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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.
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.
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.
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.
Universal screening for postpartum depression is recommended in many countries. Knowledge of whether the disclosure of depressive symptoms in the postpartum period differs across cultures could improve detection and provide new insights into the pathogenesis. Moreover, it is a necessary step to evaluate the universal use of screening instruments in research and clinical practice. In the current study we sought to assess whether the Edinburgh Postnatal Depression Scale (EPDS), the most widely used screening tool for postpartum depression, measures the same underlying construct across cultural groups in a large international dataset.
Ordinal regression and measurement invariance were used to explore the association between culture, operationalized as education, ethnicity/race and continent, and endorsement of depressive symptoms using the EPDS on 8209 new mothers from Europe and the USA.
Education, but not ethnicity/race, influenced the reporting of postpartum depression [difference between robust comparative fit indexes (∆*CFI) < 0.01]. The structure of EPDS responses significantly differed between Europe and the USA (∆*CFI > 0.01), but not between European countries (∆*CFI < 0.01).
Investigators and clinicians should be aware of the potential differences in expression of phenotype of postpartum depression that women of different educational backgrounds may manifest. The increasing cultural heterogeneity of societies together with the tendency towards globalization requires a culturally sensitive approach to patients, research and policies, that takes into account, beyond rhetoric, the context of a person's experiences and the context in which the research is conducted.
Recent evidence suggests that postpartum psychiatric episodes may share similar etiological mechanisms with immune-related disorders. Pre-eclampsia is one of the most prevalent immune-related disorders of pregnancy. Multiple clinical features are shared between pre-eclampsia and postpartum psychiatric disorders, most prominently a strong link to first pregnancies. Therefore, we aimed to study if pre-eclampsia is a risk factor for first-onset postpartum psychiatric episodes.
We conducted a cohort study using the Danish population registry, with a total of 400 717 primiparous women with a singleton delivery between 1995 and 2011. First-lifetime childbirth was the main exposure variable and the outcome of interest was first-onset postpartum psychiatric episodes. The main outcome measures were monthly incidence rate ratios (IRRs), with the period 11–12 months after birth as the reference category. Adjustments were made for age, calendar period, reproductive history, and perinatal maternal health including somatic and obstetric co-morbidity.
Primiparous women were at particularly high risk of first-onset psychiatric episodes during the first month postpartum [IRR 2.93, 95% confidence interval (CI) 2.53–3.40] and pre-eclampsia added to that risk (IRR 4.21, 95% CI 2.89–6.13). Having both pre-eclampsia and a somatic co-morbidity resulted in the highest risk of psychiatric episodes during the 3-month period after childbirth (IRR 4.81, 95% CI 2.72–8.50).
We confirmed an association between pre-eclampsia and postpartum psychiatric episodes. The possible explanations for this association, which are not mutually exclusive, include the psychological impact of a serious medical condition such as pre-eclampsia and the neurobiological impact of pre-eclampsia-related vascular pathology and inflammation.
Women with a history of bipolar disorder or postpartum psychosis are at extremely high risk of relapse postpartum. Although lithium prophylaxis has demonstrated efficacy in reducing postpartum relapse, the timing of prophylaxis remains controversial given the balance of risks and benefits for the mother and fetus. The authors compared lithium use during pregnancy compared to its initiation postpartum in women at high risk for postpartum psychosis.
Between 2003 and 2010, 70 pregnant women at high risk for postpartum psychosis were referred to the authors'psychiatric outpatient clinic. Women who were initially medication-free were advised to start lithium prophylaxis immediately postpartum. Women already taking maintenance lithium during pregnancy were advised to continue treatment.
All women with a history of psychosis limited to the postpartum period (n=29) remained stable throughout pregnancy despite being medication-free. Of the women with bipolar disorder (n=41) 24.4% relapsed during pregnancy, despite prophylaxis use by the majority throughout pregnancy. The postpartum relapse rate was highest in women with bipolar disorder who experienced mood episodes during pregnancy (60.0%). In contrast, none of the 20 women with postpartum psychosis using postpartum prophylaxis relapsed, compared to 44.4% of postpartum psychosis patients who declined prophylaxis.
The authors recommend initiating prophylactic treatment immediately postpartum in women with a history of psychosis limited to the postpartum period, to avoid in utero fetal exposure to prophylactic medication. Patients with bipolar disorder require continuous prophylaxis throughout pregnancy and the postpartum period to reduce peripartum relapse risk.
Women with a history of bipolar disorder or postpartum psychosis are at extremely high risk of relapse postpartum. Although lithium prophylaxis has demonstrated efficacy in reducing postpartum relapse, the timing of prophylaxis remains controversial. Here we evaluate the use of lithium during pregnancy compared to initiation postpartum in women at high risk for postpartum psychosis.
In total, 76 pregnant women at high risk for postpartum psychosis were referred to our psychiatric outpatient clinic between 2003 and 2010. Women who were medication-free at the time of initial evaluation were advised to start lithium prophylaxis immediately postpartum. In contrast, women already on maintenance lithium during pregnancy were advised to continue this treatment.
All women with a history of psychosis limited to the postpartum period (PP, n = 30) remained stable throughout pregnancy despite being medication-free. In contrast, 23.9% of women with a history of bipolar disorder (BD, n = 46) relapsed during pregnancy, despite the majority using prophylaxis throughout pregnancy. Postpartum relapse was highest in women with BD who experienced mood episodes during pregnancy (63.6%). Remarkably however, none of the 21 women with PP using postpartum prophylaxis relapsed, compared to 44.4% of PP patients who declined lithium prophylaxis.
We recommend initiating prophylactic treatment immediately postpartum in women with a history of psychosis limited to the postpartum period, offering an important clinical advantage by avoiding in utero fetal exposure to prophylactic medication. Additionally, patients with BD require continuous prophylaxis throughout pregnancy and the postpartum period to effectively reduce their peripartum relapse risk.
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