This review summarises the psychiatry of the puerperium, in the light of publications during the past 5 years. A widevariety of disorders are seen. Recognition of disorders of the mother–infant relationship is important, because thesehave pernicious long-term effects but generally respond to treatment. Psychoses complicate about one in 1000deliveries. The most common is related to manic depression, in which neuroleptic drugs should be used with caution.
Post-traumatic stress disorder, obsessions of child harm, and a range of anxiety disorders all require specificpsychological treatments. Postpartum depression necessitates thorough exploration. Cessation of breastfeeding isnot necessary, because most antidepressant drugs seem not to affect the infant. Controlled trials have shown thebenefit of involving the child’s father in therapy and of interventions promoting interaction between mother and infant.
Owing to its complexity, multidisciplinary specialist teams have an important place in postpartum psychiatry.
The traditional view that there are three postpartum Disorders of the mother-infant relationship psychiatric disorders—the maternity blues, puerperal Childbirth presents many challenges to the mother: psychosis, and postnatal depression—is an oversimpli- trauma, sleep deprivation, breastfeeding, adjustments in fication. The range of disorders is wide. This review focuses conjugal and other relationships, and social isolation.
on those important to general psychiatrists and family However, the central and most important psychological practitioners. It does not cover mild disorders that require no process is development of the relationship with the infant.
treatment (such as the maternity blues), nor grieving over Disturbances in this process were recognised long ago, fetal loss, nor rare complications (such as organic when hatred of children12,13 and child abuse14 were psychoses), nor the effect of childbirth on eating disorders or described. Various terms have been used for these ethanol misuse. It draws attention to gaps in knowledge and disturbances. “Bonding” is a useful lay term, but neither “bonding” nor “attachment” describes the essentialsymptom, which is the mother’s emotional response to the infant—aversion, hatred, or pathological anger. “Mother- The sudden onset of psychosis after childbirth has intrigued infant interaction” reflects this response and has the medical practitioners for centuries. More than 2000 papers advantage that it can be recorded and measured. But the have been published. This group of disorders is diverse, concept of “postnatal depression with impaired mother- including psychogenic and organic psychoses.1 Only one infant interaction” is inadequate to encompass such a form is commonly seen in countries with modern obstetric profound emotional disorder, which can occur without services. This form is generally called puerperal psychosis depression.15 The concept of mother-infant relationship and takes the form of mania, severe depression (with disorder is controversial. It is not recognised in the tenth delusions, confusion, or stupor), or acute polymorphic revision of the International Classification of Diseases (cycloid) psychosis. Record-linkage studies2,3 (ICD-10) nor the Diagnostic and Statistical Manual IV incidence of about one per 1000 births. The claim that this is (DSM-IV). One of the challenges for ICD-11 and DSM- a “disease in its own right” was disproved long ago by the V is to find a place for these disorders, so that they can be long-term case studies of Esquirol,4 and there is now much recognised by practitioners and referred for expert evidence for a link with manic depressive psychosis.1Childbirth, together with abortion1,5 and menstruation,6 is one of the triggers of bipolar episodes in susceptible women.
Research on these triggers is a promising avenue to a greater Motherhood and Mental Health reviewed published work up to understanding of manic depression. Puerperal psychosis has the end of 1995, citing over 2000 articles on postpartum a high and specific heritability (figure 1).7 The recurrence disorders. For this review, I used PubMed to screen articles rate is about one in four pregnancies. In treatment, published in the past 7 years, under the headings haloperidol should be used with caution, because dangerous “postpartum depression” (760 articles since 1995), “mother- side-effects including neuroleptic malignant syndrome have infant relationship disorders” (290 articles), “postpartum been reported.1,8,9 The newer neuroleptic drugs, such as anxiety” (370 articles, overlapping considerably with olanzepine, seem to be safer, although their safety has not yet postpartum depression), “postpartum post-traumatic stress been proven by treatment trials. Electroconvulsive treatment disorder” (26 articles), and “postpartum obsessive is useful,10 and lithium can be effective prophylaxis.11 compulsive disorder” (20 articles). I passed over those ineastern European and far eastern languages, or in journals I could not obtain before the deadline set by The Lancet. After studying the abstracts, I obtained about 200 articles for closer study. They included all substantial investigations.
Given the constraints on space, the decision on what to Professor Emeritus, University of Birmingham (Prof I Brockington FRCP) include was a personal judgment. I selected all controlled Correspondence to: Prof Ian Brockington, Lower Brockington Farm, treatment and prevention trials, weighty and unusual studies, and those that best illustrated well-affirmed points. THE LANCET • Vol 363 • January 24, 2004 • For personal use. Only reproduce with permission from The Lancet publishing Group.
For more direct evidence, there are studies of the effects of “postnatal depression” on the child. Most have not assessed the mother-infant relationship, but Murray and colleagues19 made brief audio recordings and videotapes of mother-child interaction. They compared 61 mothers in Cambridge, UK, depressed 5–6 weeks after childbirth, with 42 controls. Mother-child interaction was assessed at 2 months, and the children were followed up for 5 years.
Cognitive functioning was not affected by maternal depression but was predicted by mother-infant interaction (r=0·29, p<0·05). More research should be focused on the effects of these disorders on children’s intellectual development and mental health, and their relation to childabuse and neglect.
Figure 1: Proportion of deliveries followed by postpartum psychosis in manic depressive patients with and without a questionnaires,20,21 which can also be used to chart progress in treatment (figure 2). An interview, in which Reproduced with permission from Ian Jones.7 24 probes explore the mother-infant relationship, hasbeen published.1 Observational data can be obtained in treatment. This process will involve a difficult innovation, hospital22,23 or at home.24 Other objective measures, such because “hatred” does not fit comfortably with the as videotapes,25 can be used. However, more research is concept of disease or illness. If hatred of a rival or political needed to improve our recognition and measurement of enemy is not an illness, why should a mother’s hatred and these disorders, clarifying the link between symptoms rejection of an infant be listed as a disease? But medicine explored by interviews and questionnaires and direct has pragmatic rather than logical boundaries, and observations of mother-infant interaction.
psychiatry often challenges the definition of disease.
In management, depression should be treated, even Disorders of the mother-infant relationship are when signs are negligible. The specific psychological prominent in 10–25% of women referred to psychiatrists treatment is play therapy in various forms,26 interaction after childbirth.1 At the extreme of rejection of the infant, coaching, or baby massage,27,28 which can be undertaken the mother may try to persuade a family member to take by nursing staff or psychologists. The aim is to help the over care permanently or may demand that the baby be mother to enjoy her interactions with the child. There adopted. She may try to escape. The most poignant have been two prophylactic intervention studies. In Brazil, manifestation is the wish that the baby disappear—be Wendland-Carro and colleagues29 randomly assigned stolen or succumb to cot death. Rejection is accompanied videotape instruction of two kinds to 37 mothers: one in many cases by pathological anger, with shouting, group received information about interaction with their cursing, or screaming at the infant, accompanied by babies, and the other information about care-giving skills.
impulses to strike, shake, or smother the child. These A month later, home observations showed increased disorders are more common, intractable, and serious in sensitive responsiveness in mothers receiving guidance on their effects than puerperal psychosis. With treatment, mother-infant interaction. In South Africa, Cooper and they can resolve completely. Without it, there are high colleagues30 reported an intervention study in a Xhosa risks of child abuse and neglect, long-term impairment of community, involving unqualified community workers.
the mother-child relationship, and psychiatric or learning 20 visits improved not only mother-infant interaction but disorders in the children. The effects have been studied also the height and weight of the infants.
indirectly through cohort studies of children born afterrefused termination of pregnancy.16,17 For example, a Danish study18 followed up unwanted children in a cohort Although puerperal melancholia has been recognised for of 4269 male births. A combination of birth complications centuries, American research in the 1950s drew attention and early child rejection carried a risk of violent to the prevalence of milder postpartum depression.31 criminality four times higher than the reference category.
A concept of postnatal depression emerged, which hasbeen useful as a lay term. It reduces stigma and enables mothers with various postpartum psychiatric disorders to recognise that they are ill and to seek help. It is a focus for self-help groups and lobbying to improve services.
As a medical concept, however, it is less useful. Unless practitioners appreciate that the concept is merely a rubric, research and clinical practice will be left at a basic level.32 Patients who score above threshold on screeningquestionnaires or meet criteria for major depression are heterogeneous: their illnessess include a variety of anxiety, obsessional, and post-traumatic stress disorders, together with depression associated with adversity and primarydepression linked to bipolar disorder. A diagnostic 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 concept needs an epidemiological association, indicating the presence of specific causal factors. This association islacking for postpartum depression. Depression is common Figure 2: Scores on the postpartum bonding questionnaire in all women, whether infertile, menopausal, pregnant, (PBQ) in a patient followed up for 17 weeks puerperal, or involved in child-rearing. The rates of Factor 1 indicates a mild disorder; abnormal above 12. Factor 2 indicates depression show little difference between women just after rejection and pathological anger; abnormal above 17. Factor 3 indicatesinfant-focused anxiety, abnormal above 9.
THE LANCET • Vol 363 • January 24, 2004 • For personal use. Only reproduce with permission from The Lancet publishing Group.
Of 868 articles listed by PubMed, 128 were published in 1977–95 and 760 since then. Research has been done worldwide, with more than 50 studies from outsidenorthern Europe, North America, and Australia. Most have confirmed the frequency of the disorder. Of particularinterest are studies comparing minority groups, in Malaysia,40 the USA,41 and Australia.42,43 One study involved11 centres: 44 it showed that depression was most frequent in India (32%), Korea (36%), Guyana (57%), and Taiwan (61%). Causal associations include previous and hereditary depression, life events, and disturbed relationships. Several large cohort studies have confirmed these associations. A Danish study of 5252 women, of whom 5·5% were depressed at 4 months after childbirth, identified four risk factors: previous psychiatric illness, high parity, prepartum distress, and social isolation.45 The Avon Longitudinal Figure 3: Depressive symptoms during pregnancy, shortly after Study of Pregnancy and Childhood, which involved 9208 delivery, 6 months later, and at 5-year follow-up women in Bristol, UK, found that depression at 8 weeks Reproduced with permission from Social Psychiatry and Psychiatric post partum was related to material deprivation and low social support.46 Some studies have reported unusualassociations: grand multiparity in Turkey,47 disappointment colleagues’ cohort study of 8556 pregnant women, with the sex of the child in Hong Kong,48 and immigration depression rates were highest during pregnancy and at in Israel.49 The influence of heredity has been explored by 5-year follow-up and lower during the postpartum period use of an Australian twin register. Responses from (figure 3).35 There is no confirmation of the severity of 539 monozygotic and 299 dizygotic twins showed that postpartum depression in suicide statistics. A Finnish genetic factors explained 25–38% of the variance.50 A record-linkage study36 found 30 suicides within 12 months hormonal influence on some postpartum depressions was of childbirth in 1987–94 (519 139 births). The rate shown by Bloch and colleagues,51 who induced hypogo- therefore was six per 100 000 births, which is lower than nadism in 16 women by means of leuprolide acetate, an the rate in the overall Finnish female population of nine agonist of gonadotropin-releasing hormone. They replaced per 100 000 per year.37 A Danish record-linkage study38 oestrogen and progesterone to mimic pregnancy, achieving found only 14 suicides within a year of childbirth in a mean oestrogen concentrations of 278 pg/mL and proges- 20-year period (1973–93) during which there were terone 64 ng/mL (well below peak pregnancy values). To 1 270 117 births; 3 the rate is one per 100 000 births, mimic the puerperium, they abruptly replaced hormones compared with the rate in the Danish female population of with placebo. Eight women without a history of psychiatric 12 per 100 000 per year.37 Nevertheless, the suicide of newly disorders remained well, but five of eight who had had delivered women, which can be combined with filicide, is a postpartum depression developed mild affective disorders, matter of great concern. Data on the predictors of The diagnosis of postpartum depression is facilitated by Maternal morbidity and mortality are not the only the involvement of midwives and health visitors in the reasons why effective action to deal with postpartum puerperium. The Edinburgh postnatal depression scale depression is necessary. Postpartum depression can have (EPDS)52 is widely used and has been translated into many pervasive effects on the family. Although deficits are not languages. A Norwegian paper reviewed 18 validation universal in depressed mothers,39 depression can lead to studies.53 The EPDS also measures anxiety54,55 and could be reduced interaction and irritability misdirected at the a general screening tool for the whole range of postpartum psychiatric disorders.56 Other questionnaires used are the Depression may be the most frequent psychiatric general health questionnaire, the Beck depression disorder seen after childbirth. During the past 7 years, the inventory,57 and the postpartum depression screening output of publications on this subject has greatly increased.
6 sessions of cognitive-behavioural counselling Home visits by a nurse, supported by a social 7 psychoeducational visits, involving partners 859 puerperal women scoring ≥9 on EPDS A single counselling session on obstetric unit, 3 forms of psychological treatment from 8 to relationship difficulties, but only in short term Table 1: Randomised controlled treatment trials THE LANCET • Vol 363 • January 24, 2004 • For personal use. Only reproduce with permission from The Lancet publishing Group.
2 antenatal instruction periods with or without upsets”, especially if partner attended also Victoria, Australia 917 women delivered by caesarean 10 home visits by a community support worker 99 women expecting first or second child 4 sessions interpersonal therapy in groups 3 months of visits by midwives trained in Table 2: Randomised controlled prophylactic trials A positive score on a self-rating questionnaire needs to antenatal clinics. Some have had previous postpartum be followed by an interview clarifying the symptoms of episodes. Some are already depressed. Others have depression and coexisting psychiatric disorders. The obvious risk factors such as frictional relationships, social wider context must be explored, including the woman’s isolation, addiction, or unwanted pregnancy. Another life history, personality, and circumstances; the course of research priority is to find the best way of screening the pregnancy, including parturition and the puerperium; pregnant women. Support from community nurses, and relationships with partner, other children, family of voluntary agencies, or groups can begin during pregnancy.
origin, and, especially, the infant. In addition to If pregnant women are well, all that is necessary is to diagnosing depression and other disorders, vulnerability establish contact, so that a recurrence is diagnosed and factors and the availability of support must be identified.
treated promptly. Table 2 summarises 11 randomised Treatment is focused on depression and any underlying controlled prophylactic trials30,82–91 that used psychological vulnerability. It will always involve psychotherapy,59 interventions, some of which were disappointing.
generally given by hospital and community nurses, health Prophylactic antidepressive drug therapy is rational in visitors, and lay counsellors. It may involve medication or women at risk of recurrence, but a double-blind other specific treatments. In pharmaceutical treatment, no randomised trial showed unexpectedly that nortriptyline drug is clearly superior, but there have been many did not prevent recurrence in mothers with a history of publications on drug treatment in lactating women, with more than 50 reviews. The most recent is that of Wisner The findings in tables 1 and 2 show that the and colleagues60 and the most detailed is by Spigset and involvement of the babies’ fathers had a positive effect,75,82 Hägg.61 The suckling infant is at risk because of the and that three intervention studies improved mother- immaturity of body systems: lack of body fat, low plasma protein binding, immature liver and kidney, andundeveloped blood–brain barrier. Nevertheless, few adverse effects have been reported, and the general view is Bydlowski and Raoul-Duval93 described PTSD after that breastfeeding can continue and that, with the childbirth in 1978. Long ordeals during labour led to exceptions of nefazodone,62 doxepin,63 and fluoxetine,60 secondary tocophobia, and the recurrence of tension, antidepressant agents can be given. To illustrate the safety nightmares, and flashbacks towards the end of the next pregnancy. There are now about 40 publications on this concentrations in mothers and infants: they fell in the disorder, which has been called the fourth postpartum mothers but did not change in the infants, indicating that mental disorder.94 The stressful experience is pain in most insufficient drug had reached the infant through cases, but loss of control and fear of death can be the breastmilk. Antidepressive drugs should be used focus.95,96 There have been eight quantitative studies cautiously in lactating mothers, and administration after a (table 3).93,97–103 Case reports suggest that depression, an Gregoire and colleagues65 researched the effect of 17␤- (p<0·0001). This study adds to many others, going back 70 years,66 in support of oestrogen’s antidepressive properties. By contrast, a controlled prophylactic trial of Many studies have been concerned with psychological 2·8% at 6 weeks 1·5% at 6 months post partum interventions. Table 1 summarises 13 randomised controlled treatment trials.68–81 All but one were beneficial.
Prevention is important in women with a history of postpartum depression. There is a great opportunity to identify women at risk during their attendance at Table 3: Quantitative studies of postpartum PTSD THE LANCET • Vol 363 • January 24, 2004 • For personal use. Only reproduce with permission from The Lancet publishing Group.
dysfunction can result. In Stockholm, half of mothers with deprivation. It is not easy to treat. A baby monitor can be a very negative birth experience at their first delivery useful, as can nights of respite, when another trusted avoided any further pregnancy.105 These women should be person looks after the infant and the mother sleeps under referred for specific psychological treatment, such as sedation. Involvement of a panel of mothers who have massed practice, which might accelerate accommodation recovered from this disorder is useful, as in other postpartum disorders. Many mothers are excessivelyanxious about the health and safety of their children, described as maternity neurosis113 or maternal separation Distress about the bodily changes resulting from anxiety.114 There is some evidence that severe postpartum pregnancy and childbirth are common. Such women anxiety has adverse effects on the child, with a high complain of weight gain, stretch marks, or scars. They are proportion of insecure and disorganised attachments.115 reluctant to undress in front of their partners, avoid Drug treatment can be used, but, in lactating women, looking at themselves naked, and can even avoid being anxiolytic benzodiazepines should be used with caution.
seen in public. In an unpublished prospective interview They are well absorbed from the gut, have long half-lives, study of over 200 patients in the UK and New Zealand, and are more slowly metabolised by the liver in infants.
this distress amounted to dysmorphophobia in 14% of Lethargy and weight loss have been reported in an infant exposed to diazepam. For this reason, oxazepam has been Conjugal jealousy is another disorder sometimes linked recommended.61 A woman with infant-focused anxiety to pregnancy and childbirth. Preoccupying worries about may avoid the infant in a typical phobic reaction.116 Such the spouse’s fidelity are an understandable reaction to women respond well to treatment by desensitisation in a pregnancy changes and the relative quiescence of sexual mother and baby unit. Many cases of postpartum anxiety life. Most publications are case reports.1 disorders require the skills of a clinical psychologist, using unpublished study mentioned above, postpartum morbid relaxation techniques and cognitive therapy.
jealousy was evident in 5% of women.
Complaints about obstetric management can be preoccupying. They are relatively common after Obsessions of infanticide were one of the first postpartum emergency caesarean section.106 Childbirth is a key disorders to be described,117 and several recent series have experience, and a woman may feel bitter disappointment been published.118–120 The central symptom is of impulses over delivery perceived as mismanaged. Such feelings can to attack the child, but the setting is different from the lead to litigation and in some cases preoccupy the woman pathological anger that precedes child abuse. The mother for weeks or months and interfere with care of the infant.
is gentle and devoted. She experiences extravagant These disorders are sometimes confused with PTSD, but infanticidal impulses, together with fantasies of the the dominant emotion is ruminative anger not anxiety, family’s horror and grief, causing intense distress and and the treatment is different—distraction from the leading to reduced contact with the baby. The content can perceived injury and redirection of attention to positive include child sexual abuse.121 Classic papers were written by Chapman122 and Button and Reivich,123 who found 42 cases among 1317 consecutive consultations. Buttolphand Holland124 reported that 27 of 39 female patients with Anxiety disorders specific to the puerperium obsessive compulsive disorder had onset or worsening in Several studies have reported the effect of pregnancy on pregnancy or after childbirth. Jennings and colleagues125 panic disorder. A review of eight studies showed no interviewed 100 depressed mothers: 21 had repeated thoughts of harming their children and took precautions, improvement, but in 44% there was an exacerbation in and 24 were afraid to be alone with their children. An the postpartum period and in 10% new onset in the puerperium.107 Recent studies suggest that postpartum compulsive disorder and found that childbirth was the anxiety disorders are underemphasised and are more only life event significantly associated with onset. The common than depression.108,109 There could be a biological management involves specific psychological treatment as basis for some postpartum anxiety. McIvor and well as antidepressant therapy. Avoidance of the child colleagues110 studied the growth-hormone response to should be discouraged, and cuddling and play apomorphine (a test of dopamine D2 receptor sensitivity) encouraged, strengthening positive maternal feelings.
in 14 puerperal women with a history of depression. Thegreatest increase in receptor sensitivity was found in three women who developed postpartum anxiety disorders.
Given the diversity of postpartum mental illness and its ICD-10 and DSM-IV give criteria for anxiety disorders risks for infants, there is a case for setting up specialist as a group, but the focus of anxiety is also important, services for pregnant and puerperal women. In the UK, because it can indicate specific psychological treatment.
after the pioneering initiative of Main 50 years ago,127 a This issue is a challenge for the next generation of wealth of experience has been gained, through the international classifications. De Armond111 described fear concentration of severe cases in mother and baby units.
of the newborn infant based on the awesome However, in the absence of service evaluation, good responsibility of care. Most women are shielded from this clinical practice is based on ideas and innovation, rather fear by family support, but in isolated nuclear families it than rigorous outcome data. The essence of these services can be a severe problem. Support from family or nursing staff is all that is required. Fear of cot death can reach a psychiatrists, psychologists, nurses (probably also nursery pathological degree.112 Reproductive losses (eg, recurrent nurses), and social workers. The aims are prevention, miscarriage) or infertility of long duration can be an early diagnosis, and versatile intervention, with the antecedent factor. The main manifestation is nocturnal minimum family disruption. Such teams can serve a wide vigilance. The mother lies awake listening to the infant’s area, taking over the treatment of severe and intractable breathing, and often checks that he or she is still alive.
illness, developing services, training staff, and conducting This fear can last for months and lead to exhausting sleep research. They can provide a trial of mothering in THE LANCET • Vol 363 • January 24, 2004 • For personal use. Only reproduce with permission from The Lancet publishing Group.
complex cases, and give medicolegal advice. Domiciliary 16 Kubic˘ka L, Mate˘jc˘ek Z, David H P, Dytrych Z, Miller WB, Roth Z.
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17 Myrhman A, Rantakallio P, Isohanni M, Jones P, Partanen U.
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45 Nielsen Forman D, Videbech P, Hedegaard M, Dalby Salvig J, THE LANCET • Vol 363 • January 24, 2004 • For personal use. Only reproduce with permission from The Lancet publishing Group.
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The dark side of Davos’s magic mountain A surreal mix of Nazis, American pilots, refugees and Swiss crossed paths on Davos’s snowy streets and in its sanatoriums in the 1930s and 40s. In her intimate political documentary, “A l’ombre de la montagne”, Swiss filmmaker Danielle Jaeggi explores the mythical alpine resort, its clinics and this obscure period of Swiss history via

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