A new mother who has anxiety and depression

It is essential to investigate unusual mental health symptoms in a new mother, says Dr Tillmann Jacobi

A 23-year-old woman with no significant medical history gave birth to a healthy boy after 41 weeks of pregnancy.

She was discharged on the same day without any complications. Three days later her mother reported concerns to the GP, as the woman seemed  anxious and depressed.

Apparently, she seemed uninterested in the baby and talked instead to an imaginary father of the child, whereas the biological father had left during the pregnancy.

When the GP visited she seemed unusually enthusiastic but also rather puzzled about the fact that she was now ‘a mum’ and wanted people to understand that she had ‘made a real contribution to mankind’.

Puerperal psychosis
Also called postpartum psychosis or postnatal psychosis, puerperal psychosis is rare and affects one or two women in 1,000 births.

Although the name suggests that it may appear any time within the first six weeks, the onset is typically two to four days after delivery and is believed to be caused by hormonal changes. It is not preventable and may affect any mother. Studies have identified risk factors, including a personal or family history of psychiatric illness, particularly bipolar disorder.

Problems during pregnancy do not seem to increase the risk, but it is doubled by complications during delivery. There is a suggestion that the risk is increased if the baby is delivered by caesarean section, and the incidence is known to be higher with first children.

The recurrence rate of puerperal psychosis is quite high, with estimated rates between 15 and 25 per cent, but it is not clear whether the risk is passed on to offspring.

It is important not to confuse puerperal psychosis with a ‘post-partum blues’, which usually develops weeks or months after birth.

Symptoms
The range of symptoms in puerperal psychosis might be broad, but can be narrowed  down to specific features that suggest a more serious problem. In particular, marked insomnia, irrational behaviour and extreme mood swings.

A woman with severe depressed symptoms as part of a puerperal psychosis may express guilt, worthlessness and withdrawal from the child, as well as exhaustion, anxiety and possibly suicidal ideation.

If there is mania she may be very excited or very talkative about the arrival of the child and over-confident about how to deal with it. Overactivity will produce inappropriate actions and she is likely to neglect the baby as she plans shopping, holidays or work.

There may be auditory hallucinations or delusions including exaggeration of a conviction that the child is malformed or otherwise abnormal.

In all cases there may be immediate physical dangers to the mother and child through neglect, mishandling or even active, ‘intended’ infanticide.

Management
It is essential to identify the psychosis early. Referral should be made after a discussion with the obstetrician and a psychiatrist, and the patient may need to be sectioned.

Initial in-patient treatment is normal, but there can be advantages in an early return to home treatment.

One essential element is to allow as many bonding opportunities between mother and baby as possible. Breast-feeding, although desirable for bonding, may not be possible.

Medical treatment with antipsychotics, lithium or antidepressants often produces an improvement within days. Psychological treatment may have a place but is ineffective in the early stages, and in specific cases electro-convulsive treatment might be suggested.

Recovery can take weeks or  months, often longer if mania is the main feature.

Usually a fairly complex team approach with the input from doctors, specialist nurses, health visitors, social worker and others is required, and it is important to support the surrounding family.

Around 50 per cent of women eventually fully recover, but puerperal psychosis can leave an entire family and a woman with long-term issues regarding her emotions and function.

In this case the mother and baby were admitted to a psychiatric unit with an on-site nursery.

The mother recovered after eight months, and there was no further episode of puerperal psychosis at a subsequent pregnancy five years later. 

Dr Jacobi is a salaried GP in York

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