Postpartum Mood Disorders

What Are Postpartum Mood Disorders?

Pregnancy is a whirlwind of tons of emotions and sensations – our body is ever changing as well as our wishes, dreams, plans, hopes, and expectations that come at us both from every direction. It’s completely normal to feel overwhelmed by the idea of bringing a new life and person into the world, while strangers and loved ones alike bombard you with their experiences and ideas.

Most pregnant women feel their appetite increase, an eager anticipation of the new life to come, and sleep should be good (excepting getting comfortable, which is always a challenge during pregnancy). Normal worries and concerns will be sprinkled throughout the pregnancy experience, but they shouldn’t dominate our days or nights.

Ask yourself, “Do I emotionally feel like ‘me’ most of the day?” “Can I to sleep at night?” “Am I mostly excited about the baby coming?,” and “Am I eating enough?”

All of the above should be answered with a resounding “YES.”

If you’re not, it’s time to seek out a specialized health care practitioner who can help understand what’s happening with you

Depression and anxiety affect just as many pregnant women as new mothers, and can happen to the strongest, most intelligent, and loving moms. If you experience depression during your pregnancy, speak to your obstetrician – this is called antepartum depression, and it affects a great many men and women during pregnancy. There are a number of ways you can get help, and not all of them involve medications.

Every trimester you should either be given a formal screening or simply asked a few key questions to determine how you’re doing emotionally.  Receiving the right help during pregnancy will not only be best for you and your entire family, it will help you minimize the risk of postpartum depression.

Several days to weeks after giving birth, some mothers and fathers notice that they’re experiencing some strange symptoms, (most commonly) sadness, and/or anxiety after the birth of their child.

An estimated 1 out of every 6 women and 1 out of every 10 men experiences troubling depression or anxiety after the birth or adoption of a child, and in most people, these feelings are generally transient in nature. Given the tremendously stressful period of learning to live life with a newborn or new child is tremendously stressful to all involved, which is why we now recognize then men can also have postpartum mood disorders.

During the postpartum period, about 85% of women experience some type of mood disturbance. Generally, these symptoms are mild and short-lived; however, 10 to 15% of women and men go on to develop more significant symptoms of depression or anxiety. Postpartum psychiatric illnesses are typically divided into categories:

• Antenatal/Antepartum Depression
• Postpartum Baby Blues
• Postpartum Depression
• Postpartum Anxiety Disorders
• Postpartum OCD
• Postpartum Psychosis

It may be useful to conceptualize these disorders as existing along a continuum, where postpartum blues is the mildest and postpartum psychosis the most severe form of postpartum mood disorders.

Postpartum mood disorders are often characterized by despondency, emotional instability, anger, guilt, tearfulness, worrying, anxious thoughts or images, feelings of inadequacy and the inability to cope. It may occur shortly after the arrival of a new baby or many months later. For some, symptoms may begin in pregnancy; which is called or Antenatal Depression. The types of postpartum mood disorders generally lay on a spectrum.

Risk Factors for Developing Postpartum Mood Disorders:

Some things can make you more likely than others to develop postpartum mood disorders, including PPD. These are called risk factor. and having a risk factor or a few doesn’t mean for sure that you’ll have any problems with your mental health during or after pregnancy, but these risk factors, may increase your chances. Talk to your health care provider to see if you’re at risk for a postpartum mood disorder.

Your health care provider should assess you for PPD at your postpartum care checkups, including questions about your risks, feelings, stress level, as well as your moods.

Risk factors for postpartum mood disorders include:

• Depression during pregnancy (Antenatal depression) or you’ve had major depression or another mental illness before
• Family history of depression or mental health disorders.
• You’ve been physically or sexually abused in your life
• Problems with your partner, including domestic violence (also called intimate partner violence or IPV).
• Extra stress in your life, such being separated from your partner, the death of a loved one, or an illness that affects you or a loved one.
• Unemployed or have low income, little education, or little support from family or friends.
• Pregnancy is unplanned or unwanted, or you’re younger than 19.
• You have diabetes. Diabetes can be pre-existing diabetes (also called pre-gestational diabetes) or it can be gestational diabetes.
• Pregnancy complications such as premature birth, birth before 37 weeks of pregnant
• Multiples (twins, triplets) pregnancy
• Pregnant with a child who has been diagnosed birth defects
• Experiencing pregnancy loss.
• You have trouble breastfeeding or caring for your baby.
• Infant is sick or has ongoing health conditions.
• Negative thoughts about being a mom and/or having trouble adjusting to being a parent.

Negative thoughts and feelings about being a mom may include:

• Doubts that you can be a good mom
• Pressure to be a perfect mom
• Feeling that you’re no longer the person you were before you had your baby
• Feeling that you’re less attractive after having your baby
• Having no free time for yourself
• Feeling tired and moody because you aren’t sleeping well or getting enough sleep

What is Antenatal Depression?

Depression during pregnancy, or antepartum depression, is a mood disorder just like clinical depression as far as symptoms are concerned. Mood disorders are biological illnesses that involve changes in brain chemistry and men and women who suffer from major depression are at a higher risk for developing antenatal depression.

During pregnancy, as I’m sure you’re aware, hormone changes affects the chemicals in your brain, including those that tell you to eat, sleep, and rest. Some of the other hormone changes are directly related to Antenatal Depression and Antenatal Anxiety. Unfortunately, these hormones can be exacerbated by difficult life situations, stress, and other factors which can result in depression during pregnancy.

Women with Antepartum Depression tend experience some of the following symptoms for at least two weeks:

• Persistent sadness
• Problems concentrating
• Sleeping too little or too much
• Loss of interest in activities that you usually enjoy
• Recurring thoughts of death, suicide, or hopelessness
• Anxiety without a trigger
• Feelings of guilt or worthlessness
• Change in eating habits

What Are The Postpartum Baby Blues?

Specialists believe that approximately 50 to 85% of women and men experience postpartum blues during the first few weeks after delivery; part of it is related to wildly changing hormone levels, the stress of having a new person to care for, and not feeling as though they’ll be able to manage. As this type of mood disorder is common – even expected, it can be more accurate to consider The Baby Blues as a normal experience following childbirth rather than a psychiatric illness.

Rather than feelings of sadness, men and women with The Baby Blues more commonly report mood lability, tearfulness, anxiety, and/or irritability. These symptoms typically peak on the fourth or fifth day after delivery and may last for a few hours or a few days, remitting spontaneously within two weeks of delivery.

While these symptoms are unpredictable and often unsettling, they do not interfere with a woman’s ability to function. No specific treatment is required; however, it should be noted that sometimes The Baby Blues heralds the development of a more significant mood disorder, particularly in women who have a history of depression.

If symptoms of depression persist for longer than two weeks, you should be evaluated to rule out a more serious postpartum mood disorder.

What Is Postpartum Depression (PPD)?

PPD tends to emerge over the first two to three months postpartum but can occur at any point after delivery. Some men and women actually note the onset of milder depressive symptoms during pregnancy. Postpartum depression is clinically indistinguishable from depression occurring at other times during a woman’s life.

In women and men who have milder cases of PPD, it can be quite difficult to detect postpartum depression because many of the symptoms used to diagnose depression (such as sleep and appetite disturbance, fatigue) also occur in postpartum women in the absence of depression.

The Edinburgh Postnatal Depression Scale is a 10-item questionnaire that may be used to identify women who have PPD.

On this scale, a score of 12 or greater or an affirmative answer on question 10 (presence of suicidal thoughts) raise concern and indicate a need for more thorough evaluation.

Edinburgh Postnatal Depression Scale  (EPDS)[1] The questionnaire below is called the Edinburgh Postnatal Depression Scale (EDPS) The EDPS was developed to identify women who may have postpartum depression.  Each answer is given a score of 0 to 3 . The maximum score is 30. Please select the answer that comes closest to how you have felt in the past 7 days: 1. I have been able to laugh and see the funny side of things   As much as I always could  Not quite so much now  Definitely not so much now  Not at all 2. I have looked forward with enjoyment to things  As much as I ever did  Rather less than I used to  Definitely less than I used to  Hardly at all 3. I have blamed myself unnecessarily when things  went wrong   Yes, most of the time  Yes, some of the time  Not very often  No, never 4. I have been anxious or worried for no good reason  No, not at all  Hardly ever  Yes, sometimes  Yes, very often 5. I have felt scared or panicky for no very good reason   Yes, quite a lot  Yes, sometimes  No, not much  No, not at all 6. Things have been getting on top of me   Yes, most of the time I haven’t been able to cope at all.  Yes, sometimes I haven’t been coping as well as usual  No, most of the time I have coped quite well.  No, I have been coping as well as ever. 7. I have been so unhappy that I have had difficulty sleeping   Yes, most of the time  Yes, sometimes  Not very often  No, not at all 8. I have felt sad or miserable   Yes, most of the time  Yes, quite often  Not very often  No, not at all 9. I have been so unhappy that I have been crying  Yes, most of the time  Yes, quite often  Only occasionally  No, never 10. The thought of harming myself has occurred to me   Yes, quite often  Sometimes  Hardly ever  Never If you have had ANY thoughts of harming yourself or your baby, or you are having hallucinations  please tell your doctor or your midwife immediately OR GO TO YOUR NEAREST HOSPITAL EMERGENCY ROOM. A score of more than 10 suggests minor or major depression may be present. Further evaluation is recommended. Postpartum Depression (Postnatal Depression) Postpartum depression is major depression that occurs after giving birth. Symptoms are present for most of the day and last for at least 2 weeks. As many as 1 in every 7 women (14%) suffers postpartum depression .In a study of 209 women referred for major depression during or after pregnancy 11.5% reported start of depression during pregnancy, 66.5 % reported start of depression  within 6 weeks after childbirth (early postpartum), and 22% reported onset 6 weeks after childbirth (late postpartum), One woman reported onset of depression at more than 27 weeks after childbirth. Racing thoughts, psychotic symptoms (such as hallucinations or delusions), or a family history of bipolar disorder (BPD) may indicate bipolar disorder is present. Treatment Treatment of depression during pregnancy and after childbirth is based on expert opinion. “Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide some direction”. The following are some treatment options that have been suggested . Mild depression Psychotherapy such as cognitive-behavioral therapy (CBT) OR interpersonal therapy Mild Depression postpartum while breast-feeding Psychotherapy with or without antidepressant (sertraline or paroxetine) Severe Depression Psychotherapy AND fluoxetine Alternative medications: sertraline or  tricyclic antidepressant Severe Depression postpartum while breast-feeding Supportive services AND sertraline Alternative medication: Paroxetine

Some of the symptoms of postpartum depression include:

• Depressed or sad mood
• Persistent sadness not otherwise explained
• Tearfulness
• Loss of interest in usual activities
• Feelings of guilt
• Feelings of worthlessness or incompetence
• Fatigue
• Sleep disturbance
• Change in appetite
• Poor concentration
• Suicidal thoughts

What Causes Postpartum Depression?

The postpartum period is characterized by a rapid shift in the hormonal environment. Within the first 48 hours after delivery, estrogen and progesterone concentrations fall dramatically. As these gonadal steroids modulate neurotransmitter systems involved in the regulation of mood, many investigators have proposed a role for these hormonal shirts in the emergence of postpartum affective illness.

While seems as if there is no consistent correlation between serum levels of estrogen, progesterone, cortisol, or thyroid hormones and the occurrence of postpartum mood disturbance, some investigators hypothesize that there is a subgroup of women who are particularly sensitive to the hormonal changes that take place after delivery. This population of women may be more vulnerable to PPD and to other hormonally driven mood disturbances, such as those occurring during the premenstrual phase of the menstrual cycle or during the perimenopause.

Other factors may play a role in the development of PPD. One of the most consistent findings is that among women and men who report marital dissatisfaction and/or inadequate social supports, postpartum depressive mental illnesses is more common. Several investigators have also demonstrated that stressful life events occurring either during pregnancy or near the time of delivery appear to increase the likelihood of postpartum depression.

While all of these factors may act together to cause PPD, the emergence of this disorder probably reflects an underlying vulnerability to affective illness. Women with histories of major depression or bipolar disorder are more vulnerable to PPD, and women who develop PPD will often go on to have recurrent episodes of depression unrelated to pregnancy or childbirth.

Who is at Risk for Postpartum Depression?

All women are vulnerable to postpartum depression, regardless of age, marital status, education level, or socioeconomic status. While it is impossible to predict who will develop PPD, certain risk factors for PPD have been identified, including:

• Previous episode of PPD
• Depression during pregnancy (antenatal depression)
• History of depression or bipolar disorder
• Recent stressful life events
• Inadequate social supports
• Marital or family issues

What Is Postpartum Anxiety?

Recent research suggests that 6% of pregnant women and 10% of postpartum women develop significant anxiety disorders. Sometimes these men and women experience anxiety alone, and sometimes they experience it in addition to postpartum depression. You do not have to be diagnosed with OCD to experience these common symptoms of perinatal anxiety

Generalized anxiety is common in both the general population and the postpartum period, however some women may also develop more challenging types of anxiety, such as panic disorder, and/or hypochondriasis in the postpartum period. Postpartum obsessive-compulsive disorder has also been reported, in which women report disturbing and intrusive thoughts of harming their infant.

• Constant worry
• Feeling that something bad is going to happen
• Racing thoughts
• Disturbances of sleep and appetite
• Inability to sit still
• Physical symptoms like dizziness, hot flashes, and nausea

Risk factors for perinatal anxiety and/or panic disorder may include a personal or family history of anxiety, previous perinatal depression or anxiety, or thyroid imbalance; however, many men and women develop Postpartum Anxiety without any risk factors.

Postpartum Panic Disorder is a form of anxiety with which the sufferer feels very nervous and has recurring panic attacks after the birth or adoption of a baby or child. During a panic attack, he or she may experience any or all of the following:

• Shortness of breath
• Feeling of someone sitting on his or her chest
• Chest pain
• Claustrophobia
• Dizziness
• Heart palpitations
• Numbness and tingling in the extremities.

Panic attacks seem to go in waves, but it is important to know that they will pass and will not hurt you.

What Is Postpartum Obsessive-Compulsive Disorder?

Postpartum Obsessive-Compulsive Disorder (OCD) is probably most misunderstood and misdiagnosed of the perinatal mood disorders. It is estimated that as many as 3-5% of new mothers and some new fathers will experience some of these symptoms. The repetitive, intrusive images and thoughts are very frightening and can feel like they come “out of the blue.” Fortunately, postpartum OCD is temporary and treatable with professional help. If you feel you may be suffering from one of this illness, know that it is not your fault and you are not to blame.

Research has shown that these images are anxious in nature, not delusional, and have very low risk of being acted upon. It is far more likely that the parent with this symptom takes steps to avoid triggers and avoid what they fear is potential  harm to the baby.

Some women and men do not have OCD but are bothered by obsessive-compulsive symptoms.

Symptoms of Postpartum Obsessive-Compulsive symptoms can include:

• Obsessions, also called intrusive thoughts, which are persistent, repetitive thoughts or mental images related to the baby. These thoughts are very upsetting and not something the woman has ever experienced before.
• Compulsions, where the mom may do certain things over and over again to reduce her fears and obsessions. This may include things like needing to clean constantly, check things many times, count or reorder things.
• A sense of horror about the obsessions
• Overly occupied with keeping your baby safe
• Compelled to do certain things over and over again to help relieve her anxiety and fears–This can include counting things, ordering things, listing things, checking and rechecking actions already performed, and cleaning repeatedly. This may manifest itself in cleaning, feeding, or taking care of the baby.
• May recognize these obsessions but feels horror and shame associated with them
• Obsessions or thoughts that are persistent, are repetitive and can include mental images of the baby that are disturbing
• Fear of being alone with the baby
• Women who suffer from PPOCD often know that these thoughts, actions, and feelings are not normal and do not act on them. But the obsession can get in the way of a mom taking care of her baby properly or being able to enjoy her baby. With the right treatment, women with PPOCD can experience freedom from being controlled by these obsessions and compulsions
• Fear of being left alone with the infant
• Hypervigilance in protecting the infant

Moms with postpartum OCD know that their thoughts are bizarre and are very unlikely to ever act on them.

Risk factors for postpartum OCD include a personal or family history of anxiety or OCD.

Given the potential adverse effects of untreated mood and anxiety symptoms in either the mother, father, careful screening and early recognition of anxiety symptoms during the postpartum period is recommended. Antepartum anxiety are temporary and treatable with professional help. If you feel you may be suffering from one of these illnesses, know that it is not your fault and you are not to blame.

What Is Postpartum Post-Traumatic Stress Disorder (PPTSD)?

Postpartum post-traumatic stress disorder (P-PTSD) often affects women who experienced a real or perceived trauma during childbirth or immediately after the baby was born.

P-PTSD is not a well-researched postpartum mood disorder, but for the estimated 3 to 16 percent of new moms and dads who suffer from it, this postpartum mood disorder is very real and incredibly frightening. P-PTSD can greatly impact the way they experience parenthood and care for their new baby.

For most women, the safe delivery of a healthy baby is moment remembered with great happiness. But not every new mom’s birth experience is a joyful one. In fact, more than a third of recently delivered moms describe their birth as traumatic, and the American College of Obstetricians and Gynecologists estimate that 3 to 16 percent display severe traumatic stress responses in the postpartum period. Like war veterans who suffer from PTSD – intrusive memories and flashbacks after suffering traumatic experiences on the battlefield – moms with P-PTSD look at their childbirth experience as a source of pain and anxiety and suffer from very similar post-traumatic symptoms.

P-PTSD is triggered by a traumatic event or events – real or perceived –– during pregnancy, labor, delivery, or during the postpartum period.

A mom-to-be may experience a traumatic event, such as severe morning sickness, fertility treatments, or serious pregnancy complications. Some women might experience trauma during childbirth if their labor was long and painful, if there was a cord prolapse, shoulder dystocia, a severe tear, previously undiscovered birth defects, hemorrhage, or an emergency C-section.

Trauma may result from a home birth that resulted in a transfer to a hospital due to complications; it could be from a planned hospital delivery that ended up unexpectedly at home. Trauma may develop if someone who’d wanted an intervention-free birth ends up requiring life-saving interventions.

Postpartum traumas may include having a premature baby, a baby who needs to be in the NICU, breastfeeding difficulties, or worse, a stillbirth or loss of a child early on.

Often the trauma is an emotional one: feelings of being powerless, of not being listened to, of not having adequate support during childbirth.

It’s important to remember that postpartum PTSD can develop after a real or perceived threat of death of the mother, father, or baby.

Traumas that may cause postpartum post-traumatic stress (P-PTSD) disorder include:

• Unplanned or emergency C-section
• Emergency complication such as prolapsed umbilical cord
• Birth that requires invasive interventions such as vacuum extractor or forceps
• Baby requiring a NICU stay
• Lack of support and assurance during the delivery
• Lack of communication from the birth and support team
• Feelings of powerlessness

Symptoms of P-PTSD may include:

• Nightmares and flashbacks to the birth or trauma
• Anxiety and panic attacks
• Feeling a detachment from reality and life
• Irritability, sleeplessness, hyper-vigilance, startles more easily
• Avoidance of anything that brings reminders of the event such as people, places, smells, noises, feelings
• May begin re-experiencing past traumatic events, including the event that triggered the disorder

Women who are experiencing PPTSD need to talk with a health care provider about what they are feeling. With the correct treatment, these symptoms will lessen and eventually go away.

What Is Postpartum Psychosis?

Postpartum Psychosis (PP) is a severe, but treatable, form of mental illness that occurs after having a baby. It can happen ‘out of the blue’ to women without previous experience of mental illness. There are some groups of women, women with a history of bipolar disorder for example, who are at much higher risk. PP normally begins in the first few days to weeks after childbirth. It can get worse very quickly and should always be treated as a medical emergency. Most women need to be treated with medication and admitted to hospital.

Postpartum psychosis is the most severe form of postpartum mood disorders and is extremely – extremely dangerous. Postpartum Psychosis is a medical emergency. If you believe a friend or loved one is suffering from Postpartum Psychosis, don’t wait: call 911. This is an emergency.

Fortunately, postpartum psychosis It is a rare postpartum mood disorder that occurs in approximately 1 to 2 per 1000 women after childbirth.

The presentation is often dramatic, with onset of symptoms as early as the first 48 to 72 hours after delivery. The majority of women with puerperal psychosis develop symptoms within the first two postpartum weeks.

With the right treatment, women with PP do make a full recovery. Recovery takes time and the journey may be tough. The illness can be frightening and shocking for both the woman experiencing it and her family. Women do return to their normal selves, and are able to regain the mothering role they expected. There is no evidence that the baby’s long term development is affected by Postpartum Psychosis.

There are a large variety of symptoms that women with PP can experience. Women may be:

• Excited, elated, or ‘high’.
• Depressed, anxious, or confused.
• Excessively irritable or changeable in mood.

Postpartum Psychosis includes one or more of the following:

• Strange beliefs that could not be true (delusions).
• Hearing, seeing, feeling or smelling things that are not there (hallucinations).
• High mood with loss of touch with reality (mania).
• Paranoia
• Attempts to harm the child or herself
• Severe confusion.

These are also common symptoms:

• Being more talkative, sociable, on the phone an excessive amount.
• Having a very busy mind or racing thoughts.
• Feeling very energetic and like ‘super-mum’ or agitated and restless.
• Having trouble sleeping, or not feeling the need to sleep.
• Behaving in a way that is out of character or out of control.
• Feeling paranoid or suspicious of people’s motives.
• Feeling that things are connected in special ways or that stories on the TV or radio have special personal meaning.
• Feeling that the baby is connected to God or the Devil in some way.

It appears that in most cases, postpartum psychosis represents an episode of bipolar illness; the symptoms of puerperal psychosis most closely resemble those of a rapidly evolving manic (or mixed) episode. The earliest signs are restlessness, irritability, and insomnia. Women with this disorder exhibit a rapidly shifting depressed or elated mood, disorientation or confusion, and erratic or disorganized behavior. Delusional beliefs are common and often center on the infant.

Auditory hallucinations that instruct the mother to harm herself or her infant may also occur.

Risk for infanticide, as well as suicide, is significant in this population.

How Are Postpartum Mood Disorders Treated?

Postpartum depression presents along a continuum, and the type of treatment selected is based on the severity and type of symptoms present. However, before initiating psychiatric treatment, any medical causes for mood disturbances (including thyroid dysfunction and/or anemia) must be excluded. Initial evaluation of a man or woman for postpartum mood disorders should always include a thorough and complete history, a physical examination, as well as routine laboratory tests.

Non-pharmacological therapies are often useful in the treatment of postpartum depression. It has been wildly demonstrated that short-term cognitive-behavioral therapy (CBT) was as effective as treatment with fluoxetine in women who have postpartum depression. Interpersonal therapy (IPT) has also been shown to be effective for the treatment of women with mild-to-moderate postpartum depression. Not only is IPT effective for treating the symptoms of depression, women who receive IPT may also benefit from significant improvements in the quality of their interpersonal relationships.

These non-pharmacological interventions may be particularly attractive to those patients who are reluctant to use psychotropic medications (such as women who are breastfeeding) or for women who have milder forms of depressive illness. Women with more severe postpartum depression may choose to receive pharmacological treatment, either in addition to or instead of these non-pharmacological therapies.

Only a few studies have systematically assessed the pharmacological treatment of postpartum depression.

Conventional antidepressant medications (fluoxetine, sertraline, fluvoxamine, and venlafaxine) have shown efficacy in the treatment of postpartum depression, standard antidepressant doses were both effective and well tolerated. The choice of an antidepressant should be guided by the woman’s prior response to antidepressant medication and side effect profile. Specific serotonin reuptake inhibitors (SSRIs) are ideal first-line agents, as they are anxiolytic, non-sedating, and well-tolerated.

For women who cannot tolerate SSRIs, bupropion (Wellbutrin) may be an alternative; although one pilot study suggests bupropion may not be as effective as SSRIs

Tricyclic antidepressants (TCAs) are frequently used and, because they tend to be more sedating, may be more appropriate for women who present with prominent sleep disturbance. Given the prevalence of anxiety symptoms, adjunctive use of a benzodiazepine (including clonazepam, lorazepam) may be very helpful to help ease anxiety and allow for relaxation.

While it’s difficult to reliably predict which women in the general population will experience postpartum mood disorders, it is possible to identify certain subgroups of women (such as men and women with a history of mood disorders) who are more vulnerable to postpartum affective illness.

Current research indicates that prophylactic interventions may be instituted near or at the time of delivery to decrease the risk of postpartum illness. Several studies demonstrate that women with histories of bipolar disorder or puerperal psychosis benefit from prophylactic treatment with lithium instituted either prior to delivery (at 36 weeks gestation) or no later than the first 48 hours postpartum.

Women and men with postpartum psychiatric illness are offered a variety of services by clinicians with particular expertise in these areas:

• Clinical evaluation for postpartum mood and anxiety disorders
• Medication management
• Consultation regarding breastfeeding and psychotropic medications
• Recommendations regarding non-pharmacological treatments
• Referral to support services within the community

Puerperal psychosis is considered a psychiatric emergency that typically requires inpatient treatment.

Acute treatment with either typical or atypical anti-psychotic medications is indicated. Given the well-established relationship between puerperal psychosis and bipolar disorder, postpartum psychosis should be treated as an affective psychosis and a mood stabilizer is indicated.

Electroconvulsive therapy (ECT) is well-tolerated and rapidly effective for severe postpartum depression and psychosis.

Can I Take Medications While Breastfeeding?

The nutritional, immunologic and psychological benefits of breastfeeding have been well-documented. Women who plan to breastfeed must be informed that all psychotropic medications, including antidepressants, are secreted into the breast milk, though concentrations in the breast milk appear to vary widely throughout the day The amount of medication to which an infant is exposed depends on several factors including, dosage of medication, rate of maternal drug metabolism, and frequency and timing of feedings.

Over the past five years, we’ve learned more regarding the use of various antidepressants during breastfeeding. Available data on the tricyclic antidepressants, fluoxetine, paroxetine, and sertraline during breastfeeding have been encouraging and suggest that significant complications related to an infant’s exposure to these medications in breast milk appear to be rare. While less information is available on other antidepressants, there have been no reports of serious adverse events related to infant exposure to these medications.

Women who have bipolar disorder may discover breastfeeding may be much more problematic. The first concern is that on-demand, around-the-clock breastfeeding may significantly disrupt the mother’s sleep, which can increase her vulnerability to a relapse of bipolar disorder during the postpartum period. Second, there have been reports of toxicity in nursing infants who have been exposed to various mood stabilizers in the breast milk, including lithium and carbamazepine. Lithium, a gold standard in management of bipolar disorder, is excreted at high levels in the mother’s milk, so infant serum levels of Lithium are relatively high, which brings an increased risk of neonatal toxicity. Exposure to carbamazepine and valproic acid in the breast milk has also been associated with hepatotoxicity (liver toxicity) in a nursing infant.

If you’ve been diagnosed and treated for bipolar disorder, the very best thing that you can do for yourself and your infant is to develop a postpartum plan with your psychiatrist and your OB, based on the symptoms you experienced before you were pregnant. In this plan, you can address your postpartum concerns and ways to manage these concerns.

Additional Things You Can Do To Help Postpartum Mood Disorders: