Women are at significant risk for severe psychiatric illness after childbirth, particularly during the first three months. Suicide is a rare but tragic outcome of untreated psychiatric illness in this setting, but it is also preventable.
In order to prevent suicide, we must be able to identify which women are at highest risk for suicide. This is not an exact science at this point; however, we do know that women with histories of psychiatric illness are clearly at greater risk. Danish researchers observed that suicide risk increased dramatically after childbirth and was nearly 300 times higher in women with postpartum psychiatric illness than in women with no psychiatric history (mortality rate ratios, MMR=289.42; 95% CI=144.02-581.62). While women with any type of postpartum psychiatric illness are at increased risk for suicide, the risk for suicide, and infanticide, is the highest in women suffering from postpartum psychosis.
In an article published in JAMA Psychiatry, Luykx and colleagues discuss strategies for reducing the risk of suicide and infanticide in postpartum women, focusing specifically on women at risk for postpartum psychosis. They argue for taking a multi-pronged approach.
Primary prevention refers to the prevention of illness or injury before it occurs. The women at greatest risk for postpartum psychosis are those with a history of bipolar disorder and/or a previous episode of postpartum psychosis after an earlier pregnancy. Luykx and colleagues recommend that this group of women at high risk for postpartum psychosis (and suicide) should be referred for specialist care during pregnancy in order to create a postpartum psychosis prevention plan. Ongoing treatment with a mood stabilizer, such as lithium, decreases the risk of postpartum psychiatric illness. In addition, they emphasize the importance of adequate sleep, as well as support from family and friends, as a means of reducing risk.
Secondary prevention refers to the early detection of illness and early intervention in order to reduce the risk of adverse outcomes associated with the illness. This involves the recognition of psychiatric illness in women with no previous history. This can be challenging as many women and their families may not be familiar with the signs and symptoms of psychiatric illness in this setting. Early detection thus hinges upon educating obstetric providers how to recognize symptoms of postpartum depression and psychosis and facilitating access to specialized care for women with severe psychiatric illness.
Tertiary prevention refers to minimizing the full impact of the illness. Postpartum psychosis is a psychiatric emergency, and when a clinician suspects that a woman may have postpartum psychosis, the woman should receive a thorough psychiatric evaluation that same day.
But How Do We Make This Happen?
Despite increased interest in and awareness of perinatal mood and anxiety disorders, most women with perinatal psychiatric illness, including those identified through screening in obstetric practices, do not get appropriate treatment for their symptoms. According to a recent review conducted by Dr. Nancy Byatt and colleagues, on average, only 22% (13.8-33.0%) of women who screened positive for depression received at least one mental health visit. There continue to be multiple barriers to obtaining treatment including stigma, limited access to specialized treatment, and cost.
Most experts in the field believe that we need more mental health treatment programs specifically designed to address the needs of this vulnerable population. These programs offer numerous advantages over traditional outpatient or inpatient treatment. In this setting, women have access to mental health providers with expertise in the treatment of pregnant and postpartum women.
Integrating these programs into routine obstetric care provides many advantages. Interdisciplinary programs can help to normalize and destigmatize perinatal psychiatric illness. Providing these services within or near existing prenatal clinics or obstetrical hospital settings can help to reduce geographic and logistical barriers to care. Furthermore, the co-location of obstetric and mental health services sends the message that attending to one’s mental health is part of the obstetrical continuum of care.
Ruta Nonacs, MD PhD
Luykx JJ, Di Florio A, Bergink V. Prevention of Infanticide and Suicide in the Postpartum Period-the Importance of Emergency Care. JAMA Psychiatry. 2019 Jul 31.
Strategies can be used to reduce the risk of suicide and infanticide in postpartum women, focusing specifically on women at risk for postpartum psychosis.