Diagnostic classification of perinatal mood disorders

Abstract

The diagnostic terms 'postpartum depression' and 'postpartum psychosis' are still widely used. This paper discussed if this is still justified in the light of recent research and if also other postpartum disorders or disorders during pregnancy should have a special entry or term in our classification systems. Based on a comprehensive review of the literature, it has to be stated that 'postpartum depression' or 'postpartum psychosis' are no specific entities in terms of having a specific aetiology, symptomatology or course. Rather, giving birth to a child with all its biological and psychosocial consequences seems to act as a major stressor, which - within a general vulnerability-stress model - can trigger the outbreak of all classical disorders in predisposed women. Symptomatology, although sometimes influenced by the specific situation of (new) motherhood in a 'pathoplastic' way, principally corresponds to the typical symptomatology of the classical disorders. The same is true for the course. From a scientific point of view, the concept and term 'postpartum depression' should therefore be abandoned as it is not a specific valid entity. A further use of this concept might even hinder research as postpartum illnesses include - as we have shown - a variety of classical disorders which have to be clearly differentiated from each other [see also ref. 8]. So far, these illnesses might sometimes have been too uncritically categorized under 'postpartum depression'. However, there are good reasons to continue to use 'postpartum' as a diagnostic 'specifier', i.e. as an addendum to the main diagnostic category (as in DSM-IV). Thus, in many cases, becoming mother in fact seems to trigger the onset or relapse of a disorder. Giving birth not only seems to be a unique psychosocial stressor in the sense of a life event, which is associated with a massive emotional upstirring, it also is a biological stressor inducing massive hormonal and other changes. Furthermore, some women seem to have a specific 'psychoneuroendocrine' vulnerability, which might lower the threshold for the outbreak of a disease and potentially also influence symptomatology, e.g. contribute to emotional lability. Most importantly, mental disorders in early motherhood confront us with specific needs and call for specific treatments. Thus, help seeking is often delayed due to shame and stigma, and diagnosis is often missed due to misinterpretation of symptoms. Services often do not adequately meet these women's needs, as they do not take into account their specific situation, problems and fears. Untreated, post- and peripartum disorders can have especially severe long-term consequences, not only for the mother, but also for the child and the whole family. Therefore, special attention and special treatment is necessary; this includes modifications of our pharmacological, non-pharmacological and psychotherapeutic treatments as well as provision of new low-threshold mother-infant services. Finally, 'postnatal' depression has proven to be helpful as a lay term and concept [8, 9]. It reduces stigma and encourages mothers to seek help. In fact, a lay movement including self-help groups and lobby groups to improve services has developed based on this obviously very appealing concept. A careful use of the addendum with all the above-named restrictions could therefore be helpful in practice. hi conclusion, although postpartum depression or postpartum psychoses are no specific entities from an aetiological point of view, the diagnostic specifier 'postpartum' should not be abandoned. Clinical utility would in this case be the criterion for the specifier rather than diagnostic validity, which has also been suggested as worthwhile by First et al. [102]. Other peripartum disorders, such as anxiety, OCD or PTSD, could also be marked with a corresponding 'specifier'. In line with our argumentation, the postpartum specifier should be used not only for new-onset cases but for all cases prevalent during the first postpartum year - independent of onset - to indicate the specific needs for care and treatment during this period. A 'pregnancy' specifier should be introduced correspondingly. Both specifiers would, in our opinion, help to improve clinical practice and research if clearly defined and used as an addendum to the main diagnostic category.