PERINATAL

PSYCHIATRY
MODERATOR: DR. NAVKIRAN S. MAHAJAN
 INTRODUCTION
◦ Perinatal mental illness refers to psychiatric disorders that are prevalent during
pregnancy and as long as 1 year after delivery.

◦  Perinatal disorders ranging from mild depression and anxiety, mania, to florid
psychosis all fall under the rubric of perinatal mental illness.

◦ Disorders that were present before pregnancy, or recurring along with

disorders that emerge during pregnancy or in the postpartum period, are all
considered perinatal mental illnesses. 
 DIAGNOSTIC CRITERIA
◦ According to ICD-11,
Mental and Behavioural disorders associated with pregnancy, childbirth and the
puerperium.
Syndromes associated with pregnancy or the puerperium (commencing within
about 6 months after delivery) that involves significant mental and behavioural
features. If the symptoms meet the diagnostic requirements for a specific mental
disorder , that diagnosis should also be assigned.
◦ 6E20: Mental and Behavioural disorders associated with pregnancy, childbirth
and the puerperium, without psychotic symptoms
A syndrome associated with pregnancy or the puerperium (commencing within
about 6 weeks after delivery) that involves significant mental and behavioural
features, most commonly depressive symptoms.
◦ Does not include delusions, hallucinations or other psychotic symptoms.
◦ Not used to describe mild and transient depressive symptoms that do not meet
the diagnostic requirements for a depressive episode, which may occur soon
after delivery (so called post-partum blues)
◦ 6E20.0 : Postpartum depression NOS
◦ 6E20.Y : Other specified mental and behavioural disorders associated with
pregnancy, childbirth and the puerperium, without psychotic symptoms
◦ 6E20.Z : Mental and Behavioural disorders associated with pregnancy,
childbirth and the puerperium, without psychotic symptoms, unspecified
 DIAGNOSTIC CRITERIA
6E21: Mental and Behavioural disorders associated with pregnancy, childbirth
and the puerperium, with psychotic symptoms
A syndrome associated with pregnancy or the puerperium (commencing
within about 6 weeks after delivery) that involves significant mental and
behavioural features, including delusions, hallucinations or other psychotic
symptoms.
Mood symptoms are also typically present.
If the symptoms meet the diagnostic requirements for a specific mental
disorder, that diagnosis should also be assigned.
◦ 6E2Z : Mental and Behavioural disorders associated with pregnancy, childbirth
and the puerperium, unpecified.
◦ In DSM-V,
In Specifiers for Depressive disorder and Specifiers for Bipolar and Related
Disorders, there is a specifier :
With peripartum onset: This specifier can be applied to the current or, if full
criteria are not currently met for a depressive disorder, most recent episode of
major depression if onset of mood symptoms occurs during pregnancy or in the
4 weeks following delivery.
According to DSM-V,
There is a specifier in Brief Psychotic Disorder, i.e.
With post-partum onset: If the onset is during pregnancy or within 4 weeks post-partum.
◦ Criteria for Brief Psychotic Disorder
◦ A. Presence of one (or more) of the following symptoms.
◦ At least one of these must be (1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
Note: Do not include a symptom if it is a culturally sanctioned response.
B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full
return to premorbid level of functioning.
C. The disturbance is not better explained by major depressive or bipolar disorder with psychotic
features or another psychotic disorder such as schizophrenia or catatonia, and is not attributable to the
physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
 FUTURE DIRECTIONS
◦ Changes in the classification of perinatal psychiatric disorders are needed as there
is lack of clarity to its nomenclature, few of the reasons are as follows:
a) Rationale for the 4 to 6‑week postpartum‑onset specifier not clearly mentioned
in both ICD and DSM systems, especially when there is evidence that the risk of
postpartum mental illnesses may be high in the first trimester to the 1st year after
childbirth
b) Nonpsychotic episodes are included but with no adequate reasons mentioned
c) For depressive disorders, the postpartum ‑onset specifier will need to be extended
d) Some of the episodes in the postpartum period are believed to be influenced
by hormonal changes (and associated neurotransmitter changes);
◦ However, long‑term outcome studies suggest that episodes of PP are most
often an initial manifestation of bipolar disorder.
◦ However, the abrupt onset and characteristic phenomenology could suggest
the researchers to consider a biological etiology for this condition
e) Postpartum psychiatric disorders may manifest weeks beyond the 1st month
or 6 weeks after delivery.
PERINATAL
DISORDERS
 PERINATAL DEPRESSION
◦ Minor or major depression affects up to 25 percent of pregnant women, a
similar rate as nonpregnant women.

◦ Postpartum depressive syndromes affect 15 percent of mothers.

◦ Completed suicide is a leading cause of death in new mothers, and infanticide

is another devastating outcome which has brought this disorder frequent media
attention.
◦ Rate of depression relapse was 68 percent in women who discontinued
antidepressants prior to pregnancy, compared to 26 percent in women who
maintained their medication during pregnancy.
◦ 50 to 75 percent of relapses occurred in the first trimester, which argues
against delaying medication until second trimester.
◦ Duration of the depressive episode, a history of more recurrences, and a major
depressive episode in the 6 months prior to pregnancy were associated with
increased likelihood of pregnancy relapse.

CTP EDITION 10TH

◦ Postpartum episodes are commonly characterized by obsessive compulsive,
particularly intrusive violent thoughts, psychotic symptoms, and anxiety.
◦ Risk factors:
 Personal or family history of depression
 Personal history of previous depressions related to reproductive events (such
as PMDD or previous PPDs)
 Multiple or severe psychosocial problems, trauma, or chronic interpersonal
difficulties
 Childhood sexual abuse history(50% incidence of PPD)
◦ SCREENING offers little hope for symptom improvement if referrals for treatment
cannot be made.
◦ Because the assessment of perinatal disorders can be confounded by somatic
complaints common to the perinatal period, such as sleep and eating disturbances,
decreased sexual interest, weight gain, and fatigue,
◦ widespread use of the Edinburgh Postnatal Scale for Depression, which deemphasizes
such symptoms, has become a common instrument utilized by obstetricians, family
doctors, psychiatrists, and pediatricians.
◦ Extensive experience with the ten-item Edinburgh Postnatal Depression Scale (EPDS)
has shown it to accurately identify depression in pregnant and postpartum women
 POST-PARTUM BLUES
◦ Most common constellation of mood symptoms experienced by women.
◦ Occurring in 50 to 80 percent of women in the immediate postpartum period.
◦ Include transient symptoms and rapid mood shifts, including tearfulness,
irritability, anxiety, insomnia, lack of energy, loss of appetite, and the general
experience of feeling overwhelmed—particularly with regard to newborn
caregiving tasks.

CTP EDITION 10TH

◦ Onset typically occurs after the third postpartum day, after the mother has
left the hospital after delivery.
◦ Symptoms typically peak by day 5 and spontaneously resolve by day 10
postpartum.
◦ 20 to 25 percent women who experience symptoms of postpartum blues will
go on to experience postpartum major depression.
◦ Treatment of the postpartum blues should include psychoeducation, validation
of the mother’s experience, and careful monitoring for a worsening or
prolongation of symptoms.
 Perinatal Anxiety
◦ 8.5 to 13 percent with increase to 20 percent when subsyndromal forms of
anxiety are included.
◦ Rates of anxiety comorbidity in women with perinatal depression reach 50
percent.
◦ Medical diagnoses such as hypo/hyperthyroidism, anemia, and hypertension
have a similar phenotype and should be ruled out.
◦ Prenatal stress and pregnancy-specific stress symptoms are associated with
increased glucocorticoid concentrations in the mother–fetus dyad, pregnancy
complications, earlier timing of delivery, prematurity, and low birth weight.
◦ Risk factors in pregnancy include:
young adulthood,
 single motherhood,
 pregnancy complications,
 stressful life events,
 poor physical health, and
 past year victimization
◦ Assertive screening in pregnancy is therefore warranted and affective
symptoms shouldn’t be assumed to be normative responses to pregnancy.
◦ Both antenatal anxiety and depression are highly predictive of PPD, which is
important in framing the decision-making process for treatment choices in
pregnancy.
 OCD
◦ Subsyndromal obsessive-compulsive disorder (OCD) symptoms:
◦ 25 percent prevalence in perinatal women,
◦ May be an exaggeration of adaptive maternal behavior.
◦ Most common OCD manifestations include: aggressive obsessions, contamination
obsessions, and cleaning and checking compulsions.
◦ OCD and depression in postpartum women are highly comorbid (40 percent)
◦ Subsyndromal aggressive obsessions are significantly more common in postpartum
compared with nonpostpartum women.
◦ Ego-dystonic aggressive obsessions toward the infant, usually regarded as highly
distressing by new mothers, must be distinguished from ego-syntonic aggressive
ideation which may accompany depression and psychosis
 PTSD
◦ Reported in 20 to 33 percent of new mothers, while the prevalence of PTSD
ranges from 1.7 to 6 percent.
◦ These symptoms can be categorized into context of delivery complications,
reactions to miscarriage, and reactions linked to previous sexual trauma.
◦ The importance of treatment stems from difficulties in mother–infant bonding
or even avoidance of contact with infant in this disorder.
 Panic disorder
◦ similar prevalence in pregnancy compared to the general population of
approximately 1 to 3 percent.
◦ There may be an increased prevalence of new onset panic disorder in the first
3 months postpartum based upon a retrospective study, which awaits
confirmation in a prospective study design.
 MANAGEMENT OF PERINATAL
DEPRESSION AND ANXIETY
◦ SSRIs
◦ CBT
◦ Reproductive hormones
◦ Psychosocial interventions
 Perinatal Depression and Anxiety
Treatment
◦ Avoiding or stopping medication use during pregnancy may be more harmful
than taking a medication.
◦ For new onset of depression, an SSRI may be tried initially because such
agents are associated with a low risk of toxic effects in patients taking an
overdose, as well as with ease of administration.
◦ However, if the patient has previously had a positive response to a specific
drug from any class of antidepressants, that agent should be strongly
considered
◦ Slow increases in the dose are helpful in managing side effects.
◦ Women who have given birth recently often are sensitive to medications side
effects, possibly related to anxious, agitated features early in the postpartum course.
◦ Treatment should be initiated at half of the recommended starting dose (e.g., 25 mg
of sertraline per day or 10 mg of paroxetine per day) for 4 days, and doses should be
increased by small increments (e.g., 25 mg of sertraline per week or 10 mg of
paroxetine per week) as tolerated until full remission is achieved.
◦ If the patient has a response to an initial trial of medication lasting 6 to 8 weeks, the
same dose should be continued for a minimum of 6 months after a full remission has
been achieved to prevent a relapse.
◦ If there is no improvement after 6 weeks of drug therapy or if the patient has a
response but then has a relapse, a medication change (within-class or different
class) is recommended.
◦ Drug doses may need to be increased in the third trimester during the period
of increased hepatic metabolism and expansion of blood volume.
◦ Long-term maintenance treatment for the prevention of recurrence should be
considered for women who have had three or more episodes of severe
depression.
 NEONATAL ADAPTATION
SYNDROME
◦ Reported to affect 30 percent of late pregnancy, SSRI-exposed newborns, and substantially
more preterm infants are affected.
◦ Features of poor neonatal adaptation include
 respiratory difficulty,
 hypoglycemia,
hypertonia,
jitteriness,
vomiting,
 seizures,
 sleep disturbances.
◦ The syndrome appears to be time limited with greatest incidence in the first 48
hours postbirth, but potentially extending to 2 weeks postbirth.
◦ While one study provided evidence for similar rates of neonatal signs in the
absence of SRI exposure in 2 weeks prior to delivery, thus implicating
maternal or other neonatal factor in this syndrome.
◦ Another study found increased adaptation syndrome risk even after control for
maternal characteristics.
◦ Fluoxetine and CBT were similarly effective and fluoxetine was significantly
more effective than placebo
◦ For PPD with comorbid anxiety, both antidepressant and CBT were
efficacious; however there was no added benefit of combining modalities.
◦ PPD treatment or prophylaxis with the reproductive hormones estrogen and
progesterone:
In an RCT of transdermal 17β-estradiol 200 mg per day versus placebo, the
estradiol-treated group had a significant reduction in depression scores
beginning 4 weeks after treatment initiation that was maintained at 3 months.
sublingual estradiol (mean dose of 4.8 mg/day)
intramuscular depot-progestogen norethisterone enanthate 200 mg at 48 hours
postdelivery.
 OTHER TREATMENT
MODALITIES
◦ Psychosocial interventions
◦ Five-week morning 7,000 lx bright light therapy
◦ Fish oil administered in a dose of 1 g, 50 percent eicosapentaenoic acid (EPA)
and 50 percent docosahexaenoic acid (DHA)
◦ Given comorbidity of depression and anxiety and overlap of treatments for both, it
is reasonable to offer behavioral treatments as described above for depressive
syndromes.
◦ There was no added benefit of 12-group CBT to paroxetine in women with
comorbid depression and anxiety.
◦ Notably, prevention of postpartum anxiety has been successful in prenatal
educational formats to deliver CBT for postpartum OCD symptom reduction as
well as parenting communication for reducing postpartum generalized anxiety and
improving overall postpartum adjustment and marital satisfaction.
◦ Standard guidelines for the treatment of GAD, PTSD, OCD, and panic disorder
should inform the treatment of postpartum women with these disorders, using
specific psychotherapeutic interventions when available.
◦ Medication management described in standard guidelines includes SSRIs as a
first-line treatment; however there is also considerable evidence for the benefit of
TCAs, such as clomipramine for OCD and imipramine for panic disorder.
◦ Nightmares of PTSD can be effectively treated with the alpha-1 adrenergic
receptor antagonist prazosin, and could benefit this population.
◦ The use of benzodiazepines to promote sleep and/or treat residual anxiety
symptoms.
◦ Screen for alcohol use and be vigilant for the development of hypertension and pre‐
eclampsia.
◦ Women who take SSRIs may be at increased risk of post‐partum haemorrhage.
◦ When taken in late pregnancy, SSRIs may increase the risk of persistent pulmonary
hypertension of the newborn. The absolute risk is very low.
◦ The neonate may experience discontinuation symptoms, which are usually mild,
such as agitation and irritability, or rarely respiratory distress and convulsions (with
SSRIs). The risk is assumed to be particularly high with short half ‐life drugs such as
paroxetine and venlafaxine. Continuing to breastfeed and then ‘weaning’ by
switching to mixed (breast/bottle) feeding may help reduce the severity of reactions.
 Bipolar disorder and preganancy
◦ 50 percent of women with bipolar I disorder had perinatal mood disorder
episodes, with 25 percent constituting nonpsychotic mania and 20 percent
constituting mania or psychotic depression
◦ Mothers with bipolar II disorder had more widely distributed timing of mood
episode, both during pregnancy and after 1- month postpartum.
◦ Clinicians should maintain a high suspicion for bipolarity given some
indication that this diagnosis might be missed in as many as 50 percent of
cases presenting with unipolar PPD.
◦ Somatic treatments are the front line treatments
◦ close clinical monitoring and efforts to enlist the aid of social supports to
prevent sleep disruption and stabilize social rhythms
◦ Illness recurrence:
after discontinuation of treatment was 3-fold higher in the postpartum period
compared to nonpostpartum women with bipolar disorder.
mood stabilizer treatment in pregnancy (vs. those who discontinue abruptly)
have half the rates of recurrence, but may still have recurrence rates of 20 to 25
percent.
◦ Lithium prophylaxis in late pregnancy or with 24 hours postbirth: 10-fold
decrease in the rate of postpartum illness recurrence.
◦ For unresponsive illness, benzodiazepines, antipsychotics, and ECT also have
an important role.
◦ A low-dose, mid-potency antipsychotic, such as perphenazine, can be added as
a PRN agent for prodromal or breakthrough symptoms.
 NICE RECOMMENDATIONS
■ For women who have had a long period without relapse, the possibility of switching to a safer drug
(antipsychotic) or withdrawing treatment completely before conception and for at least the first trimester should
be considered.
■ The risk of relapse both pre and post partum is very high if medication is discontinued abruptly.
■ No mood stabiliser is clearly safe. NICE recommends the use of mood ‐stabilising antipsychotics as a
preferable alternative to continuation with a mood stabiliser.
■ Women with severe illness or who are known to relapse quickly after discontinuation of a mood stabiliser
should be advised to continue their medication following discussion of the risks.
■ NICE recommends that if lithium is considered essential in a woman planning pregnancy, the woman be
informed of the risk of foetal malformations and the risk of toxicity in the baby if lithium is continued during
breastfeeding.
Lithium plasma levels should be monitored more frequently throughout pregnancy and the post-natal period,
and lithium should be stopped during labour.
 NICE RECOMMENDATIONS
◦ Women prescribed lithium should undergo appropriate monitoring of the foetus in
liaison with foetal medicine obstetric services to screen for Ebstein’s anomaly.
◦ NICE advises against the use of valproate in pregnancy. Valproate should be
discontinued before a woman becomes pregnant. Women, who are planning a
pregnancy should be advised to gradually stop the drug because of the high risk of
foetal malformations and adverse neurodevelopment outcomes after any exposure in
pregnancy.
◦ If valproate is the only drug that works for a particular woman, and this is seen as the
only option for her during pregnancy, then she needs to be given a clear briefing of the
risks and to sign a consent form confirming that she understands the risk of
malformations and developmental delays.
◦ NICE advises discussing the possibility of stopping carbamazepine if a woman
is planning a pregnancy or becomes pregnant.
◦ If carbamazepine is used, prophylactic vitamin K should be administered to
the mother and neonate after delivery.
◦ In acute mania in pregnancy use an antipsychotic and if this is ineffective
consider ECT.
◦ In bipolar depression during pregnancy use cognitive behavioural therapy
(CBT) for moderate depression and an SSRI for more severe depression.
Lamotrigine is also an option.
 Nonaffective Psychosis
◦ This category includes diagnoses of schizophrenia, delusional disorder, brief and unspecified
psychosis.
◦ While first-generation antipsychotics (FGAs) are associated with diminished fertility rate via
hyperprolactinemia and anovulation, second-generation antipsychotics (SGAs) are associated
with normal fertility rates and high rate of unwanted pregnancies and repeated abortions in this
population.
◦ These are often high-risk pregnancy due to low rates of prenatal care, high rates of poverty,
homelessness, poor social supports, poor nutrition, high use of prescribed medications, alcohol,
drugs, and tobacco.
◦ These women also have increased rates of sexual abuse pre-pregnancy and physical abuse in
pregnancy. Often these mothers are less aware of signs of labor and delivery and are at greater
risk of obstetric complications.
◦ Common delusional themes include ideas that the birth did not occur, that the
baby is dead or defective and there can also be command hallucinations to
harm the baby.
◦ Fifty percent of these mothers are separated from infants at discharge from the
obstetric hospital due to incapacity to provide for child’s minimal needs for
physical sustenance.
◦ There is a 75 percent puerperal recurrence rate in schizophrenia and a 100
percent readmission rate 10-year post index postpartum admission due to
schizophrenia relapse
 NICE RECOMMENDATIONS
◦ Patients with a history of psychosis who are maintained on antipsychotic medication should be advised to
discuss a planned pregnancy as early as possible.
◦ Be aware that drug‐induced hyperprolactinaemia may prevent pregnancy. Consider switching to an
alternative drug if hyperprolactinaemia occurs and a pregnancy is planned.
◦ If a pregnant woman is stable on an antipsychotic and likely to relapse without medication, advise her to
continue the antipsychotic. Switching medication is generally not advised owing to the risk of relapse.
◦ Consider using the antipsychotic that has worked best for the woman after discussion of benefits and
risks. This may minimise foetal exposure by avoiding the need for higher doses if the woman relapses,
and/or multiple drugs should relapse occur.
◦ The most reproductive safety data are available for quetiapine, olanzapine, risperidone and haloperidol,
with more limited data for clozapine, aripiprazole and ziprasidone. Quetiapine has a relatively low rate of
placental passage.
◦ Advise about diet and monitor for excessive weight gain.
◦ Monitoring for gestational diabetes. NICE recommends that women be offered an
oral glucose tolerance test.
◦ NICE recommends avoiding depot preparations and anticholinergic drugs in
pregnancy unless a depot is needed to keep a woman well through the perinatal
period.
◦ Antipsychotic discontinuation symptoms can occur in the neonate (e.g. crying,
agitation, increased suckling). This is thought to be a class effect. When
antipsychotics are taken in pregnancy it is recommended that the woman gives
birth in a unit that has access to paediatric intensive care facilities.
 POST-PARTUM PSYCHOSIS
◦ Most severe of the perinatal mood disorders.
◦ 0.1 to 0.2 percent (1 in 1,000 to 1 in 500) of postpartum women.
◦ Escalates rapidly to florid psychosis within days postpartum and often results
in presentation for treatment within 3 weeks postpartum.
◦ Commonly associated with bipolar disorder, unipolar psychotic depression, or
a family history of affective disorder.
◦ Large percentage of de novo postpartum psychosis cases for whom a brief
psychotic (formerly called cycloid psychosis) clinical picture is evident,
characterized by
Disorganized behavior
 Rapid shifts from excited to inhibited motoric states, from confusion to
lucidity, and from anxiety/paranoia to happiness.
 Auditory or visual hallucinations
 Paranoid or grandiose delusions,
 Elements of delirium or disorientation are common
Extreme deficits in judgment and high levels of impulsivity.
◦ In one study that examined brief psychosis cases 12 years later, the clinical
phenotype shifted to one of bipolar disorder in 16 to 20 percent of cases.
◦ During follow-up in this study, there was a striking lack of psychotic
recurrence in nearly 30 percent of women with an index episode of postpartum
psychosis;
◦ furthermore these women were largely unmedicated at the time of follow-up.
◦ It is a Medical Emergency because of the potential risk for infanticide or
suicide and therefore imminent referral to a psychiatrist, hospitalization, or
initiation of antipsychotic medication is indicated.

◦ 70-fold increased risk of suicide in the first 12-month postpartum with peak
rates within a few days to a few weeks after discharge.
◦ If recognized in its early stages and treated aggressively, postpartum psychosis
can have a good prognosis.
◦ Maintenance on antipsychotic medication as per standard treatment guidelines
is recommended.
◦ Women at high risk for psychosis, many of whom have a diagnosis of bipolar
disorder, have been successfully treated with immediate postpartum initiation
of lithium.
◦ High-dose estradiol-administered postdelivery was shown to reduce the risk of
recurrent postpartum psychosis in an open study that awaits replication.