Overview
This lecture covers the mental health risks that pregnancy and childbirth pose to women, the consequences of perinatal mental illness for mother, child and family, and the risk-benefit reasoning behind prescribing in pregnancy and lactation. It is built around a severity spectrum of postpartum mood change — baby blues (common, transient, not a disorder), postpartum depression (serious and disabling), and postpartum psychosis (rare, a psychiatric emergency) — and works outwards from that spine to risk factors, an explanatory model, screening tools, the downstream effects of untreated illness on mother-infant interaction and child development, medication decisions in pregnancy and breastfeeding, and finally paternal perinatal mental health.
Framing: when and how maternal mental illness presents
Timing:
- Antenatal — during pregnancy.
- Postpartum — from birth until up to a year.
Presentations:
- Continuation of an existing mental disorder
- Relapse in a pre-existing condition
- New onset mental disorder
- Baby blues
Why doctors are particularly concerned about mental health during pregnancy:
- Women with pre-existing conditions are at risk of relapse, since they may cease their medication during pregnancy.
- Pregnancy can be a stressful time — physical complications, anxiety, social difficulties; family violence is more prevalent in pregnancy.
- Effect of substance abuse during pregnancy on the developing foetus.
Learning objectives for the lecture: understand the risk pregnancy and childbirth pose to women’s mental health; understand the impact mental illness can have on mother, child and family; be able to think about the risk-benefit analysis regarding medication in pregnancy and lactation.
The spectrum of postpartum mood changes
The three postpartum conditions sit on a single severity axis, running from left to right: transient, non-pathological → serious, disabling → psychiatric emergency. Prevalence falls as severity rises.
| Condition | Prevalence | Band on the spectrum |
|---|---|---|
| Postpartum blues | 50–75% | Transient, non-pathological (annotated: increased risk for MDD) |
| Postpartum depression | 10% | Serious, disabling |
| Postpartum psychosis | approx. 0.1% | Psychiatric emergency |
Source figure: Achieving Remission in Depression: Managing Women and Men in the Primary Care Setting (Kornstein, Steiner, Miranda, Krishnan).
Small print immediately beneath this chart is cut off/illegible at the bottom edge of the figure on both slides where it appears — apparently a citation, partially reading "...1998..."; not transcribable.
Baby blues
- Onset 3rd–5th day.
- Lasts a few hours to days.
- Good periods occur in between.
- Features: overwhelmed, tearful, exhausted, irritable.
- With support, rest and good nutrition, the baby blues resolve naturally.
- If persisting beyond 2 weeks, screen for PPD or a related disorder.
- Not a disorder; transient.
Watch for PPD being normalised as "just the baby blues" — this is a key route to missed diagnosis.
Postpartum depression: definition and epidemiology
- Depression that occurs within 4 weeks of birth/whānautanga.
- Around 10–16% of women experience postpartum depression.
- Prevalence is not elevated relative to other times, but the diagnosis can be missed because it is dismissed as hormonal imbalance or baby blues.
- Sufferers can feel isolated and ashamed, because childbirth is culturally celebrated and the expectation is that new mothers will be joyful.
- DSM-5 criteria are the same as at any other time in a woman’s life.
- Suicide is the leading cause of maternal death in New Zealand and several other Western countries.
- PPD is seen across all cultures and socio-economic status.
- PPD can have lasting effects on children/tamariki.
PPD risk factors
- Previous history of depression or PPD
- Discontinuation of medication(s) by a woman with a history of depression
- Childhood abuse
- Negative attitude towards the pregnancy
- Lack of social support / social isolation / domestic violence
- Having twins or triplets
- Losing a baby (e.g. stillbirth, late miscarriage)
- Pregnancy and birth complications — risk for PTSD
Psychiatric history is the strongest single predictor. Incidence of post-natal depression by prior history (Kornstein et al. figure):
| Group | Incidence of post-natal depression |
|---|---|
| General population | approx. 12% |
| History of major depression | approx. 25% |
| History of postpartum depression | approx. 50% |
Incidence roughly doubles with a history of major depression, and doubles again with a history of postpartum depression.
How to understand PPD
Three explanatory domains:
Biology
- Sudden change in hormone levels
- Lack of sleep
- Pain, feeding issues
Stress
- Sudden change in lifestyle
- Societal expectation of the “Happy Mother”
Feelings of loss
- Loss of autonomy (personal freedom) and time
- Loss of opportunity
- Loss of relationship with partners, friends
- Loss of finances
- Loss of sexuality, femininity, appearance
- Loss of occupational identity — debate over whether to return to work or stay at home with the child, which may bring feelings of guilt
Detection of PPD
- Screen all women who have had a baby, and be aware of the risk factors for PPD.
- Consultation with the patient and/or family, significant other: ask depression screening questions, feelings towards the baby, social situation and support.
- Edinburgh Postnatal Depression Scale — can be used during pregnancy and postpartum; 10 item, self-administered; easy to score.
- PHQ-9.
Impact of untreated PPD
Effects on the mother’s interactions with the infant:
- Decrease in affectionate behaviour
- Decreased responsiveness to infant cues
These effects are more likely if the PPD is chronic and/or severe, and untreated.
Effects on childhood development:
- Increased behaviour problems when young
- Poorer educational outcomes
- Diminished social competence
- Increased rates of mental disorder and risky behaviour in childhood and adolescence
Cross-references given on the slides: ELM2 lectures on Middle Childhood, Adolescence, and Childhood Disorders 1 & 2. Two videos were signposted but their content is not in the slides — women’s own accounts of PPD, and the Still Face Experiment.
Postpartum psychosis
- 1–2 episodes per 1000 births.
- Clinical onset is rapid, mostly in the first 2 weeks postpartum.
- Severe disorder with potentially tragic outcomes: associated with suicide and infanticide (infanticide is rare — 1–3 of 50,000 births).
- Can be a recurrence of pre-existing bipolar disorder or schizophrenia, or may be new onset.
- Women with a history of bipolar disorder or schizophrenia have a higher risk of developing PPD [the slide writes “PPD” here, within the postpartum psychosis slide].
- Usually requires an inpatient stay and medication (antipsychotic and mood stabiliser).
Symptoms:
- Extreme agitation
- Paranoia, confusion, disorientation
- Inability to sleep/eat (emphasised on the slide)
- Losing touch with reality
- Delusions — fixed, false beliefs or thoughts that are unlikely to be true, e.g. that the baby is possessed by the devil
- Hallucinations (tactile, auditory, visual)
- Disorganised behaviour
- Psychomotor agitation
- Incoherent speech, irrational thinking
Warning sign: extreme sleep disruption.
Cross-references given on the slides: ELM3 lectures on Severe Depression & Bipolar, and Schizophrenia 1 & 2.
Clinical considerations in pregnancy and breastfeeding
- Treatment of breastfeeding mothers requires careful risk/benefit assessment.
- The risk of treatment must be weighed against the risk of untreated illness to mother and infant:
- Mood stabilisers used to treat bipolar disorder (e.g. Lithium) and antipsychotic medications have teratogenic effects.
- Antidepressants (SSRIs) are safer, but there are some concerns and research is ongoing.
- Antidepressants are excreted into human breast milk — no clear harms, but research is ongoing.
- But maternal depression also has adverse effects on infants.
- Additional factors to consider: severity of illness, psychiatric history, history of response, available safety data in lactation.
Paternal mental health
- Depression: 5–10% overall, from the 1st trimester to 1 year after delivery.
- The biggest correlation is with depression in the partner; also associated with marriage problems.
- Lifestyle change contributors: role with partner and child, sharing attention; stress at work; feeling physically separated.
- Fathers’ mental health can affect their children:
- directly, via the quality of their interactions or genetic effects
- indirectly, via their support to the mother and the family environment
- Paternal postnatal mental disorders are also associated with next-generation effects on behaviour, emotional development and educational outcomes.
Summary points
- Maternal mental health issues range from baby blues and transient distress, through post-natal depression, to postpartum psychosis.
- They can impact the self (mother), the father or partner, the child, and the family.
- They can start during pregnancy.
- They should be screened for by health professionals seeing either mother or baby.
- The risk/benefit analysis of medication must be considered when treating pregnant and breastfeeding women.
- If untreated and chronic or severe, they carry immediate risk of suicide or infanticide, and long-term intergenerational effects.
Self-test
- Distinguish the antenatal from the postpartum period as defined in this lecture.
- List the four ways maternal mental illness can present.
- Explain why doctors are particularly concerned about mental health during pregnancy.
- Place baby blues, postpartum depression and postpartum psychosis on the severity spectrum, and give the prevalence of each.
- Describe the time course and features of baby blues.
- Explain why baby blues matters clinically even though it is not a disorder.
- State the threshold at which persisting baby blues should prompt screening for PPD.
- Define postpartum depression, including its time window and prevalence.
- Explain why postpartum depression is under-diagnosed despite its prevalence being no higher than at other times.
- State what suicide represents among causes of maternal death in New Zealand.
- List the risk factors for postpartum depression.
- Give the incidence of post-natal depression in the general population, after a history of major depression, and after a history of postpartum depression.
- List the three explanatory domains used to understand PPD, with two contributors under each.
- List the losses that may contribute to PPD.
- Describe how PPD should be detected, naming the two screening instruments given.
- Describe the effects of untreated PPD on the mother’s interactions with her infant, and state the condition under which these are more likely.
- List the effects of untreated PPD on childhood development.
- Describe the epidemiology and onset of postpartum psychosis.
- List the symptoms of postpartum psychosis and name the single warning sign the lecture highlights.
- Explain the risk/benefit reasoning for psychotropic medication in pregnancy and breastfeeding, naming which drug classes are teratogenic and which are comparatively safer.
- Describe paternal perinatal depression: prevalence, its strongest correlate, and the two routes by which a father’s mental health affects his children.
- A woman is seen on day 4 postpartum. She is tearful, exhausted and irritable, but has good periods and settles with rest. Predict the likely course and state your management.
- A woman with a history of bipolar disorder presents on day 10 postpartum. She has not slept for three nights, is agitated and paranoid, and believes her baby is possessed. Identify the condition, its urgency, and the likely treatment setting.
- A woman with a history of postpartum depression, currently on an SSRI, tells you she has stopped the medication because she is pregnant. Explain why this decision raises her risk, and outline the factors you would weigh in advising her.
- Explain how untreated maternal depression links the spectrum of postpartum mood change to intergenerational outcomes, drawing on at least two themes from this lecture.
Answers
Reveal answers
- Antenatal is during pregnancy; postpartum is from birth until up to a year after.
- Continuation of an existing mental disorder; relapse in a pre-existing condition; new onset mental disorder; baby blues.
- Women with pre-existing conditions may cease medication in pregnancy and so risk relapse; pregnancy is stressful (physical complications, anxiety, social difficulties, and family violence is more prevalent in pregnancy); and substance abuse in pregnancy affects the developing foetus.
- Baby blues sits in the transient, non-pathological band at 50–75%; postpartum depression in the serious, disabling band at 10%; postpartum psychosis in the psychiatric emergency band at approximately 0.1%. Severity rises as prevalence falls; the blues band is annotated with increased risk for MDD.
- Onset on the 3rd–5th day, lasting a few hours to days with good periods in between; the woman feels overwhelmed, tearful, exhausted and irritable. It resolves naturally with support, rest and good nutrition.
- Because PPD can be normalised as baby blues and therefore missed; the blues band also carries an increased risk for major depressive disorder.
- Persisting beyond 2 weeks — screen for PPD or a related disorder.
- Depression occurring within 4 weeks of birth/whānautanga, affecting around 10–16% of women. DSM-5 criteria are the same as at any other time in a woman’s life.
- It is dismissed as hormonal imbalance or baby blues, and sufferers feel isolated and ashamed because childbirth is culturally celebrated and new mothers are expected to be joyful.
- It is the leading cause of maternal death in New Zealand and several other Western countries.
- Previous history of depression or PPD; discontinuation of medication by a woman with a history of depression; childhood abuse; negative attitude towards the pregnancy; lack of social support, social isolation or domestic violence; having twins or triplets; losing a baby (stillbirth, late miscarriage); pregnancy and birth complications, which also carry a risk for PTSD.
- General population approximately 12%; history of major depression approximately 25%; history of postpartum depression approximately 50% — roughly a doubling at each step.
- Biology (sudden change in hormone levels; lack of sleep; pain and feeding issues); Stress (sudden change in lifestyle; societal expectation of the “Happy Mother”); Feelings of loss (see next answer).
- Loss of autonomy and time; loss of opportunity; loss of relationship with partners and friends; loss of finances; loss of sexuality, femininity and appearance; loss of occupational identity, including guilt over the decision to return to work or stay home.
- Screen all women who have had a baby and know the risk factors. Consult the patient and/or family or significant other, asking depression screening questions, feelings towards the baby, and social situation and support. Use the Edinburgh Postnatal Depression Scale (usable in pregnancy and postpartum; 10 items, self-administered, easy to score) and the PHQ-9.
- Decreased affectionate behaviour and decreased responsiveness to infant cues; more likely if the PPD is chronic and/or severe, and untreated.
- Increased behaviour problems when young; poorer educational outcomes; diminished social competence; increased rates of mental disorder and risky behaviour in childhood and adolescence.
- 1–2 episodes per 1000 births, with rapid clinical onset mostly in the first 2 weeks postpartum. It may be a recurrence of pre-existing bipolar disorder or schizophrenia, or new onset, and is associated with suicide and infanticide (infanticide rare, 1–3 per 50,000 births).
- Extreme agitation; paranoia, confusion, disorientation; inability to sleep/eat; losing touch with reality; delusions (e.g. the baby is possessed by the devil); hallucinations (tactile, auditory, visual); disorganised behaviour; psychomotor agitation; incoherent speech and irrational thinking. The warning sign is extreme sleep disruption.
- Treatment requires careful risk/benefit assessment: the risk of treatment is weighed against the risk of untreated illness to mother and infant. Mood stabilisers such as lithium and antipsychotics have teratogenic effects; SSRIs are safer though some concerns remain and research is ongoing, and they are excreted into breast milk with no clear harms identified so far. Maternal depression itself also harms infants. Additional factors: severity of illness, psychiatric history, history of response, and available safety data in lactation.
- Depression affects 5–10% of fathers overall from the 1st trimester to 1 year after delivery. The biggest correlation is with depression in the partner (also with marriage problems). It affects children directly through the quality of interactions or genetic effects, and indirectly through the father’s support to the mother and the family environment; paternal postnatal disorders are associated with next-generation effects on behaviour, emotional development and educational outcomes.
- This fits baby blues (day 3–5 onset, good periods, transient). Expect natural resolution with support, rest and good nutrition; it is not a disorder. If symptoms persist beyond 2 weeks, screen for PPD or a related disorder, since PPD can be normalised as baby blues.
- Postpartum psychosis — rapid onset in the first 2 weeks, in a woman with pre-existing bipolar disorder, with extreme sleep disruption as the warning sign plus agitation, paranoia and a delusion. It is a psychiatric emergency associated with suicide and infanticide, and usually requires an inpatient stay with medication (antipsychotic and mood stabiliser).
- Discontinuation of medication by a woman with a history of depression is itself a listed risk factor for PPD, and a history of postpartum depression already raises incidence to roughly 50%. Weigh the risk of the medication against the risk of untreated illness to mother and infant, noting SSRIs are the safer class (some concerns, research ongoing), and consider severity of illness, psychiatric history, history of response, and available safety data in lactation.
- Untreated, chronic or severe illness anywhere along the spectrum reduces affectionate behaviour and responsiveness to infant cues, which is linked to increased behaviour problems, poorer educational outcomes, diminished social competence, and increased mental disorder and risky behaviour in childhood and adolescence; at the emergency end there is immediate risk of suicide or infanticide. The same intergenerational pattern appears for paternal postnatal disorder, which is itself most strongly correlated with depression in the partner — so detection and screening of both parents is the lever on long-term outcomes.