Postpartum Mental Health
Summary
Perinatal mental health disorders encompass a spectrum ranging from the common, self-limiting Baby Blues to severe Postnatal Depression (PND) and life-threatening Puerperal Psychosis. Suicide is the leading cause of maternal death in the first year after birth (MBRRACE). Early recognition is vital. The "Gold Standard" of care for severe illness is admission to a Mother and Baby Unit (MBU) to keep the dyad together. [1,2]
Clinical Pearls
The "Kaleidoscopic" Nature of Psychosis: Unlike typical mania or schizophrenia, Puerperal Psychosis presents with a rapidly fluctuating picture. A patient can be lucid one hour, deeply depressed the next, and deliriously manic the next. This often leads to false reassurance during brief assessments.
Bipolar Risk: Women with a history of Bipolar Disorder have a 50% risk of developing Puerperal Psychosis. They require a prophylactic management plan before birth (often starting meds immediately post-delivery).
Baby Blues is Normal: It happens in >50% of women around Day 3-5 (coinciding with milk coming in). It resolves spontaneously by Day 10. If it persists >2 weeks, it is Depression, not Blues.
Incidence
- Baby Blues: 50-80%.
- Postnatal Depression: 10-15%.
- Puerperal Psychosis: 0.1-0.2% (1-2 per 1000 births).
Risk Factors
- PND: Previous history of depression, Poor social support, Domestic violence, Traumatic birth.
- Psychosis: History of Bipolar Disorder (RR x100), Previous PP, Family history.
Mechanisms
- Hormonal Crash: Precipitous drop in Oestrogen and Progesterone immediately after placental delivery.
- Sleep Deprivation: Chronic sleep loss triggers mania in susceptible individuals (Bipolar diathesis).
- Psychosocial: Adjustment to new role, isolation, pressure.
| Condition | Onset | Features | Treatment |
|---|---|---|---|
| Baby Blues | Day 3-7 | Tearful, Lability, Irritable. | Reassurance. |
| Postnatal Depression | less than 1-3 Mo | Low mood, Anhedonia, Guilt ("Bad mother"), Bonding issues. | CBT / SSRI. |
| Puerperal Psychosis | Day 0-14 | Mania, Delusions, Hallucinations, Confusion. | MBU Admission + Antipsychotics. |
| Postpartum Thyroiditis | Variable | Fatigue, Palpitations, Mood change. | Thyroxine / Beta blockers. |
Puerperal Psychosis (The Emergency)
Postnatal Depression
Physical Screen (Exclude organic causes)
- TFTs: Postpartum Thyroiditis (Thyrotoxicosis or Hypothyroidism) mimics mood disorders.
- FBC: Severe Iron Deficiency Anaemia.
Functional
- Risk Assessment:
- Suicide?
- Harm to baby (intentional or neglect)?
- Harm to other children?
Management Algorithm
ASSESS SEVERITY
↓
┌─────────┼─────────┐
MILD MODERATE SEVERE
(Blues) (PND) (Psychosis)
↓ ↓ ↓
SUPPORT H. VISITOR EMERGENCY
Wait & talking Rx REFERRAL
See SSRI (Crisis Team)
↓ ↓
Consider ADMISSION TO
Perinatal MOTHER & BABY
Psych Team UNIT (MBU)
Pharmacotherapy
- Depression:
- Sertraline: First line (low excretion in breast milk).
- Paroxetine: Safe in breastfeeding (but withdrawal risk).
- Avoid: Fluoxetine (long half-life, accumulates in milk).
- Psychosis:
- Antipsychotics: Olanzapine / Quetiapine.
- Mood Stabilisers: Lithium (monitor baby if breastfeeding), Valproate (Safe after pregnancy, generally avoid if childbearing potential but allowed in acute phase).
- ECT (Electroconvulsive Therapy): Highly effective and rapid for severe psychosis/catatonia. Safe in breastfeeding.
The Mother and Baby Unit (MBU)
- Specialist psychiatric ward where mother is admitted with her baby.
- Goal: Treat mother while supporting attachment and parenting skills. Separation is traumatic and avoided unless safety demands it.
- Maternal Suicide: Leading cause of death.
- Infanticide: Rare but catastrophic outcome of untreated psychosis.
- Child Development: Maternal depression linked to poor cognitive/emotional development in child (attachment disorder).
- Baby Blues: Resolves spontaneously.
- PND: Good prognosis with treatment. Recurrence risk 30-50% in future pregnancies.
- Psychosis: Full recovery is the norm (>90%). However, 50% recurrence risk in next pregnancy (requires prophylaxis).
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| CG192 | NICE (2014) | Antenatal and Postnatal Mental Health. Prioritise MBU admission. |
| Prescribing | UKTIS / LactMed | Databases for drug safety in lactation. |
Landmark Evidence
1. MBRRACE Reports (Ongoing)
- Consistently highlight that psychiatric disease outstrips obstetric causes (sepsis/haemorrhage) for late maternal mortality (6 weeks to 1 year). "Think Sepsis" campaigns were matched by "Think Psychosis".
What are the Baby Blues?
It is a very common feeling of being weepy, emotional, or irritable a few days after giving birth. It is caused by the sudden drop in pregnancy hormones and exhaustion. It goes away by itself in a week or so.
What is Postnatal Depression?
It is a deeper depression that doesn't go away. You might feel you can't cope, that you are a "bad mother", or you might feel numb towards the baby. It is an illness, not a weakness, and it treats well with therapy or medication.
What is Puerperal Psychosis?
This is a rare medical emergency where the mother becomes very confused, manic, or loses touch with reality soon after birth. It is very dangerous but treatable. The mother needs to be in a hospital, ideally a special "Mother and Baby Unit" where the baby can stay with her.
Is medication safe for the baby?
Many antidepressants (like Sertraline) are considered safe for breastfeeding because very little gets into the milk. A healthy mum is the most important thing for a healthy baby.
Primary Sources
- NICE. Antenatal and postnatal mental health: clinical management and service guidance (CG192). 2014.
- MBRRACE-UK. Saving Lives, Improving Mothers’ Care. 2021.
- Jones I, et al. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the postpartum period. Lancet. 2014.
Common Exam Questions
- Diagnosis: "Woman 3 days post-partum, crying?"
- Answer: Baby Blues (Normal).
- Safety: "Woman 5 days post-partum, thinks baby is God?"
- Answer: Puerperal Psychosis. Admit urgently.
- Prescribing: "SSRI of choice in breastfeeding?"
- Answer: Sertraline (or Paroxetine).
- Risk: "History of Bipolar, pregnant now?"
- Answer: High risk of postpartum psychosis. Refer to Perinatal Psych.
Viva Points
- Why MBU?: Separation of mother and infant causes significant distress and impairs long-term attachment. We only separate if the mother is a direct physical threat to the baby.
- Tokophobia: Severe fear of childbirth. Can be an indication for elective C-Section if it affects mental health significantly.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.