Psychiatric Evaluation of the Peripartum Patient

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Psychiatric Times, Vol 38, Issue 9,

How can you be better prepared to interview and care for peripartum patients? This CME shows you how.

CATEGORY 1 CME

ACTIVITY GOAL

After participating in this activity, you should be better prepared to interview and care for peripartum patients.

LEARNING OBJECTIVES

1. Understand the basic components and specific features of the psychiatric interview with the peripartum patient.

2. Identify the main risk factors for developing peripartum illness and understand how to manage them.

TARGET AUDIENCE

This accredited continuing education (CE) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

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Physicians’ Education Resource®, LLC designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is funded entirely by Physicians’ Education Resource®, LLC. No commercial support was received.

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This accredited CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this accredited CE activity is for continuing medical education purposes only and is not meant to substitute for the independent clinical judgment of a physician relative to diagnostic or treatment options for a specific patient’s medical condition. The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of Physicians’ Education Resource®, LLC.

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The peripartum period is not necessarily a time of emotional well-being,1,2 highlighted by the fact that about 1 in 13 women develop new-onset major depressive disorder (MDD) while pregnant.3 (The term “peripartum” in this article refers to pregnant women and women who are up to 1 year postpartum.) In the postpartum period, 1 in 7 women will develop MDD and are at high risk for psychiatric hospitalization.4,5 Thus, comprehensive psychiatric evaluation of the peripartum patient is an essential skill. The mainstay of assessment remains the clinical interview; as such, careful and systematic psychiatric evaluation during these periods is crucial for diagnosis, risk assessment, and treatment. The general psychiatric evaluation, however, must be expanded and tailored to the needs of the peripartum patient (Table 1).

Case Discussion

“Ms Taylor” is a married woman, aged 28 years, who is 24 weeks pregnant and has no psychiatric history. She reports being unable to sleep for more than 6 hours per night and feels exhausted throughout the day. Associated symptoms include tearfulness, low energy, and low motivation. She reports frequent arguments with her husband about sharing household and childcare responsibilities.

History of Present Illness

In addition to elucidating the patient narrative and thoroughly investigating the chief complaint, the clinician may wish to inquire specifically about the following general topics: thoughts and feelings about pregnancy, contraceptive plans, relationship status, and sources and quality of psychosocial support. If the patient is pregnant, the clinician must inquire about the patient’s thoughts and feelings about the current pregnancy. This includes specific fears about pregnancy, delivery, or the postpartum period; relationship with obstetrician; relationship with partner (if applicable); use of any fertility technologies for conception; thoughts and feelings about parenthood; plans for delivery; and plans for feeding the newborn. Exploration of whether the pregnancy was planned or unplanned may be a particularly rich line of inquiry, especially when considering that 45% of pregnancies in the United States are unintended.6

If the patient is postpartum, focus on thoughts and feelings about the newborn and new responsibilities. Discussions should include their new identity as a mother (or as a mother of multiple children, if this child is not her first); experience with labor and delivery; plans for feeding the newborn; and emotional supports and plans for childcare.

Case Discussion, Continued

Ms Taylor tearfully shares that she did not want to get pregnant. She has felt pressure to have a second baby and reluctantly stopped taking her contraceptive. She believes she cannot care for a newborn because she has “too much on her plate.” She has been unable to focus at work, has missed deadlines, and feels unmotivated.

Review of Symptoms

When reviewing pertinent positive and negative symptoms relevant to the chief complaint, the clinician should consider the common, rare, and emergency psychiatric syndromes affecting the peripartum patient. Although stigma for mental illness is ubiquitous, the clinician should be aware that stigma may be heightened for this patient population. As such, patients may be less forthcoming with symptoms unless specifically asked about them by the clinician.

Depressive symptoms. About 3% to 6% of women will experience the onset of a major depressive episode during pregnancy or in the weeks or months following delivery.7 Fifty percent of postpartum major depressive episodes begin prior to delivery8 and, therefore, these episodes are referred to as having peripartum onset. Women with peripartum major depressive episodes often have severe anxiety and may experience panic attacks.9 Depression with somatic symptoms may present at higher rates in the peripartum time period than described by the general population.2 Many pregnant women choose to discontinue medications during pregnancy. Unfortunately, women who discontinue their medication have a relapse rate of 68%, 5 times higher than the rate of those who continue their antidepressant medication.1,10

Notably, “baby blues,” a term used to describe transient low mood for 2 weeks postpartum, does not meet criteria for a major depressive episode. However, studies have demonstrated that mood and anxiety symptoms during pregnancy, as well as the baby blues, increase the risk for a postpartum major depressive episode (Table 2).11

Anxiety symptoms. Rates of anxiety spectrum disorders in peripartum patients approximate those in the general population of women.2 However, there may be a slight increase in the prevalence of such disorders in the first trimester of pregnancy.1 For example, rates of obsessive-compulsive disorder (OCD) are higher in peripartum patients as compared with the general population.12 Intrusive thoughts or images and anxious ruminative thoughts associated with OCD typically involve ego-dystonic thoughts of harm coming to the infant.2 These intrusive thoughts help to distinguish ego-dystonic thoughts from the ego-syntonic thoughts of harming the baby that are often observed in postpartum psychosis; the latter is a psychiatric emergency. For patients who experienced traumatic pregnancy and/or traumatic delivery, it is important to assess for posttraumatic stress symptoms.

Psychotic symptoms. Postpartum psychosis can occur as part of an existing or new presentation of bipolar disorder (BD) or exclusively postpartum without concomitant BD.13 Postpartum psychosis is a psychiatric emergency typically requiring inpatient hospitalization due to increased risk for suicide and infanticide. It often presents shortly after delivery with rapid deterioration.14 Postpartum psychosis can appear similarly to delirium with delusions surrounding the patient’s newborn.3 Careful inquiry about abnormal, odd, bizarre, or psychotic thinking about their unborn baby (if pregnant) or their new baby (if postpartum) is crucial. Schneiderian first-rank symptoms (eg, auditory hallucinations, thought withdrawal/insertion, thought broadcasting, delusional perception, etc) are rarely seen.15

The best-known predictive factors for psychotic symptoms are previous episodes of postpartum psychosis or a history of BD (Table 2).3,16 Other known risk factors include primiparity,3 family history,3,13,16 obstetric trauma,16 and sleep deprivation.13 It is important to rule out medical causes, including infection, eclampsia, thyroid disorders,3 and autoimmune encephalitis.14,17 Once a woman has had a postpartum episode with psychotic features, the risk of recurrence with each subsequent delivery is estimated to be between 30% and 50%.18

While there are few data about the risk of relapse in peripartum patients diagnosed with a primary psychotic disorder, the risk appears comparatively lower than with patients diagnosed with BD, perhaps even comparable with nonpregnant women.3

Manic or hypomanic symptoms. Women with BD have a 37% risk of relapse in the peripartum period. This risk is significantly higher (85.5%) in women who discontinue medication.16,19 Women with BD are more likely to relapse than those with unipolar depression or those with any other psychiatric illnesses.3,16 Reviewing manic or hypomanic symptoms should always accompany a thorough review of depressive symptoms.

Self-harm or violence. In addition to routine screening for suicidal and homicidal ideation, clinicians must include screening for feticide, infanticide, and/or filicide. Studies suggest that 41% of women with postpartum depression and children under 3 years old report filicidal thoughts,20 and 19.3% of women report thoughts of self-harm.4 Postpartum psychosis is associated with an increased risk of infanticide and suicide.

Case Discussion, Continued

Ms Taylor has often thought it would be easier if she were to fall asleep and never wake up. She adamantly denied any desire to kill herself because it would be devastating to her family. She denied homicidal, filicidal, or feticidal ideation. Although she has had trouble sleeping, she denied other symptoms of mania or psychosis. She no longer enjoys activities that previously brought pleasure. She divulges that she has had similar symptoms in the past.

Past Psychiatric History

While reviewing the patient’s past illness history, the clinician should specifically inquire about past psychiatric symptoms during times of significant reproductive hormone shifts: menstrual cycles, previous pregnancies, previous postpartum periods, initiation or discontinuation of hormonal contraception, or use of assisted-reproductive technologies (ART). This information can inform the clinician’s assessment of the patient’s future risk for peripartum psychiatric symptoms. Premenstrual syndrome and premenstrual dysphoric disorder are associated with an almost 2-fold increased risk for postpartum depression.21

Case Discussion, Continued

Ms Taylor experienced a depressive episode following the birth of her first child. Her husband worries these symptoms will return and wants her to resume antidepressants; however, Ms Taylor is opposed to the idea. She says she does not want to do anything that could “hurt my baby.” She believes it is normal to feel sad during postpartum and claims she can “push through it.” Upon further questioning, she shared that she had trouble bonding with her first child and disclosed frequent and disturbing intrusive thoughts about her newborn suffocating in his blankets. She reluctantly agreed to take sertraline prescribed by her obstetrician at 6 weeks postpartum; her depressive symptoms resolved within a month.

Components of Psychiatric History

Substance history. Substance use during pregnancy is often underreported and associated with increased risk of congenital abnormalities, low birth weight, preterm delivery, small size for gestational age, and fetal demise.22 If the patient is currently using substances, clarify the last use relative to estimated time of conception. Supporting the patient in partnering with the OB/GYN is essential to getting appropriate fetal screening for possible birth defects and planning for potential neonatal withdrawal syndromes. Particular attention should be paid to whether the patient is currently utilizing medication-assisted treatment for a substance use disorder and what treatments have worked in the past to help the patient achieve or maintain sobriety.

Family psychiatric history. Family history of peripartum psychiatric illness is associated with increased risk for the peripartum patient. Inquiring about the past psychiatric history of the patient’s mother, sisters, and aunts can be helpful for risk stratification.13,14

Medications. Documentation of current and past trials of psychotropic medication should include maximum dosages, efficacy, adverse effects, and prior use during preconception, pregnancy, or postpartum. Although the safety of using medications during the peripartum period is outside the scope of this article, the evaluating psychiatrist should inquire about the patient’s (and partner’s, if applicable) thoughts and feelings about medications taken during pregnancy or postpartum.

Social history. The patient’s social milieu may be predictive of risk for peripartum psychiatric symptoms and decompensation. Importantly, it may also suggest modifiable risk factors that can be addressed in the comprehensive treatment plan. The social history should include past trauma and abuse, stressful life events, financial supports, social supports, childcare, and relationships with significant others. Lack of social supports is a critical predictor of postpartum depression; therefore, identifying reliable supports is vital.

Mental status exam. The mental status examination for peripartum patients is different from that of other patients (Table 3).14

Medical/surgical/obstetric history. The medical and surgical history of the peripartum patient should include a review of nodal obstetrical events, inclusive of pregnancies, deliveries, lactation, contraception, any experiences with infertility, and any corresponding psychological sequelae.

Contraception and infertility. A discussion of a woman’s obstetrical history should include questions about future pregnancies and contraception. This not only has direct implications for family planning, but also medication selection as it relates to teratogenicity. Discussions around family planning may also involve questions regarding the use of ART. The psychological impact of infertility and ART is well documented and can include anxiety, depression, guilt, blame, helplessness, anger, loss of control, and a sense of loss or mourning.23,24

Pregnancy and delivery. For each pregnancy, tactfully explore whether they were desired or planned as well as outcomes and delivery methods. Unplanned pregnancies are associated with adverse physical and mental health outcomes for mother and baby, including later presentation to prenatal care, poorer-quality relationships with partners, lower levels of social supports, higher levels of marital conflict, lower participation of the child’s father in childcare, and postpartum depression.25,26 For women with a history of elective or spontaneous abortion or fetal demise, the clinician should inquire about psychological reactions, coping, support, and expectations for current or future pregnancies. Attention should be paid to any history of obstetrical complications and/or trauma.

Lactation. Clinicians should specifically explore how a mother’s lactation preferences and beliefs compare with those of her partner. When partners are explicitly engaged in the breastfeeding discussion, they can identify distinct roles for themselves, including assisting with chores, spending time with the baby, changing diapers, and ensuring that the mother is comfortable while feeding.27 For women with prior pregnancies, it is useful to review prior feeding methods (ie, breastfeeding, bottle feeding, formula use, expressed breast milk, donor breast milk, combination feeding, etc), and for what duration each modality was used. Barriers to breastfeeding should be noted and explored, particularly if breastfeeding in subsequent pregnancies is desired.

Case Discussion, Continued

Ms Taylor worries about breastfeeding due to difficulty latching and mastitis with her first child. The birth of her first child was complicated by premature rupture of membranes and Cesarean delivery at 32 weeks gestation. Her son required newborn intensive care unit admission. She recalls difficulty breastfeeding and bonding with her baby. She feels anxious about another preterm birth.

Concluding Thoughts

The peripartum period, inclusive of pregnancy through the first year postpartum, is a vulnerable time for both incident and recurrent psychiatric illness (Table 4).2,3,12,28-30 The psychiatric evaluation of the peripartum patient builds upon the standard psychiatric interview and provides a critical foundation for the treatment alliance. The clinician should explore thoughts and feelings related to pregnancy, delivery, feeding, fertility, conception, and available social supports; document obstetrical/gynecologic history; and pay close attention to psychiatric symptoms that confer additional risk, including postpartum manic and psychotic symptoms, and thoughts of feticide/infanticide/filicide and/or suicide. An empathic and methodical clinical interview will facilitate timely and accurate psychiatric diagnosis. This in turn will allow the patient and clinician to work collaboratively towards symptom resolution and remission.

Case Conclusion

Ms Taylor ultimately agreed to resume sertraline for treatment of MDD, moderate, with peripartum onset. She experienced full remission by 35 weeks gestation. She delivered a healthy baby girl via normal spontaneous vaginal delivery and, with support from a lactation consultant, she was able to breastfeed. Her husband formula-fed the infant at night so that Ms Taylor could get much-needed rest. She remained euthymic on sertraline throughout the first year postpartum.

Dr Vaughn is an assistant professor at the Albert Einstein College of Medicine and the director of consultation-liaison and emergency psychiatry at Montefiore Medical Center, Weiler Hospital. She is also the program director for the consultation-liaison psychiatry fellowship at Montefiore-Einstein. Dr Vileisis graduated from psychiatry residency at Montefiore Medical Center in June 2021 and is currently a fellow in women’s mental health at Brown University. Dr Caravella is an associate professor of psychiatry at NYU Grossman School of Medicine and the associate director of the consultation-liaison psychiatry service for NYU Langone Health’s Manhattan campuses. Dr Deutch is a clinical assistant professor of psychiatry at NYU Grossman School of Medicine and an attending psychiatrist on the NYU Langone Tisch Hospital’s consultation-liaison psychiatry service. She is also the site director for women’s mental health at NYU Langone.

Acknowledgment: The authors wish to acknowledge Natalie Rasgon, MD, PhD, for her guidance in preparing this article.

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