Best Practice & Research Clinical Obstetrics & Gynaecology
5The long-term psychiatric and medical prognosis of perinatal mental illness
Introduction
The perinatal period is a critical time in a women's life that is influenced by multiple factors that have consequences on the outcome of the pregnancy, but also may have significant long-term implications. Misri et al. [1] cogently described a ‘women's life span approach model to perinatal health,’ which recognises the myriad of determinants in the perinatal period and integrates the social, psychological, behavioural, environmental and biological forces that shape pregnancy and provide a model that demonstrates the interrelationships that influence long-term health. In this model, the entire life span is considered, including the role of preconception health factors that may occur long before pregnancy begins (i.e. pre-pregnancy obesity), as well as the multiple determinants that require targeted intervention to allow for improvements in perinatal outcomes [1]. This is important, as growing evidence suggests that complications during the perinatal period may provide a window into a woman's long-term health [2]. The stressors of major hormonal fluctuations, sleep deprivation, and caring for a new infant may trigger perinatal mental illness and unmask a psychobiological vulnerability that may manifest as psychiatric disease in later life. In this chapter, we take a multiple determinants approach and discuss long-term psychiatric and medical consequences of perinatal mental illness. We first examine the long-term risk of developing a chronic mood disorder (both unipolar and bipolar depression) among women who experience perinatal mental health and also discuss perinatal obsessive–compulsive disorder and long-term prognosis. Second, we discuss the strength of the evidence linking perinatal mental illness with obstetrical and other medical outcomes, including weight retention, pregnancy complications, and lactation difficulties.
Section snippets
Long-term psychiatric complications of perinatal mental illness
Perinatal mental illness confers potential serious long-term psychiatric and medical consequences for the mother, her baby, and the family [3], [4], [5]. Some are the result of maladaptive behaviours by women who experience depression during pregnancy. Women with antenatal depression are less likely to participate in recommended prenatal care practices, and are at increased risk of engaging in risky health behaviours, such as smoking and substance use in pregnancy [4], thereby increasing risk
Biological underpinnings and long-term risk of perinatal mental illness
Childbirth acts as a powerful trigger for depressive episodes in some women, and women with histories of mood disorders are vulnerable to a psychobiological postpartum trigger [23], [24], [25]. Recent work by Di Florio et al. [23] documents that more than 70% of parous women with a history of a mood disorder will experience at least one perinatal mood episode in relationship to pregnancy and childbirth. Moreover, women with previous histories of a mood disorder (unipolar and bipolar disorder)
Long-term obstetrical and medical outcomes of perinatal mental illness
Research on maternal perinatal mental illness with non-psychiatric long-term outcomes is scant; however, evidence of a link between perinatal anxiety and depression has been found with both pregnancy complications and reduced lactation initiation and duration. Both pregnancy complications and impaired lactation are associated with long-term maternal disease risk, and so it is plausible that women who experience perinatal mental illness may be at increased risk of other chronic disease
Clinical implications and directions for future research
Existing data suggest that psychiatric, obstetrical, and medical complications during pregnancy and the puerperium provide a window into a woman's long-term health. Women with a prior history of perinatal mood disorder (unipolar and bipolar depression) are at significantly increased risk for a recurrent episode in both the context of childbearing and outside of the perinatal period. Furthermore, evidence suggests that women with perinatal mental illness may be more likely to develop pregnancy
Conclusion
Childbirth acts as a powerful trigger for mood episodes in some women, and women with histories of a mood disorder are particularly vulnerable. Risk of recurrence of perinatal mental illness is considerable, both in the context of childbearing and outside of the perinatal period. Thus, perinatal mental illness does have long-term psychiatric outcomes that must be appropriately managed and addressed by the woman in partnership with her providers. Important evidence also links perinatal mental
Conflict of interest
None declared.
References (117)
- et al.
Integrated perinatal health framework. A multiple determinants model with a life span approach
Am J Prev Med
(2003) - et al.
Rates of maternal depression in pediatric emergency department and relationship to child service utilization
Gen Hosp Psychiatry
(2004) - et al.
Depressive symptoms during pregnancy: impact on neuroendocrine and neonatal outcomes
Infant Behav Dev
(2011) The association between pregnancy processes, preterm delivery, low birth weight, and postpartum depressions: the need for interdisciplinary integration [review]
Am J Obstet Gynecol
(2005)- et al.
Depression and anxiety in women during pregnancy and neonatal outcome: data from the EDEN mother-child cohort
Early Hum Dev
(2012) - et al.
Psychological factors associated with persistent postnatal depression: past and current relationships, defence styles and the mediating role of insecure attachment style
J Affect Disord
(2005) - et al.
Antenatal risk factors for postnatal depression: a large prospective study
J Affect Disord
(2008) - et al.
Treatment of mood disorders during pregnancy and postpartum
Psychiatr Clin North Am
(2010) - et al.
Endocrine factors in the etiology of postpartum depression
Compr Psychiatry
(2003) - et al.
Is perinatal depression familial?
J Affect Disord
(2006)
The effectiveness of antenatal interventions to prevent postnatal depression in high-risk women
J Affect Disord
Reproductive cycle-associated mood symptoms in women with major depression and bipolar disorder
J Affect Disord
The role of central oxytocin in obsessive compulsive disorder and related normal behavior
Psychoneuroendocrinology
The cognitive mediation of obsessive–compulsive symptoms: a longitudinal study
J Anxiety Disord
Intensive cognitive-behavioural treatment for women with postnatal obsessive–compulsive disorder: a consecutive case series
Behav Res Ther
Excess pregnancy weight gain and long-term obesity: one decade later
Obstet Gynecol
Depression and anxiety in early pregnancy and risk for preeclampsia
Obstet Gynecol
The impact of very premature birth on the psychological health of mothers
Early Hum Dev
Acute stress disorder among parents of infants in the neonatal intensive care nursery
Psychosomatics
Pregnancy as a window to future health [editorial comment]
Obstet Gynecol
Rates and risk of postpartum depression: a meta-analysis
Int Rev Psychiatry
A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction
Arch Gen Psychiatry
Suicidal mothers
J Inj Violence Res
A study of the risk of mental retardation among children of pregnant women who have attempted suicide by means of a drug overdose
J Inj Violence Res
Congenital abnormalities in children of 43 pregnant women who attempted suicide with large doses of nitrazepam
Pharmacoepidemiol Drug Saf
Continuity in self-report measures of maternal anxiety, stress, and depressive symptoms from pregnancy through two years postpartum
J Psychosom Obstet Gynaecol
Perinatal depression: prevalence, screening accuracy, and screening outcomes
Evid Rep Technol Assess (Summ)
A prospective study of perinatal depression and trauma history in pregnant minority adolescents
Am J Obstet Gynecol
Prevalence of suicidality during pregnancy and the postpartum
Arch Womens Ment Health
Maternal mortality and psychiatric morbidity in the perinatal period: challenges and opportunities for prevention in the Australian setting
Med J Aust
Maternal depressive symptoms at 2 to 4 months post partum and early parenting practices
Arch Pediatr Adolesc Med
Individual and combined effects of postpartum depression in mothers and fathers on parenting behavior
Pediatrics
Prenatal and postpartum depression in fathers and its association with maternal depression: a meta-analysis
JAMA
A meta-analysis of predictors of postpartum depression
Nurs Res
Perinatal episodes across the mood disorder spectrum
JAMA Psychiatry
Familiality of postpartum depression in unipolar disorder: results of a family study
Am J Psychiatry
Episodes of mood disorders in 2252 pregnancies and postpartum periods
Am J Psychiatry
Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance
Am J Psychiatry
Risk of recurrence in women with bipolar disorder during pregnancy: prospective study of mood stabilizer discontinuation
Am J Psychiatry
Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings
JAMA Psychiatry
Depressive and anxiety disorders in the postpartum period: how prevalent are they and can we improve their detection?
Arch Womens Ment Health
New parents and mental disorders: a population-based register study
JAMA
Prevention of recurrent postpartum depression: a randomized clinical trial
J Clin Psychiatry
Depressive symptoms in early pregnancy, two months and one year postpartum-prevalence and psychosocial risk factors in a national Swedish sample
Arch Womens Ment Health
Postpartum depression: a disorder in search of a definition
Arch Womens Ment Health
Cortisol response to ovine corticotropin-releasing hormone in a model of pregnancy and parturition in euthymic women with and without a history of postpartum depression
J Clin Endocrinol Metab
Genetic influences on post-natal depressive symptoms: findings from an Australian twin sample
Psychol Med
Genome-wide linkage and follow-up association study of postpartum mood symptoms
Am J Psychiatry
Using animal models to disentangle the role of genetic, epigenetic and environmental influences on behavioral outcomes associated with maternal anxiety and depression [review]
Front Psychiatry
New insights into perinatal depression: pathogenesis and treatment during pregnancy and postpartum [review]
Dialogues Clin Neurosci
Cited by (73)
Kind of blue – An evaluation of etiologies for prenatal versus postnatal depression symptoms
2023, Journal of Affective DisordersSystematic Review of Self-Report Measures of Maternal Self-Efficacy
2022, JOGNN - Journal of Obstetric, Gynecologic, and Neonatal NursingPerinatal mental illness and maternal autoimmune disease: A review of current evidence and avenues for future research
2022, Frontiers in NeuroendocrinologyTiming of perinatal mental health needs: data to inform policy
2022, American Journal of Obstetrics and Gynecology MFMCitation Excerpt :Our findings corroborate previously published data, which showed that just over one-quarter of women who lost Medicaid coverage and became uninsured in the postpartum period reported being depressed in the months after giving birth.25 Childbirth can act as a powerful trigger for mood disorders, and pregnancy and the postpartum period may unmask depressive symptomatology.26 A significant percentage of women who experience perinatal depression and who do not receive treatment will develop recurrent long-term mental health disorders.27,28
Exposure to environmental chemicals and perinatal psychopathology
2022, Biochemical PharmacologyCitation Excerpt :Lastly, the use of breast milk as a matrix is potentially problematic because certain exposures, specifically those identified as EDCs, have been shown to affect breastmilk production and breastfeeding behavior in both animals and humans [80–83,97,98]. Therefore, studies that rely on breast milk for exposure assessment may be biased by this selection of delivering and nursing women, especially given the additional links between lactation and perinatal depression [99–102]. The biological mechanisms underlying the observed associations between environmental toxicants and perinatal depression are heterogeneous in nature.