Prevalence of autoimmune thyroid dysfunction in postpartum psychosis

Pregnancy complications and autoimmune diseases in women: systematic review and meta-analysis

BACKGROUND

Pregnancy complications might lead to the development of autoimmune diseases in women. This review aims to summarise studies evaluating the association between pregnancy complications and the development of autoimmune diseases in women.

METHODS

Medline, CINAHL, and Cochrane databases were searched up to January 2024. Nineteen pregnancy complications and 15 autoimmune conditions were included. Title, abstract, full-text screening, data extraction, and quality assessment were performed by two reviewers independently. Data were synthesised using narrative and quantitative methods. Results were presented using odds ratios (OR), relative risks (RR), incidence rate ratios (IRR), and 95% confidence intervals (CI).

RESULTS

Thirty studies were included. One study reported composite exposure to pregnancy complications had a risk of any autoimmune disease RR 3.20 (2.90-3.51) compared to women without pregnancy complications. Women with hyperemesis gravidarum had a higher risk of developing coeliac disease (n = 1) IRR 1.98 (1.27-2.94), Crohn's disease (n = 1) IRR 1.61 (1.25-2.04), psoriasis (n = 1) IRR 1.33 (1.01-1.71), and rheumatoid arthritis (n = 2) IRR 1.35 (1.09-1.64). Miscarriage associated with subsequent diagnosis of Sjogren syndrome (n = 2) IRR 1.33 (1.06-2.81) and rheumatoid arthritis (n = 4) OR 1.11 (1.04-1.20). Gestational hypertension/preeclampsia was linked with the development of systemic sclerosis (n = 2) IRR 2.60 (1.10-4.60) and T1DM (n = 2) IRR 2.37 (2.09-2.68). Stillbirth associated with composite autoimmune conditions (n = 2) RR 5.82 (95% CI 4.87-6.81) and aIRR 1.25 (1.12-1.40). Postpartum psychosis was associated with autoimmune thyroid disease (n = 1) aIRR2.26 (1.61-2.90).

CONCLUSIONS

Women with pregnancy complications subsequently had a higher risk of being diagnosed with autoimmune conditions. Whether this is due to pre-existing undiagnosed health conditions or being causally linked to pregnancy complications is not known.

Hormones, psychotic disorders, and cognition in perinatal women: a mini review

Previous scientific evidence has shown a relationship between hormones and the onset and relapse of perinatal psychotic disorders (PPD) in women during pregnancy, childbirth, and the postpartum period. In healthy women the interaction between hormones and cognitive changes has been confirmed mainly in memory, attention, and executive function during pregnancy and postpartum, which respond to adaptive demands related to parenting tasks. In women with psychotic episodes there is a significant impairment in several cognitive functions, but studies of the perinatal period are limited. The objective of this mini review is to analyze the main findings to identify whether hormonal changes interact with the onset of PPD and cognitive impairment in perinatal women. The studies included samples of women with psychosis, risk of developing psychosis, bipolar psychosis, schizoaffective psychosis, and psychotic symptoms, during pregnancy and postpartum. Findings contributed to knowledge about five hypotheses regarding the relationship between hormones in the perinatal period and the appearance of PPD. Nevertheless, this review did not find reports of evidence of a relationship between hormonal production and cognitive function among women with clinically diagnosed PPD, suggesting a research gap. Clinical implications of assessing hormonal production and cognitive function in PPD are discussed. Although the evidence identified is scarce and heterogeneous, the findings call for further research with clinical samples on the role of hormones in perinatal psychotic disorders, especially as they relate to the study of cognition. This will promote more consistent evidence and understanding of PPD etiopathology that can guide early and effective multidisciplinary interventions.

Postpartum Psychosis: A Proposed Treatment Algorithm

Background

Postpartum psychosis (PPP) is a psychiatric emergency that generally warrants acute inpatient care. PPP is marked by the sudden onset of affective and psychotic symptoms with a rapid deterioration in mental state. Evidence suggests that PPP is a discrete disorder on the bipolar disorder spectrum with a distinct treatment profile and prognosis.

Methods

We conducted a PubMed database search for various terms involving PPP and its treatment and included peer-reviewed articles published in English.

Objective

To provide a treatment algorithm for the management of PPP based on available evidence.

Results

Pharmacological therapy is the mainstay of PPP management in the acute phase. Evidence points to a combination of antipsychotics and lithium in the acute treatment of PPP. Electroconvulsive therapy can offer a rapid treatment response where required. Lithium appears to have the best evidence for relapse prevention and prophylaxis in PPP. Psychoeducation is essential and psychosocial interventions used in bipolar disorder may be effective in PPP.

Conclusion

Early detection and prompt treatment with antipsychotics and lithium, followed by maintenance treatment with lithium, is associated with a favourable prognosis in PPP.Reprinted from J Psychopharmacol 2023; 37:960-970, with permission from Sage Journals. Copyright © 2023.

Postpartum Psychosis as a Consequence of Thyroiditis Versus Relapse: A Diagnostic Dilemma

Thyrotoxicosis can exhibit overlapping symptoms of psychosis in the general population. Each of these pathologies has well-established workups and management. Rare presentations of thyroiditis and psychosis in the postpartum state have been seen in case studies mostly, but data on the prevalence of postpartum psychosis in association with postpartum thyroiditis are not available. Here, we present a unique case of a patient with a history of bipolar disorder who originally presented with postpartum thyroiditis that was worked up and managed appropriately. However, on follow-up, the patient was found to have progressed into prominent psychosis. Both thyroiditis and psychosis were managed individually with full remission upon discharge and is doing well today. The co-occurrence of postpartum psychosis and thyroiditis presents a unique challenge for timely diagnosis and management. We present a case of a young woman initially diagnosed with postpartum thyroiditis needing further management of postpartum psychosis due to persistent symptoms. Clinical presentation supported with a prior history of mood disorder increases the likelihood of these diagnoses together.

Postpartum psychosis: A proposed treatment algorithm

BACKGROUND

Postpartum psychosis (PPP) is a psychiatric emergency that generally warrants acute inpatient care. PPP is marked by the sudden onset of affective and psychotic symptoms with a rapid deterioration in mental state. Evidence suggests that PPP is a discrete disorder on the bipolar disorder spectrum with a distinct treatment profile and prognosis.

METHODS

We conducted a PubMed database search for various terms involving PPP and its treatment and included peer-reviewed articles published in English.

OBJECTIVE

To provide a treatment algorithm for the management of PPP based on available evidence.

RESULTS

Pharmacological therapy is the mainstay of PPP management in the acute phase. Evidence points to a combination of antipsychotics and lithium in the acute treatment of PPP. Electroconvulsive therapy can offer a rapid treatment response where required. Lithium appears to have the best evidence for relapse prevention and prophylaxis in PPP. Psychoeducation is essential and psychosocial interventions used in bipolar disorder may be effective in PPP.

CONCLUSION

Early detection and prompt treatment with antipsychotics and lithium, followed by maintenance treatment with lithium, is associated with a favourable prognosis in PPP.

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: The Role of Women's Health Care Providers and the Health Care System

Importance

The postpartum period is a time of high risk for serious psychiatric symptoms and hospitalization. Postpartum psychosis (PPP) is the most severe disorder that emerges during this time, with significant and wide-ranging consequences that can include suicide and infanticide.

Evidence Acquisition

A PubMed, MEDLINE, and PsycINFO search was completed for English-language publications about PPP, including subtopics (eg, infanticide, maternal suicide). Citations in these articles were also reviewed for relevant references.

Results

Although it is clear that the triggering event for PPP is childbirth, the processes by which this occurs are not fully understood, which is a critical need for being able to predict, prevent, and manage PPP. There are risk factors that contribute to PPP, and specific groups of women may be at increased risk (eg, women with bipolar disorder). Many questions and challenges remain related to the phenomenology, nosology, prevention, and treatment of PPP. However, there are changes that women's health care providers and systems can take to improve the care of women at risk of and experiencing PPP.

Results

Of the 1382 articles reviewed, 8 met eligibility criteria, representing 6 distinct cohorts and 726 subjects. Synthetic slings available for review were either tension-free vaginal tape (TVT) or minisling. The vast majority of studies demonstrated similar short- and long-term success rates of AFS and SS procedures utilizing a range of outcome measures. Both AFS and TVT sling had low recurrence rates in short- and long-term follow-up. However, AFS had significantly longer operative time, and longer hospital stay. Bladder perforation, on the other hand, occurred more commonly in TVT sling. Health-related quality-of-life scores, including sexual function, were similar between groups.

Conclusions and Relevance

Postpartum psychosis is a rare but serious condition. However, recovery is possible. Women's health care providers and systems can improve the care by better understanding the needs of women and families, offering patient-centered discussions and options for care, particularly those that promote recovery, minimize risk, and limit the interruption of the maternal-infant bond. Improving the prevention and treatment of PPP can have a broad impact for women, children, and families.

Complexities of cooccurrence of catatonia and autoimmune thyroiditis in bipolar disorder: A case series and selective review

In recent years the neurobiological underpinnings of catatonia have been an emerging area of interest. Catatonia is frequently encountered in mood disorders, neurological disorders and systemic illnesses. Furthermore, the manifestation of catatonia in autoimmune disorders such as NMDA receptor antibody encephalitis and thyroiditis reinforces its neuropsychiatric nature. Irrespective of cause benzodiazepines and electroconvulsive therapy remain the standard treatments for catatonia, although a proportion fail to respond to the same. This report describes three women with pre-existing bipolar disorder presenting in catatonia. Interestingly in all three, while benzodiazepines and electroconvulsive therapy failed, a dramatic resolution of catatonia with corticosteroids was noted following the detection of Hashimoto's thyroiditis. Hashimoto's encephalopathy presenting as catatonia has been reported, but our patients' profile differed in having had an a priory diagnosis of bipolar disorder. Given that both catatonia and thyroid dysfunction are frequently encountered in bipolar disorder, Hashimoto's encephalopathy as a potential cause for this concurrent manifestation in bipolar disorder may be overlooked. Therefore, it is essential to suspect Hashimoto's encephalopathy when catatonia manifests in bipolar disorder. A timely evaluation would be prudent as they may fail to respond to standard treatments for catatonia but respond remarkably to corticosteroids, saving much time and angst. Recent evidence implicates immune system dysfunction, with neuroinflammation and peripheral immune dysregulation contributing to the pathophysiology of bipolar disorder as well as catatonia. Findings from this study reaffirm the role of immune system dysfunction common to the etiopathogenesis of all these disorders, highlighting the complex interplay between catatonia, thyroiditis and bipolar disorder.

Perinatal mental illness and maternal autoimmune disease: A review of current evidence and avenues for future research

This review summarizes evidence on the association between perinatal mental illness and maternal autoimmune disease and identifies avenues for future research. Perinatal mental illness has several characteristics in common with autoimmune disease, including increased incidence in the early postpartum period, recurrence across pregnancies, evidence of elevated immune-mediated cytokines, and familial risk, as well as the general predominance of mental illness in females versus males. Several studies have demonstrated elevated risk of maternal autoimmune disease in women with perinatal mental illness, and of perinatal mental illness in those with autoimmune dysfunction, suggesting a bi-directional relationship. Further research is needed to elucidate the importance of the specific diagnosis, severity, and timing of perinatal mental illness and specific diagnosis of autoimmune disease, as well as the relative importance of perinatal versus non-perinatal mental illness. Such research could have implications for prevention, treatment, and follow-up of perinatal mental illness.

Postpartum depression in maternal thyroidal changes

Evidence in the literature has suggested that there may be an association between thyroid antibodies and depression during pregnancy and in the postpartum period. Thus, this study aims to conduct a systematic review on the prevalence of postpartum depression (PPD) in women with thyroid abnormalities during pregnancy or in the postpartum period. For this review, we used four databases (PubMed, Lilacs, Scielo, and Scopus). Fifteen studies were selected; one study used a case–control design, four used a cross-sectional design and ten utilized prospective cohort designs. All studies were restricted to up to 1 year postpartum, and 46.7% focused on a period between immediate postpartum and 6 months postpartum. Estimates of the prevalence of PPD in pregnant women with thyroid disorders ranged between 8.3% and 36.0%. For follow-up studies, the cumulative incidence of self-reported depression from the primary episode in the first postpartum year was 6.3% in a high-city survey. Although some authors consider the status of positive anti-TPO antibodies to be a possible marker of vulnerability to depression , it is not yet possible to conclude whether thyroid function in the pregnancy-puerperal cycle is involved with the development of PPD.

Immune System Alterations and Postpartum Mental Illness: Evidence From Basic and Clinical Research

The postpartum period is a time associated with high rates of depression and anxiety as well as greater risk for psychosis in some women. A growing number of studies point to aberrations in immune system function as contributing to postpartum mental illness. Here we review evidence from both clinical and animal models suggesting an immune component to postpartum depression, postpartum anxiety, and postpartum psychosis. Thus far, clinical data primarily highlights changes in peripheral cytokine signaling in disease etiology, while animal models have begun to provide insight into the immune environment of the maternal brain and how central inflammation may also be contributing to postpartum mental illnesses. Further research investigating peripheral and central immune function, along with neural and endocrine interactions, will be important in successfully developing novel prevention and treatment strategies for these serious disorders that impact a large portion of new mothers.

Perinatal Mental Illness and Risk of Incident Autoimmune Disease: A Population-Based Propensity-Score Matched Cohort Study

Background

Studies have demonstrated elevated risk for autoimmune disease associated with perinatal mental illness, but the extent to which this risk is specific to mental illness arising perinatally, and not mental illness generally, is unknown. Our objective was to compare the risk of autoimmune disease in women with mental illness arising within the perinatal period to (1) women with mental illness arising outside the perinatal period and (2) women who did not develop mental illness.

Methods

We conducted a population-based matched cohort study of women aged 15–49 years with no history of mental illness or autoimmune disease in Ontario, Canada, 1998–2018. The exposed, 60,701 women with mental illness arising between conception and 365 days postpartum were propensity score-matched to (1) 264,864 women with mental illness arising non-perinatally and (2) 469,164 women who did not develop mental illness. Hazard ratios (HR) for autoimmune disease were generated using Cox proportional hazards models.

Results

The incidence of autoimmune disease was similar among women with mental illness arising perinatally compared to those with mental illness arising non-perinatally (138.4 vs 140.7 per 100,000 person-years; HR 0.98, 95% CI 0.92–1.05), and elevated among women with mental illness arising perinatally compared to those who did not develop mental illness (138.4 vs 88.9 per 100,000 person-years; HR 1.54, 95% CI 1.44–1.64). The HR for the latter comparison was more pronounced for autoimmune disease with brain-reactive antibodies than other autoimmune disease.

Conclusion

Perinatal mental illness is associated with increased risk of autoimmune disease that is no different than that of mental illness arising non-perinatally. Women with mental illness, regardless of the timing of onset, could benefit from early detection of autoimmune disease.

The role of the immune system in postpartum psychosis

Postpartum psychosis is the most severe psychiatric disorder associated with childbirth. The risk is particularly high for women with a history of bipolar disorder or schizoaffective disorder, or those who have suffered a previous episode of postpartum psychosis. However, the aetiology of the illness remains unclear. Pregnancy and the early postpartum are times of significant immunological change. Furthermore, alterations to the immune system have been implicated in the onset and course of various psychopathologies, both related and unrelated to childbirth. Emerging evidence, from studies on immune related disorders, immune cells and inflammatory markers, suggests that the immune system might also be involved in the pathophysiology of postpartum psychosis. Furthermore, recent research has also begun to explore the potential mechanisms underlying immune dysfunction in postpartum psychosis (e.g., disturbances in the Treg-CCN3 protein-(re)myelination axis). Nevertheless, more research is required to understand whether immune dysfunction is a cause or consequence of postpartum psychosis and to clarify the exact mechanisms involved. The aim of this short review is to present the current findings on immune system dysregulation in postpartum psychosis, discuss possible mechanisms underlying the association, highlight potential challenges and confounders and provide suggestions for future research.

Postpartum psychosis: a diagnosis for the DSMV

Postpartum psychosis (PPP) is a serious disorder that is associated with maternal and infant morbidity and mortality, yet it is denied a diagnostic classification in the Diagnostic and Statistical Manual of Mental Disorders (DSM). PPP was included in the DSMI (1952) and the DSMII (1968). It was removed from DSMIII (1980). The purpose of this article is to review the history of postpartum psychosis in the DSM and provide the mechanism and research that argues for the inclusion of postpartum psychosis as a separate diagnostic entity in the DSM. This work describes a proposal to the DSMV committee in 2020 for inclusion of PPP as a unique diagnosis based on the cognitive disorganization that accompanies psychotic symptoms. The proposal for inclusion provides the required criteria such as a rationale for the proposed change and evidence that PPP is distinct from other disorders. Validators are described. Reliability studies and benefits of inclusion are provided. We were unable to gain consensus on the presence of cognitive impairment for all postpartum psychotic episodes. The committee opined that we did not demonstrate proof that PPP is a distinct diagnosis. However, the committee acknowledged that the current "specifier" may be insufficient, and thus the option favored by the committee is that it could be added to Sect. 3 of the DSM, "Conditions for Further Study." In the next proposal, we suggest that the unique temporal relationship of symptom onset to childbirth deserves consideration as unique criteria for diagnostic distinction of PPP.

Risk factors for postpartum relapse in women at risk of postpartum psychosis: The role of psychosocial stress and the biological stress system

BACKGROUND

Postpartum psychosis is the most severe psychiatric disorder associated with childbirth, and the risk is particularly high for women with a history of bipolar disorder, schizoaffective disorder or those who have suffered a previous episode of postpartum psychosis. Whilst there is a lot of evidence linking stress to psychosis unrelated to childbirth, the role of stress in the onset of postpartum psychosis has not been fully investigated.

METHODS

A prospective longitudinal study of 112 pregnant women, 51 at risk of postpartum psychosis because of a DSM-IV diagnosis of bipolar disorder (n = 41), schizoaffective disorder (n = 6) or a previous postpartum psychosis (n = 4) and 61 healthy women with no past or current DSM-IV diagnosis and no family history of postpartum psychosis. Women were followed up from the third trimester of pregnancy to 4 weeks' post partum. Women at risk who had a psychiatric relapse in the first 4 weeks' post partum (AR-unwell) (n = 22), were compared with those at risk who remained well (AR-well) (n = 29) on measures of psychosocial stress (severe childhood maltreatment and stressful life events) and biological stress (cortisol and inflammatory biomarkers).

RESULTS

Logistic regression analyses revealed that severe childhood maltreatment (OR = 4.9, 95% CI 0.5-49.2) and higher daily cortisol in the third trimester of pregnancy (OR=3.7, 95% CI 1.2-11.6) predicted psychiatric relapse in the first 4 weeks' post partum in women at risk of postpartum psychosis after adjusting for clinical and sociodemographic covariates.

CONCLUSION

The current study provides evidence for the role of psychosocial stress and the biological stress system in the risk of postpartum relapse in women at risk of postpartum psychosis.

Thyroid function in postpartum psychosis: An exploratory study

The study aimed to compare thyroid function between psychosis with postpartum onset (PPO), psychosis without postpartum onset (PWPO), and normal postpartum females (HC). Twenty women were recruited in each of the three groups. The PPO group had significantly greater psychopathology and shorter episodes compared to the PWPO group. The PPO group was found to have significantly greater right lobe volume than the other groups. The PPO group also had significantly higher FT4 levels than the HC group. We conclude that isolated increase in FT4 and thyroid lobe volumetric changes could be more specifically associated with psychosis of post-partum onset.

Phenomenology, Epidemiology and Aetiology of Postpartum Psychosis: A Review

Postpartum psychoses are a severe form of postnatal mood disorders, affecting 1–2 in every 1000 deliveries. These episodes typically present as acute mania or depression with psychosis within the first few weeks of childbirth, which, as life-threatening psychiatric emergencies, can have a significant adverse impact on the mother, baby and wider family. The nosological status of postpartum psychosis remains contentious; however, evidence indicates most episodes to be manifestations of bipolar disorder and a vulnerability to a puerperal trigger. While childbirth appears to be a potent trigger of severe mood disorders, the precise mechanisms by which postpartum psychosis occurs are poorly understood. This review examines the current evidence with respect to potential aetiology and childbirth-related triggers of postpartum psychosis. Findings to date have implicated neurobiological factors, such as hormones, immunological dysregulation, circadian rhythm disruption and genetics, to be important in the pathogenesis of this disorder. Prediction models, informed by prospective cohort studies of high-risk women, are required to identify those at greatest risk of postpartum psychosis.

A new molecular risk pathway for postpartum mood disorders: clues from steroid sulfatase-deficient individuals

Postpartum mood disorders develop shortly after childbirth in a significant proportion of women. These conditions are associated with a range of symptoms including abnormally high or low mood, irritability, cognitive disorganisation, disrupted sleep, hallucinations/delusions, and occasionally suicidal or infanticidal ideation; if not treated promptly, they can substantially impact upon the mother's health, mother-infant bonding, and family dynamics. The biological precipitants of such disorders remain unclear, although large changes in maternal immune and hormonal physiology following childbirth are likely to play a role. Pharmacological therapies for postpartum mood disorders can be effective, but may be associated with side effects, concerns relating to breastfeeding, and teratogenicity risks when used prophylactically. Furthermore, most of the drugs that are used to treat postpartum mood disorders are the same ones that are used to treat mood episodes during non-postpartum periods. A better understanding of the biological factors predisposing to postpartum mood disorders would allow for rational drug development, and the identification of predictive biomarkers to ensure that 'at risk' mothers receive earlier and more effective clinical management. We describe new findings relating to the role of the enzyme steroid sulfatase in maternal postpartum behavioural processes, and discuss how these point to a novel molecular risk pathway underlying postpartum mood disorders. Specifically, we suggest that aberrant steroid hormone-dependent regulation of neuronal calcium influx via extracellular matrix proteins and membrane receptors involved in responding to the cell's microenvironment might be important. Testing of this hypothesis might identify novel therapeutic targets and predictive biomarkers.

Factors associated with postpartum depression among women in Vientiane Capital, Lao People's Democratic Republic: A cross-sectional study

Postpartum depression is a worldwide public health concern. The prevalence of postpartum depression is reported to be greater in developing countries than in developed countries. However, to the best of our knowledge, no papers on postpartum depression in the Lao People’s Democratic Republic have been published. In order to strengthen maternal and child health, the current situation of postpartum depression should be understood. This study aims to determine the prevalence of postpartum depression and identify factors associated with postpartum depression in Vientiane Capital, Lao People’s Democratic Republic. Study participants were 428 women 6–8 weeks postpartum who visited four central hospitals in Vientiane Capital for postnatal care from July to August 2019. Structured questionnaires were used to collect socio-demographic, obstetrical and infant, and psychiatric data about the women and their partners. The Edinburgh Postnatal Depression Scale (EPDS) was used to identify suspected cases of postpartum depression with the cut-off score of 9/10. Multivariable logistic regression was used to examine independent factors that were associated with suspected postpartum depression (EPDS ≥10). The mean age of the 428 women was 28.1 years, and the prevalence of suspected postpartum depression was 31.8%. Multivariable logistic regression using variables that were statistically significant on bivariate analyses indicated that three variables were associated with suspected postpartum depression: unintended pregnancy (AOR = 1.66, 95% CI 1.00–2.73, P = 0.049), low birth satisfaction (AOR = 1.85, 95% CI 1.00–3.43, P = 0.049), and depression during pregnancy (AOR = 3.99, 95% CI 2.35–6.77, P <0.001). In this study, unintended pregnancy, low birth satisfaction, and depression during pregnancy were independent risk factors for postpartum depression. These results suggest that the mental health of pregnant women should be monitored, and that health care services, especially family planning and supportive birth care, should be strengthened to prevent postpartum depression.

Variation of Behavioral Health Care by Behavioral Health Symptom Profile Among a Diverse Group of Pregnant and Parenting Mothers

This study examines the association between behavioral health symptoms and use of behavioral health care (BHC; i.e., past year counseling and/or regular use of psychiatric medication) among a diverse group of mothers of toddlers. Data were from the Fragile Families and Child Wellbeing study (N = 4205 mothers). The association between symptom profiles (i.e., depressive, anxiety, and alcohol and drug dependence) and use of BHC was estimated with logistic regression models. Potential moderation by race/ethnicity was examined. Complex symptom profiles, older age, functional limitations, prior behavioral health symptoms, and having Medicaid were associated with increased BHC use. While BHC use varied by symptom profile (but not by race/ethnicity), BHC use was low across profiles. Pregnant women and women of color were most likely to have unmet needs, underscoring the need to improve screening and management systems for these populations.

Medawar's Paradox and Immune Mechanisms of Fetomaternal Tolerance

Brazilian-born British biologist Dr. Peter Medawar played an integral role in developing the concepts of immunologic rejection and tolerance, which led to him receiving the Nobel Prize "for the discovery of acquired immunologic tolerance" and eventually made organ transplantation a reality. However, at the time of his early work in tolerance, a paradox to his theories was brought to his attention; how was pregnancy possible? Pregnancy resembles organ transplantation in that the fetus, possessing paternal antigens, is a semi-allogeneic graft that can survive without immunosuppression for 9 months. To answer this question, Medawar proposed three hypotheses of how a mother supports her fetus in utero, now known as "Medawar's Paradox." The mechanisms that govern fetomaternal tolerance are still incompletely understood but may provide critical insight into how to achieve immune tolerance in organ transplantation. Here, we review current understanding of the immune factors responsible for fetomaternal tolerance during pregnancy and discuss the potential implications for advances in transplantation science.

Neurobiology of maternal mental illness

This chapter provides an overview of current research discoveries beginning to uncover the neurobiology of maternal mental illness. Results are described according to standard diagnostic categories (specifically, perinatal depression, perinatal anxiety and OCD, postpartum psychosis and bipolar disorder, and trauma and posttraumatic stress disorder), yet we aim to put this approach in context with the introduction of a classification model for psychiatric research, the research domain criteria, gaining traction in basic and clinical translational fields. We first review a new area of study, the neuroplasticity of the pregnant and postpartum brain, as work here has relevance for understanding the pathophysiology of mental disorders and may provide clues to changes in brain functioning that are related to compromised parenting in the context of postpartum depression. We next provide background information on neuroendocrine and immune changes during pregnancy and, to a lesser extent, the postpartum period, as alterations in these systems are significantly implicated in underlying neurobiology of mental illness for peripartum women. Our discussion of the major mental illnesses for pregnant and postpartum women includes neuroendocrine changes, neuroinflammation, and neurotransmitter alterations, as well as circuit dysfunction. Overall, remarkable progress has been made in identifying variations in neurobiology (and related systems) involved in maternal mental illness; yet, it is clear that, as classified with standard diagnostic systems, these are heterogeneous disorders and there is individual variability in the alterations in neurobiology for the same illness.

Postpartum psychosis in bipolar disorder: no evidence of association with personality traits, cognitive style or affective temperaments

BACKGROUND

Bipolar disorder has been associated with several personality traits, cognitive styles and affective temperaments. Women who have bipolar disorder are at increased risk of experiencing postpartum psychosis, however little research has investigated these traits and temperaments in relation to postpartum psychosis. The aim of this study is to establish whether aspects of personality, cognitive style and affective temperament that have been associated with bipolar disorder also confer vulnerability to postpartum psychosis over and above their known association with bipolar disorder.

METHODS

Personality traits (neuroticism, extraversion, schizotypy and impulsivity), cognitive styles (low self-esteem and dysfunctional attitudes) and affective temperaments (including cyclothymic and depressive temperaments) were compared between two groups of parous women with DSM-IV bipolar I disorder: i) 284 with a lifetime history of postpartum psychosis within 6 weeks of delivery (PP group), ii) 268 without any history of mood episodes with onset during pregnancy or within 6 months of delivery (no perinatal mood episode, No PME group).

RESULTS

After controlling for current mood state, and key demographic, clinical and pregnancy-related variables, there were no statistically significant differences between the PP and No PME groups on any of the personality, cognitive style or affective temperament measures.

CONCLUSIONS

Personality traits, cognitive styles and affective temperaments previously shown to be associated with bipolar disorder in general were not specifically associated with the occurrence of postpartum psychosis. These factors may not be relevant for predicting risk of postpartum psychosis in women with bipolar disorder.

Postpartum psychosis in a non-native language-speaking patient: A perspective on language barriers and cultural competency

Postpartum psychosis is a condition characterised by rapid onset of psychotic symptoms several weeks after childbirth. Outside of its timing and descriptions of psychotic features, minimal research exists due to its relative rarity (1 to 2 per 1000 births in the USA), with greater emphasis on postpartum sadness and depression. With the existing literature, cultural differences and language barriers previously have not been taken into consideration as there are no documented cases of postpartum psychosis in a non–English-speaking patient. Correctly differentiating postpartum psychosis from other postpartum psychiatric disorders requires adeptly evaluating for the presence of psychotic symptoms with in-depth history taking. Here, we present a case of postpartum psychosis in a Japanese-speaking only patient, with an associated clinical course and culturally appropriate approach to treatment. A review of postpartum psychosis and language/cultural considerations are also discussed, with attention on the Japanese concept of ‘Satogaeri bunben’.

Neuroendocrine Networks and Functionality

Women undergo developmental and cyclic changes in hormonal exposures that affect brain function and mental health. Some women are more vulnerable to the effects of these hormonal exposures, for reasons that remain to be determined. Evidence to date indicates that anxiety and mood disorders are the most sensitive to hormonal fluctuations in women but there is also growing evidence for a protective effect of female reproductive hormones on schizophrenia. The hormonal exposures of the menstrual cycle, pregnancy, the postpartum period, lactation, and menopause are quite different and may be associated with at least partially distinct symptom profiles.

Cytokine alterations in first-onset postpartum psychosis-clues for underlying immune dysregulation

BACKGROUND

Emerging evidence suggests a possible role for immune system dysregulation in the pathogenesis of postpartum psychosis (PP) but the evidence is limited. The current study sought to determine the serum cytokines/ chemokine changes associated with first-onset PP.

METHODS

Women with first onset PP were recruited as cases and the cytokines/ chemokine changes were compared against healthy postpartum (HP) and healthy non-postpartum (HNP) women.There were 20 subjects in each of the three groups. Levels of serum cytokines and Monocyte Chemoattractant Protein-1 (MCP-1) were estimated with a cytometric beadarray assay.

RESULTS

HP group showed significantly elevated levels of interleukin (IL)-6 as compared to HNP group. Whereas, the first onset PP group showed significantly elevated levels of both IL-6 and IL-8 as compared to HNP group.

CONCLUSION

Postpartum period appears to be a state of altered immune functioning considering the elevated level of IL-6 in both HP and PP group. Additionally, IL-8 appears to play a role in the manifestation of PP. Our study highlights the immune alterations associated with first-onset PP.

Recognizing and Managing Postpartum Psychosis: A Clinical Guide for Obstetric Providers

Postpartum psychosis is a psychiatric emergency that affects 1 to 2 per 1000 women. Key clinical features include mood fluctuation, abnormal thoughts or behaviors, and confusion. Women with a history of bipolar disorder are at heightened risk, as are first-time mothers; current research on the causes focuses on biological triggers, such as immune dysregulation. Women with postpartum psychosis require inpatient hospitalization and should be treated with lithium, antipsychotics, and benzodiazepines.

Inflaming sex differences in mood disorders

Men and women often experience different symptoms or rates of occurrence for a variety of mood disorders. Many of the symptoms of mood disorders overlap with autoimmune disorders, which also have a higher prevalence in women. There is a growing interest in exploring the immune system to provide biomarkers for diagnosis of mood disorders, along with new targets for developing treatments. This review examines known sex differences in the immune system and their relationship to mood disorders. We focus on immune alterations associated with unipolar depression, bipolar depression, and anxiety disorders. We describe work from both basic and clinical research examining potential immune mechanisms thought to contribute to stress susceptibility and associated mood disorders. We propose that sex and age are important, intertwined factors that need to be included in future experimental designs if we are going to harness the power of the immune system to develop a new wave of treatments for mood disorders.

Lithium exposure during pregnancy: outcomes for women who attended a specialist antenatal clinic

INTRODUCTION

Lithium treatment in pregnancy represents a significant dilemma for women and treating health professionals alike. The complexity of risk-benefit analysis is impacted by limited information.

METHODS

A cohort study of 33 women with severe mental illness, who were prescribed lithium at any time during the pregnancy, and gave birth between December 2007 and January 2015 at a specialist antenatal clinic in Western Australia. A descriptive comparison for women who continued lithium throughout pregnancy, and those who ceased on discovery of pregnancy was undertaken examining demographic, obstetric, neonatal and psychiatric variables.

RESULTS

Women who were prescribed lithium, irrespective of whether they continued or discontinued the medication represented a high risk group obstetrically, with high rates of smoking overall (33%) medical comorbidities (54%) and antenatal complications (88%). Preconception counseling occurred in 33% of the cohort but increased the likelihood of continuing lithium in pregnancy (p = .007). Compared to those who ceased lithium, women who remained on lithium through the pregnancy had increased rates of fetal ultrasound abnormalities such as abdominal circumference >90th % (p = .005). Psychiatric relapses through the antenatal and immediate postpartum period appeared to be due to a combination of factors.

DISCUSSION

Pregnant women with severe mood disorders treated with lithium are a vulnerable, high-risk obstetric population who would benefit from preconception counseling, regular antenatal care in a tertiary center, delivery with neonatal pediatric support and experienced psychiatric management.

Psychiatric Emergencies in Pregnancy and Postpartum

The perinatal period is a vulnerable time for the acute onset and recurrence of psychiatric illness. Primary care providers are opportunely positioned to intervene for women who present with mood decompensation, excessive anxiety, or psychosis during the perinatal period. Owing to increased screening efforts in obstetrical clinics and amount of contact during the perinatal period, obstetricians may be able to identify patients who need treatment before their symptoms become severe. In this article, we address imminent and emergent psychiatric symptoms in the perinatal period including management and risk reduction to help obstetrician/gynecologists treat and/or refer patients as clinically appropriate.

Postpartum Depression and Subsequent Autoimmune Diseases in Taiwan

Postpartum depression (PPD) is one of the most common examples of postnatal morbidity, but the subsequent risks of autoimmune diseases in patients with PPD have yet to be fully investigated. This nationwide population-based study utilized data of the National Health Insurance Research Database of Taiwan for the period from 1996 to 2013. In total, 45,451 women with primiparity were identified. Among them, 542 patients with PPD were enrolled as a study group while 2165 matched patients without PPD were enrolled as a control group. The demographic characteristics and comorbidities of the patients were analyzed, and Cox regression analysis was applied to calculate the hazard ratios for the risk of autoimmune diseases. Of the 2707 women enrolled in this study, 469 (17.3%) patients with newly diagnosed autoimmune diseases were identified, including 123 (22.7%) in the PPD group and 346 (16%) in the non-PPD group. After adjusting for confounding factors, it was determined that the patients with PPD had a significantly higher risk of subsequent autoimmune diseases (adjusted hazard ratio (aHR): 1.61, 95% confidence interval (CI): 1.30–1.99; p < 0.001). Specifically, increased risks of pernicious anemia (aHR: 3.85, 95% CI: 2.06–7.22), rheumatoid arthritis (aHR: 2.62, 95% CI: 1.28–5.39), and Graves’ disease (aHR: 1.57, 95% CI: 1.05–2.33) were observed in the PPD group. This study demonstrated that patients with PPD have higher risks of subsequent autoimmune diseases, especially pernicious anemia, rheumatoid arthritis, and Graves’ disease. This useful information provides physicians with clues regarding the associations between autoimmune diseases and PPD.

Comorbidity of autoimmune thyroid disorders and psychiatric disorders during the postpartum period: a Danish nationwide register-based cohort study

BACKGROUND

The postpartum period is well-known risk period for the first onset of autoimmune thyroid disorders (AITDs) as well as first onset of psychiatric disorders. These two disorders are some of the most prevalent medical conditions postpartum, often misdiagnosed and disabling if left untreated. Our study was designed to explore the possible bidirectional association between AITDs and psychiatric disorders during the postpartum period.

METHODS

A population-based cohort study through linkage of Danish national registers, which comprised 312 779 women who gave birth to their first child during 1997-2010. We conducted Poisson regression analysis to estimate the incidence rate ratio (IRR) of psychiatric disorders among women with first-onset AITDs, the IRR of AITDs among women with first-onset psychiatric disorders as well as the overlap between these disorders using a comorbidity index.

RESULTS

Women with first-onset AITDs postpartum were more likely to have first-onset psychiatric disorders than women who did not have postpartum AITDs (IRR = 1.88, 95% confidence interval (CI): 1.25-2.81). Women with first-onset postpartum psychiatric disorders had a higher risk of AITDs than women with no psychiatric disorders (IRR = 2.16, 95% CI: 1.45-3.20). The comorbidity index 2 years after delivery was 2.26 (95% CI: 1.61-2.90), indicating a comorbidity between first-onset AITDs and psychiatric disorders.

CONCLUSIONS

First-onset AITDs and psychiatric disorders co-occur in the postpartum period, which has relevance to further studies on the etiologies of these disorders and why childbirth in particular triggers the onset.

Understanding the pathophysiology of postpartum psychosis: Challenges and new approaches

Postpartum psychosis is a severe psychiatric condition which affects 1-2 of every 1000 mothers shortly after childbirth. Whilst there is convincing evidence that the condition is precipitated by a complex combination of biological and environmental factors, as yet the pathophysiological mechanisms remain extremely poorly defined. Here, I critically review approaches that have been, or are being, employed to identify and characterise such mechanisms; I also review a recent animal model approach, and describe a novel biological risk model that it suggests. Clarification of biological risk mechanisms underlying disorder risk should permit the identification of relevant predictive biomarkers which will ensure that “at risk” subjects receive prompt clinical intervention if required.

Immune system aberrations in postpartum psychosis: An immunophenotyping study from a tertiary care neuropsychiatric hospital in India

Postpartum psychosis (PP) is associated with significant morbidity to both mother and infant. Immune system dysregulation during PP is reported in recent studies. This study attempted to determine immune signatures associated with first-onset PP by flow cytometry. Peripheral blood showed decreased naive CD4 and CD8 T cells, while activated CD8 and memory regulatory T cells (Tregs) were increased in women with PP as against healthy controls. The CD14^-CD16⁺non-classical monocytes, CD11c+myeloid DCs and cytotoxic CD56^dimCD16⁺ were reduced, while CD56^brtCD16^+/-regulatory NK cells were elevated in women with PP. The variations in immune cell subsets highlight the generalized immune dysregulation in PP.

Neuroendocrine Networks and Functionality

Women undergo developmental and cyclic changes in hormonal exposures that affect brain function and mental health. Some women are more vulnerable to the effects of these hormonal exposures, for reasons that remain to be determined. Evidence to date indicates that anxiety and mood disorders are the most sensitive to hormonal fluctuations in women but there is also growing evidence for a protective effect of female reproductive hormones on schizophrenia. The hormonal exposures of the menstrual cycle, pregnancy, the postpartum period, lactation, and menopause are quite different and may be associated with at least partially distinct symptom profiles.

Psychosis Crisis Associated with Thyrotoxicosis due to Graves’ Disease

We present the case of a patient with previous psychiatric illness, acutely exacerbated by thyroid storm due to Graves' disease, in whom treatment with antipsychotics induced catatonia. These associations are extremely rare and may be confused with Hashimoto's encephalopathy, especially in the presence of anti-thyroid antibodies in cerebrospinal fluid. The treatment consists in the control of the triggering disease (in this case the resolution of the thyrotoxicosis) and the use of benzodiazepines. However, in some cases, the resolution of psychiatric symptoms is partial and may require the use of electroconvulsive therapy.

A pharmacological mouse model suggests a novel risk pathway for postpartum psychosis

Postpartum psychosis (PP) is a severe psychiatric disorder affecting a small proportion of new mothers shortly after childbirth. The molecular pathophysiology underlying the disorder is currently poorly understood, and there are no amenable animal models for the condition; maternal deficiency for the enzyme steroid sulfatase has been proposed as a potential risk mechanism. Here we show that inhibition of steroid sulfatase with 667-COUMATE (10mg/kg p.o.) in new mouse mothers results in behavioural abnormalities that can be partially alleviated by the administration of the clinically-efficacious antipsychotic ziprasidone (0.3-1.0mg/kg i.p.). The pattern of behavioural abnormalities in 667-COUMATE-treated mice implicated a genetic substrate at 21-23cM on chromosome 15; of the 17 genes within this chromosomal interval, only one (Nov/Ccn3) was significantly differentially expressed in the brains of vehicle and 667-COUMATE-treated mice. Two additional members of the Ccn family (Ccn2/Ctgf and Ccn4/Wisp1) were also significantly differentially expressed between the two groups, as were three further genes co-expressed with Nov/Ccn3 in brain (Arhgdig) or previously implicated in disorder risk by clinical studies (Adcy8 and Ccl2). The expression of Nov/Ccn3, but not of the other differentially-expressed genes, could be normalised by ziprasidone administration (1.0mg/kg). NOV/CCN3 lies directly under a linkage peak for PP risk at 8q24, and the associated protein possesses numerous characteristics that make it an excellent candidate mediator of PP risk. Our data suggest the 667-COUMATE-treated mouse as a model for PP with some degree of face, construct, and predictive validity, and implicate a novel, and biologically-plausible, molecular risk pathway for PP.

Benign thyroid disease in pregnancy: A state of the art review

Thyroid dysfunction is the commonest endocrine disorder in pregnancy apart from diabetes. Thyroid hormones are essential for fetal brain development in the embryonic phase. Maternal thyroid dysfunction during pregnancy may have significant adverse maternal and fetal outcomes such as preterm delivery, preeclampsia, miscarriage and low birth weight. In this review we discuss the effect of thyroid disease on pregnancy and the current evidence on the management of different thyroid conditions in pregnancy and postpartum to improve fetal and neonatal outcomes, with special reference to existing guidelines on the topic which we dissect, critique and compare with each other. Overt hypothyroidism and hyperthyroidism should be treated appropriately in pregnancy, aiming to maintain euthyroidism. Subclinical hypothyroidism is often pragmatically treated with levothyroxine, although it has not been definitively proven whether this alters maternal or fetal outcomes. Subclinical hyperthyroidism does not usually require treatment and the possibility of non-thyroidal illness or gestational thyrotoxicosis should be considered. Autoimmune thyroid diseases tend to improve during pregnancy but commonly flare-up or emerge in the post-partum period. Accordingly, thyroid auto-antibodies tend to decrease with pregnancy progression. Postpartum thyroiditis should be managed based on the clinical symptoms rather than abnormal biochemical results.

Exaggerated Increases in Microglia Proliferation, Brain Inflammatory Response and Sickness Behaviour upon Lipopolysaccharide Stimulation in Non-Obese Diabetic Mice

The non-obese diabetic (NOD) mouse, an established model for autoimmune diabetes, shows an exaggerated reaction of pancreas macrophages to inflammatory stimuli. NOD mice also display anxiety when immune-stimulated. Chronic mild brain inflammation and a pro-inflammatory microglial activation is critical in psychiatric behaviour.

OBJECTIVE

To explore brain/microglial activation and behaviour in NOD mice at steady state and after systemic lipopolysaccharide (LPS) injection.

METHODS

Affymetrix analysis on purified microglia of pre-diabetic NOD mice (8-10 weeks) and control mice (C57BL/6 and CD1 mice, the parental non-autoimmune strain) at steady state and after systemic LPS (100 μg/kg) administration. Quantitative PCR was performed on the hypothalamus for immune activation markers (IL-1β, IFNγ and TNFα) and growth factors (BDNF and PDGF). Behavioural profiling of NOD, CD1, BALB/c and C57BL/6 mice at steady state was conducted and sickness behaviour/anxiety in NOD and CD1 mice was monitored before and after LPS injection.

RESULTS

Genome analysis revealed cell cycle/cell death and survival aberrancies of NOD microglia, substantiated as higher proliferation on BrdU staining. Inflammation signs were absent. NOD mice had a hyper-reactive response to novel environments with some signs of anxiety. LPS injection induced a higher expression of microglial activation markers, a higher brain pro-inflammatory set point (IFNγ, IDO) and a reduced expression of BDNF and PDGF after immune stimulation in NOD mice. NOD mice displayed exaggerated and prolonged sickness behaviour after LPS administration.

CONCLUSION

After stimulation with LPS, NOD mice display an increased microglial proliferation and an exaggerated inflammatory brain response with reduced BDNF and PDGF expression and increased sickness behaviour as compared to controls.

Autoimmune Encephalitis in Postpartum Psychosis

OBJECTIVE

Significant immunological alterations have been observed in women with first-onset affective psychosis during the postpartum period. Recent studies have highlighted the possibility that a subset of patients with first-onset severe psychiatric episodes might suffer from undiagnosed autoimmune encephalitis. Therefore, the authors performed a three-step immunohistochemistry-based screening for CNS autoantibodies in a large cohort of patients with postpartum psychosis and matched postpartum comparison subjects.

METHOD

Ninety-six consecutive patients with postpartum psychosis and 64 healthy postpartum women were included. Screening for antibodies in patient serum was performed using immunohistochemistry. Samples showing any staining were further examined by immunocytochemistry using live hippocampal neurons and cell-based assays to test for anti-N-methyl-d-aspartate (NMDA) receptor antibodies. Cell-based assays for all other known CNS antigens were performed in those samples with immunocytochemistry labeling but negative for NMDA receptor antibodies.

RESULTS

Four patients (4%) with neuropil labeling suggestive for extracellular antigen reactivity were identified. Serum samples from all four patients showed clear extracellular labeling of live hippocampal neurons. Two women had the specific staining pattern characteristic for anti-NMDA receptor antibody positivity, which was confirmed by cell-based assays. Neither patient with anti-NMDA receptor antibody positivity had evidence of an ovarian teratoma. The other two patients tested negative by cell-based assays for all known CNS antigens. None of the matched postpartum comparison subjects had confirmed neuronal surface antibodies. The two patients with anti-NMDA receptor antibodies both showed extrapyramidal symptoms following initiation of treatment with low-dose haloperidol.

CONCLUSIONS

In patients with acute psychosis during the postpartum period, systematic screening for anti-NMDA receptor autoantibodies should be considered. The acute onset of severe atypical psychiatric symptoms in young female patients should raise the index of suspicion for anti-NMDA receptor encephalitis, particularly in the setting of neurological symptoms, including extrapyramidal side effects of antipsychotic treatment.

Psychiatric consultation to the postpartum mother

The immediate postpartum period is a time of acute vulnerability to mental illness, which presents unique challenges for the psychiatric consultant. Because the postpartum hospital stay is typically brief, the consultant must have a working knowledge of postpartum physiology and the myriad forms of mental illness that may emerge in this vulnerable time, in order to quickly make a diagnosis and formulate a treatment plan. This review aims to characterize the most common reasons for postpartum consultation, review postpartum physiology and psychiatric conditions, and propose an evidence-based, practical approach to treatment. A literature search using the terms "postpartum," "obstetric," "consultation," and "psychiatry" yielded six studies that identified reasons for psychiatric consultation to the obstetrics and gynecology services. These studies informed the structure of the article such that we review the most common reasons for consultation and how to approach each issue. The most common reason for consultation is past psychiatric history, often in the absence of current symptoms. For each clinical situation, including depression, adverse birth events, and psychosis, we present a differential diagnosis, as well as risk factors, clinical signs, and recommended treatment.

Clinical characteristics of inflammation-associated depression: Monocyte gene expression is age-related in major depressive disorder

Increased inflammatory activation might only be present in a subgroup of depressed individuals in which immune processes are especially relevant to disease development. We aimed to analyze demographic, depression, and trauma characteristics of major depressive disorder (MDD) patients with regard to inflammatory monocyte gene expression. Fifty-six naturalistically treated MDD patients (32 ± 12 years) and 57 healthy controls (HC; 31 ± 11 years) were analyzed by the Inventory of Depressive Symptomatology (IDS) and by the Childhood Trauma Questionnaire (CTQ). We determined the expression of 38 inflammatory and immune activation genes including the glucocorticoid receptor (GR)α and GRβ genes in purified CD14(+) monocytes using quantitative-polymerase chain reaction (RT-qPCR). Monocyte gene expression was age-dependent, particularly in MDD patients. Increased monocyte gene expression and decreased GRα/β ratio were only present in MDD patients aged ⩾ 28 years. Post hoc analyses of monocyte immune activation in patients <28 years showed two subgroups: a subgroup with a severe course of depression (recurrent type, onset <15 years) - additionally characterized by panic/arousal symptoms and childhood trauma - that had a monocyte gene expression similar to HC, and a second subgroup with a milder course of the disorder (73% first episode depression, onset ⩾15 years) - additionally characterized by the absence of panic symptoms - that exhibited a strongly reduced inflammatory monocyte activation compared to HC. In conclusion, monocyte immune activation was not uniformly raised in MDD patients but was increased only in patients of 28 years and older.

Postpartum psychosis in a woman with Graves' disease: a case report

OBJECTIVE

Thyroid dysfunction is common during pregnancy and the postpartum period and is known to cause psychiatric disturbances. A woman with Graves' disease and psychosis in the postpartum period is described.

METHODS

A 22-year-old woman with Graves' disease developed fluctuating orientation, catatonia, delusions of persecution and auditory hallucinations 3 days following childbirth.

RESULTS

The report discusses the clinical presentation. Treatment of both conditions led to the resolution of symptoms.

CONCLUSION

Graves' disease with postpartum psychosis may present with delirium, catatonia and prominent auditory hallucinations and responds well to a combination of psychotropic and antithyroid drugs. Thyroid dysfunction should be assessed for and managed adequately in postpartum psychosis.

Mood disorders and parity - a clue to the aetiology of the postpartum trigger

BACKGROUND

Episodes of postpartum psychosis have been associated with first pregnancies in women with bipolar I disorder. It is unclear, however, if the effect extends to episodes at other times in relation to childbirth and to women with other mood disorders such as major depression and bipolar II disorder. This primiparity effect, which is also seen in other pregnancy related conditions such as pre-eclampsia, is a potentially important clue to the aetiology of childbirth related mood episodes.

METHODS

Participants were interviewed and case notes reviewed. Best-estimate diagnoses were made according to DSM-IV criteria. Data on the occurrence of episodes in pregnancy and the postpartum were available on 3345 full term deliveries from 1667 participants, 934 with bipolar I disorder (BD-I), 278 with bipolar II disorder (BD-II) and 455 with recurrent major depression (RMD).

RESULTS

Onsets of psychosis/mania within 6 weeks of childbirth were overrepresented in primiparae (p=0.007) with BD-I. Although primiparity was not associated with perinatal bipolar depression, there was an association with the onset of depression within 6 weeks in women with RMD (p=0.035). Whilst women experiencing a postpartum episode were less likely to go on to have further children, this did not account for the association with primiparity.

LIMITATIONS

Data were collected retrospectively. Information on pharmacological treatment was not available.

CONCLUSIONS

Primiparity is associated not only with postpartum psychosis/mania in BD-I, but also with postpartum depression in RMD. Psychosocial factors and biological differences between first and subsequent pregnancies may play a role and are candidates for examination in further studies.

Inflammatory activation is associated with a reduced glucocorticoid receptor alpha/beta expression ratio in monocytes of inpatients with melancholic major depressive disorder

In this study, we used new technology to investigate whether a coherent pattern of enhanced expression of inflammatory and other immune activation genes in circulating monocytes is found in patients with major depression. Since a high inflammatory state of monocytes might be related to glucocorticoid resistance, we also included the genes for the two isoforms of the glucocorticoid receptor. For this study, we aimed at finding a similar coherent pattern of inflammatory and immune activation genes in monocytes of patients with MDD and recruited 47 medication-free melancholic MDD inpatients and 42 healthy controls. A quantitative-polymerase chain reaction (Q-PCR) monocyte gene expression analysis was performed using a panel of inflammatory-related genes previously identified as abnormally regulated in mood disorder patients. Selected serum cytokines/chemokines were assessed using a cytometric bead array. Depressive symptoms were analysed using Hamilton depression scores (HAMD). Thirty-four of the 47 monocyte inflammatory-related genes were significantly upregulated and 2 were significantly downregulated as compared to controls, the latter including the gene for the active GRα in particular in those with a high HAMD score. The reduced GRα expression correlated strongly to the upregulation of the inflammatory genes in monocytes. Serum levels of IL6, IL8, CCL2 and VEGF were significantly increased in patients compared to controls. Our data show the deregulation of two interrelated homoeostatic systems, that is, the immune system and the glucocorticoid system, co-occurring in major depression.

Preventive interventions for postnatal psychosis

BACKGROUND

Postnatal psychosis is a worldwide life-threatening condition that affects one to two in every 1000 new mothers. It has an abrupt onset within a month of childbirth. Affected new mothers rapidly develop frank psychosis, cognitive impairment, and disorganised behaviours. Factors that increase the risk of postnatal psychosis include primiparous mothers who are single, women who are older, or with a past psychiatric history and family history of affective psychosis, prenatal depression and autoimmune thyroid dysfunction. The risk of a future postnatal recurrence is 25% to 57%. Preventive interventions for postnatal psychosis aim at identifying women with risk factors, early recognition of imminent psychosis through screening, and preventive drug therapy. Mood stabilisers, antipsychotic drugs and hormone therapy may be beneficial in the prevention of postnatal psychotic episodes in women at risk.

OBJECTIVES

To investigate the best available evidence for interventions aimed at preventing postnatal psychosis.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register and the Cochrane Central Register of Controlled Trials (CENTRAL) in October 2012 using the search strategy of the Cochrane Schizophrenia Group.

SELECTION CRITERIA

All randomised controlled trials relevant to the prevention of postnatal psychosis.

DATA COLLECTION AND ANALYSIS

Two review authors inspected all citations to ensure reliable selection. If we had included relevant trials, we planned to assess the methodological quality of identified trials using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions. Two review authors would have independently extracted data. For homogenous dichotomous data, we planned to calculate the risk ratio (RR), 95% confidence interval (CI), and the number needed to treat to benefit/harm (NNTB/NNTH) on an intention-to-treat basis.

MAIN RESULTS

There are no included studies in this review. The electronic search produced three relevant references, among which we identified two old planned trials that seem never to have started, and one which we excluded a study because it was a report of a case series.

AUTHORS' CONCLUSIONS

This is not an empty review - it is a review full of unanswered questions. Despite growing interest in women's mental health, the literature in the area of postnatal psychosis is still very limited. It seems that clinicians have no choice but to continue with their current practices guided solely by varied clinical judgement. Women at risk of postnatal psychosis and their relatives are justified to be disappointed in the medical/research fraternity. A post hoc PubMed topic (not methodology-specific) search identified mainly case series. Policy makers have no trial-based evidence upon which to base their guidelines. Certainly, preventive interventions for postnatal psychosis are difficult to justify with confidence without well-designed, well-conducted, and well-reported randomised studies. Available publications suggest that such studies are possible and funders of research may wish to make this work a priority.

Immune system dysregulation in first-onset postpartum psychosis

BACKGROUND

Accumulating evidence suggests that dysregulation of the immune system represents an important vulnerability factor for mood disorders. Postpartum psychosis (PP) is a severe mood disorder occurring within 4 weeks after delivery, a period of heightened immune responsiveness and an altered endocrine set point. Therefore, the aim of this study was to examine immune activation in patients with first-onset PP at the level of monocytes, T cells, and serum cytokines/chemokines.

METHODS

We included 63 women admitted with first-onset PP. Control groups included healthy postpartum (n = 56) and nonpostpartum (n = 136) women. A quantitative-polymerase chain reaction monocyte gene expression analysis was performed with 43 genes previously identified as abnormally regulated in nonpostpartum mood disorder patients including the isoforms of the glucocorticoid receptor. Peripheral blood mononuclear cells percentages were measured by fluorescence-activated cell sorter analysis, whereas serum cytokines/chemokines were determined with a cytometric bead array.

RESULTS

In healthy women, postpartum T cell levels were significantly elevated compared with nonpostpartum. Patients with PP failed to show the normal postpartum T cell elevation. In contrast, these patients showed a significant elevation of monocyte levels and a significant upregulation of several immune-related monocyte genes compared with control subjects postpartum and nonpostpartum. Furthermore, the glucocorticoid receptor α/β gene expression ratio was decreased in monocytes of PP patients, strongly correlating with their immune activation.

CONCLUSIONS

This study demonstrates a robust dysregulation of the immuno-neuro-endocrine set point in PP, with a notable over-activation of the monocyte/macrophage arm of the immune system.

Perinatal depression and anxiety: beyond psychopharmacology

A discussion of pharmacologic and nonpharmacologic management of mental disorders in the pregnant woman is presented, with the focus on alternative health approaches and nutrition awareness. The article explores some considerations of modifiable risk factors thought to play a role in epigenetic manifestations of infant and child illness. Several case examples show the potential for integrative medicine in patients of reproductive age.

Down-regulation of inflammation-protective microRNAs 146a and 212 in monocytes of patients with postpartum psychosis

BACKGROUND

Postpartum psychosis (PP) is thought to belong to the bipolar spectrum. Recently we described an immune activation signature in monocytes of patients with PP using gene expression profiling. Immune activation genes are regulated by microRNAs (miRNAs). We therefore profiled miRNA expression in monocytes of PP patients to identify differentially expressed miRNAs between PP and the healthy state.

METHODS

In a profiling study we carried out miRNA profiling using TaqMan array human microRNA A cards v2.0 and monocytes of 8 PP patients. Data were analyzed against monocytes of healthy postpartum women (CP). Nine miRNAs were selected and tested using individual Q-PCR in a larger validation study on monocytes of 20 PP patients, 20 CP and 20 healthy non-postpartum women (HC).

RESULTS

In the validation study miR-146a expression was significantly down-regulated in the monocytes of first onset PP patients as compared to CP and HC; miR-212 expression was significantly down-regulated in PP patients with prior bipolar disorder. In silico miR-146a targeted 4 genes of the previously described monocyte activation signature in bipolar disorder; miR-212 targeted 2 of such genes. In a correlation study decreased expression of miR-146a in monocytes was related to decreased natural T regulator cells in PP patients; decreased miR-212 was correlated to increased Adrenomedulin and decreased IL-6 expression in monocytes and to higher Th2 cell levels.

CONCLUSIONS

This study identified changes in miR-146a and -212 expression in PP. Since these miRNAs are linked to inflammation, the study strengthens the view that PP is an inflammation-like condition.