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OBSTETRICS
Perinatal psychiatric disorders: an overview
Elena Paschetta, MD; Giles Berrisford, MD; Floriana Coccia, MD; Jennifer Whitmore, MD; Amanda G. Wood, PhD;
Sam Pretlove, MD; Khaled M. K. Ismail, PhD

O ver the past decade, Perinatal


Mental Health (PNMH) has
gained increased attention in policy
Perinatal mental illness has a significant implication on maternal health, birth outcomes,
and the offsprings development. Prevalence estimates of perinatal psychiatric illnesses
documents, medical literature, and the range widely, with substantial heterogeneity in different population studies, with a lower
media. This was particularly triggered prevalence rate in high- rather than low- or middle-income countries. Because of the
by reports from the United Kingdom, potential negative impact on maternal and child outcomes and the potential lability of
demonstrating that PNMH was the these disorders, the perinatal period is a critical time to identify psychiatric illnesses.
leading cause of maternal mortality Thus, obstetricians and midwives play a crucial role in assessing womens mental health
within the rst year postpartum.1 Thus, needs and to refer identified women promptly for multidisciplinary specialist assessment.
health services in several countries are However, there is still limited evidence on best practice assessment and management
focused on implementing clinical man- policies during pregnancy and postpartum. This review focuses on the prevalence of
agement systems that ensure the delivery common perinatal mental disorders and antenatal screening policies to identify women at
of high-quality services for this group of risk. The effect of these conditions and their management on pregnancy, fetal outcomes,
vulnerable women.2,3 These policies and child development are discussed.
have reduced PNMH-related maternal
mortality.4 However, the impact of Key words: childbirth, mental illness, offspring, postpartum, pregnancy
these services on other maternal, fetal,
and child outcomes is less clear. The service structure, and currently service There is a well-documented variation
recommendation for effective multidis- delivery is highly variable.5 in prevalence by ethnic origin.17,18
ciplinary PNMH services has not been The purpose of this review is to
complemented by clear guidance about summarize the current literature on Mood disorders
perinatal psychiatric illness, focusing Mood disorders include perinatal
on the magnitude of the problem, depression and bipolar affective disorder
From the Birmingham Womens National Health (BPAD). Perinatal depression can occur
and review current screening policies,
Service Foundation Trust (Drs Paschetta,
examining risk factors and critically either during pregnancy or within the
Pretlove, and Ismail); Perinatal Mental Health
Service, Birmingham and Solihull Mental Health evaluating the impact of suggested evi- rst 12 months after delivery. This diag-
Foundation Trust (Drs Berrisford, Coccia, and dence based managements on maternal, nosis is made if the woman suffers with
Whitmore); School of Psychology, College of Life fetal, and child outcomes. consistently low mood along with a xed
and Environmental Sciences (Dr Wood), and number of biological or cognitive symp-
School of Clinical and Experimental Medicine,
toms for at least 2 consecutive weeks.
College of Medical and Dental Sciences
(Dr Ismail), University of Birmingham,
Classification Epidemiological studies in Western soci-
Birmingham, UK. Perinatal psychiatric disorders (Figure 1) eties reported rates of antenatal and
Received May 31, 2013; revised Oct. 2, 2013; are wide ranging and can arise for the postnatal depressive episodes ranging
accepted Oct. 4, 2013. rst time during the perinatal period between 5%,12,19 33%,6,8,9,11,20-26 and 10-
There was no specic funding for this review. or may represent a relapse of a preex- 15%,6,19,23,27-29 respectively.
E.P. is a Clinical Research Fellow at Birmingham isting condition. In Western societies, Higher prevalence rates seem to occur
Womens National Health Service Foundation estimates of mental health problems in low-income settings.30-34 It is imper-
Trust funded by the Department of
during the perinatal period range ative to differentiate postnatal depres-
Neuroscience, Postgraduate School of
Psychiatry, Psychiatric Clinic, University of considerably, with substantial heteroge- sion from postnatal blues. The latter is
Turin (Italy). neity in different population studies.6-8 regarded as a normal variation of
The authors report no conict of interest. Mood and anxiety disorders are the emotional change occurring after child-
Reprints: Khaled M. K. Ismail, PhD, Academic most prevalent mental illnesses found birth35 in which as high as 50-85% of
Department, Birmingham Womens National during this period.7-12 Literature reports women can experience symptoms of
Health Service Foundation Trust, Edgbaston, higher rates of perinatal psychiatric dis- mild depressive symptoms, anxiety,
Birmingham B15 2 TG, UK. orders in low- and lower-middle-income irritability, mood swings, and increased
k.ismail@bham.ac.uk.
countries.13-15 Less than 8% of women tearfulness. Postnatal blues typically
0002-9378/$36.00
suspected to have perinatal mental ill- peak on the fourth or fth day post-
2014 Mosby, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2013.10.009 nesses are currently receiving any type of partum and usually resolve spontane-
mental health care in these countries.16 ously by day 10.36,37

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FIGURE 1
Classification of common perinatal mental disorders

This figure summarizes common perinatal psychiatric disorders that can occur during the perinatal period.
GAD, generalized anxiety disorder; OCD, obsessive-compulsive disorder; PNMD, perinatal mental disorders; PTSD, posttraumatic stress disorder.
Paschetta. Perinatal Mental Health. Am J Obstet Gynecol 2014.

BPAD is characterized by episodes of Their reported prevalence rates range Psychotic disorders
mania or hypomania, typically alter- from 4.5%34 to 15%.20,22,31,44 Some au- The lifetime prevalence of schizophrenia
nating with episodes of depression. thors suggest that following childbirth, is approximately 1-2%.58 Key manifes-
Childbirth is often related to the initial an increasing proportion of women tations of disease include psychotic
onset of BPAD.38,39 Up to 50% of women experience PTSD.45-48 However, other symptoms such as hallucinations and
with a history of BPAD have a risk of studies report higher rates of OCD and delusions, affective disturbances such
relapse perinatally,40,41 especially after GAD in postpartum women compared as emotional blunting, and signicant
childbirth, when this risk is higher for with general population.49-52 occupational and social dysfunction.
BPAD than any other form of mental Among specic phobias, tokophobia The risk of relapse during the rst 3
illness.42 Studies indicate that the risk of (a morbid fear of childbirth) is gaining months postpartum is approximately
relapse is highest in the rst 2 weeks increased attention in clinical practice, 24-25%,59,60 especially following treat-
postpartum, typically commencing as especially for the high perinatal comor- ment discontinuation.61,62
early as between days 2 and 4.43 bidity with mood and anxiety disor-
ders53 and the frequent request of Puerperal psychosis
Anxiety disorders elective cesarean section. Preliminary This is reported to occur following 1-2
A wide range of anxiety disorders reports have shown that treatment for per 1000 births,29,63-65and has its onset
are seen perinatally; these include tokophobia and comorbid psychiatric commonly within the rst 2 weeks
obsessive compulsive disorder (OCD), conditions53 during pregnancy can lead postpartum.42,66 Women usually develop
posttraumatic stress disorder (PTSD), to a signicant reduction of the fear of paranoid, grandiose, or bizarre de-
generalized anxiety disorder (GAD), vaginal delivery with a withdrawal in lusions, mood lability, and perplexity.
panic disorder, and specic phobias. request for cesarean sections.54-57 These features represent a dramatic

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change from previously perceived nor-
mal functioning.67 It is estimated that TABLE
approximately two-thirds of women Risk factors for PNMDs
suffering from a puerperal psychosis will PNMDs Risk factors
experience a relapse after subsequent AND Previous PPD and nonperinatal depression75-77
deliveries.68 Preexisting BPAD is one of Recent adverse life events27,76,77,101,102,105,107,235-241
the greatest risk factors.69 Low socioeconomic status15,27,76,77,90,101,102,105,107,108,110-112,235-241
Insufficient emotional/social support26,105
Substance-use disorders Unplanned pregnancy76,77,79
Unfavorable obstetric79/pregnancy outcomes242-244
Alcohol and tobacco are the most Chronic physical illness245
prevalent substances consumed by Previous miscarriages246
childbearing-aged women, followed by Domestic violence95
various illicit drugs,70,71 especially PPD Past history of psychiatric disorders8,85,86
methamphetamines.72 Alcohol use dur- Depression/anxiety during current pregnancy87,88
ing pregnancy is one of the leading Maternity blues247
preventable causes of birth defects, in- Biological factors (genetic, hormonal, others)80-84
tellectual disability, and neurodevelop- Recent adverse life events27,76,77,101,102,105,107,235-241
Low socioeconomic status15,27,76,77,90,101,102,105,107,108,110-112,235-241
mental disorders,73 whereas mothers Insufficient emotional/social support15,113,101,102,105,107,235-240
using illicit drugs are at high risk Poor marital relationship101,102,105,107,235-240
of psychiatric comorbidity and poorer Unplanned pregnancy15,113
obstetric outcomes.74 Because of the Immigration/premigration stress248,249
paucity of research, further investiga- Personality traits90,101,102
Unfavorable obstetric/pregnancy outcomes8,83,105
tions into the magnitude and manage- Unfavorable neonatal outcomes250,251
ment of these conditions are required. Chronic/current physical illnesses113,252
Substance misuse as an isolated perinatal History of PMS89,90 and PMDD91,92
psychiatric disorder is beyond the scope History of physical/sexual abuse93,94,253,254
of this review. Multiple births255,256
Domestic violence15,95-100
Childcare stress/infant temperament90,101,102
Prediction
PPs Previous episodes of PPs114
Antenatal screening for mental health Personal history of psychotic disorders and BPAD114
issues and risk factors allows early diag- Family history of PPs and BPAD114
nosis, appropriate liaison with relevant Insufficient emotional/social support115-117
professionals, timely discussion regard- Sleep disturbance119
ing treatment, and nalizing manage- PNADs Personal history of ADs120,121
ment plans throughout the perinatal Insufficient emotional/social support 120,121
period. This can help reduce the negative Previous miscarriages246
History of physical/sexual abuse120,121
impact of the mental illness on the Multiple births121,255,256
woman, her child, and her extended Unfavorable pregnancy243,244/neonatal250 outcomes
family. Efcient strategy of screening Maternity blues247
relies on identifying clinically vulnerable PTSD Unfavorable obstetric/pregnancy and neonatal outcomes123,124,251
subgroups. The Table summarizes the Perinatal death123,124
known risk factors of the common AD, anxiety disorders; AND, antenatal depression; BPAD, bipolar affective disorder; NICU, neonatal intensive care unit; PMS,
perinatal mental disorders (PNMDs). premenstrual syndrome; PMDD, premenstrual dysphoric disorder; PNAD, perinatal anxiety disorders; PNMD, perinatal mental
disorders; PPs, puerperal psychosis; PPD, postpartum depression; PTSD, posttraumatic stress disorder.
A past history of postpartum and
Paschetta. Perinatal Mental Health. Am J Obstet Gynecol 2014.
nonperinatal depression75-77and psycho-
social factors are the most important
predictors of antenatal depression.78,79
Likewise, postpartum depression (PPD) potential biological factors involved in and depression or anxiety during the
is caused by a combination of biolog- its psychopathology.82 Recent researches current pregnancy.87,88
ical80 and psychosocial determinants. have also focused on the role of omega-3 Recent evidence also found other
There is preliminary evidence that fatty acids83 and specic polymorphisms important predictors, such as a his-
genetic factors may contribute to as of serotonin metabolism enzymes84 in tory of premenstrual syndrome89,90 and
much as one third of its etiological the development of PPD, but the nd- premenstrual dysphoric disorder,91,92
variance.80 Hormones, such as estrogen ings thus far have been inconclusive. To and a history of physical or sexual
and progesterone,81 as well as thyroid date, the strongest predictors of PPD is a abuse93,94and domestic violence.95-100
dysfunction have been suggested as past history of psychopathology8,85,86 The levels of childcare stress, infant

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temperament, and vulnerable maternal visits. Attention should be paid to any history of serious affective disorder
personality traits90,101,102 seem to be sign of poor self-care and over- or un- (59%), such as puerperal psychosis
other important and stable determinants deractivity. Particular care should be and severe depression4 ; substance use;
of PPD.103,104 given to suicidal ideation or thoughts and intimate partner problems.126,135
Finally, small but signicant pre- of harming the baby, substance abuse, Furthermore, maternal suicide can
dictors include obstetric and pregnancy and domestic violence. One of the be associated with a risk of infanti-
complications,8,83,105 especially hyper- most important risk factor is a previ- cide.133,136 It is a rare event but can have
emesis and premature contractions,106 ous personal or family history of psy- tragic consequences, so it is important
and socioeconomic status,90,101,107-112 chopathology. It is essential to take a to highlight.
which conversely represents a strong focused history on past or present Up to 50% of pregnancies in the
predictor of PPD in the developing severe mental illness, previous treatment general population are unplanned, and
world.15,113 The disparity in the rates of by a psychiatrist or specialist mental the rate is even higher in women
perinatal mental disorders between health team, and any personal or suffering from mental illness.137 Among
women living in high- and low-income family history of perinatal mental health these women, the frequency of sexual
settings suggests social rather than bio- problems. activity may be normal, but contracep-
logical determinants.113 The literature shows a wide variability tive use may be lower and autonomous
Predictors of puerperal psychosis of antenatal screening tools for perinatal reproductive decision-making compro-
include previous episodes or family psychiatric disorders in different coun- mised.138 Women with mental illnesses
history; personal history of psychotic tries.127 The British National Institute often start their pregnancy without
disorders, especially schizophrenia; per- for Health and Clinical Excellence having their medications optimized and
sonal or family history of BPAD114; guidelines2 specically recommend the often stop taking them abruptly when
medication nonadherence; poor social utilization of the Whooley questions128 they nd out they are pregnant, which
support115-117; younger age; and un- to screen for antenatal depression. frequently leads to a relapse of their
planned pregnancy.118 Sleep distur- However, some authors127 highlighted a psychiatric symptoms.40,42,66,69,115,139
bances have also been found as an lack of evidence in its effectiveness and They are more likely to default ante-
important risk factor for puerperal psy- also a need for further research to iden- natal care appointments, use substances,
chosis relapse in susceptible women.119 tify universal screening tools. have a poor diet, and be overweight, all
Considering anxiety disorders, previ- When these strategies are instigated, of which are lifestyle factors associated
ous lifetime episodes, low social support, care must be taken to ensure that with poor obstetric outcomes.59,140-143
a history of child abuse, and a perception all women are screened and assessed It is increasingly recognized that
of high peripartum stress are all risk because it has been recognized that severe mental illnesses can be an un-
factors for experiencing anxiety disor- in practice, implementation can be derlying cause of pregnancy-related
ders during the perinatal period.120,121 patchy.129 All pregnant women identi- medical disorders and obstetric compli-
Multiparity has also been identied as ed as high risk should have a shared cations.83,144-159 It is suggested that one
another potential contributor to gener- multidisciplinary care plan for their biological mechanism linking severe
alized anxiety in pregnancy.121 With re- late pregnancy and early postnatal mental illnesses and some pregnancy-
gard specically to PTSD, during the management.117 related complications is a result of the
postpartum period, PTSD has been promoting effect of these illnesses on
found to be associated with behavioral Effects on short-term outcomes the immune system that subsequently
health risks and PTSD at the onset of Mental illness in the perinatal period increases the levels of inammatory
pregnancy.122 Other known risk factors can have a signicant impact on markers and altering proinammatory
of postpartum PTSD include younger maternal health, birth outcomes, and cytokines regulation.160
age, severe preeclampsia, cesarean fetal development. The British Con- Another possible biological mecha-
section, lower gestational age, lower dential Enquiries into Maternal Deaths nism is represented by the overactivity
birthweight, baby admitted to the reported that psychiatric disorders of the maternal neuroendocrine system
neonatal intensive care unit, and peri- contributed to 12% of all maternal caused by maternal psychosocial stress
natal death.123,124 deaths in 2002-2005.130 Currently, sui- and preexisting psychiatric symp-
Finally, women with a past or current cide is a leading cause of perinatal toms.161,162 Several studies reported an
psychiatric disorder, especially puerperal maternal deaths in industrialized coun- association between maternal mental
psychosis and severe depression,4 a tries, but there is still little research on illness/stress and changes in the fetal heart
substance-use disorder, and intimate its prevalence and correlates,131,132 rate and vascular distribution as well as
partner problems have been found at especially in the developing world.133 negative fetal outcomes, including intra-
increased risk of postpartum suicide Among female suicide victims of uterine growth retardation,83,154,161,163
attempt compared with controls.125,126 reproductive age, recent data show a lower Apgar scores,164,165 congenital
Inquiries about psychiatric symptoms high prevalence of an existing mental malformations,143,151,154,165-168 and peri-
should be made at the initial antenatal health diagnosis126,132,134 or a past natal loss.146,154,165,168-171

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Women with mental disorders more have been documented in neonates drug exposure is still mostly unclear.195
frequently misuse substances.140 Pre- exposed to typical antipsychotics, in- The use of pharmacogenomics to pre-
natal exposure to cocaine and amphet- cluding withdrawal symptoms, extrapy- dict maternal plasma drug concentra-
amines is associated with several ramidal signs, neonatal jaundice, and tions and fetal drug exposure is expected
adverse outcomes, such as spontaneous intestinal obstruction.183 Other authors to increase in the future, but there is still
abortion, preterm births, placental found an association between low limited clinical use of currently available
abruption, congenital abnormalities, birthweight and the use of typical anti- methods of therapeutic monitoring of
neonatal poor feeding, lethargy, and psychotics in pregnancy and large-for- drug concentrations in making treat-
seizures. Alcohol use is associated with gestational-age babies and the use of ment decisions.196
spontaneous abortion, growth restric- atypical antipsychotics, especially olan-
tion, and birth defects; moreover, fetal zapine and clozapine.189 An increased Long-term effects
alcohol syndrome is a common cause of risk of gestational diabetes has been The multiple psychosocial difculties
long-term sequelae for the infant. Pre- found related to the use of olanzapine experienced by women with mental
natal tobacco exposure can induce and clozapine.148,185 disorders can have adverse effects on the
spontaneous abortion, ectopic preg- Prenatal exposure to lithium may development of mother-infant attach-
nancy, placental insufciency, low be associated with a small increase in ment197 and the child.198 Children of
birthweight, fetal growth restriction, Ebsteins anomaly (probably overvalued parents with psychiatric illnesses are at
and preterm delivery, whereas mari- in the past),184 cardiac arrhythmias, hy- increased risk of neglect or inadequate
juana use has been found related to poglycemia, nephrogenic diabetes insip- care and the later development of psy-
fetal growth restriction.172,173 All these idus, polyhydramnios, reversible changes chopathology.199-204 Several studies have
substances can also predispose to in thyroid function, hyperparathy- also shown a link between antenatal
neonatal withdrawal syndrome, which, roidism,190 premature delivery, abnor- stress/anxiety and behavioral/emotional
interestingly, increased in the past 25 mally large infants, oppy infant problems in the child.205-220
years.174 syndrome, lethargy, and poor suck Mechanisms underlying these effects
Psychotropic medications may also reexes.154,183,184,191 have only just been started to be
have an impact on outcomes. Prenatal Among other mood stabilizers, pre- studied in humans. Literature evidence
antidepressant use has been found natal exposure to valproic acid (VPA) supports a link between prenatal mood
associated with lower gestational age has been found related with neural and the development of the fetal
at birth, preterm birth,175 and small tube defects, craniofacial, limb and brain.221 One potential pathway to
increased risk of persistent pulmonary cardiovascular anomalies, genitourinary early deregulation is fetal programming
hypertension of the newborn.176 Expo- malformations, low birthweight, neo- of the hypothalamic-pituitary-adrenal
sures of concern include that of natal hepatotoxicity, coagulopathies, axis.222,223 There is a strong correlation
untreated maternal illness as well as hypoglycemia, and an increased risk between maternal and fetal levels of
medication exposure.177,178 Conversely, of withdrawal symptoms and cognitive cortisol,224 suggesting there is a pas-
no signicant risk of stillbirth, neonatal impairment.154,183,184,191 Carbamaze- sage of cortisol across the placenta.
mortality, postnatal mortality,179,180 and pine has teratogenic risks similar to VPA Recent ndings show that cortisol and
major congenital malformations181,182 but less frequent and severe,154,183,191 pregnancy-specic anxiety indepen-
has been found, apart from a slight whereas fetal exposure to lamotrigine dently predicted child anxiety. Children
increased risk of cardiac malformations has not been found to be related to exposed to elevated prenatal maternal
associated with rst-trimester paroxe- major anomalies, excluding an increased cortisol and pregnancy-specic anxiety
tine exposure.154,183,184 risk of midline facial clefts.154 are at increased risk for developing
With regard to antipsychotics, there Evidence from the treatment of epi- anxiety problems during the preado-
is no conclusive evidence of their lepsy, however, suggests an increased lescent period.220 Fetal exposure to
structural teratogenicity.183,185 There are risk of major congenital malformations maternal mental illnesses and psycho-
2 case reports of pregnancy loss in following prenatal exposure to anticon- social stress result in subsequent risk for
women taking atypical antipsychotic vulsants,192,193 particularly at higher poor health outcomes171 and a wide
aripiprazole,186 whereas other observa- doses192 and in polytherapy.193 spectrum of pediatric diseases in the
tional studies found no increased risk Lastly, benzodiazepine use during offspring.225
of stillbirth, gestational age at birth, the rst trimester may be associated Many studies to date have not taken in
and perinatal syndromes187,188 in preg- with cleft lip and palate, skeletal abnor- to account the impact of medication
nant women under antipsychotics. malities, and central nervous system dys- exposure in key gestational stages on
There have been reports of self-limiting function.194 Neonatal toxicity includes longer-term outcomes in the child.226 It
extrapyramidal or possible withdrawal withdrawal symptoms and oppy infant is critical to disambiguate the effects of
symptoms in neonates exposed to syndrome.154,183,184,191 medications used to manage these dis-
atypical agent risperidone in the third The contribution of various genetic orders from the maternal psychiatric
trimester.188 Transient complications factors in directing the variability of fetal illness itself.

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Management
FIGURE 2
Multidisciplinary nonpharmacological
Multidisciplinary models for managing PNMDs
interventions
All current guidelines2,3 recommend
obstetricians and hospital/community
midwives identify women (preferably
at their early pregnancy assessment) with
past or present severe mental illness
including schizophrenia and other psy-
choses, BPAD and moderate to severe
depression, a previous psychiatric treat-
ment, and a family history of perinatal
psychiatric disorder. Women identied
at risk need to be referred to specialist
perinatal mental health professionals
for further assessment, specic in-
terventions, and the monitoring of their
mental health both during pregnancy
and postpartum.
Some of these guidelines2 recognize
the need for a written care plan for
women so that information can be
shared between obstetric and specialist
This figure summarizes all the proposed multidisciplinary models for the management of perinatal
perinatal mental health services and
mental disorders.
all professionals involved in their care.
CPN, community psychiatric nurse; PNMD, perinatal mental disorders; PNMH, perinatal mental health.
Conditions such as substance abuse
Paschetta. Perinatal Mental Health. Am J Obstet Gynecol 2014.
and domestic violence should also be
considered as risk factors for perinatal
mental health morbidity and should be
managed by specialist services. risk of relapse. Based on individual need, for depression in both antenatal and
In women whose pregnancy or post- these women may be advised to start postnatal period.2,3 In pregnant women
partum year is complicated by serious prophylactic treatment during preg- with recurrent depressive disorder, it is
mental illness, apart from specic phar- nancy or soon after delivery and may be important to continue pharmacological
macological interventions, the available referred to mother and baby units as a treatment because moderate to severe
guidelines2 recommend establishing spe- precaution should their mental health depression is unlikely to respond to
cialized community perinatal teams to deteriorate. talking therapies. Moreover, discontin-
monitor their mental state during preg- Nonpharmacological treatment such uation of antidepressants can often lead
nancy and postpartum. Mother and as cognitive behavioral therapy and to relapse (75%) in the rst trimester.139
baby units are used to treat acutely ill interpersonal therapy228 may be of Women with a previous history of
women who cannot be safely managed benet, but evidence is limited for this puerperal psychosis and who are drug
in the community within the last weeks except for the treatment of depression.2 free during pregnancy should be advised
of pregnancy or after childbirth.227 The recommendations for screening to start an atypical antipsychotic and/or
Women who develop a puerperal psy- at booking have been widely but not a mood stabilizer at 32 weeks gestation.
chosis or who are at a very high risk universally implemented. It is of huge Because of the higher risk of relapse
of relapse227 should ideally be admitted concern that access to specialized peri- after subsequent pregnancies,68 during
with their baby to these specialized units. natal mental health services is still not which these women are reluctant to
This enables mothers to remain with readily available in most countries.5,229 consider medication in pregnancy, it is
their baby in a safe supervised environ- Figure 2 summarizes the proposed recommended to commence treatment
ment in which they can also be treated multidisciplinary models for managing immediately after delivery, preferably
for their psychiatric illness. perinatal mental disorders. before the discharge from hospital. This
Women with a past personal or family way therapeutic levels will be established
history of severe mental illness should be Pharmacological interventions when the woman enters the high-risk
carefully monitored by specialist mental Selective serotonin reuptake inhibitors period in the rst week postpartum.43
health professionals throughout the (SSRIs; with the exception of paroxe- Puerperal psychosis is usually very
perinatal period because of the higher tine)230 are advised as rst-line treatment responsive to treatment, but delays in

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