East Asian Arch Psychiatry 2016;26:104-8

ORIGINAL ARTICLE

Dr Parth Singh Meena, MB, BS, MD, Department of Psychiatry, Jawahar Lal Nehru Medical College, Ajmer, India.
Dr Ruchi Soni, MB, BS, MD, Department of Psychiatry, Jawahar Lal Nehru Medical College, Ajmer, India.
Dr Mahendra Jain, MB, BS, MD, Department of Psychiatry, Jawahar Lal Nehru Medical College, Ajmer, India.
Dr Charan Singh Jilowa, MB, BS, MD, Department of Psychiatry, Jawahar Lal Nehru Medical College, Ajmer, India.
Dr Omprakash, MB, BS, MD, Department of Psychiatry, Jawahar Lal Nehru Medical College, Ajmer, India.

Address for correspondence: Dr Parth Singh Meena, 946/1, Christian Ganj, Ajmer, India.
Tel: (91-0141) 275 1308, 919414456991; Email: parthaiims@gmail.com

Submitted: 12 July 2015; Accepted: 16 May 2016

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Introduction

Giving birth to a child is considered a life-changing event for a women. Pregnant women and their families expect the postpartum period to be a happy time, characterised by the joyful arrival of a new baby. The postpartum period begins immediately after the birth and continues for about 6 weeks. During this time, the body undergoes major changes in haemodynamics and genitourinary recovery, as well as hormonal and emotional states. These changes and processes along with the stress of assuming the responsibilities of being a mother have profound physical and psychological effects, some of which can progress to overt psychopathological states.¹ The World Health Organization describes the postpartum period as the most critical and yet the most neglected phase in the lives of mothers and babies.² Strong temporal associations have been reported between childbirth and psychiatric morbidities.³ A number of biological, psychosocial, and interpersonal factors have been found to be responsible for the occurrence of postpartum psychiatric disorders.⁴

Risk Factors

Biological factors that are known to predispose to the onset of psychiatric disorders in the postpartum period may be genetic, endocrine and biochemical, or related to change in sleep patterns. Endocrine factors implicated in postpartum psychiatric disorders include dysregulation of the hypothalamic-pituitary-gonadal axis,^5,6 and changes in cortisol and thyroid hormone levels and action.⁷ Following delivery and for the first few days, the prolactin level increases and oestrogen level drops suddenly, thereby altering dopamine transmission and leading to affective changes.^8,9 Decrease in protein-bound iodine level leads to decreased thyroid hormone and can result in depressive disorders and psychosis. Low levels of serotonin and tryptophan, high levels of norepinephrine metabolite, and decreased cyclic adenosine monophosphate levels during the postpartum period have also been implicated in aetiopathogenesis of postpartum blues⁹ and depression.¹⁰

Certain social and interpersonal factors that may influence postpartum psychiatric disorders are lower social class, single motherhood, marital problems, an unsupportive spouse, and a hostile work environment.¹¹ Women who experience problems in their spousal or partner relationship tend to experience more mental health–related problems during the perinatal period. Women with unsupportive, uninvolved, and quarrelsome or alcoholic partners are particularly vulnerable to postpartum psychiatric problems.^12-15

Cognitive Impairment

Cognition is a comprehensive term used to describe higher mental functions and includes attention, memory, language, orientation, praxis, executive function, judgement, and problem solving. During the postpartum period, women may experience cognitive dysfunction in terms of their thinking ability, poor memory or recent memory loss, forgetfulness, difficulty in concentration, and distractibility. They may have a reduced ability for intentional learning and semantic memory retrieval. Alterations in the level of hormones such as oestrogen, progesterone, and glucocorticoids can also influence cognitive function of women during the postpartum period.^10,16 Dysfunction of the hypothalamus- pituitary-adrenal axis¹⁷ and brain-derived neurotrophic factor (BDNF) have been implicated in cognitive problems during this time.¹⁸

Postpartum psychiatric disorders place both the mother and infant at risk and have been associated with significant long-term effects on child development and behaviour.¹⁹ Few studies have compared cognitive functioning and behavioural problems in postpartum women with those of non-pregnant women. Most studies provide information regarding prevalence and specific risk factors associated with postpartum mental health disorders but do not compare the psychiatric morbidity (depression, anxiety, stress, and cognitive dysfunction) with that of non-pregnant women. The present study was undertaken to evaluate cognitive impairment and other psychiatric morbidities in postpartum women and compare them with healthy non-pregnant women.

Methods

A cross-sectional study was conducted at the Department of Obstetrics and Gynaecology, Jawahar Lal Nehru Medical College, Ajmer, India from November 2014 to February 2015 Women who had a normal vaginal delivery were included in the study as cases. Non-pregnant healthy female patients served as controls. The sample for the cases constituted 200 consecutive women who attended the Obstetrics and Gynaecology Outpatient Department for first follow-up 7 days after childbirth. A total of 100 controls were taken from family members and caregivers of the cases. All subjects gave written informed consent. Groups were matched for age and socio-economic status. A semi-structured demographic profile proforma along with the scales were completed by both groups. The study was conducted after obtaining approval of the institutional ethics committee and concerned authorities.

The inclusion criteria were: (1) women who came to the Obstetrics and Gynaecology Outpatient Department for first follow-up 7 days after childbirth; (2) age between 20 and 40 years; (3) educated above primary school level; and (4) provided written informed consent for the interview. Women were excluded if they had: (1) pre-existing neuropsychiatric, neurological, or major medical disorders; (2) a history of diabetes mellitus and / or hypertension during pregnancy; (3) a substance use disorder; (4) significant sensory, visual or hearing impairments or intellectual deficiency; or (5) were prescribed long-term medication such as steroids, antiepileptic drugs or other drugs that are known to cause cognitive dysfunction or psychopathology.

Assessment Tools

Brief Cognitive Rating Scale

The Brief Cognitive Rating Scale (BCRS) is designed specifically to assess syndromes of cognitive decline. It assesses the magnitude of cognitive impairment on 5 clinical axes, each scored on a Likert scale of 1 to 7 using specified criteria. Items are scored on the basis of a structured clinical interview. The BCRS differs from virtually all other currently used clinical instruments for cognitive disturbances in that it includes mood changes such as depression, anxiety, agitation, and psychosis. Thus, the effects of interventions on cognition and associated functioning can be specifically assessed. The BCRS is part of the triad of assessments with global deterioration scale and functional assessment staging.²⁰

Trail Making Test Part B

The Trail Making Test Part B (TMT-B) is associated with the processes of distinguishing between numbers and letters, integration of 2 independent series, the ability to learn an organising principle and apply it systematically, and reveal retention and integration, verbal problem solving, and planning.²¹ A TMT-B cut-off of 3 minutes or 3 errors (the ‘3 or 3 rule’) was used in our study and is supported by many studies.²²

Standardised Mini-Mental State Examination

The standardised Mini-Mental State Examination (SMMSE) is a bedside screening test for cognitive impairment derived from the MMSE (Mini-Mental State Examination), and is the most widely used instrument to measure cognitive impairment. It contains 12 questions that are asked in sequence to generate a total score of 30. Scores of < 18 indicate severe cognitive impairment, 18 to 23

mild impairment, and ≥ 24 is reflective of no impairment. It has good content and concurrent validity²³ and is organised into discrete subsections measuring orientation, registration, attention and concentration, recall, language, and construction. This test is easy to administer and takes only a few minutes to complete. Inter-rater and intra-rater reliability are good.²⁴

Depression Anxiety and Stress Scale 21

The Depression Anxiety and Stress Scale 21 (DASS-21) is a 21-item self-report questionnaire designed to assess the severity of core symptoms of depression, anxiety, and stress. It is appropriate for both patient and non-patient adult populations. In completing the DASS-21, the individual is required to indicate the presence of a symptom over the previous week. It is rated on a 4-point Likert scale and each item is scored from 0 (‘did not apply to me at all over the last week’) to 3 (‘applied to me very much or most of the time over the past week’). The order of the 21 items is randomised so that items of the same scale are not clustered together. Each of the scales is then broken down into subscales, each comprising 2 to 5 items. The reliability scores of the scales in terms of Cronbach’s alpha rate the depression scale at 0.91, the anxiety scale at 0.84, and the stress scale at 0.90 in the normative sample. The mean (± standard deviation) for each scale was 6.34 ± 6.97 for depression, 4.70 ± 4.91 for anxiety, and 10.11 ± 7.91 for stress.²⁵

Statistical Analysis

Unpaired t test and appropriate statistical tests were used to analyse the data.

Results

The mean age of the women was 21 years. The mean (± standard deviation [SD]) SMMSE total score was 23.73 ± 4.69 for the cases and 26.73 ± 2.71 for the controls; significant difference was noted between the groups (p < 0.001). The mean BCRS total score of the study group was 1.50 ± 0.44, significantly higher than that of the controls (1.08 ± 0.18, p < 0.001). Data analysis revealed significant difference between cases and controls in respect to TMT-B total time taken (p < 0.001) [Table 1].

On administering DASS-21, the mean depression subscore of cases was significantly higher (15.08 ± 4.46) than that of controls (8.26 ± 2.60, p < 0.001). The mean anxiety subscores of DASS-21 were also significantly higher for postpartum women than controls (11.63 ± 3.73 vs. 6.44 ± 2.12, p < 0.001). The same applied when stress subscores of DASS-21 were analysed: 17.6 ± 3.62 for cases and 12.63 ± 3.16 for controls (p < 0.001) [Table 2].

Discussion

The association between childbirth and psychiatric disorders is well known. Shortly after a woman gives birth, a host of changes occur within the mother. These changes are physiological, hormonal, psychological, and cognitive.²⁶

The peculiarity of this period in terms of biological and psychological changes has made the study of psychiatric disorders during the perinatal period an area of intense research.

The SMMSE test covers a variety of cognitive domains, including orientation to time and place, short- and long-term memory, registration, recall, constructional ability, language, and the ability to understand and follow commands. The performance of postpartum women on SMMSE was significantly inferior to that of the controls (p < 0.001).

The SMMSE is primarily used as a screening test and the results need to be validated and supported by other tests. The other tests that were applied to assess the cognitive functions of the subjects were BCRS and TMT-B.

Kane et al²⁷ conducted a clinical psychiatric survey of 137 obstetric patients and found subjective evidence of anxiety, depression, and cognitive dysfunction in 87 (64%) women. Cognitive dysfunction was striking on mental status examination and on cognitive tasks. The clinical phenomenon was an inability to sustain attention, distractibility, and poor recent memory. Jarrahi-Zadeh et al²⁸ assessed 86 women during the third trimester of pregnancy and on the third day postpartum using cognitive tests, including TMT, Porteus Maze Test, and test for emotionality using Minnesota Multiphasic Personality Inventory, and Neuroticism Scale Questionnaire. In all, 16% of women during the puerperium experienced fogginess and multiparous women experienced more fogginess than primipara. Frequency of emotional and cognitive dysfunction was greater among multiparous women.²⁸ Crawley²⁹ assessed cognitive functions in 198 women during the postpartum period and noted that certain aspects of cognition were lower than those of a group of non- pregnant women. Postpartum women also reported more cognitive failures and readily provided examples of perceived impairments in cognition. It would appear that cognitive deficits were of low importance during the postpartum period. Deficits in memory, concentration, clarity of thought, and attention was reported by women both during pregnancy and in the first year following child birth.²⁹

Results from the current study reveal that cognitive impairment assessed by most of the neuropsychological tests is present in a significant proportion of postpartum women. A significant difference was noted between the scores of cases and controls for the SMMSE, BCRS, and TMT-B (p < 0.001), confirming cognitive impairment in the postpartum period. Attention, speed of performance, visual scanning, sequential abilities, executive function, psychomotor performance, and perceptual organisation were also impaired in the postpartum period. The results of the present study are consistent with the reports of earlier investigations.^28,29

Adaptation to new circumstances poses a challenge during this period. Several studies have reported depressive symptoms in the postpartum period; the predominant feature is lack of interest in caring for the infant. Anxiety and stress symptoms were also noted, presenting mainly as excessive concern about the infant’s health. Chandran et al³⁰ assessed 359 women living in rural south India in the last trimester of pregnancy and 6 to 12 weeks after delivery. The incidence of postpartum depression was 11%. Low income, birth of a daughter when a son was desired, relationship difficulties with mother-in-law and parents, adverse life events during pregnancy, and lack of physical help were risk factors for the onset of postpartum depression.³⁰

Kumar and Robson³¹ found depressive disorder in 23% of mothers at 6 to 8 weeks after childbirth. More than half of the patients remained ill after 6 months. The incidence of postpartum depression ranged from 10% to 30%.

On administering DASS-21, the mean depression, anxiety, and stress subscores of the study group were significantly higher than the controls (all p < 0.001). Factors that contributed to depression, anxiety, and stress during this period could be attributed to both nature and nurture with special emphasis on social and interpersonal factors. These included lower social class, single motherhood, marital problems, unsupportive spouse, and hostile work environment. The study results delineate the huge psychological distress that prevails during the postpartum period, and that needs to be addressed so that appropriate measures can be taken to minimise the problems and provide a healthy period of early motherhood.

Conclusions

The association of the puerperium with psychiatric morbidity has long been known. The peculiarity of this period and the biological and psychological changes have made the study of psychiatric disorders during the perinatal period an area of intense research. The present study concludes that women during the postpartum period have significant cognitive deficits. There is also an increased prevalence of depression, anxiety, and stress that adversely affects the physical and mental health of the mother and the child’s development and behaviour.

Acknowledgement

We convey our sincere gratitude to the participant subjects without whose support the study would not have been possible.

Declaration

No financial aid or support was taken from any agency. No author has any conflict of interest in this study.

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