Severe mental illness

Although not as common as those conditions considered earlier, severe mental illnesses have a significant impact in the perinatal period. Severe postpartum episodes can be a recurrence of an ex­isting mental illness, such as bipolar disorder or schizophrenia, or in around 50% of cases, the first episode of psychiatric illness.

Postpartum psychosis

The term ‘puerperal' or ‘postpartum psychosis' is commonly used in clinical practice and research for a heterogeneous group of psychi­atric episodes with onset in the immediate postpartum period (in 90% of cases within 2 weeks after delivery) (45). The word ‘psych­osis' in this context can, however, be confusing (46). In the majority of cases, the symptomatology and prognosis resemble that of an af­fective disorder rather than that of schizophrenia. Patients usually present with severe manic, depressive, or mixed symptoms. Positive psychotic symptoms such as delusions and hallucinations, confu­sion, and perplexity are also common. Some women may present with the typical symptoms of the so-called polymorphic/cycloid psychosis (47). In other cases, however, the term ‘postpartum psych­osis' is used to describe manic or mixed episodes without psychotic symptoms. In the assessment of women with significant psychiatric symptoms with onset in the immediate postpartum, one evaluation is usually not enough, as the picture fluctuates over time, can escalate rapidly, and severity is sometimes difficult to recognize (48, 49).

The debate on the validity and nosology of postpartum psychosis, especially in relation to bipolar disorder, is ongoing. The current clas­sification systems DSM-5 and ICD-10 do not recognize postpartum psychosis as a separate nosological entity. However, some authors have maintained that there are several advantages in adopting a sep­arate diagnosis of puerperal psychosis for both research and clinical practice (50).

Differential diagnosis

The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom has underscored that a number of maternal deaths are due to the misattribution of psychotic symp­toms to postpartum psychosis rather than to ‘organic' disorders (51). Several ‘organic' disorders can cause psychosis: infections; pre­eclampsia and eclampsia (52); autoimmune (53), metabolic (54-56) and para-neoplastic disorders; encephalitis and cerebral vascular diseases (57); and syndromes associated with substance abuse and withdrawal.

On the other hand, the tendency to label all psychiatric perinatal episodes as ‘postpartum depression' can lead to the wrong manage­ment and to an underestimation of the risk of suicide and infanti­cide, sometimes with dramatic consequences (51, 58).

Epidemiology

Although postpartum psychosis can be considered a rare disorder (50), certainly when compared to postpartum mood disorders more generally, it can have a potentially fatal impact and is therefore im­portant to identify and manage. Studies based on hospital admission have estimated an incidence of 1-2 per 1000 deliveries (11). This es­timate, however, does not account for women treated as outpatients and will also include women admitted for other reasons than an epi­sode that could be labelled as postpartum psychosis.

The specific link between childbirth and the triggering of manic/ affective psychosis is well established (11, 12, 44, 50, 59, 60). The relative risk of having a first lifetime manic episode in the first month postpartum is over 23 times higher than 1 year after childbirth (11).

For the majority of women affected (two in three according to a retrospective study), postpartum psychosis represents the first psy­chiatric episode (61). In this group without a psychiatric history, postpartum psychosis is very difficult to predict (61). There are, however, risk factors that have been associated with postpartum psychosis. Women with a history of bipolar disorder have a one in five chance of a delivery affected (12); a previous episode of post­partum psychosis confers an even higher risk, around one in two (62). A family history of postpartum psychosis has also been iden­tified as a risk factor (63), although molecular genetic studies have yet to fulfil their promise (64). Although several factors associated with pregnancy and delivery have been explored, the only robust risk factor identified is primiparity (65, 66). The association between primiparity and postpartum psychosis is not a mere reflection of the fact that women with a history of postpartum psychosis tend not to have further pregnancies and it has been hypothesized that it may be due to the biological differences between first and subsequent preg­nancies (66). Research, in fact, has failed to demonstrate an associ­ation between psychosocial factors and postpartum psychosis (67, 68). A particularly intriguing hypothesis is that postpartum psych­osis may be underpinned by immune dysregulation. This hypoth­esis is based on the observation of a marked increase in the rates of postpartum autoimmune thyroiditis and immune biomarkers alter­ations in women with postpartum psychosis (69). It has also been hypothesized that there is an aetiological link between postpartum psychosis and eclampsia.

Treatment

In the majority of cases, postpartum psychosis is the first contact with psychiatric services in women without apparent risk factors (61). A prompt diagnosis and treatment are therefore paramount. Postpartum psychosis is a psychiatric emergency. Admission is ne­cessary in the majority of cases, even when the family is supportive (48). NICE recommends the admission of the mother with the baby to specialized mother and baby units; however, these are not always available. There is accumulating evidence that mother and baby units not only are preferred by the women (71), but also lead to better outcomes and shorter durations of admission (64).

Postpartum psychosis requires pharmacological treatment. However, there are no randomized controlled trials specifically ad­dressing postpartum psychosis. A recent clinical study conducted in the Netherlands followed up for 9 months women with post­partum psychosis to evaluate the efficacy of an empirical treatment algorithm consisting sequentially of (a) benzodiazepines, then (b) benzodiazepines and antipsychotics, then (c) benzodiazepines, antipsychotics, and lithium. With adherence to this stepped regimen, they observed a complete remission of the symptomatology in more than 98% and 80% of women maintained the remission for the en­tire period of observation. In addition, significantly higher relapse rates were seen in women treated with an antipsychotic only com­pared to those treated with lithium only (plasma concentrations 0.6-0.8 mmol/L) (72).

Severe psychotic symptoms in pregnancy, catatonia, lack of re­sponse to pharmacological treatment, and suicidality are among the most common indications for electroconvulsive therapy (64). Although there are no randomized controlled trials for electrocon­vulsive therapy in the perinatal period, the evidence of effectiveness is promising (73).

A referral to social services should not be made routinely and should be supported by a careful risk-benefit evaluation (64) (see ‘Schizophrenia’).

One study has suggested that women with a history of isolated postpartum psychosis (without bipolar episodes outside the puer- perium) may be at lower risk for a recurrence in pregnancy than women who also have experienced non-postpartum episodes of illness. The risk of recurrence after childbirth, however, is elevated in this group and women should consider starting prophylactic pharmacotherapy immediately after delivery (62).

Prognosis

If promptly identified and treated the prognosis is good, with over 95% of patients achieving remission within 1 year (72). The me­dian duration of illness is considerably shorter for women treated with pharmacotherapy (40 days) (72) than for those without (8 months) (75). If misdiagnosed or untreated, postpartum psych­osis is one of the major risk factors for suicide after childbirth and in tragic but rare circumstances may also be linked with infanti­cide (Box 18.3).

In a retrospective study on 116 women with postpartum psychosis, only 58% of women had a further pregnancy (61). Recurrence rates are around 50% for further postpartum episodes and between 50% and 70% for bipolar recurrences outside the puerperium (76, 77).

Postpartum psychosis has a negative impact on the life of the woman, with one study reporting 18% of marriages ending after the severe postpartum episode (61). The stigma affecting all mental dis­orders is in this case accompanied by that of being a ‘bad mother’ and by feelings of guilt for the consequences of the illness on the baby (71).

Bipolar disorder

As we have discussed, over 50% of episodes of postpartum psychosis are the first episode of illness, but there is strong evidence of a spe­cific relationship to bipolar disorder.

Box 18.3 Principles of care for women with psychiatric disorders preconception, in pregnancy, and postpartum according to NICE

Clinicians should discuss with all women of childbearing potential and a mental disorder the use of contraception and any plans for a pregnancy, including how it would affect the psychiatric illness and vice versa. Even if the woman is not planning a pregnancy, the prescription of psycho­tropic drugs should take account of the up-to-date data on teratogenic risk. Valproate should not be prescribed to women of childbearing potential.

Women planning a pregnancy or those in the perinatal period should be sensitively provided with relevant, understandable informa­tion on treatment and prevention options. The discussion should in­clude women's preferences, circumstances, and the acknowledgement of the many areas of uncertainty. Anamnestic information is important to personalized treatment. An integrated health plan should be devel­oped in collaboration with the woman and, if she agrees, her partner, family, or caregiver and a healthcare professional should be responsible for coordinating it. Regular monitoring of the symptoms is important and increasing contacts with the health services may be necessary.

For severe psychiatric disorder, referral to a secondary mental health service should be considered. Specialist advice may also be sought when psychotropic medication is started.

Source data from Antenatal and postnatal mental health: clinical management and ser­vice guidance | Guidance and guidelines | NICE. Available at: http://wwwmice.org.uk/ guidance/cg192 (accessed 19 March 2015).

Clinical presentation and epidemiology

Over 70% of mothers with bipolar disorder have suffered at least one episode of mood disorder in the perinatal period, and over one in four have experienced an episode of postpartum psychosis (12). Although the emphasis for women with bipolar disorder has always been on psychotic/manic episodes, a large retrospective study on 1212 women with bipolar disorder found that non-psychotic de­pression is the most common mood episode in the perinatal period (12). It does appear, however, that there is a closer relationship be­tween childbirth and episodes of mania and psychosis. Over 90% of manic/psychotic episodes occur within the first 4 weeks after child­birth, while one depressive episode in four has its onset later in the postpartum period, after the first month (12).

The association between childbearing and bipolar disorder is specific for delivery and for manic/psychotic episodes. The risk of manic/psychotic episodes is significantly lower after miscarriage or termination than after delivery whereas depressive episodes are equally common following each of these pregnancy outcomes (60). The high risk of recurrence after delivery does not seem merely re­lated to the discontinuation of medications during pregnancy, as re­currences are three times more frequent postpartum when lithium (a first-line treatment for bipolar disorder) is discontinued due to preg­nancy than when the woman stops taking it for other reasons (70% vs 24%) (78).

Treatment

The pharmacological treatment of bipolar disorder during preg­nancy often requires difficult decisions and needs to be evaluated in light of the high risk of recurrence and the negative impact that the illness may have on the fetus (4, 48, 64). The discontinuation of lithium during pregnancy, especially if abrupt, doubles the risk of a recurrence (79). A women’s psychiatric history can help indi­vidualize these decisions. A longitudinal study found that not one of 29 women with a history of postpartum psychosis with no episodes outside the perinatal period had a recurrence during a subsequent pregnancy, while 10 of 41 women with a history of bipolar disorder outside the puerperium had a recurrence during pregnancy, with a risk doubled in those without mood-stabilizing therapy (19% vs 40%) (62).

Similar to postpartum psychosis, there is a lack of randomized controlled trials on the treatment of postpartum bipolar depression. A naturalistic study on 34 women with postpartum bipolar depres­sion initially misdiagnosed as unipolar showed that the discontinu­ation of antidepressants and the introduction of a mood-stabilizing therapy improved symptoms in 88% of cases (19).

Psychological interventions and psychoeducation should always be considered, even if specific evidence for these approaches in the perinatal period is lacking (64).

Schizophrenia

Schizophrenia is a chronic, highly disabling, and severe mental dis­order that affects about 1% of the general population. Symptoms usually start in early adulthood and are commonly grouped in three categories: positive (hallucinations, delusions, thought and movement disorders), negative (blunted expression of emotions, anhedonia, difficulty beginning and sustaining activities, reduced speaking), and cognitive (poor executive functioning and working memory, trouble focusing or paying attention).

Although women with schizophrenia may have lower fertility, with the development of newer antipsychotic medications that im­pact less on prolactin levels, more women with this disorder are be­coming mothers (64). The close relationship of episodes of illness following childbirth observed in bipolar disorder is not found for schizophrenia, a marked distinction between the two disorders (11, 44). Women with schizophrenia may, however, require hospital ad­mission to monitor and facilitate the mother-baby relationship, even in the absence of a severe symptomatic recurrence (81).

There is a paucity of evidence on the management of schizo­phrenia in the perinatal period. A preliminary study found that a collaboration between services and the women’s partner in the care of the baby leads to an improvement in the symptomatology (82). Although women with schizophrenia may successfully parent, many do have difficulties. Indeed, studies have shown that the diagnosis of schizophrenia, together with that of personality disorders and sub­stance abuse or dependence, are associated with an increased risk of involvement of social services (64). The loss of custody of a child represents a severe threat and a traumatic event (71) that can pre­cipitate a crisis and a worsening clinical picture. According to the Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom, 31% of mothers who committed suicide during pregnancy had been referred to social services (83). The fear of losing custody can also have a negative impact on the patient­doctor relationship and may induce the woman to deny the symp­toms in the hope of maintaining the maternal role (71,84). Although schizophrenia is associated with problems with the maternal role and a 25-fold increased risk of social service supervision compared to psychotic depression, women with schizophrenia are not ne­cessarily unable to fulfil the maternal role (64). Among the factors that should be considered in assessing the potential for successful parenting are (valid also for other psychiatric disorder) (a) psych­otic symptoms involving the baby or passivity experiences; (b) the

partner's psychiatric history, and (c) the social context, including in­timate partner violence and abuse (64).