switch from mania to depression (or vice versa) within the same episode. Atypical features include perplexity, confusion, emotions like extreme fear and ecstasy, catatonia or rapid changes of mental state with transient delusional ideas; these are so striking that some authors have regarded them as a distinct, specific disease, but they are the defining features of acute polymorphic (cycloid) psychoses, and are seen in other contexts (for example, menstrual psychosis) and in men.

Course and treatment

Without treatment, these psychoses can last many months; but with modern therapy they usually resolve within a few weeks. A small minority follow a relapsing pattern, usually related to the menstrual cycle. Mothers who suffer a puerperal episode are liable to other manic depressive or acute polymorphic episodes, some of which occur after other children are born, some during pregnancy or after an abortion, and some unrelated to childbearing. Puerperal recurrences occur after at least 20% of subsequent deliveries, or over 50% if depressive episodes are included [5].

Severe overactivity and delusions may require rapid tranquilization by neuroleptic (antipsychotic) drugs, but they should be used with caution because of the danger of severe side effects including the neuroleptic malignant syndrome [6]. Electro-convulsive (electroshock) treatment is highly effective [7]. Mood stabilising drugs such as lithium are also useful in treatment and possibly the prevention of episodes in women at high risk (that is, women who have already experienced manic or puerperal episodes). The location of treatment is an issue: hospitalisation is disruptive to the family, and it is possible to treat moderately severe cases at home, where the sufferer can maintain her role as wife, mother and home-maker, and build up her relationship with the newborn. This requires the presence, round the clock, of competent adults (such as the baby's maternal grandmother, and frequent visits by professional staff [8]. If hospital admission is necessary, there are advantages in conjoint mother and baby admission. Yet multiple factors must be considered in the subsequent discharge plan to ensure the safety and healthy development of both the baby and her mother[9]This plan often involves a multidisciplinary team structure to follow-up on mother, baby, their relationship and the entire family.

Suicide is rare, and infanticide extremely rare, during these episodes. It does occur, as illustrated by the famous cases summarized below. Infanticide after childbirth is usually due to profound postpartum depression (melancholic filicide) when it is often accompanied by suicide [10]

Causes

These are world-wide disorders. Their incidence has been carefully measured by state-of-the-art epidemiological studies, and is somewhat less than 1/1,000 deliveries [11]. They are more common in first time mothers. As recognized by Marcé (1962), the link to menstruation, and especially menstrual psychosis, is an important clue to the cause [12] [13]. Molecular genetic studies suggest that there is a specific heritable factor [14]. There is evidence of linkage to chromosome 16 [15].

Famous Cases

Melanie Blocker-Stokes

Melanie Blocker-Stokes, of Chicago, IL, committed suicide by jumping from a building on June 11, 2001. In February 2001 she gave birth to a healthy baby girl. In the weeks following the birth of her daughter, she developed severe depression, in which (4 weeks after the birth) she stopped eating and drinking and could no longer swallow. She thought her neighbours had all closed their blinds because they thought she was a bad mother (a postpartum depressive psychosis).[16] She was in and out of Chicago area hospitals several times over period of a few months. Her death led to the proposal of the Melanie Blocker-Stokes Postpartum Depression Research and Care Act (H.R. 846 and S. 450), intended to expand research into the condition.[17] Melanie's story (as well as several others) can be found in "Understanding Postpartum Psychosis: A Temporary Madness" (Praeger and Greenwood Publishers) by Teresa M. Twomey.

Andrea Yates

Andrea Yates methodically drowned her 5 children in a bathtub in her Clear Lake City, Houston, Texas house on June 20, 2001. Her mental health began to deteriorate with the birth of each of her children, combined with other external stressors. She attempted suicide twice and was hospitalized twice in a psychiatric facility in 1999 after delivering her fourth child. Yates was warned against having any more children, but conceived approximately 7 weeks later. 3 months after the birth of her fifth child and shortly after the death of her father, she began rapidly to degenerate. She was hospitalized twice more, and eventually released with orders that she should not be left alone. During an hour when her husband had left for work and her mother-in-law was scheduled to arrive, she killed all five of her children. She was consequently committed to a high-security psychiatric hospital. Her case attracted a great deal of media attention, particularly to the concept of serious mental illness following (and also caused by) childbirth. Some of this coverage proved to be problematic and misleading. For example, the National Organization for Women (NOW) initially incorrectly noted on their website that Yates had suffered from postpartum depression. The Individualist Feminists quickly pointed out that Yates suffered from postpartum psychosis, a more serious and much less common disorder, and that the clinical definition of postpartum depression does not list infanticide as a symptom.[18][19] This misrepresentation of Yates' illness stigmatized a large number of mothers and made them less likely to seek professional help for fear of being seen as a threat to their children and consequently being committed. NOW promptly revised their statement to indicate postpartum psychosis.[20][21]

Legal Status

Several nations including Canada, Great Britain, Australia and Italy recognize post partum mental illness as a mitigating factor in cases where mothers kill their children.[22] In the United States, such a legal distinction is not currently made.[22] Britain has had Infanticide Act since 1922.

In 2009, Texas legislator Jessica Farrar proposed a bill that would recognize postpartum psychosis as a defense for mothers who kill their infants.[23] Under the terms of the proposed legislation, if jurors concluded that a mother's "judgment was impaired as a result of the effects of giving birth or the effects of lactation following the birth," they would be allowed to convict her of the crime of infanticide, rather than murder.[22] The maximum penalty for infanticide would be two years in prison.[22]

References

  1. ^ Brockington I F (2006) Eileithyia's Mischief. The Organic Psychoses of Pregnancy, Parturition and the Puerperium. Bredenbury, Eyry Press
  2. ^ Brockington I F (1996). Motherhood and Mental Health. Oxford, Oxford University Press, Chapter 4
  3. ^ Pfuhlmann B, Stoeber G, Franzek E, Beckmann H (1998) Cycloid psychoses predominate in severe postpartum psychiatric disorders. Journal of Affective Disorders 50: 125-134
  4. ^ Osiander F B (1797) Neue Denkwuerdigkeiten fuer Aerzte und Geburtshelfer. Rosenbusch, Goettingen, volume 1, pages 52-128
  5. ^ Robertson M M A, Jones I, Haque S, Craddock N (1995) Risk of puerperal and non-puerperal recurrence of illness following affective puerperal (post-partum) psychosis. British Journal of Psychiatry 186: 258-259
  6. ^ Price D K, Turnbull D J, Gregory R P, Stevens D J (1989) Neuroleptic malignant syndrome in a case of puerperal psychosis. British Journal of Psychiatry 155: 849-852
  7. ^ Reed P, Sermin N, Appleby L, Faragher B (1999) A comparison of clinical response to electroconvulsive therapy in puerperal and non-puerperal psychoses. Journal of Affective Disorders 54: 255-260
  8. ^ Oates M (1988) The development of an integrated community-orientated service for severe postnatal mental illness. In R Kumar, I F Brockington (editors) Motherhood and Mental Illness: Causes and Consequences. London, Wright, pages 133-158
  9. ^ Almeida A, Merminod G, Schechter DS (2009). Mothers with severe psychiatric illness and their newborns: a hospital-based model of perinatal consultation. Journal of ZERO-TO-THREE: National Center for Infants, Toddlers, and Families, 29(5), 40-46.
  10. ^ Brockington I F (1996) Motherhood and Mental Health. Oxford, Oxford University Press, Chapter 8
  11. ^ Terp I M, Mortensen P B (1998) Post-partum psychoses: clinical diagnoses and relative risk of admission after parturition. British Journal of Psychiatry 172: 521-526
  12. ^ Marcé L V (1862) Traité Pratique des Maladies Mentales. Paris, Martinet, page 146
  13. ^ Brockington I F (2008) Menstrual Psychosis and the Catamenial Process. Bredenbury, Eyry Press
  14. ^ Jones I, Craddock N (2001) Familiarity of the puerperal trigger in bipolar disorder: results of a family study. American Journal of Psychiatry 158: 913-917
  15. ^ Jones I, Hamshere M, Nagle J M, Bennett P, Middle F, Green E, Heron J, Segurado R, Lambert D (2007) Bipolar affective puerperal psychosis: genome-wide significant evidence for linkage to chromosome 16. American Journal of Psychiatry 164: 1-6
  16. ^ http://www.melaniesbattle.org/story/html
  17. ^ Office of Legislative and Policy Analysis. 2007. "Melanie Blocker-Stokes Postpartum Depression Research and Care Act". http://olpa.od.nih.gov/legislation/108/pendinglegislation/postpartum.asp
  18. ^ McLellan, Faith (2 December 2006). "Mental health and justice: the case of Andrea Yates". The Lancet (Amsterdam: Elsevier) 368 (9551): 1951–1954. doi:10.1016/S0140-6736(06)69789-4. http://www.thelancet.com/journals/lancet/article/PIIS0140673606697894/fulltext. Retrieved 2008-04-10. 
  19. ^ "(Killing your baby is not listed as a symptom or outcome of the depression.)"; Wendy McElroy, Rallying around a Baby Killer, ifeminist.com, Aug. 28, 2001 Article
  20. ^ "NOW is ringing an alarm bell about postpartum depression, which drives non-working mothers to infanticide....The increasing tendency to lump postpartum depression in with infanticide made them afraid to tell anyone about their depression. They didn't want to be viewed as threats to their children, they worried about being committed. Because postpartum depression had been demonized, they were less likely to risk being stigmatized by seeking help...NOW should be discussing postpartum psychosis -- a comparatively rare and much more serious disorder -- that includes psychotic reactions such as hallucinations and delusions."; Wendy McElroy, Rallying around a Baby Killer, ifeminist.com, Aug. 28, 2001 Article
  21. ^ NOW President Kim Gandy, Tragedy Focuses Attention on Postpartum Psychosis, September 6, 2001 Statement;(Modified statement made about a week after ifeminist.com pointed out NOW's error identifying Yate's disorder as "postpartum depression" reflects update with focus on the more rare and child endangering disorder of postpartum psychosis.)
  22. ^ a b c d "When Infanticide Isn't Murder". http://www.huffingtonpost.com/jacob-m-appel/when-infanticide-isnt-mur_b_279703.html. Retrieved 2009-11-12. 
  23. ^ Proposed Texas House bill would recognize postpartum psychosis as a defense for moms who kill infants







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