Baby Blues, Postnatal Depression & Puerperal Psychosis

Question 1

Define

Answer 1

Definitions:

o Baby blues – mild, self-limiting low mood in the postnatal period - 50% new mothers

o Postpartum depression (PPD) – pervasive low mood in the postnatal period - 10-15% new mothers

o Puerperal psychosis – acute onset of psychotic illness in the postnatal period - 0.1% new mothers

Question 2

Aetiology / Risk factors

Answer 2

Aetiology = unclear; falling levels of oestrogens, progesterone and cortisol postnatally; thyroid hormones dropping

Aetiology and Risk factors

• previous miscarriages or difficult birth experiences
• history of depression
• isolation, poor support, stressful living conditions or major life events
• unplanned pregnancy
• difficult childhood experiences and poor self-esteem
• struggling with a pressure to ‘do things right’.
• Large number of existing children
• Low income
• Single mother
• Young age
• Primigravida
• Antipsychotics (esp. risperidone) – dopamine inhibition and hyperprolactinaemia

Question 3

Symptoms

Answer 3

Blues – emotional lability, irritability, poor sleep and concentration

Onset 3-5 days post-natal -> recover within 10-14 days

Symptoms:

• Insomnia
• Fatigue
• Tearfulness and labile mood
• Anxiety
• Irritability
• Impaired concentration
• Baby blues last <2 weeks; any longer = PPD

Depression in pregnancy / Post-partum Depression [lasts >2w PP] – anergia, anhedonia, low mood

• Onset during pregnancy to 1 year post-natal -> recover within ~4 weeks

Psychosis - delusions (mania, delusions, hallucinations), thoughts of self-harm:

• Onset from 2-3 days post-partum to 1 year post-natal -> recover within 6-12 weeks
• Not defined by DSM-V or ICD-10

Tends to follow three patterns:

• Delirium
• Affective (like psychotic depression or mania) 70-80% have BPAD or schizoaffective
• Schizophreniform

Question 4

Investigations

Answer 4

Investigations = MSE and depression rating scales may be used

• 1st: Depression screening questions à low mood, anhedonia
• 2nd: Edinburgh Post-Natal Depression Scale (score >12 = likely depressive episode)

o SAFETY NET: confirm if she has had thoughts of harm to self; harm to others (baby); suicide (±plans), delusions

Question 5

Management

Answer 5

Blues – reassurance, support (as self-limiting) child and analyse it with the psychiatrist for improvement

Depression (severity-dependent; criteria same as non-pregnant depression)

Breastfeeding-safe antidepressants

• Sertraline
• Paroxetine

Psychosis – psychiatric emergency-> inpatient admission

1. The first line of treatment for moderate to severe depression: is high-intensity psychological intervention (such as CBT).
2. If this is refused, or symptoms do not improve, then an antidepressant should be used. NICE suggests a selective serotonin re-uptake inhibitor (SSRI) or tricyclic antidepressant (TCA). 

Sertraline or paroxetine are the SSRIs of choice in breastfeeding women (avoid fluoxetine due to long half life)

• For pregnant women who have not used antidepressants, any SSRI (with the exception of paroxetine) is a reasonable first choice
• NOTE: After 20 weeks selective serotonin reuptake inhibitors (SSRIs) have been associated with persistent pulmonary hypertension of the newborn
• Serotonin withdrawal syndrome is a self-limiting condition with usual neonatal symptoms including hypotonia, irritability, excessive crying, sleeping difficulties and mild respiratory distress. It is more likely to occur with paroxetine

Question 6

Complications/ Prognosis

Answer 6

• Poor emotional attachment to child
• Long-term psychiatric morbidity
• Suicide (up to 5% in puerperal psychosis)
• Infanticide (up to 4% with puerperal psychosis)

Prognosis:

• Postnatal depression recurrence = 30%
• Puerperal psychosis recurrence = 20%

Ask if they have ever had this during pregnancy