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Psychiatric mood disorders can and do occur in pregnant women. Women with antepartum depression have a risk of poor nutrition, substance abuse, and prenatal noncompliance. Careful assessment of risk and benefits to the pregnant woman and to the unborn child must be made before pharmacologic therapy is initiated. The three postpartum mood disorders--postpartum "blues," postpartum depression, and postpartum psychosis--are common, and education is an important instrument in the treatment of these disorders.
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PMID:Antepartum and postpartum depression. 1128 Oct 10

The macrophage theory of depression proposes that an excessive secretion of monocyte/macrophage cytokines causes symptoms of depression. It has been suggested that changes in immune function that accompany pregnancy and childbirth could contribute to the affective symptoms suffered by many puerperal women. Tumour necrosis factor alpha (TNFalpha) is a pro-inflammatory cytokine that has been implicated in inflammatory infections and immune diseases. Production of TNFalpha has been shown to be regulated by oestrogen, which suggests it as a potential candidate for susceptibility to post-partum mood disorders. Several polymorphisms have been identified in the TNFalpha gene. The -308 promoter polymorphism has been associated with elevated production of TNFalpha and has been found to influence the neurological outcome of various infections. In a case-control association study, we have examined the frequency of this polymorphism in groups of parous DSM-IV Bipolar females with (N = 116) and without (N = 56) puerperal psychosis, and a female non-psychiatric comparison group (N = 72). We provided no support for the hypothesis that this polymorphism influences susceptibility to bipolar disorder, or acts as a trigger for puerperal psychosis. However, variation at other polymorphisms within TNFalpha or in other oestrogen-regulated genes involved in immune function remain interesting candidates for study in post-partum mood disorders.
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PMID:Tumour necrosis factor alpha and bipolar affective puerperal psychosis. 1132 46

A high prevalence of psychiatric illness has been noted in the postpartum period. Recent research looks to the potential effects of maternal illness during this period on child development. With the promotion of breast feeding for well-documented medical benefits, there has been increasing attention to the potential effects on the infant of exposure to medication via breast milk. This article reviews the current literature on the secretion of psychotropic medication into breast milk, and any known negative effects. The shortcomings of these studies are highlighted, and recommendations to the clinician are given within the limitations of the current state of knowledge. The World Health Organization (WHO) has estimated that depression will be 1 of the 2 major illness burdens confronting the world by 2020. The incidence of depression is 2-fold higher in women than in men, and the average age at onset is 25 years. These facts combined with the noted risk of a marked increase in psychiatric illness postpartum have serious implications. Depression occurring at this time can present with depressed mood, anxiety, and difficulties coping with the infant. Suicide, although not more common in depression, is at the severe end of the spectrum in those with puerperal psychosis and bipolar disorder. The morbidity associated with depression is not confined to women suffering from it; there are also potential negative effects of maternal depression on child development, on older children, and on the woman's partner. These effects include impaired bonding and cognitive and behavioral delays in the infant and difficulties in childhood. Moreover, the increased use of antidepressants in the Western world in combination with the strong promotion of breast feeding also has implications for the dependent infant. What do we know? And, what are the risks?
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PMID:Treating mental illness in lactating women. 1154 66

The Psychiatry department of the University Hospital Centre of Lille has developed, over the last 10 years, a treatment network for psychiatric disorders during pregnancy or in the post-partum period. There are liaison consultations in the maternity department, screening and management of psychopathological disorders in the perinatal period, training of midwives, support of patients seeking genetic counselling, collaboration with teams providing "medically-assisted procreation", etc. For severe disorders of the post-partum period (severe depression, serious alteration of mother-child interaction, puerperal psychosis), the Psychiatry department has a specialized unit where 3 "mother-child" groups can be admitted. This unit is particularly effective if the patients and their family understand this healthcare system and stick to it to a certain extent. Even if improvements are always possible, cases in which situations occur as an emergency, are when dysfunctions are most frequently seen. On 7th December 1998, a Crisis Intervention Unit (CIU) was created with 15 short-term beds, for stays up to 72 hours. The CIU was opened in the Psychiatry department, close to the main Accident and Emergency department, with 2 aims: firstly to provide a setting and resources for a number of emergency psychiatric situations, and secondly to provide a place and time for crisis situations which we admit to the unit, with a view to facilitating interaction and to propose in certain cases a process of crisis intervention, which later continues on an outpatient basis. After being open for a year, the CIU has proved to be an improvement to all of the healthcare services which are available. It should be noted that the situations which need highly specialized resources in such a short time, are those which cause the most acute problems. This is at times when the emergency services network, with its internal logic, require another network based on a different logic, that the interface problems are at their most acute. The situations reported here, which require a fluid interface between the emergency services and the "mother-child" networks, are examples. We report 3 clinical situations, which illustrate 3 possibilities of action: the first, in which 2 successive stays in the CIU allowed an admission to the "mother-child" unit in satisfactory conditions, the second, in which overall management was based on hospitalization in the Obstetrics department and several visits to our Unit, and the last one, in which the whole medico-psycho-social approach was set up after a single stay of 3 days. Since the opening of Crisis Intervention Unit, around 1,000 patients have been treated there; 37 were women with difficulties with their pregnancy, 17 of whom required direct intervention by the "mother-child" team. The contexts were: 5 prenatal depressions, 4 post-partum depressions, 3 cases of hyperemesis gravidarum, 5 rejections of pregnancy and/or situations at risk of infanticide. The almost constant suicidal risk should be noted, or even attempted suicide, at the time of admission to the CIU. The other 20 women had psychopathological disorders linked to sterility, medically-assisted pregnancy, termination of pregnancy or pregnancy in women suffering from long-term somatic illnesses (insulin-dependent diabetes, lupus, etc.). When a psychopathological episode occurs during pregnancy, it is essential to preserve the developing relationship with the child in an intermediate place, in a healthcare perspective and to prevent any future impairment of the quality of the mother-child relationship by the psychiatric disorder. The Crisis Intervention Unit is not an emergency "mother-child" unit. Other French experiences have been reported, an example being mother-baby hospitalization in a crisis centre. The aim of our interventions is not the same, and our local context, together with the availability of a healthcare network on different floors, which is specific and close-by, allows this approach. Also, the contribution of Liaison Psychiatry in emergency situations should not be minimized. It is necessary to work in collaboration with the obstetricians. In fact, the chance to work with us was given by asking for a hospitalization in the Obstetric unit, during the prepartum period of pregnancies with a psychiatric risk. This way of proceeding allows somatic monitoring in hospital to be performed, whenever the risk run by the mother and/or the child requires it. This "analogue" procedure, however preventative it may be, does not always allow specific treatment of the psychiatric disorders to be given, despite liaison psychiatry interventions. Our interventions are not a specialized "mother-child" unit, or a substitute for Liaison Psychiatry, but they are specifically aimed at the context of the crisis. Obviously, it is precisely this dimension of the crisis which makes the other types of management temporarily unsuitable. This new working framework, with the simple possibility of admitting women and interacting with them in a crisis situation, with the aid of the competence of "mother-child" teams, most often seems to allow an alternative to hospitalization in the Psychiatry department, at the same time keeping up quality management of problems linked to the pregnancy or post-partum period. The specificity of the CIU, with its project of taking the special psychiatric vulnerability of pregnancy into account, makes sure that the psychopathological aspects of the crisis situation and the physiological aspects of adaptation reactions to the perinatal period are not neglected, but that are respected by this type of interaction/intervention.
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PMID:[Value of a consultation center and crisis intervention in addressing psychiatric disorders in the perinatal period]. 1196 46

This document contains major provisions of the 1988 Costa Rican Decree regulating sterilizations. These regulations constitute a basic guideline to be followed by all physicians. Sterilization requests must be signed by all interested parties and must contain the medical justification for the procedure. Such requests must be approved unanimously by sterilization committees or forwarded to the Committee of Human Reproduction of the Executive Board of the College of Physicians and Surgeons. Sterilizations may be indicated for patients with cardiology problems, endocrinological problems, genetic and hereditary diseases (men and women), gynecological-obstetrical diseases or problems, blood disorders, kidney disorders, pulmonary disorders, neurological disorders, cancer, rheumatic diseases, peripheral vascular disorders, and mental illness (brain damage, mental slowness, chronic schizophrenia, severe manic-depression, repeated postpartum psychosis). In the case of mental illness, patients will be examined and will receive psychiatric follow-up to prevent procedural abuse. The express consent of parents or legal guardians is required in the case of minors.
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PMID:Decree No. 18080-S regulating sterilizations, 22 March 1988. 1228 39

Postpartum psychic disorders can be mainly divided into 3 groups: The so-called postpartum blues, the postpartum depression and the postpartum psychosis. The postpartum blues occurs 3 - 5 days postpartum in 50 - 70 % of deliveries mostly disappearing after one week without specific therapy. However, 20 - 30 % of patients will develop a depression in their further postpartum course so that a thorough evaluation concerning depression is warranted, if blues symptoms persist more than 2 weeks. Postpartum depression can be found in 10 - 15 % of deliveries and mostly occurs several weeks or months after delivery with symptoms of depressive mood, sleeping disorders, anxiety, loss of interest and accord and feelings of guilt up to suicidal ideas. In order not to misinterpret them as postpartum blues specific questions concerning the mood of the young mother during the postpartum examination - if necessary using the Edinburgh scale - are recommended. In patients with known risk factors for a postpartum depression (i. e. postpartum depression or psychosis in previous pregnancies, depression disorder, anxiety disorder, bipolar illness), a thorough survey is mandatory and - if necessary - a prophylactic treatment in cooperation with the psychiatrist. Less severe forms of postpartum depression can mostly be treated with psychotherapy and sociotherapy on an outpatient basis. In more severe cases, antidepressant drugs (selective serotonin reuptake inhibitors, SSRIs or some tricyclic drugs) are indicated. Postpartum anxiety and compulsive disorders respond well to psychotherapy; besides in anxiety disorders benzodiazepines are recommended, in compulsive disorders SSRIs. Postpartum psychoses (about 0.1 - 0.2 %) most often occur in bipolar or schizoaffective disorders or after postpartum psychosis. They require a hopitalization mainly because of the danger of suicide and homicide toward the newborn; ideally this is performed in mother-child-units.
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PMID:[Psychic disturbances in the postpartum period: an increasing problem?]. 1460 Aug 49

Depression is a common disorder in women of childbearing age. Many women experience depressive symptoms during the postpartum period, ranging from mild postpartum blues to significant mood disorders such as postpartum depression and postpartum psychosis. The 'baby blues' are extremely common, affecting 30-75% of new mothers. This form of postpartum mood change is self-limited and requires no specific treatment other than education and support. While less common, occurring in 10-15% of births, postpartum depression has the potential for significant impact on both the health of the mother and baby. Unfortunately, affective illness in women frequently goes unrecognized and untreated. While there are effective pharmacological treatments for postpartum depression, the treatments for postpartum depression are often not utilized due to concerns about lactation. Postpartum psychosis is extremely rare, affecting one to two women per 1000 births; each case represents a true psychiatric emergency. Identifying and treating postpartum affective illness in women is critical to the health of both mother and infant. This paper reviews the literature on the diagnosis and treatment of mood disorders in the postpartum period: postpartum blues, postpartum depression and postpartum psychosis.
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PMID:Postpartum mood disorders. 1527 62

This article will challenge some of the myths surrounding women's mental health in childbearing. Pregnancy and the aftermath are very often seen as a time of joy and happiness. Yet for a significant amount of women at least ten per cent childbearing represents major emotional and psychological adjustment (Stowe et al.2005) and sadly mental health problems like post-natal depression and puerperal psychosis. It will be shown that there continues to be a need to develop new methods of caring for this client group and more women centred services. It is vital to organise and mobilize appropriate services that can assist and listen to individual women with mental health problems. It is important that women have services and space to explore their emotional and psychological problems and not have to suffer in silence. To promote mental health in childbearing their needs to be a clear emphasis in midwifery and medical education on understanding mental health in it's broadest sense. This requires developing midwifery care to where possible include partners and other family members in aiding recovery. A major step in promoting mental health is respecting the knowledge, presence and healing hands of both skilled midwives and nurses. Mental health nurses and midwives are aware of the deficits in services and care provision for women with psychological distress and mental health problems (Murray & Hamilton 2005). Care practices need to be informed by relevant interpersonal skills, research, education, prevention work, and a system of early detection and treatment of mental health problems (Cuijpers et al. 2005).
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PMID:Suffer no more in silence: challenging the myths of women's mental health in childbearing. 1728 57

Postpartum mood disorders can negatively affect women, their offspring, and their families when left untreated. The identification and treatment of postpartum depression remains problematic since health care providers may often not differentiate postpartum blues from depression onset. Recent studies found potentially new risk factors, etiologies, and treatments; thus, possibly improving the untreated postpartum depression rates. This integrated review examined several postpartum psychiatric disorders, postpartum blues, generalized anxiety, obsessive compulsive disorder, post-traumatic stress disorder, and postpartum psychosis for current findings on prevalence, etiologies, risk factors, and postpartum depression treatments.
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PMID:Depression after delivery: risk factors, diagnostic and therapeutic considerations. 1798 62

Some epidemiologic data reveal how difficult detecting atypic bipolar disorders is: 9 years of progression before the diagnosis is properly established and a specific treatment is initiated, and intervention of 4 to 5 different specialists. Incomplete symptomatology, impulsive actions, periodic alcohol abuse, compulsive buying behaviors, acute delusional episodes, medicolegal actions and comorbidities can hide or modify bipolar symptomatology. Bipolarity should be systematically screened for in case of substance abuse (40 to 60 percent of bipolar disorders), anxiety disorders (panic disorder, generalized anxiety, obsessive-compulsive disorders etc.) and feeding disorders. In these various situations, history taking and clinical examination will help to detect signs of bipolarity: reaction to antidepressants, inefficiency, paradoxical worsening, development of behavior disorders and mood changes. Besides screening for thymic disorders, the examination will be completed by history taking of thymic disorders, suicide, toxic abuse, anxiety disorders, personal history of attention deficit hyperactivity disorder in childhood, depression or postpartum psychosis in women, as well as premenstrual depressive manifestations.
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PMID:[Atypical bipolar disorders]. 1946 68


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