Classification of mental health disorders in the perinatal period: future directions for DSM-V and ICD-11

Transcription

1 Arch Womens Ment Health (2010) 13:41 44 DOI /s Classification of mental health disorders in the perinatal period: future directions for DSM-V and ICD-11 Marie-Paule Austin # Springer-Verlag 2009 Keywords Nosology. Postpartum disorders. Postnatal. Puerperal psychosis. Mood disorders Perinatal psychiatry is the specialty concerned with the mental health and illness of women from conception through to the first postnatal year. By using the term perinatal we seek to ensure not only that maternal mental health is considered from conception onwards, but that its impact on the developing mother-infant relationship, is kept in mind by clinicians, policymakers and researchers alike. While prevalence estimates for maternal disorder in the perinatal period are similar to that at other times in the child-bearing years, we know that the incidence of depression is higher in the first few weeks postpartum; that rates of dysphoria (measured by EPDS score) are similar in late pregnancy and the postnatal period; that up to 30 40% of depressive symptoms will have begun in pregnancy; that there is significant comorbid anxiety and depressive disorder in this population, and that prolonged depression will impact negatively on the mother-infant interaction (for overview see Austin 2004). Impaired mother-infant interaction, while not diagnostically identified in either the DSM or ICD classificatory systems can lead to insecure attachment with significant consequences for the mental health outcomes of the next generation (Austin 2004). In terms of maternal outcomes, we see both greater morbidity and mortality when it comes to severe mental M.-P. Austin (*) St John of God Chair Perinatal and Women s Mental Health, St John of God Health Care & School of Psychiatry, University of New South Wales, Sydney, Australia m.austin@unsw.edu.au health disorders especially postpartum. Oates (2003) has identified psychiatric morbidity as the leading cause of maternal death in the perinatal period while Appleby et al. (1998) reported an 80 fold increase in suicide in the first year postpartum in women with severe mental health conditions. Recent studies in women with significant preexisting mood disorders suggest that this group is as much, if not more, at risk of relapse perinatally, especially when unmedicated. Viguera et al. (2007) in a prospective study of pregnant bipolar women reported that overall risk of at least one recurrence in pregnancy was 71% with a twofold greater risk for women who had discontinued their mood stabilizer. In a retrospective comparison study Viguera et al. (2000) demonstrated comparable rates of relapse for unmedicated bipolar pregnant and nonpregnant women, and a ~3 fold greater rate of relapse in the 6 month postnatal period in unmedicated parturient bipolars than matched nonparturient bipolars over the same timeframe. In a prospective study of women with a major depressive episode (MDE) (Cohen et al. 2006), the rate of relapse in pregnancy in unmedicated women cf. women remaining medicated was 68% vs. 26%. This contrasts with earlier reports that pregnancy is protective for mood disorders and emphasizes the need for clinicians to undertake close monitoring and active treatment of these women in the perinatal period. This is particularly critical for women with a past history of bipolar disorder where the incidence of puerperal psychosis rises 300-fold, i.e., from 0.1% to 30%, and rises more than 500-fold (to more than 50%) for those with a past episode of puerperal psychosis (Jones 2008). The APA s DSM system has progressed over the last 20 years from a simple consideration of postpartum psychosis in the DSM-III (1980, 1987) where it was

2 42 M.-P. Austin given as an example of atypical psychosis (298.90) under psychotic disorders not elsewhere classified to the 1990s DSM-IV (1994, 2000) where we find mention of postpartum onset (within 4 weeks) as a specifier attached to mood disorders (Major Depression, Bipolar I or Bipolar II disorder) and brief psychotic disorder (see Table 1). However unlike some of the other DSM-IV specifiers (severity and psychotic features), the postpartum state cannot be numerically coded thus making it more difficult to record and less likely for it to make its way into the clinical documentation. DSM-IV also acknowledges that postpartum depressive episodes are often associated with severe anxiety or panic attacks thus highlighting the significant co-morbidity of high prevalence disorders seen at this time (Austin 2004 for overview). The World Health Organisation ICD-10 (1992) system is organised in such a way that specific biological factors are clearly implicated for the minority of postpartum episodes not classifiable under the standard mood disorder and psychosis codes. Such puerperal disorders are located under the Mental Disorders associated with Physiological disturbances & Physical factors block (F50 59), with subset F53 Mental Disorders associated with the Puerperium, not elsewhere classified defined as follows: 1) episodes commencing within 6weeks of delivery 2) episodes not meeting criteria for other mental disorders because of: a) insufficient or b) additional features making classification elsewhere inappropriate. Thus the ICD-10 nomenclature sets a small proportion of postnatal episodes apart from the rest by virtue of early postpartum onset and inability to be classified in the mainstream nomenclature due to separate aetiology (implied) and additional phenomenology. This very small number of episodes are then subdivided into postnatal depression (termed mild ), puerperal psychosis (termed severe ) and other. The rationale for the 4 6 week postpartum onset specifier, although not spelt out, seems to relate to the fact that most puerperal psychoses (which are assumed by many to be aetiologically unique) occur within the early weeks postpartum. While both DSM-IV and ICD-10 have now extended their onset specifiers to include non-psychotic episodes, they have failed to clearly outline their reasons for doing so, thereby introducing a lack of clarity to the postpartum Table 1 ICD-10 and DSM-IV classification of puerperal disorders Classification system ICD-10 (WHO, 1992) DSM-IV (APA, 1994) Puerperaldisorders: codes and descriptions Chapter: V: F00 F99 mental and behavioural disorders Block F50 F59: Mental disorders associated with physiological disturbances & physical factors subset F53: Mental disorders associated with the Puerperium, not elsewhere classified: 1) Only when commencing within 6 weeks of delivery 2) Not meeting criteria forother mental disorders because of: a) insufficient information available OR b) additional features making classification elsewhere inappropriate. Puerperal code Puerperal code descriptions F53.0 Mild disorders associated with the puerperium Depression: postnatal NOS; postpartum NOS F53.1 Severe mental and behavioural disorders associatedwith the puerperium, not elsewhere classified Puerperal psychosis NOS F53.8 Other disorders associated with the puerperium F53.9 Puerperal mental disorder, unspecified Chapter: Mood disorders; Code: x: Major depressive disorder; 296.0x x: Bipolar I disorder; : Bipolar II disorder Chapter: Schizophrenia and other psychotic disorders: Code: 298.8: Brief psychotic disorder Puerperal code Puerperal descriptions Cannot be coded in fifth digit of diagnostic code; Written addition only Postpartum onset specifier: -Can be applied to the current or most recent major depressive, manic, or mixed episode; or mixed episode in major depressive disorder, Bipolar I disorder, or Bipolar II disorder; or to brief psychotic disorder -Onset of episode within 4 weeks postpartum

3 Classification of mental health disorders in the perinatal period 43 nomenclature. In addition they do not seem to have considered that for the depressive disorders the postpartum onset specifier will need to be extended postpartum. From the above deliberations it can be seen that the nosology of postpartum disorders remains unwieldy partly because of the possibility, implicit only, that the minority of episodes commencing in the early postpartum period are underpinned by the dramatic hormonal (and associated neurotransmitter changes) occurring at parturition. While long-term outcome studies suggest that episodes of postpartum psychosis are most often an initial manifestation of bipolar disorder, the abrupt onset, and characteristic phenomenology of these early onset episodes, has led researchers to consider a biological aetiology for this condition. In spite of the literature consistently failing to identify neuroendocrine factors that might underpin puerperal onset episodes, both ICD-10 and DSM-IV have maintained a postpartum specifier, on the assumption that specific aetiological mechanisms relating to parturition will be identified (see Table 1). It now time to extend our classificatory approach to the postpartum disorders and consider a number of changes for the next generation of ICD and DSM. In particular a temporal extension of the postpartum onset specifier while acknowledging that a subset of these episodes will arise in the late antenatal period; full clarification of the rationale for a postpartum sub-classification; and extending the discussion to include a consideration not only of aetiology but also maternal and infant interaction and morbidity across the postnatal period. More specifically, the following points need consideration: 1) Broadening the onset specifier to include all mood disorders occurring in the first 6 months postpartum with an acknowledgement that a subset of these episodes will have begun in later pregnancy. 2) Maintaining the onset specifier as 6 weeks postpartum for psychotic episodes with the option for research studies that depressive episodes arising strictly in the first 6 weeks postpartum also be placed in this category. 3) Outlining the rationale for extending the postpartum onset specifier to 6 months for mood disorders in terms of: a) morbidity (both maternal and infant); b) the likelihood that the majority of postnatal episodes will arise in the context of pre-existing or evolving conditions and are not simply restricted to a small number (i.e. postnatal) of denovo episodes commencing within 4 6 weeks postpartum c) the need to examine for, and record the presence of, associated mother-infant interaction and attachment difficulties. 4) Stating more clearly the assumption of neuroendocrine or other biological underpinnings for psychotic and possibly very early postpartum onset episodes of depression. 5) Removing the Disorders associated with Physiological disturbances & Physical factors category and the not classified elsewhere descriptor in the ICD postpartum classification thereby bringing postpartum disorders into the mainstream of classification, and being more in line with the DSM classification. 6) Finally, given that most mothers and infants will be seen by general adult psychiatrists who don t always consider the impact of postnatal disorder on motherinfant interactions, encouraging clinicians to consider and code for mother-infant interaction difficulties (eg. a V61.20 parent-child relational problem code may also apply currently located under DSM-IV other conditions that may be of clinical significance ) in addition to the postpartum onset specifier. This will not only encourage clinicians to consider the impact of maternal illness on the infant, but also assists policy makers when looking at service provision for families in the perinatal period. In conclusion, in order to optimize early detection and minimize the impact of maternal mood disorders on mother, infant and family, we need to further improve our classificatory systems as they relate to the postnatal period. This will in turn allow better quality research at a time when we have an increasing capacity to explore the possible underlying mechanisms of disorders arising in the perinatal period. Conflict of interest interest. References The author declares that she has no conflict of Appleby L, Mortensen PB, Faragher EB (1998) Suicide and other causes of mortality after post-partum psychiatric admission. Br J Psychiatry 173: Austin MP (2004) Antenatal screening and early intervention for perinatal distress, depression and anxiety: where to from here? Arch Womens Ment Health 7:1 6 Cohen LS, Altshuler LL, Harlow BL et al (2006) Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA 295: Diagnostic and Statistical Manual of Mental Disorders Third Edition (DSM-III) (1980) American Psychiatric Association, Washington, DC Diagnostic and Statistical Manual of Mental Disorders Third Edition- Revised (DSM-III-R) (1987) American Psychiatric Association, Washington, DC Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR) (2000) American Psychiatric Association, Washington, DC Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) (1994) American Psychiatric Association, Washington, DC

4 44 M.-P. Austin Jones I (2008) Perinatal psychiatry. Medicine 36(9): Oates M (2003) Suicide: the leading cause of maternal death. Br J Psychiatry 183: Viguera A, Nonacs R, Cohen LS et al (2000) Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance. Am J Psychiatry 157: Viguera AC, Whitfield T, Baldessarini RJ et al (2007) Risk of recurrence in women with bipolar disorder during pregnancy: prospective study of mood stabilizer discontinuation. Am J Psychiatry 164: World Health Organisation (1992) International statistical classification of diseases and related health problems, 10th revision (ICD- 10). WHO, Geneva

5 Copyright of Archives of Women's Mental Health is the property of Springer Science & Business Media B.V. and its content may not be copied or ed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or articles for individual use.