© 2010 American Psychiatric Association
Letter to the Editor
Postpartum Depression With Psychotic Features
Veerle Bergink, M.D., and Kathelijne M. Koorengevel, M.D., Ph.D.
Rotterdam, the Netherlands
To the Editor: We would like to thank Verinder Sharma M.B.,B. S., et al. (1) for their clinically relevant article on bipolarII postpartum depression, published in the November 2009 issueof the Journal. The authors underlined the importance of screeningfor postpartum hypomanic symptoms in women with postpartum depressionbut only briefly mentioned the fact that psychotic symptomsmight provide a clue for the bipolar nature of the episode.
In our opinion, the authors’ assertions need to be formulatedmore strongly, since we follow the view that psychotic depressionwith an onset within 4 weeks of the postpartum period shouldbe considered bipolar depression, even in the absence of hypomanicsymptoms earlier in the period, as reflected by our case series(unpublished data available upon request from Bergink et al).
From 2005 to the present, we have diagnosed women with postpartumdepression referred to the Mother-Child Unit of the ErasmusMedical Centre in Rotterdam, the Netherlands. Diagnoses aredetermined using the Structured Clinical Interview for DSM-IVAxis I Disorders (2), and patients are screened for hypomanicsymptoms using the Mood Disorder Questionnaire (3).
We found that hypomanic symptoms (or a mixed state) occurredimmediately in the postpartum period in 11 patients, and thesepatients were treated with mood stabilizers and/or antipsychotics.However, we also decided to treat seven patients without hypomanicsymptoms (or a history of hypomanic symptoms) with mood stabilizers.These seven patients were diagnosed with a major depressiveepisode with psychotic features and an onset of symptoms within4 weeks of the postpartum period. Of these, six were treatedwith lithium and antipsychotics and one refused treatment. Forall except one woman, the depression went into complete remission.The one patient who did not respond to treatment with lithiumand antipsychotics received ECT, and her depression subsequentlyremitted.
We do not know what would have happened if we had treated theseseven women with antidepressants, but in our opinion antidepressanttreatment could have put these patients at an unacceptable riskfor exacerbation of symptoms. Similar to Dr. Sharma et al. (1,4), we also have the clinical experience to be mindful thatantidepressants should be used cautiously in the postpartumperiod. Over the last 4 years, eight postpartum patients werereferred to our clinic as a result of very unstable illnesscourse (manic and psychotic symptoms) after treatment with antidepressants.
Based on our clinical experience, we would recommend followingthe guidelines for treatment of bipolar II depression in patientswith depression with psychotic features and acute onset duringthe postpartum period, even in the absence of hypomanic symptomsimmediately postpartum or of a history of hypomania.
The authors report no financial relationships with commercialinterests.
- Sharma V, Burt VK, Ritchie HL: Bipolar II postpartum depression: detection, diagnosis, and treatment. Am J Psychiatry 2009; 166:1217–1221 [Abstract/Free Full Text]
- First MB, Spitzer RL, Gibbon M, Williams JBW: Structured Clinical Interview for DSM-IV Axis I Disorders, Patient Edition (SCID-P), version 2. New York, New York State Psychiatric Institute, Biometrics Research, 1995
- Hirschfeld RM, Williams JB, Spitzer RL, Calabrese JR, Flynn L, Keck PE, Jr, Lewis L, McElroy SL, Post RM, Rapport DJ, Russell JM, Sachs GS, Zajecka J: Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry 2000; 157:1873–1875 [Abstract/Free Full Text]
- Sharma V: A cautionary note on the use of antidepressants in postpartum depression. Bipolar Disord 2006; 8:411–414 [CrossRef][Medline]