Disorders and their context

Perinatal psychiatric Incidence of postnatal psychiatric disorders and

syndromes: clinical features referral/admission

Disorder Incidence (% of all births)

Margaret R Oates
‘Depression’ 15–30
Postnatal depression 10
Moderate to severe depressive 3–5
illness
Psychiatric referral 2
Admitted to psychiatric unit 0.4
Admitted with psychosis 0.2
Abstract
Births to mothers with schizophrenia 0.2
Psychiatric disorders are the leading cause of maternal morbidity, and
suicide is a leading cause of maternal death in the UK, and probably
Table 1
throughout the developed world. These disorders are very common both
in pregnancy and following delivery. This article covers the aetiology
and management of puerperal psychosis, postnatal depressive illness, for postpartum women of developing a severe depressive illness or
­anxiety, and obsessive–compulsive disorder. a psychosis, of being admitted to a psychiatric hospital, and of see-
ing a psychiatrist is greatly increased compared with that for other
Keywords anxiety; obsessive–compulsive disorder; perinatal psychiatry; women and for men.4 Women with a past history of serious mental
postnatal depression; puerperal psychosis; suicide and pregnancy illness postpartum or at other times are at particularly increased
risk (1 in 2) of a recurrence of their condition after delivery. The
less severe forms of depressive illness are probably no more com-
Psychiatric disorders are the leading cause of maternal morbid- mon in the year following delivery than at other times.7 However,
ity, and suicide is a leading cause of maternal death in the UK,1 it has been argued that the incidence of these depressive illnesses
and probably throughout the developed world. may be increased in the first 3 months.6 None the less, the lack of
evidence for increased frequency does not detract from the impact
of such an illness at an important time in a woman’s life. It is a time
Frequency of disorders
when most women would expect to be happy, and the ­distressing
Perinatal psychiatric disorders are common both in pregnancy illness interferes with every aspect of their functioning.
and following delivery. Few psychiatric disorders are associated
with a decrease in biological fertility and the prevalence of all
Relapses or recurrences of pre-existing conditions
forms of psychiatric disorder at the time of conception is thus
equivalent to that found in non-pregnant women of a similar During pregnancy most of the new-onset conditions are mild
age. The incidence of mild depressive illness and anxiety states cases of depressive illness, anxiety states, or mixed depression
in pregnancy is estimated at 10–15%, at least as common as the and anxiety. However, women with chronic or recurrent psy-
incidence postpartum. There is also evidence that anxiety levels, chiatric disorders do become pregnant, and relapses or recur-
in particular, increase throughout pregnancy and fall following rences of their condition may complicate both pregnancy and
delivery.2,3 However, in contrast to the postpartum period, there the postpartum period. This is particularly likely to happen
is no evidence of an increased incidence of psychiatric disorder when the ­ medication that has been maintaining their health is
during pregnancy, and indeed there is some evidence to suggest stopped when the pregnancy is confirmed. Pregnant women may
that the incidence of severe conditions is lower in pregnancy ­therefore suffer from relapses of:
than at other times, as is referral to psychiatric services and • anxiety disorders, including obsessive–compulsive disorder
admission to a psychiatric unit.4,5 • depressive illness
Table 1 lists the incidence of the most common postnatal • bipolar disorder
­psychiatric disorders. • schizophrenia.
After delivery, more than 10% of women suffer from a new Pregnancy is not protective against relapses of serious affec-
episode of depressive illness (of all severities), having previously tive disorder. Although uncommon, new-onset psychotic ill-
been well. Approximately 3% suffer from a moderate to severe nesses do occur occasionally in pregnancy, particularly in later
depressive illness and 0.2% from puerperal psychosis.4,5,6 The risk pregnancy. Not only are such illnesses hazardous to the mental
health and safety of the woman, they are also associated with
increased physical morbidity and mortality,1 and represent a
Margaret R Oates MB ChB DPM FRCPsych is Consultant Perinatal Psychiatrist ­considerable hazard to the unborn child.
with the Nottinghamshire Healthcare Trust and Honorary Senior
Lecturer at the University of Nottingham, UK, Clinical Director of East
New disorders in pregnancy
Midlands Perinatal Mental Health Managed Clinical Network, and
National Psychiatric Assessor for the Confidential Enquiry into Maternal The incidence of psychiatric disorder in pregnancy is mostly
and Child Health. Conflicts of interest: None declared. ­accounted for by mild depressive illness, mixed anxiety and

PSYCHIATRY 8:1  © 2008 Elsevier Ltd. All rights reserved.

 Disorders and their context

depression, or anxiety states. These disorders present most com-

Postpartum-onset disorders
monly in the early weeks of pregnancy, becoming less common
as the pregnancy progresses. They are probably predominantly Most postpartum-onset psychiatric disorders are affective dis­
of psychosocial aetiology, although for some women they will orders. However, symptoms other than those due to a disorder of
represent a recurrence of a previous episode, particularly social mood are frequently present. Conventionally, three postpartum
anxiety, panic, or obsessional disorders. Women may also be disorders are described (Table 2):
vulnerable at this time because of: • the ‘blues’
• previous fertility problems • postnatal depression
• previous obstetric loss • puerperal psychosis.
• anxieties about the viability of the pregnancy The blues is a common dysphoric, self-limiting state occurring in
• social and interpersonal adversity the first week following delivery. The clinical features of puer-
• ambivalence towards the pregnancy peral psychosis and non-psychotic postnatal depressive illness in
• other reasons for personal unhappiness. its severe and mild forms are considered below.
In the past, it was often assumed that hyperemesis gravidarum
(severe vomiting) was a psychosomatic manifestation of unhap-
Puerperal psychosis
piness and psychological disturbance. This condition is less com-
mon than in the past, and usually resolves at about 16 weeks Puerperal psychosis, the most severe form of postpartum affec-
of pregnancy. Psychological factors, particularly anxiety, and tive disorder, has been recognized and described since antiquity.
cogni­­tive misattribution remain a significant aetiological ­ factor It leads to 2 per 1000 women being admitted to a psychiatric
in some women. hospital following childbirth, mostly in the first few weeks post-
partum. This rate, while reflecting a relatively rare condition,
represents a marked increase in the risk of suffering from a psy-
Management
chotic illness and of being admitted to a psychiatric unit.5 It is
Most of the mild or minor conditions are likely to improve as the also remarkably constant across nations and over time.
pregnancy progresses. Psychological treatments and psychoso- Aetiology – most women who suffer from this condition will
cial interventions are effective for many, and caution needs to have been previously well, without obvious risk factors, and
be exercised before pharmacological interventions are initiated the illness comes as a shock to them and their families. How-
during pregnancy,8 although medication is necessary for some ever, some will have suffered from a similar illness following the
women. The abrupt cessation of medication in women with birth of a previous child; some may have suffered from a non-
severe mental illness following confirmation of pregnancy can postpartum severe affective disorder from which they have long
be problematic. An acute relapse of a severe mental illness such recovered, or they may have a family history of severe mental
as bipolar disorder, severe depressive illness, or schizophrenia ­illness. For others there may be marked psychosocial adversity. It
can pose risks not only to the woman herself but to the well- is generally accepted that biological factors (neuro-endocrine and
being of her developing baby. There is probably no rationale for genetic) are the most important aetiological factors for this condi-
the routine stopping of medication in early pregnancy (with the tion. This implies that puerperal psychosis can and does strike,
exception of valproate), and a measured approach to the use without warning, women from all social and occupational back-
of medication in pregnancy needs to be taken in these circum- grounds – those in stable marriages with much-wanted babies as
stances.2 In a few women suffering from the less severe forms of well as those living in less fortunate circumstances.
psychiatric disorder in pregnancy, childbirth itself will achieve Clinical features – puerperal psychosis is an acute, early-
a resolution of their condition. For most women, however, par- onset condition. The overwhelming majority of cases present in
ticularly those who are psychiatrically unwell in the later stages the first 14 days postpartum. They most commonly develop sud-
of pregnancy, their condition is likely to continue into the post- denly between day 3 and day 7, at a time when most women
partum period. will be experiencing the blues. Differential diagnosis between
the earliest day of a developing psychosis and the blues can
be difficult. However, puerperal psychosis steadily deteriorates
Postnatal depression
over the following 48 hours, whereas the blues tends to resolve
The term ‘postnatal depression’ (PND) has come to be used as spontaneously.
a generic term for all forms of psychiatric disorder presenting
after delivery. In the past this was undoubtedly helpful in raising
the profile of postpartum psychiatric disorders, improving their Three types of postpartum-onset psychiatric disorder
recognition, and reducing stigma, but it has become problem-
atic. Use of the term diminishes the perceived severity of these • The blues – occurs in the first week after delivery
illnesses and focuses the attention of services and clinicians on • Postnatal depression – the majority of cases present 8–12
primary care while neglecting the secondary and tertiary care of weeks after delivery; the most severe cases tend to present
mothers suffering from more serious illnesses. The term can also earlier, at 4–6 weeks
belie the phenomenological complexity of the conditions and • Puerperal psychosis – the majority occur within 2 weeks of
lead to false assumptions of diagnostic and therapeutic homo- delivery
geneity. Differential diagnosis is as important in the postpartum
period as at other times. Table 2

PSYCHIATRY 8:1  © 2008 Elsevier Ltd. All rights reserved.

 Disorders and their context

Early symptoms – the first 2–3 days of a developing puer- by their mental state. These problems, directly attributable to the
peral psychosis involves an evanescent, rapidly changing, undif- maternal psychosis, tend to resolve as the mother recovers.
ferentiated psychotic state. The earliest signs are commonly of Management – most women with psychotic illness following
­perplexity, fear – even terror – and restless agitation associated childbirth require admission to hospital, which should be to a
with insomnia. Other signs include: specialist mother-and-baby unit.
• hallucinations and delusions
• purposeless activity Prognosis
• uncharacteristic behaviour In spite of the severity of puerperal psychoses, they frequently
• disinhibition resolve relatively quickly over 2–4 weeks. However, initial
• irritation and fleeting anger recovery is often fragile and relapses are common in the first few
• resistive behaviour. weeks. Women whose condition has been predominantly manic
A woman may have transient fears for her own and her have a particular risk of entering a depressive phase before they
baby’s health and safety, or even about its identity. Even at this finally stabilize. As the psychosis resolves, it is common for all
early stage there may be, variably throughout the day, manifes- women to pass through a phase of depression and anxiety, and
tations of elation and grandiosity, suspiciousness and paranoia, preoccupation with their past experiences, and the implications
depression, or unspeakable ideas of horror. The woman may be of these memories for their future mental health and role as a
unable to attend to her own personal hygiene and nutrition, and mother. Sensitive and expert help is required to assist women
unable to care for the baby. Her concentration is usually grossly through this phase, to help them understand what has happened,
impaired and she is distractible and unable to initiate and com- and to acquire a ‘working model’ of their illness. The over-
plete tasks. Over the next few days her condition deteriorates whelming majority of women will have completely recovered by
and the symptoms usually become more clearly those of an acute 3–6 months postpartum. However, they face a substantial risk of
affective psychosis. Most women have symptoms and signs sug- recurrence should they have another child.
gestive of a depressive psychosis, a significant minority have a
manic psychosis, and very commonly women have a mixture of
Postnatal depressive illness
both – a mixed affective psychosis.
Delusions – women suffering from puerperal psychosis are Depressive illness in the puerperium, as at other times, consists
among the most profoundly disturbed and distressed found in of different subtypes of depressive illness along a spectrum of
psychiatric practice. In addition to the familiar symptoms and severity. These illnesses can be mild, moderate, or severe, with
signs of a manic or depressive psychosis, first-rank symptoms of or without biological symptoms (somatic subtype; Table 3), and
schizophrenia – particularly primary delusions, delusional mood, can be combined with prominent features of anxiety, panic, and
and delusional perception – are commonplace. Delusional ideas obsessional phenomena. At the most severe end of the spectrum,
about the identity of loved ones, health professionals, and even the depressive illnesses can merge with puerperal psychosis; at
the baby can occur. Depressive delusions about maternal and the mildest end they can merge with adjustment disorders and
infant health are commonplace. The behaviour and motives of normal emotional changes. Taken together, these illnesses affect
others are frequently misinterpreted in a delusional fashion. An more than 10% of all delivered women.
affect of perplexity and terror is often found, as are delusions
about the passage of time and other bizarre delusions. Women Severe depressive illness
can believe that they are still pregnant or that more than one Severe depressive illness with biological features affects at least
child has been born or that the infant is older than it is. 3% of all delivered women. Again, the majority of women who suf-
Other features – organic features have been described, such fer from this condition will have been well previously. However,
as confusion and disorientation. In the common mixed affective women with a previous history of severe postnatal ­ depressive
psychosis, along with the familiar pressure of speech and flight illness or severe depression at other times, or a ­family history of
of ideas comes a mixture of grandiosity, elation, and certain con- the condition, are at increased risk. Psychosocial ­factors are more
viction, alternating with states of fearful tearfulness, guilt, and a prominent in the aetiology of this condition than in puerperal
sense of foreboding. Sufferers are usually restless and agitated, psychosis, although biological factors may play a more important
resistive, seeking senselessly to escape, and difficult to reassure. role in the most severe illnesses. Nevertheless, severe postnatal
However, they are usually calmer in the presence of familiar depression can affect women from all backgrounds.
relatives.
Relationship with the baby – some women are so disturbed
and distractible, and their concentration so impaired, that they Three subtypes of non-psychotic postnatal
do not seem to be aware of their recently born infant. Others are depressive illness
preoccupied with the baby, reluctant to let it out of their sight,
and forever checking on its presence and condition. Although • Severe depressive illness (melancholia, biological depression,
delusional ideas frequently involve the child and there may be somatic subtype)
delusional ideas of infant ill-health or changed identity, it is rare • Moderate depressive illness with panic and/or obsessional
for women with puerperal psychosis to be overtly hostile to their features
child and for their behaviour to be aggressive or punitive. The • Mild depressive illness
risk to their baby lies more from an inability to organize and
complete tasks, and to handling and other tasks being impaired Table 3

PSYCHIATRY 8:1  © 2008 Elsevier Ltd. All rights reserved.

 Disorders and their context

Like puerperal psychosis, severe depressive illness is an settle, and may lead the mother to be frightened to be alone with
early-onset condition in which the woman commonly does not her child. This is easily misinterpreted by professionals, who
regain her normal emotional state following delivery. However, may fear that the child is therefore at risk.
unlike puerperal psychosis, the onset tends not to be so abrupt; Obsessional, vacillating indecisiveness is also common and
rather, the illness develops more insidiously over the next contributes to an overwhelming sense of being unable to cope
2–4 weeks. The most severe illnesses tend to present early, by with everyday tasks in marked contrast to premorbid levels of
4–6 weeks postpartum, but most present later, between 8 and competence. Although complex obsessive–compulsive behav-
12 weeks after delivery. These later-presentation illnesses may ioural rituals are relatively rare, obsessive cleaning, house-
be missed. work, and checking are very common. Intrusive obsessional
Clinical features – the familiar symptoms of severe depres- thoughts and the typical catastrophic cognitions associated
sive illness are often modified by the context of early maternity with panic attacks frequently lead to a fear of insanity and loss
and the relative youth of those suffering from the condition. of control.
• The somatic syndrome of broken sleep and early morn- Relationship with the baby – severe depression, particularly
ing waking, diurnal variation of mood, loss of appetite and when combined with panic and obsessional phenomena, has a
weight, slowing of mental functioning, impaired concentra- profound effect on the relationship with the baby in many, but
tion, extreme tiredness, and lack of vitality can easily be by no means all, women. Most women who suffer from severe
misattributed to a crying baby, understandable tiredness, and postnatal depression maintain high standards of care for their
adjustment to new routines. infants. However, many are frightened of their own feelings and
• The all-pervasive anhedonia or loss of pleasure in ordinary thoughts, and few gain any pleasure or joy from their infant. Most
everyday tasks, the lack of joy, and fearfulness for the future affected women feel a deep sense of guilt and incompetence, and
may be misattributed by the woman herself to ‘not loving the doubt whether they are caring for their infant properly. Normal
baby’ or ‘not being a proper mother’, and all too readily per- infant behaviour is frequently misinterpreted as confirming their
ceived and described as ‘bonding problems’ by profession- poor views of their own abilities. A fear of harming the baby
als. Anhedonia is a particularly painful symptom at a time is commonplace, but overt hostility and aggressive behaviour
when most women would expect to feel overwhelmed with towards the infant is uncommon. It should be remembered that
joy and happiness, and in turn contributes to the feelings of the majority of mothers who harm young babies are not suffering
guilt, incompetence, and unworthiness that are prominent in from a severe mental illness. The speedy resolution of maternal
postnatal depressive illness. These overvalued ideas can verge illness usually results in a normal mother–infant relationship.
on the delusional. However, prolonged chronic depressive illness can interfere with
• It is also common to find overvalued morbid beliefs and fears attachment and social and ­cognitive development in the longer
for the woman’s own health and mortality and for that of her term.
baby. She may misattribute normal infant behaviour to mean
that the baby is suffering or does not like her. A baby that set- Mild postnatal depressive illness
tles in the arms of more experienced people may confirm the This is the commonest condition following childbirth, affecting
mother’s belief that she is incompetent. Commonplace prob- 7–10% of all women delivered. Some women who suffer from
lems with establishing breast-feeding may become the subject this condition will be vulnerable by virtue of previous mental
of morbid rumination. health problems or psychosocial adversity, unsatisfactory mari-
• Some women with severe postnatal depressive illness may be tal or other relationships, or inadequate social support. Others
slowed, withdrawn, and, in the face of offers of help, retreat may be older, educated, and married for a long time, perhaps
from the tasks of motherhood and their relationship with the with problems conceiving, previous obstetric loss, or high levels
baby. Others may be agitated, restless, and fiercely protective of anxiety during pregnancy. Unrealistically high expectations of
of their infant and resent the contribution of others. themselves and consequent disappointment are commonplace.
Also common are stressful life events such as moving house,
Anxiety and obsessive–compulsive disorder family bereavement, having a sick baby, experience of special-
Although women with pre-existing anxiety and panic disorder care baby units, and other such events that detract from the
or obsessive–compulsive disorder (OCD) frequently experience expected pleasure and harmony of this stage of life.
relapses or recurrences postpartum, it is not known whether there Clinical features – the condition has an insidious onset in
is an increased incidence of these conditions following delivery. the days and weeks after childbirth but usually presents after
None the less, severe anxiety states, panic attacks, and obses- the first 3 months postpartum. The symptoms are variable, but
sional phenomena are common in pregnancy and after delivery. the mother is usually tearful, feels that she has difficulty coping,
These symptoms may dominate the clinical picture or accompany and complains of irritability and a lack of satisfaction and pleasure
a postnatal depressive illness. They frequently underpin mental with motherhood. Symptoms of anxiety, a sense of loneliness and
health crises, calls for emergency attention, and maternal fears isolation, and dissatisfaction with the quality of important rela-
for the infant. Repetitive, intrusive, and often deeply repugnant tionships are common. Affected mothers frequently have good
thoughts of harm coming to loved ones, particularly the infant, days and bad days, and are often better in company and stressed
are common, often leading to repetitive checking. The woman when alone. The full biological (somatic subtype) ­ syndrome of
may doubt that she is safe as a mother and believe that she is more severe depressive illness is usually absent. However, ini-
capable of harming her infant. Crescendos of anxiety and panic tial insomnia and appetite difficulties, both over-eating and
attacks may result from the baby’s crying or being difficult to under-eating, are common.

PSYCHIATRY 8:1  © 2008 Elsevier Ltd. All rights reserved.

 Disorders and their context

Relationship with the baby – dissatisfaction with mother-

hood and a sense of the baby being problematic are often central National documents relevant to perinatal mental
to this condition, particularly when compounded by difficulty in health care
meeting the needs of older children. Lack of pleasure in the baby,
combined with anxiety and irritability, can lead to a vicious circle • Department of Health. Drug misuse and dependence:
of a fractious and unsettled baby, misinterpreted by its mother as guidelines on clinical management. London: The Stationery
critical and resentful of her, and thus a deteriorating relationship Office, 1999.
between them. However, it should also be remembered that the • Department of Health. Mental Health Act 1983. Code of
direction of causality is not always from mother to infant. Some Practice, Paragraph 26.03. London: DH, 1999.
infants are very unsettled in the first few months of their life. A • Department of Health. The National Service Framework
baby who is difficult to feed and cries constantly during the day for Mental Health. Modern standards and service models.
or is difficult to settle at night can just as often be the cause of a London: DH, 1999.
mild postnatal depressive illness as the result of it. Even mild ill- • Department of Health. Safety, privacy and dignity in mental
nesses, particularly when combined with socio-economic depri- health units: guidance on mixed sex accommodation for
vation and high levels of social adversity, can lead to longer-term mental health units. Leeds: NHS Executive, 2000.
problems in mother–infant relationships and subsequent social • Department of Health. Women’s mental health: into the
and cognitive development of the child. A small minority of suf- mainstream. Strategic development of mental health care for
ferers from this condition may experience such marked irritabil- women. London: DH, 2002.
ity, and even overt hostility towards their infant, that the child is • Department of Health. National Service Framework for
at risk of being injured. Children, Young People and Maternity Services. Standard 11:
Maternity Services. London: DH, 2004.
• Lewis G, ed. Saving mothers’ lives: reviewing maternal deaths
Suicide
to make motherhood safer – 2003–2005. The Seventh Report
Suicide is a leading cause of maternal death in the UK; at least on Confidential Enquiries into Maternal Deaths in the United
2 per 100,000 women delivered (0.002%) take their own life.1 Kingdom. London: Confidential Enquiries into Maternal and
But, although suicide is approximately five times commoner fol- Child Health, 2007.
lowing delivery than during pregnancy, it is still a rare event. • National Screening Committee. Screening for postnatal
Nevertheless, the evidence is that the majority of women who depression. London: Department of Health, 2001.
kill themselves in the 12 weeks after childbirth are experiencing • Royal College of Psychiatrists. Perinatal mental health
a recurrence of a severe depressive illness or puerperal psycho- services. Recommendations for provision of services for
sis, having suffered from a similar condition following the birth childbearing women. Council Report 88. London: Royal
of a previous child or at other times. These women are typi- College of Psychiatrists, 2000.
cally well supported by family, friends, and professionals, live in • Scottish Executive. Framework for maternity services in
­comfortable social circumstances, and die violently. Scotland. Edinburgh: NHS Scotland, 2001.
Detection of the risk of recurrence of a severe postpartum ill- • Scottish Intercollegiate Guidelines Network. Postnatal
ness early in pregnancy, by ascertaining a previous psychiatric depression and puerperal psychosis. SIGN 60. Edinburgh:
history and putting into place a pro-active management plan, Royal College of Physicians, 2002.
could probably reduce the rate of suicide following delivery. • National Institute for Health and Clinical Excellence. Antenatal
and Postnatal Mental Health. Clinical Management and
Service Guidance. NICE Clinical Guideline 45. London: NICE,
Perinatal psychiatric services
2007.
National documents relating to the provision of perinatal mental
health services and the care of perinatal psychiatric disorders Table 4
are listed in Table 4. They all recommend that women with a
severe postpartum mental illness who need to be admitted to a
Conclusion
psychiatric unit should be admitted to a specialized mother and
baby unit, and not be separated from their baby unless there The full range of psychiatric disorders can complicate pregnancy
are specific reasons for doing so. They also recommend that and the postpartum year. The incidence of affective disorder,
all mental health Trusts in the UK should provide a consultant particularly at the most severe end of the spectrum, increases
with a special interest in perinatal psychiatry and a designated following delivery. The familiar signs and symptoms of psychiat-
perinatal multidisciplinary team that is available to all mater- ric disorder are all present in postpartum disorders as well, but
nity Trusts. Table 4 also refers to guidelines for the management the early maternal context and the dominance of infant care and
of drug misuse in pregnancy. The Maternity Standards of the mother–infant relationships exert a powerful pathoplastic effect
Children and Young People’s National Service Framework and on the content, if not the form, of the symptomatology. Early
the ­Confidential Enquiry into Maternal Deaths recommend that maternity is a time when the expectations are of joy, pleasure,
an obstetrician and midwife with a special interest in substance and fulfilment. The presence of psychiatric disorder at this time,
­misuse should be part of every maternal service, and that a ‘one- however mild, is therefore disproportionately distressing. No
stop shop’ model of service provision should be integrated within matter how ill the woman feels, there is still an infant and often
the ­antenatal clinic. other children to be cared for. She cannot rest and is reminded

PSYCHIATRY 8:1  © 2008 Elsevier Ltd. All rights reserved.

 Disorders and their context

on a daily basis of her symptoms and disability. Compassionate 6 Cox JL, Murray D, Chapman G. A controlled study of the onset,
understanding and skilled care aimed at speedy symptom relief duration and prevalence of postnatal depression. Br J Psychiatry 1993;
and re-establishing her confidence are thus essential. ◆ 163: 27–30.
7 O’Hara MW, Swain AM. Rates and risk of postpartum depression: a
meta-analysis. Int Rev Psychiatry 1996; 8: 37–54.
8 National Institute for Health and Clinical Excellence. Antenatal and
postnatal mental health. Clinical Management and Service Guidance.
References NICE Clinical Guideline 45. London: NICE, 2007.
1 Lewis G, ed. Saving mothers’ lives: reviewing maternal deaths
to make motherhood safer – 2003–2005. The Seventh Report on
Confidential Enquiries into Maternal Deaths in the United Kingdom. Practice points
London: Confidential Enquiry into Maternal and Child Health, 2007.
2 Kumar R, Robson KM. A prospective study of emotional disorders in • All psychiatric disorders can present in pregnancy and
childbearing women. Br J Psychiatry 1984; 144: 35–47. following birth
3 Evans J, Heron J, Francomb H, Oke S, Golding J. Cohort study of • Anxiety, panic, and obsessional features frequently
depressed mood during pregnancy and after childbirth. BMJ 2001; complicate and even dominate postnatal depression
323: 257–60. • Puerperal psychoses arise shortly after childbirth, can be very
4 Kendell RE, Chalmers JC, Platz C. Epidemiology of puerperal variable, and deteriorate rapidly
psychosis. Br J Psychiatry 1987; 150: 662–73. • Future pregnancies should be discussed with women who
5 Oates M. Psychiatric services for women following childbirth. Int Rev have suffered from a severe mental illness
Psychiatry 1996; 8: 87–98.

PSYCHIATRY 8:1  © 2008 Elsevier Ltd. All rights reserved.