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Issues relating to puerperal psychosis and its management.

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The birth of a child is generally viewed as a time for rejoicing, despite the physical pain and exhaustion experienced by many women during childbirth. However, for some women the experience can be a traumatic event for a variety of reasons. These include the new demands a baby can bring, anxieties about parenting abilities, the responsibility of looking after the baby, and a host of more complex psychological, sociological, and biological matters that arise during this time of change (Currid, 2002). When these issues are not resolved positively, women may experience further difficulties in coping or crises leading to periods of mental illness, ranging from mild to severe.


VOL: 100, ISSUE: 17, PAGE NO: 40

Thomas Currid, BSc, PGCE, RMN, is senior lecturer mental health, London South Bank University.


The birth of a child is generally viewed as a time for rejoicing, despite the physical pain and exhaustion experienced by many women during childbirth. However, for some women the experience can be a traumatic event for a variety of reasons. These include the new demands a baby can bring, anxieties about parenting abilities, the responsibility of looking after the baby, and a host of more complex psychological, sociological, and biological matters that arise during this time of change (Currid, 2002). When these issues are not resolved positively, women may experience further difficulties in coping or crises leading to periods of mental illness, ranging from mild to severe.



Many women - particularly those experiencing severe mental illness - require specialist perinatal services to assist them in their recovery. However, while this approach is advocated throughout the literature, evidence suggests that many women with severe perinatal mental illness still do not receive the specialist services they need and are treated in general mental health facilities (Department of Health, 2002; Kohen, 2001; Royal College of Psychiatrists, 2000).



Prevalence of perinatal mental illness
Women are more likely to be admitted to a psychiatric hospital following delivery than at any other time in their lives (Dean and Kendell, 1981). The Royal College of Psychiatrists (2000) estimates that about two in every 1,000 mothers will have a pre-existing severe chronic mental illness - predominately schizophrenia - while Kendell et al (1987) found that two in every 1,000 women who had given birth were admitted to hospital because of puerperal psychosis.



This figure is also representative for women admitted for episodes of non-psychotic affective disorders following childbirth. These cases are rather few in number when compared with the overall incidence of psychiatric admission or morbidity. However, a number of issues should be considered when placing them in context for giving increased priority to meeting the needs of women with perinatal mental illness.



The studies referred to are in some cases over 15 years old, and it could be argued that more up-to-date epidemiological research is needed to ascertain whether these figures are still representative. In addition, the information presented above refers only to cases admitted to hospital, while some women receive perinatal mental health care and treatment from other sources and do not require hospital admission. Okano et al (1998) found that in a Japanese cohort it was difficult to ascertain a true prevalence of perinatal mental illness because women received treatment in a range of settings and total figures were therefore not collated.



Although the epidemiological figures presented refer only to mothers, their illness must be set in the context of their wider role. Women’s Mental Health: Into the Mainstream (DoH, 2002) highlights the fact that women play a significant role in the workforce while assuming the major responsibility for homemaking and caring for children and other dependent family members. When illness strikes a mother, therefore, it will also have an impact on others around her.



Perhaps more devastatingly, the Royal College of Obstetricians and Gynaecologists’ Confidential Enquiry into Maternal Deaths (RCOG, 2001) reported that psychiatric disorders contributed to 12 per cent of maternal deaths. It also found that suicide was the leading cause of maternal death.



Puerperal psychosis
There is a tendency among clinicians to use the term postpartum or postnatal depression to describe several psychiatric disorders that occur or are exacerbated after delivery (Chaudron, 2003), including puerperal psychosis. This anomaly may have arisen because its classification remains controversial in the psychiatric establishment, despite growing evidence of its unique and distinctive presentation.



The condition is not currently classified either within the World Health Organization (1992) or American Psychiatric Association (1994) systems, yet Kumar (1990) asserts that its distinctive symptoms include perplexity, confusion, transient episodes of paranoid delusions, and catatonic or stuporous states.



Debate continues on the phenomenology of puerperal psychosis and whether or not it is a variant of some other form of psychosis such as bipolar or schizoaffective disorder. Chaudron (2003) outlines the three theories that predominate in the literature:



- It is a subtype of bipolar disorder;



- It is a unique diagnosis entity;



- It is not associated with any specific psychotic illness but can be triggered by childbirth and various other psychotic illnesses.



Regardless of which theory becomes accepted, it is important to remember that within the spectrum of illness and suffering, it is the needs that arise from the manifestation of the illness that count, rather than its particular name or label. Despite its omission from classification systems, the fact that there is no evidence on puerperal psychosis does not mean that the disorder does not exist. More research is needed so that we can better understand the condition, find the most effective models of care, and identify more exacting causes of the illness in order to reduce suffering.



The causes of puerperal psychosis remain unclear. The Royal College of Psychiatrists (2003) suggests it is most likely to be due to the effect of the huge hormonal changes that occur at the end of pregnancy and delivery. Mahe and Dumaine (2001) state that a marked decrease in oestrogen levels is simultaneously associated with the emergence of an acute psychosis, and therefore suggest this status has an aetiological role. Their hypothesis is based on the modulating effects that oestrogen has on neurotransmission systems within the brain, which in turn affect mood and mental states. This theory is supported by Ahokas and Aito (1999), who reported that the administration of oestrogen improved puerperal psychosis in women with low levels of oestrogen.



Other biological theories include genetics and thyroid dysfunction. Coyle et al (2000) found significant evidence that variation at the serotonin transporter gene (5-HTT) exerts a substantial and important influence on susceptibility to puerperal psychosis. Alongside this they found that narrowing the phenotype to women who had experienced several episodes revealed an increased effect, although they emphasised that their findings should be replicated in independent samples.



Craddock and Jones (2001) conclusively demonstrated that familial factors are implicated in susceptibility to puerperal episodes - women who have a family history of puerperal psychosis have twice the rate of puerperal episodes as those who do not. Bokhari et al (1998) highlighted the interrelating aspects of postpartum psychosis and postpartum thyroiditis.



In comparison with biologically based aetiological factors, fewer psychological or sociological causes have been linked with puerperal psychosis, although previous history is strongly correlated to vulnerability. Relapse rates of over 90 per cent have been described in women where the index (first) episode of puerperal psychosis occurred in the 24 months prior to delivery (Sichel et al, 1995), although Marks et al (1992) suggested a lower rate of 50 per cent.



Presenting features
The symptoms of puerperal psychosis usually present within two or three weeks after delivery but can vary in nature. Klompenhouwer et al (1995), in a study of 238 women, identified a number of prominent features (Box 1) that, they argue, support a special status for post- partum psychosis.



Kumar (1990) argues that a wide range of symptoms are reported by women with puerperal psychosis, and that the symptoms experienced by individual women can vary.



Confusion and perplexity
Women may display confusion and perplexity during the first few days and weeks of the illness (Klompenhouwer et al, 1995). However, these symptoms may not be constantly present, and therefore the mother may fluctuate between periods of orientation and confusion.



During the depersonalisation phase the mother may find it difficult to relate to the environment around her and may feel detached from reality. There is a loss of contact with her own personal reality, and this may result in her having difficulty in relating emotionally to her child. This, of course, has repercussions in terms of the mother’s ability to bond with her baby.



In some cases mothers report that they are experiencing hallucinations. Klompenhouwer et al (1995) found that auditory hallucinations feature in about half the patients diagnosed with puerperal psychosis, some of which can be described as voices.



Delusions are also reported among women with puerperal psychosis. Often these can be of a paranoid or grandiose nature and, when placed in context, may appear to stem from misinterpretation of current events. For example, the mother may believe that her baby is being taken away from her permanently when staff are taking it for a sleep or feeding.



Misrecognition can be common and may take the form of not recognising her partner or the father of the child, or mistaking others (such as male staff) for her partner or the father of the child. From a psychodynamic point of view Klompenhouwer et al (1995) interpreted such confusion as the expression of one of the underlying unconscious psychological conflicts experienced by the mother at this period, and considered this type of response as possibly having aetiological significance.



Mood disturbance
Mood disturbances are prominent in puerperal psychosis, and can be both manic and depressive in nature. Often mothers may present as having difficulty in sleeping, which can be the first sign of a euphoric or manic state.



Although sleep disturbance is common in women with puerperal psychosis, while they are in their manic phase they will present with an elated mood, experiencing feelings of overwhelming happiness, and mild euphoria due to the new baby. In turn this will affect thoughts and behaviour. It is not uncommon to see women experiencing a flight of ideas - quickly changing the focus of a sentence - as well as grandiose ideas suggesting, for example, that they possess special abilities.



Other thought disorders may also prevail, including erotomanic-type delusions (excessively or morbidly erotic thoughts and behaviour or a belief that one is involved in a romantic relationship with another person) and irrational judgement.



Women can also present in a depressed state, and this may be why the term postnatal depression is used as a blanket term to cover all mood disturbances in the puerpium. However, there is a difference between psychotic and non-psychotic depression and, unlike that experienced in postnatal depression, depression in puerperal psychosis is of a psychotic nature.



The external features of psychotic depression are similar to those of a non-psychotic episode; the mother may experience difficulty in undertaking everyday activities, low energy levels and psychomotor disturbances. Internally, while she may have feelings of hopelessness and extreme sadness, the thought attribution surrounding these will be of a psychotic nature. Within this state the mother may believe that she is being controlled or persecuted by others, or that part of her body or its ability to function is impaired or missing. Feelings of guilt may also feature highly.



As with thought disorders of any type, behaviour can be somewhat influenced by beliefs culminating in scenes that otherwise would not be portrayed. Mothers who are in a manic episode may exhibit signs of bizarre behaviour. Scenes of rushing around or not taking time to rest are common. Alongside this, they may also exhibit a lack of inhibition, as illustrated by the content of their speech and a disregard for other social norms. This disregard may include hostility or aggression towards others, particularly if they set limits and are perceived to be interfering with the mother’s goals.



A woman in a psychotic depressed state may have difficulty in bonding with her baby, and therefore may behave in a somewhat ambivalent manner towards the infant. This may culminate in a mother being unable to provide the full care and affection that her child needs in order to thrive.



A number of interventions are used with women who are experiencing puerperal psychosis (Box 2). However, Brockington (1996), summing up the literature on the treatment of puerperal psychosis, states that there is a dearth of treatment trials. Due to the severity of the presenting symptoms, medication in the form of antipsychotics, antidepressants or mood stabilisers are usually considered as the first-line treatment options, although there is no specific first-line choice of mood stabiliser or antipsychotic medication (Chaudron, 2003).



Careful consideration should be given to mothers who intend to continue to breastfeed their baby due to the levels of prescribed drugs that may end up in breast milk. Advising cautious use of medication with breastfeeding women, Chaudron (2003) calls on prescribers to work closely with mothers and pediatricians to monitor infant fluid status and serum levels. She also advises that infant exposure to medication is dependent on a number of variables such as dosage, metabolites, absorption, and excretion. It may therefore be necessary to advise mothers not to breastfeed while they are taking certain drugs.



Electroconvulsive therapy (ECT) is also believed to be effective in treating puerperal psychosis, particularly for women with a depressive presentation. In a study to assess the sensitivity of puerperal psychosis to ECT, Reed et al (1999) found that clinical improvements following ECT were greater in puerperal psychosis than non-puerperal psychosis according to blind ratings of change in mental state. However, they pointed to a number of methodological criticisms of their findings and suggested other explanations, such as the possibility that the effectiveness of ECT may be self-fulfilling, and the fact that diagnoses used to subdivide the total sample were obtained from case notes rather than standardised. Considering the limitations of the study, they advise that their findings should be thought of as preliminary and recommend further studies using standardised clinical ratings and key variables.



There is a dearth of literature on treatments using psychosocial interventions in puerperal psychosis. A number of factors may contribute to this:



- The condition may be seen wholly or partially as being of a biological nature in aetiological terms;



- Due to the limited number of mothers who suffer, it may be difficult to gain a representative sample.



- As it endures for a shorter period than other forms of severe psychosis it may be difficult to engage accurately in trials and studies to ascertain effectiveness;



However, there is no reason to suspect that interventions used in other forms of psychoses are not suitable or useful in treating puerperal psychosis.



Management issues
Immediate care and treatment for both mother and baby are vital and should be treated as an emergency due to a number of factors such as the risk to them both, the seriousness of the illness, the importance of preventing further deterioration, and the increased biological, psychological, and social needs of the mother. A well thought out, integrated interdisciplinary and interagency approach from the beginning to the end of care is needed, with each agency fully involved throughout.



Staff providing care need to understand that due to the complexity of the illness their role may be required for longer periods than service agreements or other protocols stipulate. This does not mean that each member of the multidisciplinary team is required to be physically present throughout, but that they commit themselves to working in partnership and communicate with the other members of the team at all times. This not only enables services to give optimum care to the mother and baby but has other benefits such as increasing team members’ own knowledge and skills. Failure to communicate effectively and coordinate care may contribute to neglect of the mother and baby and, in some cases, death (North East London Strategic Health Authority, 2003).



Many mothers will require hospitalisation when experiencing puerperal psychosis; in some cases this may involve involuntary admission on a section of the Mental Health Act 1983. Hospitalisation may take the form of admission to a mother-and-baby unit or the mother being admitted alone to an acute inpatient unit. While it is preferable to keep the mother and baby together, many areas do not have a mother-and-baby unit and are forced to separate them.



Generally it is felt that the small numbers of mothers requiring admission with their babies are insufficient to justify the setting up of a mother-and-baby unit (RCP, 2000). However, considering the distress and feelings of guilt that separation can cause for these mothers this financially driven argument is at odds with the National Service Framework for Mental Health (DoH, 2003), which pledges to provide a choice of modern, alternative, and suitable local services for people who are experiencing mental illness.



Even mothers who do obtain a place in a mother-and-baby unit can find themselves isolated from their families and the support that they provide. Since the units are few and far between, a mother may find herself some considerable distance from her home, which can prevent her partner and/or family from visiting frequently. Some mothers also face losing contact with their other children while in hospital, and also with the midwife and health visitor they know and may have already built up a rapport and trust with. These serious consequences need to be weighed up by perinatal mental health services and the associated cost in financial and human development terms are being considered.



Implications for practice
Puerperal psychosis is a severe illness requiring specialist care. While postnatal depression has been gaining increased coverage in both the literature and the media, puerperal psychosis has not received the same exposure. Since it is far less common than postnatal depression, practitioners have less chance of encountering it during their basic training. This means that there is an increased need for them to familiarise themselves with the condition, or they may not recognise it in its early stages. This will result in women not receiving the best and most effective forms of care and educational interventions as part of the recovery process.



A proactive approach to care is important in minimising the effects of puerperal psychosis. There are nine months in which a mother’s risk can be recognised, providing the relevant practitioners are aware of its known risk factors and able to refer appropriately, so this is possible to achieve.



The Royal College of Psychiatrists (2003) advises that at strategic level, health authorities should develop a perinatal mental health strategy to ensure that the knowledge, skills, and resources necessary for detection and prompt and effective treatment are in place at all levels of health care provision.



At local level, service providers must ensure they have personnel with a specific interest in working with this group and who have the specialist knowledge and skills to lead these services and to develop colleagues in other fields, such as midwifery and health visiting.



At an individual level, practitioners need to take responsibility for learning about puerperal psychosis and seek new and innovative ways of incorporating it within their practice. Although it may be a serious and complex illness, its effects on mothers and their families mean that everyone within the care spectrum has a responsibility to make it a public health priority - it should not be left to specialist services alone.



If we do not take responsibility for tackling puerperal psychosis we will not only be failing to meet the needs of mothers but may also be contributing to the suffering experienced by them and their families.



This article has been double-blind peer-reviewed.

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