Follow-up and family study of postpartum psychoses Part I: Overview

Abstract

A group of 119 patients suffering from a severe psychiatric postpartum disorder who were admitted for the first time in their life to a psychiatric hospital has been investigated. The onset of illness occurred within 3 months following delivery. The patients represented 92% of the total sample fulfilling the inclusion criteria. A follow-up investigation was performed after a mean of 21 years (range 2-35 years). Of the patients 66% had nonpuerperal psychotic episodes in later life. The diagnosis, taking into account the long-term course, was affective psychosis in 57%, schizoaffective psychosis in 18%, schizophreniform psychosis in 12%, brief reactive psychosis in 4% and schizophrenia in 9%. A bipolar psychosis was found in 31%. The relation of unipolar to bipolar psychoses corresponded to that in a control group of affectively ill women without puerperal onset. The frequency of a manic syndrome in bipolar psychoses at the index episode was the same as in nonpuerperal episodes, which does not suggest a mania-provoking pathoplastic effect of the puerperium. The comparison with female nonpuerperal controls matched for age and diagnosis revealed evidence of a better long-term course in the index patients. The risk of a puerperal relapse for further pregnancies was 35%. The global morbidity risk for functional psychoses in first-degree relatives was 11%, with affective psychoses representing the majority of secondary cases (6.8%). The index patients showed a nonsignificant lower morbidity risk in relatives than a control group of psychotically ill women without puerperal onset. The major aetiological factor found for postpartum psychoses is the relation of these disorders to functional psychoses. There is strong evidence that the postpartum period tends to provoke affective psychoses and other nonschizophrenic psychoses, but not, or only to a lesser degree, narrowly defined schizophrenias. The liability to puerperal decompensations suggests some common pathophysiological mechanism, the nature of which remains unknown.

Long-Term Course and Outcome of Severe Postpartum Psychiatric Disorders

“…Schöpf and Rust [20] gave a comparable rate of 20% monophasic illnesses among postpartum psychoses, whereas other studies [18,21] report rates between 30 and 40%. Rohde and Marneros [21], however, rated several organic disorders without a tendency to recurrence as monophasic disorders, whereas the data of Videbech and Gouliaev [18] are based solely on information from general practioners.…”

“…The generally favourable prognosis is demonstrated by the mean value of 14.1 for the total sample on the 16-point StraussCarpenter Outcome Scale. The suicide rate was rather low and corresponds to the rates in other studies [11,20]. None of our patients had ever shown a tendency to infanticide.…”

“…Whereas Arentsen [16] found that only 35% of puerperal patients had suffered recurrences after 6-30 years, Protheroe [15] observed at least one further psychiatric illness in 48% over a follow-up period of up to 35 years. Other investigators [17,18,[20][21][22] described rates between 56 and 69%. Unfortunately, several studies [17,18,21] fail to mention the exact criteria by which a relapse was defined and others [17,21] fail to specify whether outpatient episodes were taken into account.…”

“…Rohde and Marneros [21] reported no impairments in over 70% of their cases when applying the Global Assessment Scale and Disability Assessment Schedule. Schöpf and Rust [20] reported a favourable or relatively favourable global psychopathological outcome in 61% of their sample. They included the frequency of relapses in their outcome criteria however, estimating outcome as relatively unfavourable if relapses were more frequent than once every 5 years, even if recovery was total.…”

“…Davidson and Robertson [22] claimed that 28% of subsequent pregnancies were followed by a recurrence. Schöpf and Rust [20] cited a 35% risk (19 out of 54 deliveries) of puerperal relapse. Their definition of 'postpartal' as 3 months after delivery meant that they did not consider 2 women with a relapse beginning at 4-6 months after a subsequent delivery, which would have led to an increased risk of remanifestation comparable with our results.…”