The insanity of pregnancy is usually a manifestation of autointoxication, and may be accompanied by melancholic or maniacal symptoms. It usually persists throughout gestation, but disappears shortly after labour, unless the patient has an hereditary tendency to mental derangement.
—J. Whitridge Williams (1903)
The subject of mental illness was only briefly addressed by Williams in 1903, when it appears that acute puerperal psychoses were manifestations of eclampsia or sepsis. More than 100 years later, we have learned that pregnancy and the puerperium are at times sufficiently stressful to provoke mental illness. Such illness may represent recurrence or exacerbation of a preexisting psychiatric disorder, or it may signal the onset of a new condition. This 25th edition of Williams Obstetrics marks only the second edition with a focused chapter dedicated to psychiatric illnesses. To emphasize the rising national interest, American College of Obstetricians and Gynecologists President Dr. Gerald F. Joseph Jr. declared postpartum depression as an initiative in 2009.
Psychiatric disorders during pregnancy are associated with less prenatal care, substance use, poor obstetrical and neonatal outcomes, and higher rates of postpartum psychiatric illness (Frieder, 2008). Despite these known risks, obstetrical providers often are reluctant to confront or fail to identify some of these mental health issues during pregnancy. For example, Lyell and colleagues (2012) found that the diagnosis of depression was not documented in nearly half of the records of depressed women. Yet, perinatal mood disorders can have far-reaching consequences beyond the immediate effect on maternal mental health and social function by adversely affecting the mother-child relationship (Weinberg, 1998).
Also, suicide is a primary cause of death among women during the perinatal period in the United States, and major depression is among the strongest predictors of suicidal ideation (Melville, 2010). Between 2004 and 2012, self-harm, suicide, or drug overdose was the leading cause of maternal death in Colorado (Metz, 2016). In a 10-year analysis of Washington state hospitalizations, Comtois and associates (2008) studied 355 women with a postpartum suicide attempt. Substance abuse was linked with a sixfold higher and prior psychiatric hospitalization with a 27-fold greater risk for suicide. These rates rose further if there were multiple hospitalizations. Also of note, 54 percent of pregnancy-associated suicides involve intimate-partner conflict (Palladino, 2011).
PSYCHOLOGICAL ADJUSTMENTS TO PREGNANCY
Biochemical factors and life stressors can markedly influence mental health and mental illness during the perinatal period. Intuitively, pregnancy exacerbates some coexisting psychological disorders. Namely, an increased risk for mood disorders is linked with pregnancy-related shifts in sex steroid and monoamine neurotransmitter levels, dysfunction of the hypothalamic-pituitary-adrenal axis, thyroid dysfunction, and alterations in immune response (Yonkers, 2011). These changes, coupled with familial clustering of depression cases, suggest that there may be a subgroup of women at risk for developing a unipolar major depressive disorder during pregnancy.