5 Minute Pearls: Psychiatric Disorders During Pregnancy and the Postpartum

Postpartum Psychiatry: Psychiatric Disorders During Pregnancy and the Postpartum

This is a major important topic for practicing psychiatrists because, if you treat women of reproductive potential or girls prior to reproductive age, it’s really important to keep in mind reproductive safety. The fact that many psychiatric disorders start early in life, and many women really need to navigate their treatment options during the reproductive years. When we think about the individualized risk benefit/analyses, we have to always think about the risk of untreated disorders and the risk of associated problems, which can increase the risk of poor birth outcomes.

When we’re thinking about postpartum and psychiatric disorders, there’s really a range of postpartum mood and anxiety disorders, which we consider. The postpartum blues is actually a normal condition; about 80% of women will suffer from some transient mild sadness or low mood. For example, sometimes women say that they’re crying and they don’t know why, but it’s more superficial. It’s not like a major depressive episode that affects functioning and is persistent and pervasive across a period of time. 

However, we always want to watch when women are noticing mood changes to make sure it’s not becoming a major depressive episode, which we also call postpartum depression. There are various definitions of postpartum depression. DSM-5 has a perinatal specifier for major depressive episodes, but you may hear the words postpartum depression used to really denote different periods of time. For some, it’s one month out postpartum, three months out postpartum, and some advocates would say up to one year may still be considered as postpartum depression. 

POSTPARTUM PSYCHOSIS

Postpartum psychosis is a very important condition to be aware of. It’s relatively rare, affecting one out of 1000 women after childbirth. But when you think about how many pregnancies occur in [the United States] alone every year, that is really not such an unusual condition. Postpartum psychosis usually has onset soon after delivery that usually includes manic symptoms along with psychotic symptoms, and is really considered a psychiatric emergency. We definitely recommend that women who are experiencing psychotic symptoms are brought for emergency evaluation, and in most cases, postpartum psychosis necessitates hospitalization. 

BIPOLAR DISORDER

Bipolar disorder is a really important disorder to consider across pregnancy and postpartum. We know that most women will relapse if they stop their mood stabilizers for pregnancy, making pregnancy a more vulnerable time. But we also know that the postpartum is probably the most exquisitely vulnerable time for the onset of a serious mood episode in the lifetime of a woman with bipolar disorder. So, that may be a depressive episode, maybe mania or hypomania. And we also know that women with bipolar disorder are at increased risk of having postpartum psychosis. 

ANXIETY

Another note about the postpartum is that anxiety is extremely prevalent. Many women have OCD symptoms. They may have obsessive or compulsive symptoms, or the full syndrome of OCD, but very commonly what we see are obsessions. So recurrent, intrusive, distressing thoughts may occur in the context of postpartum depression or may occur on their own, and they can be just extremely distressing for women and something that really requires aggressive treatment because it can really take away from the experience of a woman having a new baby. 

It’s also really important to keep in mind that there are many resources, if you’re interested in this topic or you need more information on this topic.

POSTPARTUM RESOURCES

Postpartum Support International
Call Toll Free:
1-800-944-4773 (4PPD)
#1 en Español or #2 English

Text:
English: 800-944-4773
en Español: 971-203-7773

MGH Center for Women’s Mental Health

MGH Postpartum Psychosis Project

National Maternal Mental Health Hotline

 

Marlene P. Freeman, MD is a professor of psychiatry at Harvard Medical School where she serves as the Associate Director of the Center for Women’s Mental Health at Mass General Hospital and the medical director of the Clinical Trials Network and Institute. Dr. Freeman is the esteemed Editor in Chief for The Journal of Clinical Psychiatry, and a volunteer and a member of Postpartum Support International. 

This is Five Minute Pearls for The Journal of Clinical Psychiatry, in partnership with the American Society of Clinical Psychopharmacology.