Incidence of psychoses among Swedish first-time mothers
|Classification and external resources|
Postpartum psychosis (or puerperal psychosis) is a term that covers a group of mental illnesses with the sudden onset of psychotic symptoms following childbirth.
A typical example is for a woman to become irritable, have extreme mood swings and hallucinations, and possibly need psychiatric hospitalization. Often, out of fear of stigma or misunderstanding, women hide their condition. Although there are factors that contribute to an increased risk of developing postpartum psychosis, such as an underlying bipolar disorder, or a previous postpartum psychosis, any pregnant woman is potentially at risk. This illness can take the woman, her family and her medical providers completely by surprise. Two steps that can be taken to mitigate this risk are 1. The taking of a thorough, detailed history prior to giving birth by a competent professional, and 2. Education of medical care professionals, expectant women and their families.
In the group of illnesses that fall under "postpartum psychosis" there are at least a dozen organic psychoses, which are described under another heading "organic pre- and postpartum psychoses". The relatively common non-organic form, still prevalent in Europe, North America and throughout the world, is sometimes called puerperal bipolar disorder, because of its close link with manic depressive (bipolar) disorder; but some of these mothers have atypical symptoms (see below), which come under the heading of acute polymorphic (cycloid) psychosis (schizophreniform in the US). Puerperal mania was first clearly described by the German obstetrician Friedrich Benjamin Osiander in 1797, and a literature of over 2,000 works has accumulated since then. These psychoses are endogenous, heritable illnesses with acute onset, benign episodic course and response to mood-normalizing and mood-stabilizing treatments. The inclusion of severe postpartum depression under postpartum psychosis is controversial: many clinicians would allow this only if depression was accompanied by psychotic features (see below).
The onset is abrupt, and symptoms rapidly reach a climax of severity. Manic and acute polymorphic forms almost always start within the first 14 days, but depressive psychosis may develop somewhat later. In some cases, psychosis can develop during pregnancy.
Some women have typical manic symptoms, such as euphoria, overactivity, decreased sleep requirement, loquaciousness, flight of ideas, increased sociability, disinhibition, irritability, violence and delusions, which are usually grandiose or religious in content; on the whole these symptoms are more severe than in mania occurring at other times, with highly disorganized speech and extreme excitement. Others have severe depression with delusions, auditory hallucinations, mutism, stupor or transient swings into hypomania. Some switch from mania to depression (or vice versa) within the same episode. Atypical features include perplexity, confusion, emotions like extreme fear and ecstasy, catatonia or rapid changes of mental state with transient delusional ideas; these are so striking that some authors have regarded them as a distinct, specific disease, but they are the defining features of acute polymorphic (cycloid) psychoses, and are seen in other contexts (for example, menstrual psychosis) and in men.
Although postpartum psychosis can be severe, it is not always obvious. First, it occurs during a time that is a period of disruption for many families, so oddities may be attributed to just being tired or stressed. Second, the symptoms can wax and wane. Third, a woman may try to hide her symptoms from others. Therefore it is advisable for medical care providers to do a careful screen, not simply rely on self-reportage. Those concerned that a loved one may have this illness might want to ask her to do math problems that would have been easy for her prior to pregnancy, ask her to read a few paragraphs of something out loud, or ask her to explain the "why" of something in detail. These tasks can be difficult for a woman experiencing postpartum psychosis. The ability of the woman to perform these tasks does not mean she DOES NOT have postpartum psychosis, but the inability to do tasks she easily could do before indicates the need to seek medical help.
Course and treatment
Without treatment, these psychoses can last many months; but with modern therapy they usually resolve within a few weeks. A small minority follow a relapsing pattern, usually related to the menstrual cycle. Mothers who suffer a puerperal episode are liable to other manic depressive or acute polymorphic episodes, some of which occur after other children are born, some during pregnancy or after an abortion, and some unrelated to childbearing. Puerperal recurrences occur after at least 20% of subsequent deliveries, or over 50% if depressive episodes are included.
Severe overactivity and delusions may require rapid tranquilization by neuroleptic (antipsychotic) drugs, but they should be used with caution because of the danger of severe side effects including neuroleptic malignant syndrome. Electro-convulsive (electroshock) treatment is highly effective. Mood stabilizing drugs such as lithium are also useful in treatment and possibly the prevention of episodes in women at high risk (i.e., women who have already experienced manic or puerperal episodes). The location of treatment is an issue: hospitalization is disruptive to the family, and it is possible to treat moderately severe cases at home, where the sufferer can maintain her role as a mother and build up her relationship with the newborn. This requires the presence, round the clock, of competent adults (such as the baby's maternal grandmother), and frequent visits by professional staff. If hospital admission is necessary, there are advantages in conjoint mother and baby admission. Yet multiple factors must be considered in the subsequent discharge plan to ensure the safety and healthy development of both the baby and its mother. This plan often involves a multidisciplinary team structure to follow up on mother, baby, their relationship and the entire family.
Suicide is rare, and infanticide extremely rare, during these episodes. It does occur, as illustrated by the famous cases summarized below. Infanticide after childbirth is usually due to profound postpartum depression (melancholic filicide) when it is often accompanied by suicide. However, a woman with postpartum psychosis is a potential risk to her baby or others around her, as author Teresa Twomey says in her TEDx talk, the "cruel delusions" of this illness "can cause a mother to kill her child out of love."
Furthermore, care should be taken when attempting to get treatment for a woman with this condition because the symptoms of the illness itself can contribute to a reluctance or downright refusal of care.
Postpartum psychosis has a world-wide prevalence. Its incidence is less than 1 in 1000 deliveries. It is more common in first time mothers. The French psychiatrist Louis-Victor Marcé (1862), suggested that the link to menstruation, and especially menstrual psychosis, is important. Molecular genetic studies suggest that there is a specific heritable factor. There is evidence of linkage to chromosome 16.
Harriet Sarah, Lady Mordaunt (1848–1906), formerly Harriet Moncreiffe, was the Scottish wife of an English baronet and Member of Parliament, Sir Charles Mordaunt. She was the respondent in a sensational divorce case in which the Prince of Wales (later King Edward VII) was embroiled and, after a counter-petition led to a finding of mental disorder. After a controversial trial lasting seven days, the jury determined that Lady Mordaunt was suffering from “puerperal mania” (i.e. postpartum psychosis), at the time the summons was served on her and that she was unable to instruct a lawyer in her defense. Accordingly, her husband's petition for divorce was dismissed, while Lady Mordaunt was committed to an asylum, where she spent the remaining thirty-six years of her life.
Melanie Blocker-Stokes, of Chicago, IL, committed suicide by jumping from a building on June 11, 2001. In February 2001 she gave birth to a healthy baby girl. In the weeks following the birth of her daughter, she developed severe depression, in which (4 weeks after the birth) she stopped eating and drinking and could no longer swallow. She thought her neighbors had all closed their blinds because they thought she was a bad mother (a postpartum depressive psychosis). She was in and out of Chicago area hospitals several times over a period of a few months. Her death led to the proposal of the Melanie Blocker-Stokes Postpartum Depression Research and Care Act (H.R. 846 and S. 450), intended to expand research into the condition.
Andrea Yates methodically drowned her five children in a bathtub in her Clear Lake City, Houston, Texas house on June 20, 2001. Her mental health began to deteriorate with the birth of each of her children, combined with other external stressors. She attempted suicide twice and was hospitalized twice in a psychiatric facility in 1999 after delivering her fourth child. Yates was warned against having any more children, but conceived approximately seven weeks later. Three months after the birth of her fifth child and shortly after the death of her father, she began to rapidly degenerate. She was hospitalized twice more, and eventually released with orders that she should not be left alone. During an hour when her husband had left for work and her mother-in-law was scheduled to arrive, she killed all five of her children. Her case attracted a great deal of media attention. The Yates case was "complex and multifaceted," and "odd family dynamics, fundamentalist religious beliefs, clinical care that was fragmented at best, and the quirks and inadequacies of the American medical-insurance system all had some role in the Yates' family tragedy."
Yates was tried in 2002 and was convicted of murder, with the jury rejecting her insanity defense. Yates was sentenced to life in prison. In 2005, however, her conviction was vacated by the First Court of Appeals of Texas because one of the prosecutor's expert witnesses, Dr. Park Dietz, gave false testimony. Yates was retried in 2006 and a jury found her not guilty by reason of insanity. Yates was committed to state psychiatric hospitals, remaining institutionalized today.
Several nations including Canada, Great Britain, Australia and Italy recognize post partum mental illness as a mitigating factor in cases where mothers kill their children. In the United States, such a legal distinction is not currently made. Britain has had the Infanticide Act since 1922.
In 2009, Texas legislator Jessica Farrar proposed a bill that would recognize postpartum psychosis as a defense for mothers who kill their infants. Under the terms of the proposed legislation, if jurors concluded that a mother's "judgment was impaired as a result of the effects of giving birth or the effects of lactation following the birth", they would be allowed to convict her of the crime of infanticide, rather than murder. The maximum penalty for infanticide would be two years in prison.
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- Ruth Rendon, Andrea Yates' conviction thrown out, Houston Chronicle (January 6, 2005)
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