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ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 2  |  Page : 565-570

Psychiatric disorders in the postpartum period


1 Department of Neuropsychiatry, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Psychiatry, Menoufia University Hospitals, Menoufia, Egypt
3 Department of Psychiatry, El Khanka Mental Hospital, Egypt

Date of Submission15-Jun-2014
Date of Acceptance27-Aug-2014
Date of Web Publication31-Aug-2015

Correspondence Address:
Mohammed A Zeina
Department of Mental Health, El Khanka Mental Hospital
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.163919

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  Abstract 

Objective
The aim of this study was to determine the incidence, risk factors, clinical presentation, and complications of postpartum psychiatric disorders and the correlation between psychosocial stressors and postpartum psychiatric disorders.
Background
Postpartum psychiatric disorders are important factors that affect the quality of life - for example, employment rates, interpersonal and interfamilial communications, maternal skills, and many other social-cognitive functions - in different ways.
Patients and methods
This study was conducted on 250 women in their postpartum period who were recruited from Kfr El-Zayat General Hospital (Gharbia Governorate); of them, 50 patients fulfilled the Diagnostic and statistical manual of mental disorders, 4th ed., (DSM-IV) criteria of postpartum psychiatric disorders. All participants were evaluated by means of clinical evaluation according to DSM-IV criteria and psychometric evaluation using the Holmes and Rahe Stress Scale, the Quality of Life Scale, the Stress Level Assessment Questionnaire, the Edinburgh Postnatal Depression Scale, and the Global Assessment of Functioning Scale.
Results
In our study, 50/250 (20%) women fulfilled the DSM-IV criteria for postpartum psychiatric disorders and were classified into the following groups: postpartum blues, 68% (34/50); postpartum depression, 20% (10/50); postpartum panic disorder, 8% (4/50); and postpartum generalized anxiety disorder, 4% (2/50).
Conclusion
The postpartum period is a critical period during which time women are vulnerable to many postpartum psychiatric disorders. The incidence of postpartum psychiatric disorders in new Egyptian mothers is similar to that in many countries. The most frequent postpartum psychiatric disorder is postpartum blues. Marital, social, and economic factors play a major role in the development of the observed postpartum psychiatric disorders.

Keywords: anxiety, blues, depression, panic, postpartum psychiatric disorders


How to cite this article:
Mohamed NR, Ragab AZ, El Bahy MS, Zeina MA. Psychiatric disorders in the postpartum period. Menoufia Med J 2015;28:565-70

How to cite this URL:
Mohamed NR, Ragab AZ, El Bahy MS, Zeina MA. Psychiatric disorders in the postpartum period. Menoufia Med J [serial online] 2015 [cited 2019 Sep 20];28:565-70. Available from: http://www.mmj.eg.net/text.asp?2015/28/2/565/163919


  Introduction Top


Psychiatric disorders are important factors that affect the quality of life - for example, employment rates, interpersonal and interfamilial communications, marriage, child-bearing ability, parental skills, and many other social-cognitive areas - in different ways [1] .

Evidence suggests that the rate of onset of affective disorders is high during pregnancy, as well as during the postpartum period [2] .

Researchers have suggested that affective illness that emerges during the postpartum period does not differ significantly from the affective illness occurring in women at other times. This opinion was reflected in the Diagnostic and statistical manual of mental disorders, 4th ed., (DSM-IV) criteria, which included postpartum psychiatric illness as a subtype of either bipolar disorder or major depressive disorder [3] .

Postpartum blues (PPB) affects ~50-80% of new mothers. Symptoms may include mood swings with periods of feeling anxious, irritable, or tearful overlapping with periods of feeling well. Sleeping difficulties may also occur. The symptoms usually begin 3-4 days after delivery, worsen by days 5-7, and tend to resolve by day 12 [4] .

Postpartum depression (PPD) affects 10-20% of new mothers [5] and is characterized by tearfulness, despondency, emotional lability, guilt, loss of appetite, suicidal ideation, and sleep disturbance as well as feelings of inadequacy and inability to cope with the infant, poor concentration and memory, fatigue, and irritability [6] .

Postpartum psychosis is rare, occurring in 1-2 per 1000 deliveries, and is characterized by an acute psychotic state of confusion, delirium, delusions, hallucinations, and insomnia [7] .

Between 4 and 6% of women experience panic disorder with onset of the postpartum period. It is characterized by shortness of breath or hyperventilation, palpitation, pounding heart, or accelerated heart rate, trembling or shaking, chest pain or discomfort, sweating, feeling unreal or detached from your surroundings, feeling choked, nausea or abdominal distress, feeling dizzy, light headed, or faint, hot or cold flashes, fear (of dying, losing control, or going crazy), and/or paresthesias (numbness or tingling sensation) [8] .

Postpartum generalized anxiety disorder (PP GAD) affects 4.4% of new mothers. It is characterized by anxiety, apprehensive expectation, nervousness, fatigue, excessive and intrusive or persistent worries, a pervasive feeling of apprehension or dread, inability to tolerate uncertainty, difficulty in concentrating or focusing, muscle tension, sleep disturbance, feeling edgy and restless or jumpy, stomach problems, nausea, and/or diarrhea [9] .

Obsessive compulsive disorder is the most misunderstood and misdiagnosed of the postnatal disorders, as obsessions and compulsions could appear separately or in conjunction with the diagnosis of major depression and/or panic disorders [10] . It is estimated that as many as 3-5% of new mothers experience obsessive compulsive disorder during the postpartum period.

It is estimated that 1-7% of women during the postpartum period develop post-traumatic stress disorder after giving birth; the symptoms include exposure to a traumatic event, distressing memories about the event, nightmares, flashbacks of psychological distress, negative mood, altered sense of reality, inability to remember important aspects of the event, attempting to avoid symptoms and reminders of the event, problems with concentration, sleep disturbances, and hypervigilance [11] .

The aims of this work were to determine the risk factors, clinical presentation, and complications of postpartum psychiatric disorders and the correlation between psychosocial stressors and postpartum psychiatric disorders.


  Patients and methods Top


Patients

This was a cross-sectional study conducted during the postpartum period (6-8 weeks after delivery) and held at Kfr El-Zayat General Hospital (Gharbia Governorate) between 1 January 2013 and 31 June 2013. The women fulfilling the inclusion criteria in this study were 250 new mothers; of them 50 patients fulfilled the DSM-IV criteria for postpartum psychiatric disorders.

Inclusion criteria

All selected studied women were aged between 23 and 29 years, had completed a gestational period of not less than 28 weeks, had been pregnant for the first time, were interviewed during the postpartum period (6-8 weeks after delivery), had undergone vaginal deliveries, were breast-feeding, and were educated (able to read and answer questions on the scales without help).

Exclusion criteria

Women who either had a past history or a positive family history for psychiatric disorders, had undergone a complicated delivery, had diabetes mellitus, hypertension, renal disease, liver disease, cardiac disease, eclampsia, pre-eclampsia, puerperal sepsis, or epilepsy, had a history of drug abuse, or were illiterate were excluded.

Ethical approval and patients consent

The ethical committee of Kfr El-Zayat General Hospital approved the research on the selected group of women after revising the protocol. Patient consent was requested and the consent form was signed by all women studied.

Methods

All studied mothers approved and signed consent forms to undergo the following:

  1. Clinical assessment including:


    1. Full general medical examination and
    2. Full neurological examination.


  2. Psychiatric assessment including:


    1. Full psychiatric history and assessment according to DSM-IV criteria.
  3. Psychological assessment including:


    1. Holmes and Rahe Stress Scale (stressful life event scale).
    2. Quality of Life Scale (QOLS).
    3. Stress Level Assessment Questionnaire.
    4. The Edinburgh Postnatal Depression Scale (EPDS).
    5. Global Assessment of Functioning Scale (GAFS).
Statistical analyses

The data were collected and statistically analyzed using a personal computer equipped with statistical package for the social sciences (SPSS; SPSS Inc., Chicago, Illinois, USA). Descriptive statistics and analytical statistics were used. Descriptive statistics included number, percentage, mean (-0 X ), and SD. Analytical statistics included the ANOVA test (f-test) and the Student t-test.


  Results Top


Clinical evaluation

The prevalence of postpartum psychiatric disorders among the women fulfilling the inclusion criteria was 20% (50/250) [Table 1].

As regards mood symptoms, there was a highly statistically significant difference (P < 0.001) between patients with postpartum psychiatric disorders according to DSM-IV criteria with respect to the presence of depressed mood, lack of interest, sadness, and anxiety.

There was a statistically significant difference (P < 0.05) among patients with postpartum psychiatric disorders according to DSM-IV criteria with respect to tearfulness and feelings of guilt.

As regards disturbed thoughts, there was a highly statistically significant difference (P < 0.001) between patients with postpartum psychiatric disorders according to DSM-IV criteria with respect to the presence of fearful ideations and poor concentration. As regards vegetative symptoms, there was a highly statistically significant difference (P < 0.001) between patients with postpartum psychiatric disorders according to DSM-IV criteria with respect to loss of appetite and desire for sex, whereas there was a moderately statistically significant difference (P < 0.01) between patients with postpartum psychiatric disorders according to DSM-IV criteria with respect to the presence of insomnia.

As regards somatic symptoms, there was a highly statistically significant difference (P < 0.001) between patients with postpartum psychiatric disorders according to DSM-IV criteria with respect to the presence of shortness of breath, palpitation, chest pain, hot flushes, sweating, muscle tension, fatigue, and fainting.

Psychosocial evaluation

In the present study, one of the most significant social stressors was the death of either the mother or the father; this factor was present in 100% of PPD, postpartum panic disorder (PP Panic D), and PP GAD patients and in 11.8% of PPB patients, showing a highly statistically significant difference (P < 0.001).

In this study, unemployment of mothers (considered an economic stressor) was an apparent factor in the development of postpartum psychiatric disorders; it was present in 100% of PPD and PP Panic D patients and in 40.3% of PPB patients, showing a moderately statistically significant difference (P < 0.009).

In the present study, dissatisfaction in marital life due to problems with either husbands or families-in-law showed a highly statistically significant difference (P < 0.001), being seen in 100% of PP GAD patients, 88.2% of PPB patients, 80% of PPD patients, and 50% of PP Panic D patients.

Psychometric evaluation

  1. GAFS: In the present study, PPB patients scored the highest on the GAFS, followed by PP GAD patients, PP Panic patients, and PPD patients, with a moderately statistically significant difference (P < 0.009) [Table 2].
  2. EPDS: In the present study, only PPD patients exceeded the cutoff point (10) in the EPDS, with a highly statistically significant difference (P > 0.001) [Figure 1] and [Table 3].
  3. Holmes and Rahe Stress Scale (stressful life event scale): In this study, PP GAD patients scored the highest on the stressful life event scale (401 ± 1.56), followed by PPD patients (350.2 ± 51.6), PP Panic patients (297 ± 12.7), and PPB patients (176.4 ± 49.3), with a statistically high significant difference (P > 0.001).
  4. QOLS: The QOLS scores revealed that PP GAD patients had the lowest quality of life (34 ± 1), followed by PP Panic patients (44.6 ± 2.79), PPD patients (58.5 ± 16.7), and PPB patients (132.5 ± 36.1), with a highly statistically significant difference (P > 0.001) [Figure 2] and [Table 4].
  5. Stress Level Assessment Questionnaire: Results of the Stress Level Assessment Questionnaire showed that PP GAD patients had the highest stress level (94 ± 1), followed by PPD patients (83.8 ± 5.13), PP Panic patients (82.5 ± 0.57), and PPB patients (47.23 ± 11.1), with a highly statistically significant difference (P > 0.001) [Figure 1] [Figure 2] [Figure 3] and [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6].
Figure 1: Distribution of mean values of the Edinburgh Postnatal Depression Scale among patients who fulfi lled the Diagnostic and statistical manual of mental disorders, 4th ed., criteria for postpartum psychiatric disorders

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Figure 2: Distribution of mean values of the Holmes and Rahe Stress Scale among patients who fulfi lled the Diagnostic and statistical manual of mental disorders, 4th ed., criteria for postpartum psychiatric disorders

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Figure 3: Distribution of mean values of the Quality Of Life Scale among patients who fulfilled the Diagnostic and statistical manual of mental disorders, 4th ed., criteria for postpartum psychiatric disorders

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Table 1 Frequency of postpartum psychiatric disorders according to Diagnostic and statistical manual of mental disorders, 4th ed., criteria

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Table 2 Variations in mean values of Global Assessment of Functioning Scale among patients fulfilled Diagnostic and statistical manual of mental disorders, 4th ed., criteria of postpartum psychiatric disorders

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Table 3 Variations in the results of the Edinburgh Postnatal Depression Scale among patients fulfi lling the Diagnostic and statistical manual of mental disorders, 4th ed., criteria for postpartum psychiatric disorders

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Table 4 Variations in the results of the holmes and rahe stress scale among patients fulfi lling the Diagnostic and statistical manual of mental disorders, 4th ed., criteria for postpartum psychiatric disorders

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Table 5 Variations in the results of the quality of Life Scale among patients fulfi lling the Diagnostic and statistical manual of mental disorders, 4th ed., criteria for postpartum psychiatric disorders

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Table 6 Variations in the results of the stress level assessment questionnaire among patients fulfi lling the Diagnostic and statistical manual of mental disorders, 4th ed., criteria for postpartum psychiatric disorders

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  Discussion Top


The 6-8 weeks following delivery is a time of vulnerability to psychiatric disorders for many women [12] .

In the present study, the incidence of PPB in new mothers was 68%; the study by Gonidakis et al. [4] concorded with ours as they suggested that PPB affects ~50-80% of new mothers. The mean score for PPB patients on applying the Global Assessment Functioning Scale was 84.05 ± 7.1, indicating nonrequirement for medical treatment. Jellinek et al. [13] and Altshuler et al. [14] suggested that symptoms of PPB usually resolve by 2 weeks of delivery. When we applied the QOLS on PPB patients, we found no role for the quality of life in the development of PPB. Bradley et al. [15] did not conclusively link PPB with events of labor and delivery, social class, marital status, and other factors.

Patel et al. [5] estimated that PPD affects 10-20% of new mothers. In the present study, we found the incidence of PPD in new mothers to be 20%. Goyal et al. [16] suggested that low socioeconomic status could be associated with the incidence of PPD. We found too that socioeconomic status could be a risk factor in PPD patients. Eighty percent of PPD patients were not working, which may be an additional financial stress factor to the expenses accruing from having a new baby.

In our study, 80% of PPD patients had disturbed intrafamilial relations with their husbands and families-in-law. Glavin et al. [17] suggested that the father had an important role in the postpartum period and is often the nearest person to support the new mother.

Venkatesh et al. [18] evaluated the accuracy of EPDS in identifying PPD among primiparous adolescent mothers, suggesting that the EPDS and its shorter subscales have potential for use as effective depression screening tools. When we applied EPDS on PPD patients, 100% scored more than10, which indicated the possibility of depression and the accuracy of EPDS in the detection of PPD. Robertson et al. [19] screened for antenatal factors of PPD, suggesting a well-established relationship between stressful life events and onset of depression. Moreover, when we applied the Holmes and Rahe Stress scale, we found a strong link between stressful life events in the whole year before delivery and the development of PPD in new mothers.

Metz and Sichel [20] suggested that panic disorder affects ~10% of postpartum women. In our study we found the incidence of PP Panic D to be 8%. We found the incidence of PP GAD in new mothers to be 4%. Wenzel et al. [21] found that 4.4% of women met the diagnostic criteria for GAD. We found a correlation between familial support and development of PP Panic D and PP GAD, as 50% of new mothers with PP Panic and 100% with PP GAD had a deceased mother. Bener et al. [22] suggested that lack of family support was the major significant correlate for postpartum anxiety disorders.


  Conclusion Top


In the present study we found that the incidence of observed postpartum psychiatric disorders in new Egyptian mothers (blues, depression, panic, and generalized anxiety disorders) was similar to that observed in most published studies. Moreover, marital, social, and economic factors play a major role in the development of the observed postpartum psychiatric disorders.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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