Screening for postpartum depression and borderline personality disorder: Food for thought

We read with interest the recent paper by Judd and colleagues (2019), in which, using the Edinburgh Postnatal Depression Scale (EPDS), the authors analyzed 200 pregnant women referred to the Perinatal Consultation-Liaison Psychiatry Team over a 14-month period. Of the 86 women (43%) who scored above cutoff (⩾13), 12 (14%) had an anxiety disorder, 14 (16.3%) had borderline personality disorder (BPD) and 13 (15.1%) had a substance use disorder. An additional 23 women (26.7%) had two or more borderline personality traits.

Our own studies support and reinforce these findings. Over the past 8 years, since its opening in January 2011, 150 pregnant women have been referred to the Perinatal Psychiatric Department of the ASST Monza (Italy) for psychiatric evaluation. During their first appointment, they were assessed from a clinical point of view, according to Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) criteria, and tested using the EPDS, the Structured Clinical Interview for DSM-IV Axis II disorders (SCID-II), the Beck Depression Inventory–II (BDI-II), the Beck Anxiety Inventory (BAI), the World Health Organization Quality of Life (WHOQOL) and the Childhood Trau-ma Questionnaire (CTQ). Forty-six percent (n = 69) of the sample was affected by at least one personality disorder, with the most represented being Borderline (‘BPD’; n = 30; 20%) and Narcissistic (‘NPD’; n = 22; 14.7%) personality disorders (di Giacomo et al., 2018). Women negative to the SCID-II (n = 81) were affected by anxiety or depressive disorders. More than forty percent (41.3%) of the total sample (n = 62) scored above the cutoff at the EPDS (⩾12). Twenty-three of those positive to the EPDS (37.1%) were affected by BPD, and 17 (27.4%) did not show any sign of personality issues but had a depressive or anxiety disorder (di Giacomo et al., 2013).

Patients affected by BPD did not have significantly different average scores on the BDI (15.57 ± 9.33 vs 17.94 ± 9.75; p = 0.44) and BAI (17.52 ± 9.99 vs 17.94 ± 10.55; p = 0.90) compared to those affected by anxiety or depression. Furthermore, patients with BPD who scored low (n = 7; 30.4%), moderate (n = 11; 47.3%) and severe (n = 3; 13%) on the BDI were not statistically different compared to patients with anxiety or depression (n = 6, 35.3%; 6, 35.3%; and 2, 11.8%; respectively; p = 0.784).

Judd et al. underline the importance of correct diagnosis, as different disorders have different treatments and implications. Mothers affected by BPD may experience adverse obstetric outcomes more frequently than the general population: our own results show significantly higher rates of intra-uterine fetal death (40%; p = 0.005) and termination of pregnancy (16.6%; p < 0.0001) compared to the Italian National Registry, more emergency C-sections (40%; p = 0.04) and offspring pathological Apgar score (<7) at 5 minutes (7.1%; p = 0.04) compared to the general population who gave birth in the same period at the Obstetrical Department of the ASST Monza (about 32.900 women).

Furthermore, mothers affected by BPD have children with worse psychological outcomes when they experience psychic suffering or difficulties in bonding with their newborn. Their children showed greater withdrawn behavior that reached clinical relevance on the Child Behavior Checklist administered between 18 months and 5 years old compared to children of mothers affected by anxiety and/or depressive disorders (p < 0.0001).

Pregnant women with BPD have a level of depression equivalent to those of pregnant patients affected by depressive disorders, but they show higher rates of obstetric complications, while their children show poorer psychological outcomes. The severity of such outcomes cannot be neglected further. The clinical implications for both mothers and their children are serious; they demand a greater understanding and the timely identification of personality features in pregnant women so that prompt and adequate treatment can be offered with the aim of improving the well-being of both mother and child.