An Open Conversation About Postpartum Psychosis: An Interview with Jessie Hunt: Communications Lead, Advocate, and Expert by Experience.

Postpartum psychosis is a mental illness that is often misunderstood and stigmatized and can have a devastating impact on the women affected and their families, particularly when not identified and treated early on. The first-person perspective of experiencing a mental illness such as postpartum psychosis is remarkably powerful and can shed light on some of the hidden or misunderstood aspects of diagnosis, treatment, recovery, and getting support. With this in mind, we have prepared this interview from both an academic and lived experience perspective of postpartum psychosis, for clinicians, academics, mental health professionals, and members of the public.

The lived experiences of individuals with postpartum psychosis: A qualitative analysis.

Postpartum psychosis (PP) is a severe psychiatric illness that occurs in about 1 to 2 per 1000 people in the perinatal period. To date, qualitative research investigating PP has focused on specific topics, such as treatment experiences or the impact of the illness on patients' lives and families. These studies have included small samples of women with histories of PP, often limited to certain geographical areas or treatment centers. Given the heterogeneity in presentations of PP and access to care, larger and geographically diverse samples are needed to broadly understand this complex illness. Initiated in 2018, the Massachusetts General Hospital Postpartum Psychosis Project (MGHP3) consists of a large, international sample of those who have experienced PP. In addition to the specific aims of MGHP3, which include to better understand the phenomenology and potential genetic underpinnings of PP, this investigation invites participants to qualitatively describe their narratives of postpartum psychosis. This analysis included 130 participants who reported on 133 episodes of PP. Participants' responses to the PP narrative prompt fell under several overarching categories: 1) broad psychosocial experiences surrounding postpartum psychosis, 2) impact on the mother-baby dyad, 3) treatment experiences, and 4) recovery experiences. Our findings shed light on a range of ways in which individuals' lives are impacted by this illness, and point to areas for future research and clinical directions to improve the support and care for individuals with PP and their families.

Formation of a stakeholder group of women with a lived experience of Post-partum Psychoses (PP) - Experience from a perinatal psychiatry service in India.

Our paper describes the process of creating a stakeholder group for service development and research in Postpartum Psychosis (PP) at a Perinatal Psychiatry Service in India. We involved women who have recovered from PP as `experts by experience' in identifying areas that need attention from a research and service perspectives. A total of 13 group meetings were conducted, in which 9 group meetings involved women with lived experiences of PP and 4 group meetings were with the family members involved in the care of women during the PP episode. Of the 58 participants, 23 women and two family members expressed their willingness to participate in future stakeholder meetings. Involvement of women with PP and their caregivers as stakeholders in mental health decision-making appears feasible in a LMIC setting and should be encouraged.

Borderline personality traits are differently associated with postpartum psychosis and postpartum depression episodes in women with bipolar disorder.

BACKGROUND: Women with bipolar disorder have approximately 40 %-50 % chance of having a perinatal bipolar recurrence. Knowing the factors associated will be beneficial for the prediction and prevention of episodes. We aim to establish if borderline personality disorder traits, as measured by the BEST (Borderline Evaluation of Severity over Time) scale, are associated with perinatal psychiatric outcomes. METHODS: We recruited women with bipolar disorder as part of the BDRN (Bipolar Disorder Research Network) study. Women were interviewed and we collected their demographic and clinical information. Participants subsequently completed the BEST questionnaire. We analysed the association of BEST scores with lifetime presence/absence of perinatal bipolar relapse and, employing multinomial logistic regression, with different subtypes of perinatal outcomes: postpartum psychosis; postpartum depression, and other episodes. RESULTS: In our sample of 807, although there was no significant association between the BEST total score and perinatal episodes as a whole (adjustedOR 1.01 CI95% [0.99, 1.03], p = 0.204), we found significant differing associations with different subtypes of episodes. Women scoring highly on BEST were less likely to experience a postpartum psychotic episode (RRR 0.96 CI95% [0.94, 0.99], p = 0.005) but more likely to experience a non-psychotic depressive episode (RRR 1.03 CI95% [1.01, 1.05], p = 0.007) than no relapse. LIMITATIONS: This study is limited by its cross-sectional design and self-report nature of BEST. CONCLUSIONS: In women with bipolar disorder, borderline traits differentiate the risk of postpartum depression and postpartum psychosis, emphasise the importance of considering risk factors for these perinatal episodes separately, and may help individualise the risk for women in the perinatal period.

Establishment of the MGH Postpartum Psychosis Project: MGHP3.

OBJECTIVE: Postpartum psychosis (PP) is a severe psychiatric disorder, with incomplete consensus on definition and diagnostic criteria. The Massachusetts General Hospital Postpartum Psychosis Project (MGHP3) was established to better ascertain the phenomenology of PP in a large cohort of diverse women spanning a wide geographical range (primarily in the US), including time of onset, symptom patterns, and associated comorbidities, psychiatric diagnoses pre- and post- the episode of PP, and also to identify genomic and clinical predictors of PP. This report describes the methods of MGHP3 and provides a status update. METHOD: Data are collected from women who experienced PP within 6 months of childbirth and who provided this information within ten years of the study interview. Subject data are gathered during a one-time structured clinical interview conducted by phone, which includes administration of the Mini International Neuropsychiatric Interview for Psychotic Disorders Studies (Version 7.0.2), the MGHP3© Questionnaire, and other information including lifetime mental health history and use of psychiatric medications both prior to the episode of PP and during the subsequent time period prior to study interview. Subjects also provide a saliva sample to be processed for genomic analyses; a neuroimaging assessment is also conducted for a subset of participants. RESULTS: As of July 1, 2022, 311 subjects from 44 states and 7 countries were enrolled in MGHP3. Recruitment sources include social media, online advertisements, physician referral, community outreach, and partnership with PP advocacy groups. CONCLUSIONS: The rigorous phenotyping, genetic sampling, and neuroimaging studies in this sample of women with histories of PP will contribute to better understanding of this serious illness. Findings from MGHP3 can catalyze ongoing discussions in the field regarding proper nosologic classification of PP as well as relevant treatment implications.

Postpartum Psychosis.

PURPOSE OF REVIEW: Postpartum psychosis is a psychiatric emergency that can affect the health and life of mothers, infants, and families. Postpartum psychosis (PPP) is distinct from non-postpartum psychosis in many ways, and it is crucial to study and understand PPP to identify, treat, and possibly prevent this condition. We therefore sought to review the latest research findings about PPP with the intention of updating readers about the latest evidence base. RECENT FINDINGS: Multiple physiologic pathways have been implicated in the development of PPP, and further understanding these pathways may allow for early detection and treatment. Risk assessment and treatment should include consideration of the woman patient but also the mother-infant dyad and the larger family. It is our hope that this review of research updates in postpartum psychosis may inform clinical practice and promote specialized, evidence-based diagnosis, risk assessment, and treatment.

Perinatal mental illness and autoimmune diseases: a qualitative sistematic review.

INTRODUCTION: The term "perinatal mental illness" refers to the set of psychiatric disorders that occur during pregnancy and up to one year after childbirth. The disorders that occurred before pregnancy along with the disorders that emerge during pregnancy or in the postpartum period are all considered perinatal mental illnesses. The causes of prenatal mental illness are still unknown. However, recent studies have shown a major risk in patients with autoimmune diseases (AIDs). EVIDENCE ACQUISITION: We performed a comprehensive search of relevant studies from February 2000 to December 2021 to ensure all possible studies were captured. A systematic search of PubMed databases was conducted. We selected "autoimmune disease" as the search term, combining with "perinatal mental illness," "perinatal depression" or "postpartum anxiety" or "postpartum psychosis" or "bipolar disorder" or "postpartum blues." EVIDENCE SYNTHESIS: The results of our review show that patients with perinatal mental illness have higher risks of subsequent AIDs. In fact, when a woman develops perinatal mental illness, accurate counseling can be employed: on the one hand, the woman should be send to the psychiatrist, on the other hand she has to be informed about the increased risk of a future developement of AID. CONCLUSIONS: As described in the literature, correlation between perinatal mental illness and AID could bring new diagnostic opportunities, relevant for practical decisions. Further studies need to confirm the correlation between perinatal mental illness and AID.

Posttraumatic Stress Disorder Symptoms 2 Months After Vaginal Delivery.

OBJECTIVE: To assess the prevalence of posttraumatic stress disorder (PTSD) symptoms and identify characteristics associated with it 2 months after singleton vaginal delivery at or near term. METHODS: We conducted an ancillary cohort study of the TRAAP (TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery) randomized controlled trial in 15 French hospitals in 2015-2016. Women who had singleton vaginal delivery after 35 weeks of gestation were enrolled. After randomization, characteristics of labor and delivery were prospectively collected and paid special attention to postpartum blood loss. Posttraumatic stress disorder profile and provisional diagnosis were assessed 2 months after childbirth by two self-administered questionnaires: the IES-R (Impact of Event Scale-Revised) and the TES (Traumatic Event Scale). Associations between potential risk factors and PTSD symptoms were analyzed by multivariable logistic or linear regression modeling, depending on the type of dependent variable. RESULTS: Questionnaires were returned by 2,740 of 3,891 women for the IES-R and 2,785 of 3,891 women for the TES (70.4% and 71.6% response rate). The prevalence of PTSD symptoms was 4.9% (95% CI 4.1-5.8%; 137/2,785) with the TES, and the prevalence of PTSD provisional diagnosis was 1.6% (95% CI 1.2-2.1%; 44/2,740), with the IES-R and 0.4% (95% CI 0.2-0.8%; 9/2,080) with the TES. Characteristics associated with a higher risk of PTSD in multivariable analysis were vulnerability factors - notably migrant status and history of psychiatric disorder (adjusted odds ratio [aOR] 2.7 95% CI 1.4-5.2) - and obstetric factors - notably induced labor (aOR 1.5 95% CI 1.0-2.2), being labor longer than 6 hours (aOR 1.7 95% CI 1.1-2.5), postpartum hemorrhage of 1,000 mL or more (aOR 2.0 95% CI 1.0-4.2), and bad memories of delivery at day 2 postpartum (aOR 4.5 95% CI 2.4-8.3) as assessed with the IES-R. Results were similar with the TES. CONCLUSION: Approximately 1 of 20 women with vaginal delivery have PTSD symptoms at 2 months postpartum. History of psychiatric disorder, postpartum hemorrhage, and bad memories of deliveries at day 2 were the main factors associated with a PTSD profile.

An Australian perspective on treating perinatal depression and anxiety: a brief review of efficacy and evidence-based practice in screening, psychosocial assessment and management.

Australia is at the forefront of developing screening practices, interventions and national public health policy for perinatal women with depression and anxiety. For the last two decades Australian mental health experts and public health administrators have conducted population-wide feasibility studies on screening and incorporated these in national guidelines. This chapter outlines the wider evidence base supporting current Australian practice. Key recommendations include use of the Edinburgh Postnatal Depression Scale or the Patient Health Questionnaire-9 early in pregnancy and at 6-12 weeks postpartum, followed by psychosocial assessment. Positive depression screens need to be followed by diagnostic assessment, and clear treatment pathways must be available. Milgrom and colleagues' cognitive behavioural treatment is the only Australian program with a solid evidence base demonstrating its effectiveness for depression and associated anxiety. The face-to-face treatment has been further developed into an online program, MumMoodBooster, funded by the Federal government and available to Australian women.

Perinatal Loss: The Impact on Maternal Mental Health.

IMPORTANCE: Psychological reactions to perinatal loss, although often self-limited, may lead to significant psychological morbidities. Obstetrician-gynecologists and other maternal health providers play a key role in recognizing the range of psychological responses to perinatal loss and providing education, support, and treatment options to their patients. OBJECTIVE: This review aims to define psychological reactions associated with perinatal loss, examine psychotherapy and psychopharmacologic treatments for psychiatric morbidities, discuss interpregnancy interval following perinatal loss, and highlight brief, psychological interventions that can be implemented by maternal health providers. EVIDENCE ACQUISITION: Search terms "perinatal loss psychology," "reproductive loss grief," "perinatal psychopharmacology," "psychopharmacology grief," and "interpregnancy interval" were utilized to search PubMed, Google Scholar, and PsycINFO. RESULTS: Grief is an expected, normal response to perinatal loss. Psychological morbidities, including major depressive disorder, generalized anxiety disorder, and posttraumatic stress disorder, are also associated with perinatal loss. Risk factors for these conditions include history of a psychiatric illness, childlessness, unknown cause of perinatal loss, limited social support, and marital/relationship discord. Careful interviewing and brief screening measures can help identify patients who may suffer from depressive or anxiety disorders following reproductive loss. Patients with perinatal loss can benefit from psychological and possibly pharmacologic treatments. Recommended interpregnancy interval after perinatal loss should be customized by gestational age and cause of loss. CONCLUSIONS AND RELEVANCE: Patients with perinatal loss emotionally benefit from their reproductive health care providers acknowledging the psychological aspects of reproductive loss, inquiring about their emotional needs, and providing information regarding grief and mental health referrals.

Maternal post-traumatic stress and depression symptoms and outcomes after NICU discharge in a low-income sample: a cross-sectional study.

BACKGROUND: Having a preterm newborn and the experience of staying in the neonatal intensive care unit (NICU) has the potential to impact a mother's mental health and overall quality of life. However, currently there are few studies that have examined the association of acute post-traumatic stress (PTS) and depression symptoms and infant and maternal outcomes in low-income populations. DESIGN/ METHODS: In a cross-sectional study, we examined adjusted associations between positive screens for PTS and depression using the Perinatal Post-traumatic stress Questionnaire (PPQ) and the Patient Health-Questionnaire 2 (PHQ-2) with outcomes using unconditional logistic and linear regression models. RESULTS: One hundred sixty-nine parents answered the questionnaire with 150 complete responses. The majority of our sample was Hispanic (68%), non-English speaking (67%) and reported an annual income of <$20,000 (58%). 33% of the participants had a positive PPQ screen and 34% a positive PHQ-2 screen. After adjusting for confounders, we identified that a positive PHQ-2 depression score was associated with a negative unit (95% CI) change on the infant's Vineland Adaptive Behavior Scales, second edition of - 9.08 (- 15.6, - 2.6) (p < 0.01). There were no significant associations between maternal stress and depression scores and infant Bayley Scales of Infant Development III scores or re-hospitalizations or emergency room visits. However, positive PPQ and screening score were associated with a negative unit (95% CI) unit change on the maternal Multicultural Quality of Life Index score of - 8.1 (- 12, - 3.9)(p < 0.01) and - 7.7 (- 12, - 3) (p = 0.01) respectively. CONCLUSIONS: More than one-third of the mothers in this sample screened positively for PTS and depression symptoms. Screening scores positive for stress and depression symptoms were associated with a negative change in some infant development scores and maternal quality of life scores. Thoughtful screening programs for maternal stress and depression symptoms should be instituted.

Development of a brief psychological intervention for perinatal depression (BIND-P).

BACKGROUND: Lack of recognition in national programs, poor referral system, and non-availability of trained human resources are the important barriers for the delivery of perinatal depression (PND) services in low- and middle-income countries (LAMICs). To address this there is an urgent need to develop an integrative and non-specialist-based stepped care model. As part of its research thrust on target areas of India's National Mental Health Programme (NMHP), the Indian Council of Medical Research funded a research project on the outcome of PND at four sites. In this article, we describe the development of the primary health care worker-based stepped care model and brief psychological intervention for PND. METHODS: A literature review focused on various aspects of PND was conducted to develop a model of care and intervention under NMHP. A panel of national and international experts and stakeholders reviewed the literature, opinions, perspectives, and proposal for different models and interventions, using a consensus method and WHO implementation toolkit. RESULTS: A consensus was reached to develop an ANM (Auxillary nurse midwife)-based stepped-care model consisting of the components of care, training, and referral services for PND. Furthermore, a brief psychological intervention (BIND-P) was developed, which includes the components of the low-intensity intervention (eg, exercise, sleep hygiene). CONCLUSION: The BIND-P model and intervention provide a practical approach that may facilitate effective identification, treatment, and support women with PND. We are currently evaluating this model across four study sites in India, which may help in the early detection and provision of appropriate and integrative care for PND.

Perinatal anxiety and depressive symptoms and perception of child behavior and temperament in early motherhood.

The perinatal period is a vulnerable time for the development of psychopathology, particularly mood and anxiety disorders. In the study of maternal anxiety, important questions remain regarding the association between maternal anxiety symptoms and subsequent child outcomes. This study examined the association between depressive and anxiety symptoms, namely social anxiety, panic, and agoraphobia disorder symptoms during the perinatal period and maternal perception of child behavior, specifically different facets of development and temperament. Participants (N = 104) were recruited during pregnancy from a community sample. Participants completed clinician-administered and self-report measures of depressive and anxiety symptoms during the third trimester of pregnancy and at 16 months postpartum; child behavior and temperament outcomes were assessed at 16 months postpartum. Child development areas included gross and fine motor skills, language and problem-solving abilities, and personal/social skills. Child temperament domains included surgency, negative affectivity, and effortful control. Hierarchical multiple regression analyses demonstrated that elevated prenatal social anxiety symptoms significantly predicted more negative maternal report of child behavior across most measured domains. Elevated prenatal social anxiety and panic symptoms predicted more negative maternal report of child effortful control. Depressive and agoraphobia symptoms were not significant predictors of child outcomes. Elevated anxiety symptoms appear to have a distinct association with maternal report of child development and temperament. Considering the relative influence of anxiety symptoms, particularly social anxiety, on maternal report of child behavior and temperament can help to identify potential difficulties early on in mother-child interactions as well as inform interventions for women and their families.

"Beyond the Bump" - Insight Into the Postpartum Women's Experience of Pelvic Organ Prolapse as Expressed on Reddit.

OBJECTIVE: To qualitatively analyze the biopsychological experiences of postpartum women regarding pelvic organ prolapse (POP) as expressed on Reddit, a widely used internet platform for anonymous discussion and information sharing. POP is a prevalent condition in postpartum women, yet personal experiences are often not discussed due to social stigma. METHODS: "Beyondthebump," a Subreddit forum for postpartum mothers with >57,000 subscribers, was queried for "prolapse" to collect postings on POP in August 2018. Posts were analyzed qualitatively by 2 independent researchers. The principles of grounded theory were applied and preliminary themes were generated. These themes were used to derive emergent concepts. RESULTS: We analyzed 28 unique posts with 390 responses from 2014 to 2018. Qualitative analysis yielded 3 preliminary themes. (1) Women were unaware POP could occur postpartum and frustrated by the lack of prenatal discussion. (2) Women expressed a need for supportive, comprehensive, and immediate care. (3) Attributed symptoms of POP included pain and discomfort, causing difficulty with daily life. Three emergent concepts were derived. (1) POP is a difficult, debilitating condition with mental and physical effects. (2) Women with POP were self-driven and actively sought help. (3) There was motivation to increase POP awareness. CONCLUSION: Postpartum women's perspectives on POP focused on the difficulty of continuing life routines, self-drive for improvement, and motivation to raise awareness for others. Through learning from women's self-reported experiences, physicians can better meet women's needs and improve care for POP.

Fishing for (in)continence: long-term follow-up of women with OASIS-still a taboo.

PURPOSE: Obstetric anal sphincter injuries (OASIS) increase the risk for pelvic floor dysfunctions. The goal of this study was to examine the long-term outcomes after OASIS on pelvic floor functions and quality of life. MATERIAL AND METHODS: Between 2005 and 2013, 424 women had an OASIS at the Women University Hospital Ulm. Out of these 71 women completed the German pelvic floor questionnaire, which includes questions regarding prolapse symptoms as well as bladder, bowel and sexual function. In addition, 64 women were physically examined, including a speculum examination to evaluate the degree of prolapse, a cough test to evaluate urinary stress incontinence (SI) and an evaluation of both pelvic floor sphincter (modified Oxford score) and anal sphincter contraction. RESULTS: A high rate of pelvic floor disorders after OASIS was found, as 74.6% of women reported SI, 64.8% flatus incontinence and 18.3% stool incontinence, respectively. However, only few women stated a substantial negative impact on quality of life. The clinical examination showed that a positive cough test, a weak anal sphincter tone and a diagnosed prolapse correlated with the results of the self-reported questionnaire. CONCLUSION: On one hand, OASIS has an influence on pelvic floor function going along with lots of complaints, while on the other hand, it still seems to be a taboo topic, as none of the participants spoke about the complaints after OASIS with a doctor. Therefore, the gynecologist should actively address these issues and offer therapy options for the women with persisting problems.

The risk for nonpsychotic postpartum mood and anxiety disorders during the COVID-19 pandemic.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) appears to be the largest pandemic of our times. The aim was to recognize the risk factors for nonpsychotic postpartum mood and anxiety disorders (NPMADs) in women during the pandemic and state of emergency police lockdown in Serbia. METHODS: We assessed 108 postpartum women who completed the Edinburgh Postnatal Depression Scale (EPDS) and an additional survey constructed for this study. We also used the additional, previously mentioned survey, in 67 healthy age-matched women with children who were ≥2 years of age. The additional survey allowed us to gain insight into the impact of the pandemic as well as postpartum period on the risk of NPMADs. RESULTS: In 16 (14.8%) subjects we found a score ≥10 on EPDS. Higher rates on the EPDS were noticed in elderly, single, and unemployed, women who lost their jobs due to the pandemic, or women who were dissatisfied with their household income (p < 0.05). The risk of NPMADs was linked significantly to quarantine, and social isolation, the absence of social support, as well as having emotional problems. Postpartum women, compared to non-postpartum women, were more anxious and had feelings of helplessness during social isolation. CONCLUSION: Understanding the factors that increase the risk of NPMADs during the pandemic could help prevent mental disorders during a possible future pandemic.

Detection and Prevention of Postpartum Posttraumatic Stress Disorder: A Call to Action.

The rising maternal mortality rate has drawn increased focus to postpartum depression. However, other mental health conditions, such as birth-related postpartum traumatic stress disorder, have not garnered the same level of attention. The majority of research about postpartum posttraumatic stress disorder (PTSD) is published in journals focused on psychiatry, psychology, and nursing, where this phenomenon is well recognized. In contrast, there is a lack of awareness among most obstetricians. Consequently, few recommendations are available to guide clinical practice. This commentary will present a clinical vignette, provide background that is key to the detection of PTSD, explore available data on postpartum PTSD, and provide recommendations for recognition and prevention of this disorder.

Relationship between postpartum mood disorder and birth experience: a prospective observational study.

BACKGROUND: This study aims to investigate the relationship between the birth experience and the risk of developing postpartum depression or post-traumatic stress disorder. METHODS: In this prospective, longitudinal, observational study, women were assessed at different time points for depression and post-traumatic stress disorder. The risk of depression or post-traumatic stress disorder based on patient characteristics and specific birth events was assessed within three months postpartum. RESULTS: We enrolled 600 women; 426 were eligible for postpartum assessment. At six weeks and three months postpartum, 15.9% and 12.7% screened positive for depression respectively. Positive post-traumatic stress disorder screenings at six weeks and three months postpartum were 6.2% and 5.1% respectively. Twenty-seven women (8.3%) with a negative screening at six weeks converted to a positive depression or post-traumatic stress disorder screening at three months. A pre-existing history of anxiety or depression was associated with an increased risk of developing depression (aOR 2.12, 95% CI 1.30 to 3.47) and post-traumatic stress (aOR 3.15, 95% CI 1.42 to 7.02) within three months postpartum. The risk of developing post-traumatic stress disorder within three months postpartum was also increased among patients experiencing their first delivery (aOR 2.55, 95% CI 1.10 to 5.88) or operative management of postpartum hemorrhage (aOR 4.44, 95% CI 1.16 to 17.02). CONCLUSION: Depression and post-traumatic stress symptoms either persisted or had new onset at three months postpartum. Mental health screening and postpartum follow-up after six weeks should be considered in high-risk patients who have a history of psychopathology, nulliparity, or undergo operative management of postpartum hemorrhage.