The authors examine the potential areas of concern during the postpartum period, as well as practical approaches to differential diagnosis and treatment.
TABLE. Reasons for consultation to psychiatry by percentage of total consultation requests
The consultant’s approach
Increased psychological vulnerability, maternal capacity, and the choice of psychiatric treatment during breastfeeding are concerns specific to mothers during the postpartum period. Because caring for a newborn requires a substantial level of psychological functioning, the psychiatric assessment of a new mother includes observation of her behavior with the infant. The consultant generally has one visit in which to address all questions from the primary team.
Here, we examine the potential areas of concern underlying the most common reasons for consultation. We also provide a practical approach to differential diagnosis and treatment.
Reasons for consultation
Six retrospective chart reviews list the most common reasons for inpatient psychiatric consultation to postpartum patients.1-6 Because these studies used different terminology, we provide consolidated groupings of the reasons for consultation in the Table.
In one retrospective chart review (N = 96), the most frequent reason for referral was a report of past psychiatric illness without current symptoms, specifically “because they were deemed to be at risk of postpartum depression.”3 That study is supported by results reported in an abstract (N = 165) that showed 42% of all psychiatric consultations from the obstetric service were for past psychiatric illness alone, without current psychiatric symptoms.7 There is currently no consensus on whether consultation in the absence of symptoms is useful for health preservation or is a non-productive use of resources.
Past psychiatric history and maternal capacity. Underlying many psychiatric consultations for postpartum mothers is the question of maternal capacity (ie, the ability of the new mother to care for her newborn). The generally accepted standard is minimal capacity, not optimal parenting.8
The most useful information comes from observation of the mother’s behavior with the child, by both the consultant and the nursery staff. For example, a schizophrenic patient may be organized and appropriately attentive to her newborn and may have maternal capacity. However, the mother’s attitude is also important. A disengaged or hostile attitude toward the infant, especially in the setting of previous abuse or the removal of other children by child welfare authorities, signals a higher risk of a poor outcome.8
• Observe the mother with her infant
• Ask her and her partner about her attitude toward the pregnancy
• Evaluate stressors and supports
• Assess the family, especially for members who could monitor the mother and/or take over primary caretaking of the infant if necessary
• Ascertain the mother’s level of insight into her psychiatric illness, as low insight signals the need for more intervention
A determination of lack of maternal capacity should prompt the involvement of child welfare services.
Current depression symptoms. In evaluating current depression symptoms, the consultant must differentiate between maternity blues, which occurs in up to 80% of mothers, and postpartum depression.9 While a case of the blues is self-limited, untreated perinatal depression can have devastating sequelae, such as adverse birth outcomes; impairments in the child’s growth, attachment, and cognitive and emotional development; and elevated risk of maternal suicide.10-12
DSM-5 diagnostic criteria for postpartum depression are the same as those for MDD, but the specifier of “with peripartum onset” is applied “if onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery.” Previously, the specifier “with postpartum onset” was defined as “within 4 weeks after childbirth.” This was changed to include pregnancy-onset depressive episodes because it has emerged that postpartum depression is a heterogeneous group of biologically distinct entities, only some of which are triggered by parturition.
Certain women may be more vulnerable to postpartum depression. A prospective double-blind study of euthymic mothers (N = 16) showed that when pregnancy hormones were added and withdrawn over a 4-month period, a major depressive episode developed in 60% of women with a history of postpartum depression and in 0% of women without such a history.13 These differences may underlie a “hormone-sensitive” or “reproductive depression” phenotype, in which some women are more likely to experience depression in the context of hormonal changes.14
Because DSM criteria require at least 2 weeks of symptoms, the consultant cannot diagnose postpartum depression in the first few days postpartum while the mother is hospitalized. However, because in one-third of cases the depression starts during late pregnancy, asking about the timing of symptom onset is crucial.15 High-risk women should be identified and monitored.
Strong risk factors for postpartum depression include a past history of postpartum depression and of bipolar disorder, both of which increase the risk to approximately 50%; a history of premenstrual dysphoric disorder; and depressive or anxious symptoms during pregnancy.16 At the bedside, the consultant should use a well-validated tool such as the Edinburgh Postnatal Depression Scale, in which a score of 10 or above is considered at risk for postnatal depression.17
If the mother is asymptomatic but at high risk, the consultant should ensure close follow-up. But since almost 80% of women who had screened positive for depression in one study did not show up to their follow-up psychiatric appointment, the outpatient obstetrician may need to help monitor mood and encourage follow-up.18 Consider preventive treatment for women with a history of postpartum depression; a randomized controlled trial (N = 22) showed the risk of recurrence was 7% for those taking sertraline versus 50% for those taking placebo.19
SSRIs are first-line treatment for postpartum depression diagnosed in the hospital; however, changes in maternal P450 enzyme function necessitate a low starting dose, for example, sertraline 25 mg/d.20 We recommend making prescribing decisions based on data about the in vivo effect of antidepressants on breastfed infants, which indicate few adverse outcomes.21 After the medication is started, the consultant should ask the mother to monitor her infant for irritability, agitation, excessive crying, post-feeding vomiting, and sedation. We advise against “pumping and dumping” milk because there is no demonstrated benefit, and this practice may send a confusing message about the safety of taking medications while breastfeeding.20
Adverse obstetric events. Adverse events and coping problems are also common reasons for psychiatric consultation. After stillbirth or significant birth injury, shock and numbness are typical, followed by tearfulness, guilt, insomnia, and anxiety. Often, the mother searches for a cause of the death or injury, and anger is mixed with grief. The team may need reassurance that normal grief is occurring and that no intervention is needed beyond assessment of the mother’s social supports.
The question of whether the mother should see and hold the stillborn infant’s body has not been firmly answered. We recommend presenting the mother with the option of seeing the infant in an unbiased, nonjudgmental fashion.22 Common mistakes include reassuring her that she can have other children or forgetting to ask important questions such as whether she is planning to have a service for her child, whether she decided to name her child, or whether an autopsy was requested. Local perinatal loss support groups may be helpful.
Insomnia. Some degree of sleep disruption is inevitable postpartum, especially with recent trends toward encouraging skin-to-skin contact and rooming-in of infants. Whether the rapid decline of estradiol and progesterone has a direct effect on sleep is unknown, although rat studies indicate a sedative effect of progesterone, the withdrawal of which may exacerbate sleep disruption after delivery.23 Regardless, insomnia significant enough to lead the primary team to request psychiatric consultation should be taken seriously, especially in women at risk for perinatal depression or psychosis.
The differential diagnosis for insomnia includes an underlying psychiatric disorder, most likely anxiety, as well as an unusually wakeful rooming-in newborn infant. Interventions for primary insomnia include encouraging the mother to allow the infant to sleep in the nursery, as well as medications such as diphenhydramine. If the insomnia persists after discharge, cognitive behavioral therapy for insomnia can be beneficial.24
Anxiety. This is the most frequent comorbidity of postpartum depression,15 but it may also occur in patients with psychosis. If the mother is not depressed, at high risk for postpartum depression, or psychotic, the consultant should screen for OCD, which can mimic postpartum psychosis, as its associated obsessions may include intrusive thoughts of harming the infant. However, in OCD, these thoughts are ego-dystonic; the mother feels guilty and may avoid the infant, and her affect is not flat. Postpartum OCD should be treated similarly to non-postpartum OCD: SSRIs are first-line treatment as are exposure/response-prevention and/or cognitive behavioral therapy.
PTSD, related to extreme fear or helplessness during birth, occurs in 3.1% to 15.7% of women during the postpartum period and is often associated with depressive symptoms.25 In addition to standard PTSD treatment, such as psychotherapy and SSRIs, mothers with PTSD may also benefit from journaling about their birth experience and from reading stories of other mothers’ recovery.
Anxiety should also prompt screening for delirium, which can be the presenting symptom of limbic encephalitis and other medical conditions. If the anxiety is about the new infant’s arrival, targeted education, support, and reassurance are warranted. Relaxation techniques, meditation, and short-acting medications such as benzodiazepines can alleviate the mother’s symptoms.
Unusual behavior. Abnormal maternal behavior should prompt screening for postpartum psychosis and delirium. Postpartum psychosis occurs in 0.1% of births and clusters in families.26,27 It is strongly associated with-and may be the first manifestation of-bipolar disorder. A history of postpartum psychosis confers a risk of recurrence as high as 90%.28,29
Postpartum psychosis can mimic delirium, as symptoms can include confusion, disorientation, and visual hallucinations, which may wax and wane. Postpartum psychosis delusions often focus on the identity of the infant. In one study of mothers with postpartum psychosis (N = 108), delusions increased the risk of harm to the infant.30 The presence of delusions was associated with increased abusive behavior toward the child, especially in mothers who described the infant as a devil or as “ill fated” or who believed that they had someone else’s baby. Postpartum psychosis is a psychiatric emergency. Suicide-usually violent-is the leading cause of maternal death within the first postpartum year.31 The risk of suicide in postpartum psychosis is estimated at 0.2%, and the risk of infanticide in postpartum psychosis is estimated at 4%.31,32
For asymptomatic patients with a history of psychosis, conduct a maternal capacity evaluation to assess for psychotic neglect, persecutory delusions, mistrust of health care providers, and delusions about the baby. Ask the family about any history of violence, impulsivity, or nonadherence to care, as well as more recent functioning. Consider prevention in high-risk mothers.
In those who have a history of postpartum psychosis, consider prophylactic initiation of medication immediately postpartum with the psychotropic that has historically been most effective for the patient, such as lithium, valproate, or olanzapine. Furthermore, because the median onset of postpartum psychosis is 8 days after delivery, we recommend close follow-up in high-risk patients: for example, an obstetrics appointment 1 or 2 weeks postpartum.33 Patients with psychotic symptoms observed in the hospital should be treated with antipsychotics, mood stabilizers, and benzodiazepines as clinically indicated, and possibly psychiatric hospitalization.
Medical causes of postpartum mental status change include Sheehan syndrome, urea cycle disorders, autoimmune thyroiditis, stroke, meningitis, meningioma, and multiple sclerosis. In Sheehan syndrome, or pituitary necrosis following postpartum hemorrhage, patients may have early hyponatremia or hypoglycemia that manifests as weakness, apathy, mental slowing, confusion, and failure to lactate.
Urea cycle disorders begin with confusion that appears from 1 day antepartum to 3 days postpartum and progresses to coma; case reports describe hyperammonemia and hyperglutaminemia in patients with normal liver transaminase levels.34,35 The patient or family may report a history of nausea after high-protein meals; episodes of irritability, lethargy, and vomiting; or growth delays in the infant. Other causes of postpartum mental status change include epilepsy, alcohol withdrawal, and water intoxication from overhydration during labor.36 In addition, a recent examination of autoantibodies in women with postpartum psychosis and healthy controls revealed the presence of anti–N-methyl-D-aspartate antibodies in 2 women, both of whom had also exhibited extrapyramidal symptoms after treatment with haloperidol.37
If the patient’s level of consciousness fluctuates or if her neurologic examination reveals abnormalities, obtain head imaging studies, ammonia levels, a complete blood cell count, and a comprehensive metabolic panel. Further workup may require a neurology consultation, lumbar puncture, electroencephalography, or measurement of thyroperoxidase antibodies to avoid missing a reversible and potentially fatal cause of mental status change. Consider autoantibody testing in patients who have extrapyramidal symptoms after low-dose antipsychotic treatment.
Medication review. Consideration of medication during breastfeeding requires balancing potential risks and benefits to the mother and infant. In general, the benefit of a mentally healthy mother should outweigh the risk of medication exposure to the infant, especially when the mother is at risk for postpartum depression or postpartum psychosis. An infant serum level less than 10% of the mother’s level is generally considered “low risk” for the breastfeeding infant.38 We recommend first deciding on psychiatric treatment for the mother as if she were not breastfeeding, and then modifying treatment as necessary depending on her nursing status. For up-to-date information on the relative risks and benefits of psychotropics in breastfeeding, several websites are useful, including reprotox.org and mothertobaby.org, as well as recent reviews.39,40
Acknowledgment-The authors acknowledge the Academy of Psychosomatic Medicine (APM) for helping to bring this article to fruition. The APM is the professional home for psychiatrists providing collaborative care bridging physical and mental health. Over 1200 members offer psychiatric treatment in general medical hospitals, primary care, and outpatient medical settings for patients with comorbid medical conditions.
Dr Anderson is Clinical Assistant Professor of Psychiatry and Dr Kim is Assistant Professor of Psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. Dr Anderson reports no conflicts of interest concerning the subject matter of this article. Dr Kim has received research support from National Institute of Mental Health grant K23 MH092399 for the study of transcranial magnetic stimulation in depression in pregnant women and has consulted for expert opinion regarding postpartum depression for Neuronetics, Inc.
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