New Parents and Mental Disorders
Abstract & Commentary
By Sarah L. Berga, MD, James Robert McCord Professor and Chair, Department of Gynecology and Obstetrics; Emory University School of Medicine, Atlanta, is Associate Editor for OB/GYN Clinical Alert.
Dr. Berga reports no financial relationship to this field of study.
Synopsis: The risk of postpartum mental disorders necessitating hospital admission or outpatient treatment is increased among primiparous mothers for several months after childbirth, but an increase is not seen in fathers.
Source: Munk-Olsen T, et al. JAMA. 2006;296:2582-2589.
The aim of the present study was to determine the extent to which there is an excess risk of postpartum psychiatric disorders in women vs men. The authors note that postpartum depression afflicts about 10-15% of women and postpartum psychosis about 0.1%. Previous research showed that the risk is highest in primiparous women. One study found that 4% of men reported depressive symptoms postpartum but other studies have not confirmed this. The investigators estimated the risk of postpartum mental disorders requiring hospital admission or outpatient contact in fathers and mothers for one year following the birth of a first live-born child by performing a cohort study and survival analysis. The study population included all persons born in Denmark between January 1, 1955 and July 1, 1990 who survived to age 15 years (n = 2,357,942). The study population was linked with the Danish Psychiatric Central Register, which was computerized in 1969. There are no private psychiatric inpatient facilities in Denmark, which ensured that all admissions were represented. From 1995 onward, information on outpatient visits to psychiatric departments was included in the register. Potential psychiatric disorders included schizophrenia, unipolar depression, bipolar affective disorder, adjustment disorder, and puerperal disorders. Study participants were followed until July 1, 2005. The study population was limited to those parents who experienced a live-born singleton. Events following elective terminations and miscarriages were not included. From 1973 to 2005, a total of 630,373 women and 547,431 men became parents for the first time. A total of 1171 women and 658 men were admitted with a mental disorder to a psychiatric hospital during the first 12 months after parenthood. The prevalence of severe mental disorders for the first three months after childbirth was 1.03 per thousand births for women and 0.37 for men. The highest risk was for the interval from 10 to 19 days, which showed a RR of psychiatric hospital admission of 7.31 (CI 5.44 -9.81) compared with women who had given birth 11 to 12 months prior. The increased risk of admission among mothers remained elevated for 3 months regardless of the age of the mother. Women giving birth to their second live-born child still had an increased risk of postpartum mental disorders. After the birth of a third child, no association was found between birth and mental disorders. An excess risk of unipolar depression persisted for 5 months postpartum. The risk of outpatient contact was also increased and the highest risk (RR 2.67, CI 1.99 - 3.59) was also for the interval of 10 to 19 days postpartum. The risk of outpatient contact during pregnancy was decreased compared with the postpartum period. Given that men were much less likely to experience a severe mental disorder postpartum than women, the investigators interpreted the results as suggesting the causes of postpartum depression are more strongly linked to physiological processes related to pregnancy and childbirth than to the psychosocial aspects of parenthood. They further suggest that about 40 to 50% of postpartum depression episodes go undetected and that this has public health implications.
I chose this article because it highlights an ongoing gap in the fabric of care for American families, namely the timely detection and treatment of women with postpartum depression and related mental health conditions. In an accompanying editorial (Wisner KL, et al. Postpartum Depression: A Major Public Health Problem. JAMA. 2006;296:2616-2618), Wisner et al note that this is the first large-scale epidemiological study of postpartum psychiatric illness since the work of Kendell in Scotland more than 20 years ago. Because the findings of the two major studies converge and the risks of untreated severe postpartum psychiatric conditions are so deleterious, the collective data argue for universal screening. Wisner et al recommended that screening begin by week 2 postpartum and continue until at least 12 weeks. They advocated using the Edinburgh Postnatal Depression Scale, which is a validated 10-item questionnaire that can be readily utilized by health professionals not specifically trained in psychiatry.
The alternative reactive approach depends on mothers or family members recognizing postpartum mental health problems and initiating timely and appropriate interventions. It is hard enough for enlightened physicians who recognize postpartum depression to find appropriate referrals, but it is a nearly impossible task for new parents. Most of us are aware of the tragic consequences of untreated postpartum psychosis, including infanticide and suicide. We may be less cognizant of the toll exacted by depression or other mental health conditions that far short of psychosis. However, innumerable studies document that postpartum depression robs the infant of a mother and sets the stage for life-long emotional difficulties. The negative effects of maternal depression include impaired mental and motor development, difficult temperament, poor self-regulation, low self-esteem, and myriad sub-syndromal behavioral problems. Of promise, however: Legislation mandating education and screening for postpartum mental disorders was recently enacted in New Jersey.
It has been suggested that the quality of a society or culture can be assessed in terms of how it cares for its poor and infirm. I would make appropriate care of parents and children one of the yardsticks too. In the United States, we still generally lack enlightened employment policies that support parents, and access to care for those with postpartum depression is difficult to find. Further, despite decades of advocacy, affordable and high-quality childcare is far from being universally available. No wonder, despite our robust economic engine and high socioeconomic status, our health falls behind that of our peer group (Banks J, et al. Disease and advantage in the United States and in England. JAMA. 2006;295:2037-2045).