The link between childbirth
and psychiatric disorders
Ian Jones
Reader in Perinatal Psychiatry
MRC centre for Neuropsychiatric Genetics and
Genomics
Cardiff University
Liverpool July 2012
The link between childbirth,
abortion and psychiatric
disorders
Ian Jones
Reader in Perinatal Psychiatry
MRC centre for Neuropsychiatric Genetics and
Genomics
Cardiff University
Liverpool July 2012
The link between childbirth,
abortion and severe psychiatric
disorders
Ian Jones
Reader in Perinatal Psychiatry
MRC centre for Neuropsychiatric Genetics and
Genomics
Cardiff University
Liverpool July 2012
Plan of talk




Look at the evidence for the
link between childbirth and
episodes of severe mental
illness
What we know about this
link
Present data from Trine
Munk–Olsen on abortion
and severe episodes of
psychiatric illness
Will restrict myself to the
data on more severe end of
the spectrum of illness
Psychiatric disorder and childbirth
- concept with a long history
“A young woman in child-bed not well
purged after birth and delivery, fell into
a great delirium suddenly without any
disease afore going. She was angry
most with her best friends, husband and
mother, but she spoke many things
religiously …..”
Felix Plater 1602
“The beautiful wife of Carcinator, who
always enjoyed the best of health, was
many times attacked by melancholia
after childbirth and remained insane for
a month, but recovered with treatment”
Jao Rodrigues de Castelo Branco 1551
Important today
Classification systems (DSM, ICD)
Puerperal episodes are just episodes of illness
that happen to occur following childbirth
which is acting as a non-specific trigger
“The concept of postnatal
depression does not emerge
from 30 years of research with
much scientific credit”
Professor Ian Brockington
Motherhood and Mental Health
Is childbirth associated with increased
risk?
Number of 20
admissions 18
16
14
12
10
8
6
4
2
36 34 32 30 28 26 24 22 20 18 16 14 12 10 8
Weeks prior to delivery
6 4
2
1
2
3
4
5 6
7
8 9 10
Weeks following delivery
Kendell et al 1987
Are some women particularly at
risk?
1000
900
800
700
600
500
400
300
200
100
0
Episodes of
PP per 1000
deliveries
Di Florio et al, 2012
Jones and Craddock,
2001
Pop
BP
previous PP
Robertson et al, 2005
Perinatal episodes very common
in women with affective disorder
BPI
BPII
MDD
980
232
573
Narrow
Mania / Mixed / affective
psychosis (6 weeks)
33.3%
9.1%
0.3%
Intermediate
Plus Depression (6 weeks)
55.5%
40.1%
47.1%
Broad
Any perinatal episode
(pregnancy or within 6 months)
69.4%
69.0%
67.4%
N
DiFlorio et al, Arch Gen Psych, in press
Danish population register studies
How it is done
140571-1546
150199-0478
12 months postpartum
Born
1971
Daugther
born 1999
Psychiatric
contact?
13
Population register-based research
Limitations
Advantages
Increased risk following
childbirth
Risk of first-time hospital admission for any mental disorder
0 to 12 months postpartum
8
7
6
RR
5
mothers
4
fathers
3
2
*
1
0
0
1
2
3
4
5
6
7
months
8
9
10
11 12
*
Reference group
Is the risk across the psychosis
spectrum?
30
25
20
Relative Risk
of admission in
first
postpartum
month
15
10
5
0
UP
BP
Schiz
Munk-Olsen et al 2006
Is the risk across the psychosis
spectrum?
Munk-Olsen et al 2009
Influence of family history
30
25
No mental disorder
RR
20
Schizophrenia
Unipolar depressive disorder
15
Bipolar affective disorder
10
Adjustment disorder
Remaining diagnoses
5
0
Pregnancy
0-30 days
31-60 days
Time
2-5 months 6-11 months
Is this due to stopping
medication?
Pregnancy
% Remaining Stable
100
90
80
70
60
50
40
30
20
10
0
Postpartum
(Weeks 41–64)
(Weeks 1–40)
(n=25)
(n=42)
(n=59)
Nonpregnant
Postpartum
Nonpregnant
Pregnant
0 4 8 12 16 20 24 28 32 36 40
44
48
Weeks at Risk Off Lithium
52
(n=20)
56
60
Viguera AC. Am J Psychiatry. 2000;157:179-184.
64
Close relationship to delivery
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
Percent
100
Percent
100
10
0
10
0
1st week
2nd week
3rd week
4th week
Onset of pp by week
6th week
1
2
3
4
Onset of pp in days
Heron, et al 2007
5
6
Parity – link to first pregnancies
Di Florio et al, in preparation
Is PND marker of bipolarity?
Munk-Olsen et al, 2011
Are genetic factors involved?
“My family has a
grand tradition,
after a woman
gives birth, she
goes mad.”
Danish Abortion data
Exposure:
Childbirth
Outcome:
Mental illness
Exposure:
Abortion
Outcome:
Mental illness
Risk of first-time psychiatric contact
before and after childbirth
4
3.5
3
IRR
2.5
2
1.5
1
0.5
0
9-0
1
2
3
4
5
6
7
8
9
Months since childbirth
Adjusted for age and calendar period.
IRR: Incidence rate ratios.
Reference category: 11-12 months after delivery (first live-born child)
The horizontal bars indicate 95% confidence intervals.
10
11-12
Risk of first-time psychiatric contact
before and after induced abortion
4
3.5
3
IRR
2.5
2
1.5
1
0.5
0
9-0
1
2
3
4
5
6
7
8
9
10
Months since abortion
Adjusted for age and calendar period.
IRR: Incidence rate ratios.
Reference category: 11-12 months after abortion (first 1st trimester induced abortion).
The horizontal bars indicate 95% confidence intervals.
11-12
Risk of readmission
before and after childbirth
4
3.5
3
2.5
I
R
R
2
1.5
1
0.5
0
-9
-8
-7
-6
-5
-4
-3
-2
-1
1
2
3
4
5
6
7
8
9
10 11_12
Months before and after childbirth
Adjusted for age, calendar period, previous diagnoses, number of previous admissions, time since
previous discharge, family history of mental disorder, and previous abortions.
IRR: Incidence rate ratios.
Reference category: 11-12 months after delivery (first live-born child)
The horizontal bars indicate 95% confidence intervals.
Risk of first-time psychiatric contact
before and after induced abortion
4
3.5
3
2.5
I
R
R
2
1.5
1
0.5
0
Months before and after abortion
Adjusted for age, calendar period, previous diagnoses, number of previous admissions, time since
previous discharge, family history of mental disorder, and parental status.
IRR: Incidence rate ratios.
Reference category: 11-12 months after delivery (first live-born child)
The horizontal bars indicate 95% confidence intervals.
Relative risks vs. absolute risks
25
20
Incidence rates
15
10
5
0
9-0
1
2
3
4
5
6
7
8
9
10
11-12
Months since abortion or childbirth
IR post abortion
IR post partum
IR: Incidence rates per 1000 person years (number of new cases divided by person years at risk).
Relative risks vs. absolute risks
250
200
I
n
c
i
d
e
n
c
e
r 150
a
t
e
100
s
50
0
-9
-8
-7
-6
-5
-4
-3
-2
-1
1
2
3
4
5
6
7
8
9
10
11
12
Months before and after abortion and childbirth
Abortion
Childbirth
IR: Incidence rates per 1000 person years (number of new cases divided by
person years at risk).
So what have we learned?





Childbirth is a potent trigger of severe psychiatric
disorder
A specific relationship with bipolar disorder
No increase in rates of admission with psychiatric
disorder in the year following induced abortion
Women who have abortions are at higher risk of
psychiatric admission than women following
childbirth
Women who are admitted to psychiatric hospital
are at high risk of unwanted pregnancy and
abortion
Limitations of the Danish data:




Less severe episodes
Episodes beyond one year
Psychological reactions
Situation in other societies
Cardiff
Birmingham
Rochester USA
Arianna DiFlorio
Jess Heron
Emma Robertson Blackmore
Sue Smith
Kath GordonSmith
Aarhus Denmark
Jackie Benjamin
Trine Munk-Olsen
Elaine Green
Detelina Grozeva
Marian Hamshere
Lisa Jones
Liz Forty
George Kirov
Peter Holmans
Mick O’Donovan
Mike Owen
Nick Craddock
Bipolar Disorder
BD N .org
Research Network
[email protected]
www.marcesociety.com
www.marcesociety.com