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REVIEW ARTICLE

Postpartum psychiatric disorders: Early diagnosis and management

Shashi Rai, Abhishek Pathak1, Indira Sharma2
SAMBAL Drug De‑addiction and Psychiatric Centre, Lucknow, 2Department of Psychiatry, Institute of Medical Sciences,
Banaras Hindu University, Varanasi, Uttar Pradesh, 1Department of Psychiatry, National Institute of Mental Health and
Neurosciences, Bengaluru, Karnataka, India

ABSTRACT

Postpartum period is demanding period characterized by overwhelming biological, physical, social, and emotional
changes. It requires significant personal and interpersonal adaptation, especially in case of primigravida. Pregnant
women and their families have lots of aspirations from the postpartum period, which is colored by the joyful arrival
of a new baby. Unfortunately, women in the postpartum period can be vulnerable to a range of psychiatric disorders
like postpartum blues, depression, and psychosis. Perinatal mental illness is largely under‑diagnosed and can have
far reaching ramifications for both the mother and the infant. Early screening, diagnosis, and management are very
important and must be considered as mandatory part of postpartum care.

Key words: Perinatal mental illness, postpartum blues, postpartum period, postpartum psychosis

INTRODUCTION psychiatric disorders can adversely affect mother‑infant

Many females experience a wide range of overwhelming
emotions such as anticipation, excitement, happiness,
fulfillment, as well as anxiety, frustration, confusion, or
sadness/guilt during pregnancy and postpartum period.
The postpartum period makes them highly vulnerable to
various psychiatric disorders. Traditionally postpartum
psychiatric disorders are classified as maternity blues,
puerperal psychosis, and postnatal depression. However,
the spectrum of postpartum phenomenology is wide.
Postpartum phenomenology is characterized by a range
of emotions from transient mood lability, irritability, and
weepiness, to marked agitation, delusions, confusion, and
delirium.
interaction and attachment.[2] Hence, early diagnosis and
management of the postpartum psychiatric disorder is
extremely crucial.
DIAGNOSIS ACCORDING TO CURRENT
SYSTEMS OF CLASSIFICATION
The current psychiatric nosology has not classified
postpartum psychosis (PP) as a distinct entity. Classification
of puerperal illnesses as discrete nosological entities has
been debatable for more than 30 years.[3,4] Some school
of thought regard PP as the postpartum presentation of
an underlying disorder within the bipolar spectrum while
others consider it purely as a distinct nosological entity.[5]

Perinatal mental illness is largely under‑diagnosed, and
undertreated.[1] Untreated postpartum psychiatric disorders
can have far‑reaching ramifications for a family. At times,
the postpartum psychiatric condition can become so severe
that it warrants hospitalization. Moreover, postpartum
Address for correspondence: Dr. Indira Sharma,
“Shrishti”, N/180‑118 Rajendra Vihar, Newada, Sunderpur,
Varanasi ‑ 221 005, Uttar Pradesh, India.
E‑mail: indira_06@rediffmail.com
Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision (DSM‑IV‑TR) and the ICD-10
classification of mental and behavioural disorders: Clinical
description and diagnostic guidelines, have classified
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How to cite this article: Rai S, Pathak A, Sharma I. Postpartum DOI:

psychiatric disorders: Early diagnosis and management. Indian
10.4103/0019-5545.161481
J Psychiatry 2015;57:216-21.

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Rai, et al.: Postpartum psychiatric disorders
postpartum mental disorders differently. DSM‑IV‑TR allows
psychiatrists to use the “with postpartum onset” specifier
to brief psychotic disorder or to a current or most recent
major depressive, manic, or mixed episode with psychotic
features in major depressive disorder or Bipolar Disorder,
if onset occurred within 4 weeks postpartum. In the
ICD‑10, mental illnesses associated with puerperium are
coded according to the presenting psychiatric disorder;
a second code (e.g., 099.3) denotes association with the
puerperium. In some cases, the ICD‑10 allows for a special
code, F53 when there is insufficient information for
classification, or there are “special additional features.”
F53 can only be used if the disorder occurs within 6 weeks
of delivery.[6,7] DSM‑V has replaced the specifier “with
postpartum onset” for depressive and bipolar disorders
with the specifier “with peripartum onset.” The “with
peripartum onset” specifier is used if the onset of mood
symptoms occurs during pregnancy or within the 4 weeks
following delivery.[8] However, postpartum psychiatric
disorders may manifest weeks beyond the 1st month
or 6 weeks after delivery.[9] Hence, the utility of DSM‑V
specifier and the ICD‑10 special code in the classification
of puerperal disorders is limited.
EPIDEMIOLOGY
PP is observed in 1–2/1000 childbearing women within
the first 2–4 weeks following delivery.[10‑14] The onset of
PP is sudden and acute in nature.[15] PP is seen as early as
2–3 days following delivery. The patient can have paranoid,
grandiose, or bizarre delusions, mood swings, confused
thinking, and grossly disorganized behavior and is usually
characterized by a dramatic change from her previous
functioning. Postpartum depression (PPD) is observed in
10–13% of new mothers,[16] and maternity blues, is seen in
50–75% of postpartum women.[17]
A community‑based prospective study in India found out
the incidence of PPD in rural women to be around 11%[18]
which is comparable to incidence in western culture, where
10–15% of all mothers are affected by PPD.[16] In adolescent
mothers, PPD was observed to be around 26%.[19]
Postpartum psychiatric syndromes are seen more
commonly (81%) in patients below 25 years of age. The
majority of the Indian women conceive during this part of
the childbearing age as the age at marriage is comparatively
lower. The family history of mental illness was observed in
25% of the patients.[20]
ETIOLOGY
PP can be defined as a psychiatric manifestation with abrupt
onset after delivery, a phase characterized by overwhelming
major biopsychosocial changes. Causation of PP is generally
multifactorial.
Indian J Psychiatry 57 (Supplement 2), July 2015
Biological changes
Pathogenesis of PP has a strong biological element as
the onset is abrupt in nature. The early postpartum
period is characterized by a marked decrease in gonadal
steroids. There is a considerable decrease in the levels of
progesterone between the first and second stages of labor,
and estrogen levels drop suddenly following the expulsion
of the estrogen‑secreting placenta. Estrogen primarily
affects the monoaminergic system, especially serotonin and
dopamine; influencing affective symptoms and psychotic
symptoms respectively.[21‑24]
Psychosocial factors
Pregnancy and the transition to motherhood give birth to
a variety of psychological stressors. A woman has to adjust
to changes in her body image, her relationships with her
husband and family members, her responsibilities and the
manner in which she is perceived by the society.[24,25]
Risk factors associated with postpartum disorders
The risk factors associated with the development of
postpartum disorders are: Primigravida; unmarried mother;
cesarean sections or other perinatal or natal complication;
past history of psychotic illness, especially past history of
anxiety and depression; family history of psychiatric illness,
especially mother and sister having postpartum disorder;
previous episode of postpartum disorder; stressful life
events especially during pregnancy and near delivery;
history of sexual abuse; vulnerable personality traits and
social isolation/unsupportive spouse.[26,27]
CLINICAL FEATURES
Earlier postpartum disorders were classified as:
(i) Postpartum blues (PBs), (ii) PPD (iii) PP. This was an
oversimplification. However, in addition to these, there are
miscellaneous groups of anxiety and stress‑related disorders
occurring in the puerperium. In recent times, postpartum
disorders have been classified into five major categories:
(i) PBs, (ii) PPD, (iii) PP, (iv) postpartum post‑traumatic stress
disorder (PTSD), and (v) postpartum anxiety and obsessive
compulsive disorder (OCD). The characteristics of each
postpartum disorder are described below.
Postpartum blues
PBs, also known as “baby blues” or “maternity blues,”
is a phase of emotional lability following childbirth,
characterized by frequent crying episodes, irritability,
confusion, and anxiety. However, elation might also be
observed during the first few days following childbirth.
“Baby blues” are very common and experienced by most of
the women to some extent. However, PB is more commonly
seen in western countries because of the lack of strong
familial support and bonding. It is observed to be as high
as 40–85%. The symptoms arise within the first 10 days and
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Rai, et al.: Postpartum psychiatric disorders
peak around 3–5 days.[28] Generally symptoms of PB do not
interfere with the social and occupational functioning of
women. PB is self‑limiting with no requirement for active
intervention except social support and reassurance from
the family members. PB can be attributed to changes in
hormonal levels of women, further compounded by the
stress following delivery. However, PBs persisting for more
than 2 weeks may make women vulnerable to a more severe
form of mood disorders.[29,30]
Postpartum depression
PPD is the most common psychiatric disorder observed in the
postpartum period. PPD is generally difficult to distinguish
from depression occurring at any other time in a women’s
life. However, in PPD the negative thoughts are mainly
related to the newborn. It is seen in 10–15% of postpartum
women and, in addition to postpartum time specifier, the
diagnostic criteria is difficult to differentiate from that
of major depressive episode characterized by pervasive
depressed mood, disturbances of sleep and appetite, low
energy, anxiety, and suicidal ideation. Additionally feelings
of guilt or inadequacy about the new mother’s ability to
care for the infant, and a preoccupation with the infant’s
well‑being or safety severe enough to be considered
obsessional.[30] A large number of studies have observed
that higher incidence of anxiety symptoms is observed in
PPD than in non‑PPD. Onset can range from few days to few
weeks following delivery, generally in the first 2–3 months
following childbirth. History of major depression increases
the risk for PPD by 25%, and past history of PPD increases
the risk of recurrence to 50%.[31]
Postpartum psychosis
PP has an acute and abrupt onset, usually observed within the
first 2 weeks following delivery or, at most, within 3 months
postpartum, and should be regarded as a psychiatric and
obstetrical emergency.[32] The presence of a psychotic
disorder affects the prenatal and postpartum care adversely.
Past history of psychosis with previous pregnancies,
history of bipolar disorder, family history of psychotic
illness (e.g., schizophrenia or bipolar disorder) are some of
the major risk factors for the development of PP.[33‑35]
Most commonly symptoms include elation, lability of mood,
rambling speech, disorganized behavior, and hallucinations
or delusions. However, presentation and course of PP may
be more diverse and complex, with transient or alternating
episodes of delusions of guilt, persecution, auditory
hallucinations; delirium‑like symptoms and confusion; and
excessive activity. At times, delusions revolves around the
infant, especially that the infant is possessed, has special
powers, is divine, or is dead.[15] Infanticide and suicide
are observed in 4% and 5% of the women suffering from
PP respectively. Enquiring about suicidal and infanticidal
thoughts is crucial during the assessment of women
suffering from PP.[36‑38]
S218 Indian J Psychiatry 57 (Supplement 2), July 2015
Postpartum posttraumatic stress disorder
Bydlowski and Raoul‑Duval did landmark study on
postpartum PTSD.[39] Many studies have shown the
incidence of postpartum PTSD to be around 5.6%.[40] It is
generally characterized by tension, nightmares, flashbacks
and autonomic hyperarousal that can continue for some
weeks or months, and may recur toward the end of the next
pregnancy. This can also result in secondary tocophobia.[41]
Anxiety disorders specific to the puerperium
Many studies have observed that postpartum anxiety
disorders are under‑diagnosed and are in fact more common
than PPD.[42] De Armond[43] observed that fear of cot death
can reach up to a level of pathological degree. The most
common feature is nocturnal vigilance characterized by
the mother lying awake listening to the infant’s breathing,
and frequent checking resulting in sleep deprivation. Many
mothers are excessively worried and preoccupied about
the health and safety of their children which is known as
“maternity neurosis.”[44,45]
Obsessions of child harm
Women diagnosed with postpartum onset of major
depression may have repetitive, intrusive thoughts related
to some occurring to the baby associated with compulsive
checking behavior. Postpartum onset of OCD can occur
during gestation or within 6 weeks following delivery. The
theme of the obsessions is frequently related to thoughts/
gruesome images of harming the baby.[46‑48]
DIAGNOSIS OF POSTPARTUM PSYCHIATRIC
DISORDERS
Postpartum psychiatric disorders have largely been
under‑diagnosed, reiterating the fact that routine screening
during postpartum clinic visits should form an integral part
of the assessment. Use of a population‑specific screening
tool such as the “Edinburgh Postnatal Depression Scale,”
and the “Mood Disorder Questionnaire” can improve
awareness of healthcare providers and aid in the early
diagnosis of postpartum psychiatric disorders.[49‑51]
Studies employing screening procedures have reported
considerable increases in rates of detection of postpartum
psychiatric disorders.[52‑54] Laboratory investigations and
thorough physical examination should be done to exclude
organic etiology. Sometimes rare medical conditions, such
as frontotemporal dementia or frontal lobe tuberculoma,
and Sheehan syndrome can mimic postpartum psychiatric
disorders.[55‑57]
Important tests include a complete blood count, electrolytes,
blood urea nitrogen, creatinine, glucose, Vitamin B12,
folate, thyroid function tests, calcium, urinalysis and urine
culture in the patient with fever; and a urine drug screen.
A careful neurological evaluation is mandatory including a
brain scan (cranial computerized tomography or magnetic
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Rai, et al.: Postpartum psychiatric disorders
resonance imaging) to rule out the presence of a stroke
related to ischemia (vascular occlusion) or hemorrhage (due
to uncontrolled hypertension, ruptured arteriovenous
malformation, or aneurysm).[58,59]
TREATMENT OF POSTPARTUM PSYCHIATRIC
DISORDERS
The treatment of PPDs is generally holistic and includes
reassurance, familial and social support, psychoeducation,
and in some cases, psychotherapy and/or pharmacologic
treatment.
Nonpharmacological treatment
Individual psychotherapy is an integral part of treatment,
especially for females finding it difficult adjusting
to motherhood and/or apprehensions about new
responsibilities. Psychoeducation and emotional support
for the partner and other family members are important.
Patient and the family members should be involved
in the formulation of the treatment plan. Respite care
services should be recommended especially at night
to minimize the patient’s sleep disruption. In some
cases, interpersonal therapy (IPT) might be beneficial.
IPT is shown to result in greater reduction in depressive
symptoms and improvement in social adjustment. In cases
of PP, separation from the infant might be necessary.
Reassurance and emotional support toward the mother
can boost the self‑esteem and confidence of the mother.
Peer support and psychoeducation about PP are important
interventions. Sometimes, group psychotherapy may also
be helpful.[60,61]
Pharmacotherapy
In moderate to severe depression and PP, medication
becomes necessary. Safety and hazards of use of
psychotropic medications during lactation should be
addressed. The amount of medication to which an infant is
exposed depends on several factors like, maternal dosage
of medication, timing and frequency of dosing, rate of
maternal drug metabolism, and metabolism of the ingested
drug in the infant.[62]
Most psychotropic drugs are metabolized in the liver.
During the first few weeks of a full‑term infant’s life
capacity for hepatic drug metabolism, is about one‑third
to one‑fifth of the adult capacity. The capacity increases
gradually and by about 3 months it reaches to the level of
adult’s capacity. In premature infants or infants with signs
of compromised hepatic metabolism breastfeeding should
be deferred if the mother is on psychotropic medication.
Peak concentrations in breast milk are attained 6–8 h
after ingestion of medication. Therefore, breastfeeding
can be restricted to times when the breast milk drug
concentration is lowest, that is, just before or after taking
medication.[63‑65]
Indian J Psychiatry 57 (Supplement 2), July 2015
Antidepressants
Pharmacologic treatment studies for PPD are few and
include one double‑blind study demonstrating the efficacy
of fluoxetine or cognitive‑behavioral therapy for major or
minor depression;[66] One open study each for sertraline,
venlafaxine, and fluvoxamine.[67‑69] Approximately, 60% of
mothers initiate nursing, and most of the antidepressants
are excreted into breast milk. Sertraline, paroxetine, and
nortriptyline may be the preferred choices for nursing
women.[69] However, the total number of cases reported for
any given medication is small, and concern for infant safety
must be considered.
Antipsychotics
Atypical antipsychotics are often first‑line choices for
psychosis and mania because of their tolerability. On
the basis of a recent review of data on adverse effects in
infants, olanzapine and quetiapine were considered the
most acceptable.[70] Chlorpromazine, haloperidol, and
risperidone were classified as possible with breastfeeding,
with medical supervision. Breastfed infants must be carefully
observed for hydration status, excessive sedation, feeding
difficulties, and failure to gain weight, which are possible
signs of drug toxicity, and inform mothers to contact their
physicians when they observe such symptoms. Physicians
who prescribe medications to breastfeeding mothers could
limit infant drug exposure by choosing the lowest effective
dose, avoiding polypharmacy, and dividing daily doses to
reduce peak concentrations.[71]
Lithium
Lithium is an important medication for the management of
PP. Monitoring of lithium levels, thyroid and renal function,
and adequate hydration is mandatory during the use of
lithium. The use of lithium for breastfeeding mothers has
generally been discouraged by the American Academy of
Pediatrics (AAP) because of concerns regarding secretion of
the drug through breast milk. Plasma levels in the infant
may exceed 10% of the mother’s plasma levels, causing
toxicity in the infant especially in cases of dehydration.[72]
Lithium has been effective in decreasing relapse rates after
subsequent pregnancies, although it is not clear if lithium
should be restarted during pregnancy or immediately after
parturition. A recent study suggests that lithium prophylaxis
may be more useful in women who only have a past history
of PP than in women with bipolar disorder who have had
mood episodes outside the postpartum period as well.[73]
Anticonvulsants
Valproic acid or carbamazepine may be used to manage PP.
The AAP reported that both these drugs were compatible
with breastfeeding. Lamotrigine is Food and Drug
Administration‑approved for bipolar depression, but no
studies have examined its efficacy in PP. It is unlikely to be used
in the acute treatment phase since its titration takes weeks,
but it may have a role in maintenance treatment. Lamotrigine
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Rai, et al.: Postpartum psychiatric disorders
may be used with caution because high plasma levels of the
drug have been found in breastfeeding infants.[72,73]
Benzodiazepines
Benzodiazepines may have a role in the acute treatment
of PP. Intramuscular lorazepam and haloperidol can be
used to achieve rapid tranquilization. Once the patient
becomes more stable, oral agents can be used. However,
benzodiazepines are not recommended as monotherapy
for PP. In a study of 51 women with first‑onset psychosis
in the postpartum period, 67% achieved remission with a
combination of lithium, antipsychotics, and benzodiazepines;
18% with antipsychotics and benzodiazepines; and 6% with
benzodiazepines alone.[74]
Electroconvulsive therapy
Electroconvulsive therapy (ECT) can yield rapid symptomatic
improvement in mothers with PP or severe PPD, but it may
be challenging for women who have not previously received
any psychiatric treatment to accept this treatment option.
The only risks of ECT to a breastfeeding infant are the
medications given for anesthesia and muscle relaxation, but
since these medications are short‑acting, it is expected that
there is minimal transfer to the infant.[75]
Breast feeding
Women with PP should be advised against breastfeeding
their infants. Both breastfeeding and nocturnal childcare
are important causes of sleep loss, which in turn can lead
to further mood instability particularly in women with
bipolar disorder. Additionally, owing to psychotic state
many women are incapable of breastfeeding. However,
for suppression of lactation, dopamine agonists should be
used cautiously as these drugs may result in psychosis in
vulnerable women.[76] Women who choose to breastfeed
after improvement should be informed about the fact that
all psychotropic drugs are excreted in breast milk at varying
concentrations. The decision to breastfeed while taking
medication should be made after careful weighing the risks
and benefits to the mother as well as the infant.
COURSE AND PROGNOSIS
The prognosis of postpartum disorders is generally good
if diagnosed early and adequately treated, especially in
cases of affective psychosis and brief psychotic disorders.
Women experiencing PP arising from bipolar illness have
a good prognosis; 75–86% remained symptom‑free after
a single episode of PP. Chances of chronic disability
increase in symptoms mimicking schizophrenia. The
chances of recurrence are also very high. The relapse
rate in subsequent pregnancies can be as high as 25–40%.
Women who sought help within 1 month of delivery had
more favorable outcomes and were less likely to suffer a
long‑term disability as compared to women with late‑onset
PP (13% and 33%, respectively).[77]
S220 Indian J Psychiatry 57 (Supplement 2), July 2015
CONCLUSION
Perinatal mental illness is under‑diagnosed and may have
far‑reaching ramifications for the mother, her infant, her
relationships with her partner and other family members.
Early screening and diagnosis is very important. Healthcare
professionals should regularly screen mothers during
antepartum and postpartum visits by using a few simple
questions. The postpartum period is a time of increased
risk for the onset or exacerbation of mood instability
particularly in women with bipolar disorder. Though the
nosological status of PP remains controversial, it is generally
considered a psychotic episode of bipolar disorder. Early
identification of women at high‑risk for developing PP and
initiation of timely therapeutic approaches, consisting
of the combination of pharmacological strategies and
psychotherapeutic approaches, are the key factors to the
successful management of PP. Prospective studies higher
in the hierarchy of evidence is the need of the hour in
order to provide guidelines on prevention and treatment
interventions for postpartum psychiatric disorders.
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Source of Support: Nil, Conflict of Interest: None declared
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