Perinatal Mood Disorders

Childbirth can be one of the most painful events in a woman’s life. Coupled with the social, hormonal, and physical changes that accompany birth, it is no wonder that women feel emotionally overwhelmed following the delivery of their baby. This feeling is so common that it is often referred to as ‘baby blues’, which shockingly affects 70% of new mothers (1). However, this period should last no longer than two weeks (2). Otherwise, it could be an indication of a more serious mood disorder.

The general term for these mood disorders is ‘postpartum depression.’ Although many women experience these disorders following birth, it is also noteworthy that many experience them throughout pregnancy. The term ‘perinatal’ covers the time before birth (antenatal) and up to a year following birth (postpartum). Furthermore, these mental health issues are not limited to depressive symptoms; new mothers can experience perinatal anxiety, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), bipolar disorder, and psychosis.

Stigmas surrounding these disorders are still prevalent. Many women feel motherhood is supposed to be the happiest time of their lives. As these mental health illnesses may hinder this euphoric feeling, many women can feel shameful and isolated. This can stop women from reaching out for help and support, resulting in these disorders being underdiagnosed and underreported, creating a silent crisis among women. This must be combated with substantial education, greater research, and social normalisation.

What Causes These Mood Disorders?

Many aspects of motherhood can trigger mental illnesses in genetically vulnerable women. Mothers face considerable societal pressures, scrutinising how they care, love, and provide for their children. They also go undergo hormonal, immunological, and physical changes. The most common predisposition of perinatal mental health disorders is a psychiatric history. Furthermore, these mood disorders are more common in first-time mothers, although they can develop throughout and after any pregnancy. It is therefore assumed that the causes of these illnesses arise from an amalgamation of these factors. However, in general, there is a lack of research regarding the aetiology (causes) of perinatal mood disorders.

Depression

Perinatal depression is the most common of mood disorders. It can affect 10–15% of postpartum women, and 12% of pregnant women (2). While prior depression is the greatest risk factor, approximately 40% of women will have their first episode of depression during the postpartum period (2). Severe depressive symptoms during pregnancy have been linked to poor use of antenatal clinics, substance misuse, preterm delivery, and low birth weight (1). Postnatally, these symptoms can affect a mother’s ability to care for her baby and her ability to maintain relationships with her loved ones (1).

The symptoms are generally persistent feelings of sadness or low mood, which can include (3):

  • Lack of enjoyment and loss of interest in the wider world
  • Insomnia
  • Fatigue
  • Difficulty forming a bond with the baby
  • Withdrawing from contact from loved ones
  • Problems concentrating and making decisions
  • Frightening thoughts – for example, intrusive thoughts about harming the baby

These symptoms are heavily entwined with most of the mood disorders further discussed within this article.

Anxiety

Childbirth and motherhood are particularly stressful life events; thus it can be challenging to distinguish the symptoms of perinatal anxiety from the general fears that accompany motherhood. 

The symptoms of perinatal anxiety include (4):

  • Constant worry
  • A feeling that something bad is going to happen
  • Racing thoughts
  • Sleep and appetite disturbances
  • An inability to sit still
  • Physical symptoms – for example, dizziness, hot flushes, and nausea

The exact prevalence of anxiety in the perinatal population is unclear, as most research can group anxious symptoms within the general term ‘postpartum depression’. However, in published reports of the incidence of anxiety disorders in women, antenatal prevalence is around 13–21%, with postpartum prevalence around 11–19% (5). Identifying and distinguishing the symptoms of perinatal anxiety is important, as it has been linked to preterm delivery, foetal heart rate and motor activity, as well as PTSD following delivery (6)(7). Furthermore, postpartum anxiety can be detrimental to a mother’s self-confidence and can have long-term negative impacts on the mental development of the child (6).

OCD

Research indicates pregnant and postpartum women are more likely than the general population to experience OCD (8). This is because the perinatal period can increase the risk of OCD onset, and the chance of exacerbating symptoms in women previously diagnosed with the disorder (9). Thus, the most apparent risk factor is a previous diagnosis (9). OCD symptoms include recurrent and unwanted obsessions, along with distressing thoughts, images or compulsions, which lead to repetitive mental or behavioural acts (9). Unfortunately, the nature of these obsessions can be violent, therefore, OCD can sometimes be misdiagnosed for psychosis. However, unlike psychosis, OCD is not linked to an increased risk of carrying out these violent acts (9).

There is currently limited information regarding the prevalence of perinatal OCD. This is because assessments for OCD focus on questions about obsessions involving dirt, germs, arranging and ordering, whereas perinatal OCD is characterised by intrusive thoughts related to the infant (9). Furthermore, these thoughts may include intentionally harming the infant, harming the infant due to distraction or neglect, or even being sexually inappropriate with the infant (9). Given the horrifying nature of these thoughts, many women are hesitant to report their symptoms. One meta-analysis research study (a study that combines the results of multiple studies) suggests that OCD can affect 2% of women throughout pregnancy and 2–3% of women postpartum (8). However, more research is necessary to differentiate perinatal OCD from standard OCD.

PTSD

Most healthcare professionals think of birth trauma in terms of physical injury and can completely underestimate the psychological trauma it evokes. Postnatal PTSD can be caused by real or perceived trauma during pregnancy, childbirth, or the postpartum period (10).

Examples of instances that can trigger PTSD are (10):  

  • Emergency caesareans
  • Labour complications
  • Delivery complications
  • Unanticipated pregnancy
  • Child loss
  • Miscarriage
  • Birth defects

But in reality, even ‘normal’ births can be traumatic for women (10).

PTSD symptoms can include, flashbacks, nightmares, hypervigilance, and avoidance of reminders of the trauma (10). The strongest predictor for post-traumatic stress appears to be anxiety in late pregnancy, stressful life events, and the delivery experience (7).

There is limited research on the prevalence of PTSD, however, one study showed that about 45% of women experience traumatic labour and up to 4–6% of women developed PTSD as a result (11). More research is required in general, as well as the implementation of PTSD screening processes for women who have had challenging births or pregnancies.

Bipolar Disorder

Women with bipolar disorder are at high risk of relapse during and after pregnancy (12). Bipolar disorder is characterised by recurrent episodes of extreme depression alternating with euphoric mania and separated by periods of normalcy. Bipolar onset is rapid and throughout the postpartum period especially, the illness may be accompanied by psychotic tendencies (12).

There are two types of bipolar diagnosis: bipolar I and bipolar II. The criteria for bipolar I are symptoms that lead to significant social or occupational impairment (sometimes requiring hospitalisation) (13). The criteria for bipolar II is a disorder that does not lead to such serious measures needing to be implemented (13). Bipolar I disorder affects around 1% of the population, while bipolar II disorder affects roughly 4% (13).

Perinatal bipolar episodes are particularly dangerous as they can lead to (12):

  • Poor antenatal care
  • Insomnia
  • Substance abuse
  • Poor bonding with the baby
  • An inability to care for the baby
  • Obsessions regarding the baby
  • Delusions
  • Hallucinations

In the worst cases, episodes can lead to suicide and infanticide, usually when the mother is suffering from psychotic symptoms (12). Therefore, it is crucial to monitor the mental well-being of any mothers with a previous diagnosis of bipolar disorder, as well as observe its indications in all mothers.

Psychosis

Postpartum psychosis is one of the most dangerous, yet least understood, of perinatal mood disorders. The onset is typically sudden and occurs within the first 2 weeks after birth (14). Initial symptoms are insomnia, mood fluctuation and irritability, with a later emergence of mania, severe depression, and hallucinations (14).

Postpartum psychosis affects 1 in 500 mothers (15). Although its prevalence may initially appear low, it is important to emphasise that the relative risk of a mother experiencing psychosis during the first month after delivery is a staggering 23 times higher than at any other time during a woman’s life (15). The major risk factors appear to be a history of bipolar and/or postpartum psychosis after a previous pregnancy (15).

Unfortunately, psychosis has an increased risk of both suicide and infanticide (15). It is important to stress that for most survivors, these irrational/delusional thoughts do not evolve into violent manifestations, and they do not harm themselves or others. However, the fact remains, psychosis is a medical emergency and does require immediate professional help.

Even with its severity, our understanding of postpartum psychosis remains incomplete, with little insight into what it is, or how it can be recognised and treated. Furthermore, there are harsh stigmas surrounding mothers who suffer from postpartum psychosis, making them fearful as to how healthcare professionals will react to their symptoms. Therefore, it is crucial to educate all women, partners, and healthcare providers on its symptoms and ensure that as members of society, we do not alienate women with postpartum psychosis.

What Are The Treatments Available?

In general, mood disorders are treated in three ways (3):

  • Self-help – Through talking to friends and family, making time for enjoyment and hobbies, resting, sleeping, exercising, and implementing a healthy diet
  • Psychological therapy – Includes self-help courses, counselling, or cognitive behavioural therapy (CBT)
  • Antidepressants – Used in more severe cases

Sometimes mothers are reluctant to take medication, as antidepressants such as SSRIs (selective serotonin reuptake inhibitors) can remain active in breast milk and potentially affect child development (2). However, the risks of mental illnesses in mothers tends to outweigh the side effects of medication.

In instances of severe bipolar episodes and psychosis, different treatments may be required, such as (16):

  • Antipsychotics – To help with manic and psychotic symptoms
  • Mood stabilisers – For example lithium, which helps to stabilise mood and prevent treatment recurrence

If these treatments fail, or when the situation is thought to be life-threatening, electroconvulsive therapy (ECT) may be used (16). This involves sending an electrical current through the brain which induces a generalised seizure for psychotic relief.

Lastly, along with self-help, psychological therapy, and antidepressants, PTSD is also treated by eye movement desensitisation and reprocessing (EMDR). This involves recalling the traumatic incident in detail, while making eye movements, usually by following the movement of the therapist’s finger (17).

The Socio-economic And Racial/Ethnic Disparities

Currently, many women with perinatal mood disorders do not receive appropriate treatment for their symptoms. There is a clear disparity between treatments in racial minorities compared to white people (18), and a clear indication that mood disorders are more common in younger mothers (19) or those living in poverty (20).

Conclusion

Perinatal mood disorders are extremely complex and widely misunderstood illnesses. The symptoms of these diseases, as well as the stigmas attached to them, can seriously affect mothers through creating loneliness, distress, and guilt. We need more research on the causes of onset and prevalence of mood disorders among mothers, especially for psychosis and OCD. Although some of the tendencies are harrowing, it is crucial for us to show empathy towards mothers who live with these disorders. We must shed light on these issues, and we must ensure mothers receive the help they need to live a happy and healthy life with their babies. 

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 References

  1. Woody CA, Ferrari AJ, Siskind DJ, Whiteford HA, Harris MG. A systematic review and meta-regression of the prevalence and incidence of perinatal depression. J Affect Disord. 2017 Sep;219:86–92.
  2. Brummelte S, Galea LAM. Postpartum depression: Etiology, treatment and consequences for maternal care. Horm Behav. 2016 Jan;77:153–66.
  3. Overview – Postnatal depression [Internet]. nhs.uk. 2021 [cited 2022 Feb 28]. Available from: https://www.nhs.uk/mental-health/conditions/post-natal-depression/overview/
  4. Postpartum and Antepartum Anxiety | Postpartum Support – PSI [Internet]. Postpartum Support International (PSI). [cited 2022 Feb 26]. Available from: https://www.postpartum.net/learn-more/anxiety/
  5. Fairbrother N, Young AH, Janssen P, Antony MM, Tucker E. Depression and anxiety during the perinatal period. BMC Psychiatry. 2015 Aug 25;15:206.
  6. Nakić Radoš S, Tadinac M, Herman R. Anxiety During Pregnancy and Postpartum: Course, Predictors and Comorbidity with Postpartum Depression. Acta Clin Croat. 2018 Mar;57(1):39–51.
  7. Zaers S, Waschke M, Ehlert U. Depressive symptoms and symptoms of post-traumatic stress disorder in women after childbirth. J Psychosom Obstet Gynaecol. 2008 Mar;29(1):61–71.
  8. Russell EJ, Fawcett JM, Mazmanian D. Risk of obsessive-compulsive disorder in pregnant and postpartum women: a meta-analysis. J Clin Psychiatry. 2013 Apr;74(4):377–85.
  9. Fairbrother N, Collardeau F, Albert AYK, Challacombe FL, Thordarson DS, Woody SR, et al. High Prevalence and Incidence of Obsessive-Compulsive Disorder Among Women Across Pregnancy and the Postpartum. J Clin Psychiatry. 2021 Mar 23;82(2):20m13398.
  10. Reynolds JL. Post-traumatic stress disorder after childbirth: the phenomenon of traumatic birth. CMAJ Can Med Assoc J J Assoc Medicale Can. 1997 Mar 15;156(6):831–5.
  11. Ertan D, Hingray C, Burlacu E, Sterlé A, El-Hage W. Post-traumatic stress disorder following childbirth. BMC Psychiatry. 2021 Mar 16;21(1):155.
  12. Khan SJ, Fersh ME, Ernst C, Klipstein K, Albertini ES, Lusskin SI. Bipolar Disorder in Pregnancy and Postpartum: Principles of Management. Curr Psychiatry Rep. 2016 Feb;18(2):13.
  13. Smith DJ, Whitham EA, Ghaemi SN. Bipolar disorder. Handb Clin Neurol. 2012;106:251–63.
  14. Osborne LM. Recognizing and Managing Postpartum Psychosis: A Clinical Guide for Obstetric Providers. Obstet Gynecol Clin North Am. 2018 Sep;45(3):455–68.
  15. Bergink V, Rasgon N, Wisner KL. Postpartum Psychosis: Madness, Mania, and Melancholia in Motherhood. Am J Psychiatry. 2016 Dec;173(12):1179–88.
  16. Postpartum psychosis [Internet]. nhs.uk. 2021 [cited 2022 Feb 24]. Available from: https://www.nhs.uk/mental-health/conditions/post-partum-psychosis/
  17. Treatment – Post-traumatic stress disorder [Internet]. nhs.uk. 2021 [cited 2022 Feb 28]. Available from: https://www.nhs.uk/mental-health/conditions/post-traumatic-stress-disorder-ptsd/treatment/
  18. Kozhimannil KB, Trinacty CM, Busch AB, Huskamp HA, Adams AS. Racial and ethnic disparities in postpartum depression care among low-income women. Psychiatr Serv Wash DC. 2011 Jun;62(6):619–25.
  19. Swift ER, Pierce M, Hope H, Osam CS, Abel KM. Young women are the most vulnerable to postpartum mental illness: A retrospective cohort study in UK primary care. J Affect Disord. 2020 Dec 1;277:218–24.
  20. Dagher RK, Pérez-Stable EJ, James RS. Socioeconomic and racial/ethnic disparities in postpartum consultation for mental health concerns among US mothers. Arch Womens Ment Health. 2021 Oct;24(5):781–91.
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