Journal Article Annotations
2017, 1st Quarter
Annotations by Imran Iqbal, MD, and Nina Beizer, MD
The finding: This review from Erasumus Medical Center in the Netherlands, Stanford University, and Northwestern University outlines the epidemiological, genetic, and physiological postpartum triggers of postpartum psychosis, and then provides specific diagnostic, treatment, and prevention recommendations based on the available literature on the topic.
The article begins with two cases offering vivid accounts of postpartum psychosis. It then discusses disease course, which usually falls into one of two categories: 1) isolated postpartum psychosis (20%–50%); and 2) postpartum psychosis as an expression of bipolar mood disorder with non-perinatal episodes (50%–80%). Etiological considerations, such as genetics, hormonal changes related to pregnancy, immunological conditions such as autoimmune thyroiditis and autoimmune encephalitis, and circadian rhythm disruption are examined as they relate to the development and course of this disorder.
The authors next consider diagnostic factors. The diagnostic picture of postpartum psychosis typically involves one of three general presentations: 1) mania or mixed episodes (with or without psychotic features); 2) depressive episodes with psychotic features; and 3) psychosis without mood symptoms (less than 10% of cases). The article then reviews practical aspects of diagnostic assessment, including the importance of inpatient psychiatric hospitalization, the significance of inquiry into thoughts of suicide and infanticide, and the need for pertinent lab examinations.
Evidence-based treatment recommendations are made. The authors recommend lithium as the drug of choice during the acute phase of the illness, unless contraindicated. Electroconvulsive therapy (ECT), antipsychotic medication, or benzodiazepines are also useful adjunctive treatments for the acute phase. The review acknowledges the managerial challenges presented by a breastfeeding woman with acute onset of psychosis, and concludes that management must be individualized.
Finally, the authors review preventive aspects of care and offer additional recommendations. The overall postpartum psychosis relapse risk for women with bipolar disorder is 37%. Broken down, this risk is 66% if patients are off medication during pregnancy, and only 23% if on medication. In light of these risks, the authors recommend conducting a risk-benefit assessment and considering continuation of prophylactic medication during pregnancy, citing again the most evidence-based intervention is lithium. The risk of relapse in those women with only postpartum onset psychoses is 31%. Given the evidence, the authors also recommend lithium, in this case immediately after delivery.
Strengths and weaknesses: First, the article is comprehensive, with 110 reference publications cited. Second, it arrives at evidence-based diagnostic and treatment recommendations which are very helpful to the practitioner who may come across this rare disorder. However, as postpartum psychosis is rare, there is correspondingly very little evidence upon which to base diagnostic and treatment considerations. For that matter, the topic has not been the subject of great scientific attention and remains under-researched. The evidence based recommendations put forward by the authors rests upon less than 30 published articles, the majority of which are case reports describing a single patient. Their recommendations can only be as strong as the evidence that supports them.
Relevance: This article is relevant because rare diseases such as postpartum psychosis (incidence from 0.25 to 0.6 per 1,000 births) require regular updates as we inevitably become less experienced with them in our practice over time.
The finding: This study examines the relationship between SSRI exposure during pregnancy and the development of speech/language, scholastic, and motor disorders in offspring from those pregnancies from birth up to 14 years. They found an association between SSRI exposure during pregnancy and an increased risk of development of speech/language disorders, but did not find an association between SSRIs and the incidence of scholastic and motor disorders. The study also examined whether or not severity of depression confounded the association between maternal SSRI use and speech/language disorder in offspring, using two different proxies for depression severity, and found that it was not.
Strengths and weaknesses: One strength is that the study is a large, prospective, population-based cohort study that examined children from birth to age 14, which is a broader age range of children compared to prior studies. Other strengths include the large sample size of offspring (n=15,596) as well as the fact that the sample included typical confounders, minimizing potential confounders on the analysis conducted in this study. The prospective nature of the study also minimizes the risk of ascertainment and recall bias. The examination of clinical outcomes rather than rating scales enables the development of conclusions that are more readily clinically applicable.
Weaknesses of the study include the effect size of the findings and limitations in correcting for confounders. The effect size observed was small: the rate of speech/language delay in the SSRI-exposed group was 1.62% vs. 1.85% in the depression-exposed group vs. 1.04% in the unexposed group. With regard to confounding factors, the observational design of the study is inherently more subject to confounding factors than a randomized clinical trial. Possible confounding factors are maternal alcohol use and the many possible variables in a child’s development. Another weakness is that the study examined SSRIs filled, not explicitly whether or not they were taken, although given the association of speech/language disorders only between taking multiple SSRIs suggests that prescribing SSRIs is a reasonable proxy for whether or not SSRIs were taken, a finding confirmed by prior studies.
Relevance: This study is the first to examine whether taking SSRIs during pregnancy has any association with speech/language, scholastic, and/or motor disorders on the child. The association found between SSRI exposure and the development of speech/language disorders could help us understand more about the developmental process, as well as impact prescribing practices. Ultimately, any medication has both risks and benefits, and whether sufficiently treating a mother’s depression outweighs the risk of a possible speech/language delay in her child should be considered on a case-by-case basis.