Postpartum Mood Disorders
Postpartum Mood Disorders is a comprehensive collection of papers addressing both practical clinical problems and evolving research questions in this important area of women's mental health. The editor, an experienced clinician and teacher in the field of pregnancy-related mental disorders, sets the stage for her book by challenging the notion that all the disorders from postpartum blues through postpartum depression to postpartum psychoses are on a continuum of affective illness.
The editor suggests that postbirth "blues" are not depressive disorders. Given that the blues are very prevalent and occur at about the same timing after birth, regardless of demographic variables, psychiatric history, or life stressors, she wonders if they are a normative rather than a pathologic condition. Citing flaws in previous studies' methodology that measure only sad moods and have no way of recording joy, she suggests that researchers should test the hypothesis that postpartum blues reflect "heightened reactivity," not depression. Could the blues be the demonstration of mammals' "unique neurobiological system that is activated by postpartum hormonal changes and that promotes the initial attachment behavior between mothers and newborn babies?"
The book's contributors continue in this thoughtful style. The authors synthesize existing literature on each of the disorders, with careful critiques of existing research, suggesting refinement of research questions and improvements in methodology. They place postpartum depression in the context of reproductive-related disorders across the life cycle: depressions associated with oral contraceptive use, the premenstrual period, the puerperium, and menopause. Differential diagnosis of postpartum psychosis considering the broad range of biological causes is carefully discussed.
The psychological treatments that are described go beyond evaluation of the individual meaning of the birth to the woman. Chapters on therapy consider the woman in the context of her partner relationship, her family relationships, her mothering capacity, and her culture. Even the chapter on biological treatments with medications and electroconvulsive therapy reminds clinicians of the psychological meaning of these interventions. "The treatment of psychiatric disorders requires great sensitivity to the meaning of psychotropic medication and ECT. Although postpartum patients often enter treatment highly symptomatic, psychiatric medication itself may be experienced as a symbol of maternal inadequacy." And, "In breast-feeding patients the decision to wean should be viewed as being equally consequential as the decision to administer maternal medication."
The contributions of self-help techniques and volunteer networks are shown to enhance treatment by professionals. The important clinical problem of identification of women at high risk is addressed, with suggested preventive interventions.
The chapter on postpartum psychosis emphasizes the serious risks of the condition, including suicide and infanticide. It addresses the high prevalence of recurrent episodes and the effectiveness of prophylaxis. The authors discuss the effectiveness of hospitalizing the baby with the mother, and they also address the medicolegal issues that can arise, including prosecution of the postpartum woman for murder. This and a subsequent chapter emphasize the risks to the newborn of a mother who has a postpartum disorder for neglect, incompetent care, and ongoing problems in emotional and cognitive development.
Postpartum Mood Disorders will be helpful to clinicians caring for childbearing women, whether they are in community settings or psychiatric hospitals. Guidance for identifying women at high risk for postpartum disorders, preventing the conditions, and conducting meticulous workups of depressed or psychotic patients is clearly given. Descriptions of options for multidisciplinary biopsychosocial treatments are easy to find and follow. Equally valuable are the explanations of the state of research in each of these dimensions.
Dr. McCartney is the executive associate dean for medical education and professor of psychiatry at the University of North Carolina School of Medicine in Chapel Hill.
