50 years of perinatal psychiatry

Perinatal psychiatry has grown and developed as a psychiatric specialty over the half century of the Australian and New Zealand Journal of Psychiatry’s (ANZJP) existence. This retrospective reviews how the field of perinatal psychiatry has changed over time, moving from an interest in the more severe postpartum mental disorders (postpartum psychosis) to the mental health of women and the developmental trajectory of the foetus and infant from the time of conception until the end of the first postpartum year.

The ‘birth’ of perinatal psychiatry, as a speciality, can be dated to 1980 when a new society was formed by a group of UK and American psychiatrists (Ian Brockington, Robert Kendell, Channi Kumar, James Hamilton, Ralph Paffenbarger and George Winokur) with the aim of bringing together clinicians and researchers interested in the mental health of women over the perinatal period. It was named the Marcé Society after the 19th-century French psychiatrist, Louis-Victor Marcé, who had written a major treatise on postpartum mental illness (Traité de la Folie des femmes enceintes, des nouvelles accouchées et des nourrices). This small society rapidly grew in the ensuing decades, and a very active Australasian branch formed in the 1990s. The society has actively encouraged the involvement of consumers, and consumer groups (such as PANDA), who have taken a major advocacy role for the development of perinatal services in Australasia. The biennial international meetings of the society continue to be the major conference in perinatal psychiatry and a peak forum for the exchange of ideas.

Postpartum psychosis and mother and baby units

Psychiatrists had been interested in, and had observed a link between, childbirth and the onset of a severe psychotic illness requiring admission to psychiatric hospitals since, at least, the start of the 19th century. These were, after all, the women that were admitted to psychiatric wards. The clinical features of the disorder (postpartum or puerperal psychosis), with its atypical presentation and its remarkably stable epidemiology (1–2 cases/1000 deliveries), and good long-term outcome, fascinated researchers seeking to clarify its nosology and aetiology. These issues still remain, and debate continues about whether it is a ‘unique’ psychotic disorder or a variant of bipolar disorder; one hopes that there will be some resolution of this in the next 50 years!

The initial clinical and research interest of psychiatrists in ‘perinatal’ psychiatry was not unsurprisingly in the management of new mothers with psychotic disorders – during which it became clear that the outcome for postpartum psychosis was much more favourable than that of schizophrenia and perhaps more akin to bipolar disorder. However, one vexed issue needed to be resolved: whether it was safe and feasible to admit mothers and their babies together into hospital, with a view to maintaining the mother–infant relationship (building on Bowlby’s work on the importance of early attachment relationship). Early findings on the feasibility, and benefits of jointly admitting mothers and babies from the 1970s, contributed to the development of more specific ‘mother and baby units’. These units had clear advantages by keeping mothers and their babies in close proximity, reducing family burden and improving maternal competence, all of which supported their development. Mother and baby units predominantly managed women with the more severe psychiatric disorders, and if such units were not available, and joint admissions could not be managed in a general psychiatric ward, there was a risk that the infants would be removed from their mothers by child protection agencies; tragically, still a significant number of women with schizophrenia have their children placed in out-of-home care. Critically, joint admission allowed for the development of mothering skills, and it has been found that the infants of unwell mothers fared as well as infants of healthy mothers.

Pregnant women, and new mothers with psychotic disorders, were increasingly coming to the attention of psychiatrists, some of whom took a special interest in this population (the early ‘perinatal’ psychiatrists). The safety of prescribing antipsychotics, and mood stabilisers, during pregnancy and for nursing mothers, was a central clinical issue (Galbally et al., 2010). The other clinical focus was on how to prevent women from relapsing during the perinatal period and maintain a healthy mother–infant relationship.

Postnatal depression

The scope of perinatal psychiatry changed in the 1980s, as did the focus of psychiatry in general, to the recognition and management of common mental disorders in the community. Postnatal depression, a disorder that had previously received scant attention, was now recognised as a common affliction of new mothers, became a major focus of research. The research methodology changed; longitudinal, community-based studies supplanted studies of women in secondary care. These studies became more feasible as self-report scales were used to measure depression. A key problem, however, was that extant self-report scales had poor reliability because they targeted general depressive symptoms (some of which would be endorsed by virtue of being pregnant or a nursing mother) and not the typical symptoms of postnatal depression. Better psychometric properties were found with the Edinburgh Postnatal Depression Scale (EPDS), a short 10-item self-report scale specifically designed to screen for postnatal depression (Boyce et al., 1993). The EPDS became widely used as a case finding tool in research studies and in clinical settings to identify women with potential postnatal depression. Armed with the EPDS, many studies were conducted in Australia and New Zealand to examine its epidemiology (prevalence and risk factors), most notably the influential beyondblue study (Buist et al., 2008). One important component of this study was to evaluate awareness, and knowledge of postnatal depression among the community and health care professionals. The findings from this study led to specific government funding for perinatal mental health (the National Perinatal Depression Initiative) with a view to identifying women with depression and anxiety and improving access to care.

The advent of SSRIs, that were less sedating than traditional tricyclic antidepressants, allowed many more new mothers to have pharmacological treatment, but not before these medications were deemed not to harm the suckling infant.

Interestingly, perinatal psychiatry was not confined to the mental health of women over the perinatal period, and men (perhaps not to be outdone) also attracted research, especially regarding their coping skills over the transition to fatherhood (Condon et al., 2004), with the recognition that some men struggle with this change.

…and the infant?

While there had been considerable effort on teasing out the risk factors for postnatal depression, its impact on the infant had not really been considered until studies, conducted principally by the UK psychologist, Lynne Murray, demonstrated its adverse impact on infant development. In essence, these studies showed that depressed mothers were unable to respond, or interact, sensitively with their infants. This poor interaction, it was argued, contributed to the cognitive, behavioural and attachment problems observed in the children of mothers with postnatal depression. These findings emphasised the importance of treating postnatal depression, but it frequently goes undetected (even though this is a time of high contact with health professionals). Screening women for depression was proposed as a way to overcome this problem, and many such screening programmes have now been implemented across the world. While seemingly obvious, this not been without controversy, especially over what to screen for (risk of developing depression or depression itself), the risks of identifying false positives and how services should be organised to ensure screen positive women are fully assessed and managed.

The identification and treatment of women with postnatal depression soon became an important public health issue, with screening programmes being central, and energies devoted to preventing mental health problems being transmitted from one generation to the next (intergenerational transmission).

More attention could now be paid to the assessment of cognitive and attachment problems among the children of women with mental illness. Innovative interventions, such as the Circle of Security, were introduced to educate new mothers about the importance of the attachment relationship and, importantly, how to promote secure attachment with their infants.

Pregnancy, the starting point

The mental health of women during pregnancy became a new focus for perinatal psychiatry around the turn of the 21st century. First, it became apparent that, in addition to postnatal depression, women also suffer from depression and anxiety during pregnancy. Depressive symptoms are common during pregnancy and are known to predict postnatal depression. The high rates of major depression during pregnancy (or ‘antenatal’ depression) had not been apparent (as the focus had been on postpartum onsets), nor had its impact been considered. Perinatal depression (encompassing depression during pregnancy and postnatal depression) is now a widely used term, and depression arising during pregnancy is now included in the new ‘peripartum’ specifier in Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5).

An important issue has now emerged regarding how to treat depression during pregnancy, in particular; are the antidepressants safe? This required the use of observational data (gleaned for a variety of databases) as randomised controlled trials were not feasible for ethical reasons. A multitude of meta-analyses that examined the risk of adverse foetal outcomes following exposure to antidepressants (and other psychotropic medications) followed. There were also concerns about how antidepressant medications could possibly have an impact on ‘fetal programming’ leading to long-term neurological difficulties.

While there have been valid concerns about the safety of medications during pregnancy, it is evident that depression (and anxiety) can also have a negative impact on fetal (Stein et al., 2014), and infant development. New epigenetics findings, especially studies that have shown the effects of poor parenting, or stress, on the infant have added to the importance of recognising and treating women with significant depression and anxiety.

In summary, perinatal psychiatry has emerged and grown as a subspecialty over the past half a century, and it is still developing – because there is still much to learn. Encouragingly, it has become a popular subspecialty – possibly because it is an area of psychiatry that fully embraces a biopsychosocial and lifestyle approach – incorporating focused psychotherapies, attachment theory, state of the art pharmacotherapy and a systems approach – all with the aim of making a meaningful difference for the next generation.

Over the years, many of the researchers featured within the pages of the ANZJP have contributed to the development of this sub-speciality and hopefully the journal will continue to provide a nurturing environment for such research.