Family History Ups Postpartum Psychiatric Episodes

Deborah Brauser

May 07, 2018

NEW YORK — Having first-degree relatives with psychiatric disorders is a significant risk factor for postpartum psychiatric disorders, new research suggests.

Dr Anna Bauer

A national cohort study, which included data on more than 362,000 first-time mothers in Denmark, showed that a history of a psychiatric disorder in a first-degree relative significantly increased the risk of the new mom's experiencing psychiatric episodes herself during the postpartum period.

Having a relative, male or female, with bipolar disorder (BD) was an even greater risk factor, increasing the likelihood of a psychiatric disorder almost threefold compared with those who did not have a family history of BD.

Lead author Anna E. Bauer, PhD, Department of Psychiatry and Genetics, University of North Carolina at Chapel Hill, told Medscape Medical News the take-away message for clinicians is that collecting family history data for both male and female relatives is important for this patient population.

"For people who have never experienced a mental illness or a trauma before, it's hard to predict who's going to get these psychiatric disorders. But a family history is relatively easy to ask about and can be done earlier on during pregnancy — even before a woman might become symptomatic," said Bauer.

"It's a little more challenging because it's one more thing to add to a medical visit, but it's not invasive, it can be done without a lot of extra cost, and it can provide a fair amount of information for us — especially if there's a family history of bipolar, which can nearly triple the risk of experiencing one of these psychiatric postpartum illnesses," she added.

The results, which were presented at a press conference here at the American Psychiatric Association (APA) 2018 annual meeting, were also simultaneously published online in the American Journal of Psychiatry.

1 in 7 Women Affected

"Postpartum psychiatric disorders are one of the most common complications of pregnancy, with complications for the mom, as well as for babies and for the entire family," said Bauer. She added that about 1 in 7 women will experience some type of postpartum psychiatric disorder, ranging from unipolar disorder and anxiety to more severe conditions.

The investigators note that although past research has shown that an expectant mother's personal psychiatric history is a strong predictor of the occurrence of postpartum psychiatric episodes, "predicting who will experience a new-onset psychiatric disorder in the postpartum period remains a significant challenge."

They examined Danish registry data for 362,462 mothers (mean age, 27 years) who gave birth between 1985 and the end of 2012. Of these, 0.7% experienced a postpartum psychiatric disorder within 6 months of giving birth, and 1.1% experienced one within 12 months of giving birth.

A total of 23,350 women in the study population had a prior history of a psychiatric disorder.

For this study, first-degree relatives included mothers, fathers, and full siblings. Familial psychiatric disorders were grouped into five categories: BD, unipolar disorder, schizophrenia and related disorders, mood disorders other than BD or unipolar disorder ("other mood disorders"), and "other psychiatric disorders."

Postpartum psychiatric disorders were defined as disorders in which onset occurred within the first year after the first-time mother gave birth. "Some of this would be in people who got better, some would be people who continued to have mental illness, and some had a postpartum illness and then a later reoccurrence of a mental illness. We didn't distinguish between those groups in our study," said Bauer.

Etiologic Link?

Among all participants, for those with a first-degree relative with any psychiatric disorder, the hazard ratio (HR) for experiencing a psychiatric episode during the 6-month postpartum period was 1.45 (95% confidence interval [CI], 1.28 - 1.65).

When assessing specific familial disorders, the highest risk factor for postpartum psychiatric disorders was having a relative with BD (HR, 2.86 vs no family history of BD; 95% CI, 1.88 - 4.35).

"We expected to see an increased risk for having relatives with bipolar disorder, because a link between women who have a personal history of bipolar and postpartum mental illness has been shown before," noted Bauer.

"Also, women who experience a first-onset psychiatric illness during the postpartum period are more likely to develop bipolar disorder. So we thought there might be an etiologic link there," she said.

The risk was also increased for participants with first-degree relatives who had other mood disorders (HR, 1.78), schizophrenia (HR, 1.58), or unipolar disorder (HR, 1.52).

"As expected," having a personal history of psychiatric illness was a very strong risk factor for experiencing a postpartum psychiatric episode (HR, 8.66; 95% CI, 7.97 - 9.40), the investigators report.

"However, we found associations of family history of psychiatric disorders to be stronger among women without a personal psychiatric history, indicating that family history may be particularly helpful in a risk assessment tool for new-onset postpartum psychiatric episodes among women with no record of psychiatric disorders," they write.

Risk for psychiatric episodes during the 6-month postpartum period was similar for participants who had mothers with any psychiatric disorder (HR, 1.50) and those who had fathers with any psychiatric disorder (HR, 1.54). "This pattern persisted for all five diagnostic groups," note the researchers.

Dr Samantha Meltzer-Brody

"This is not just about 'what was your mother's pregnancy like?' or asking about a sister's pregnancy," principal investigator Samantha Meltzer-Brody, MD, Department of Psychiatry at the University of North Carolina at Chapel Hill, told Medscape Medical News.

"An important message of the study is that this is about your mother and your father, as well as brothers, that can increase your risk," she added.

The risk was "slightly elevated" when the new moms had second-degree or third-degree relatives with a psychiatric disorder (HRs, 1.16 and 1.27, respectively). Second-degree relatives included grandparents, aunts, uncles, and half siblings. Third-degree relatives included cousins.

"Fourth Trimester" Recommendations

Overall, "we found that although postpartum psychiatric disorders are uniquely female events, a history of psychiatric disorders in male relatives was just as influential as a history...in female relatives," write the investigators.

Therefore, questions about both male and female relatives, especially in regard to BD, "are of the highest importance and should be added to routine clinical screening guidelines," they add.

The US Preventive Services Task Force and the American Academy of Family Physicians currently recommend that the general adult population, including pregnant and postpartum women, be screened for depression, said Bauer at the press conference. The American Academy of Pediatrics recommends that this type of screening be conducted for new mothers at their infant's well-child checkup appointments at 1, 2, 4, and 6 months.

As reported by Medscape Medical News, the American College of Obstetricians and Gynecologists released a recommendation last month that comprehensive pregnancy care include the so-called "fourth trimester" of pregnancy, with caregivers and new mothers continuing to communicate throughout the first 3 months after birth. This includes screening for postpartum depression, anxiety, and substance use, as well as following up on preexisting psychiatric conditions.

"This is a very big deal for people who do women's and perinatal mental health. And I think there's, thankfully, a sea change in this country that's moving in the right direction," Meltzer-Brody, MD, Department of Psychiatry at the University of North Carolina at Chapel Hill, told attendees at the press conference.

However, "we haven't been doing a very good job of capturing a comprehensive family history" up front — before a woman becomes symptomatic, she added. "I think the take-home message is that we need to do better for our moms, and we need to use the information from our study to help our providers inform better practice patterns."

Asked why taking a complete family history has not been more commonly practiced previously, Meltzer-Brody said that this area has been ignored for a long time.

"Mental health issues have been the stepchild of the field of medicine in general, and women's mental health issues suffer from that even more. It's been very difficult to have assessments of these types of things, and I think we haven't understood the heritability. This is one of the first studies looking at familiality in this way," she noted.

Benefiting the Field

Michael Roy, executive editor of the American Journal of Psychiatry, told Medscape Medical News that the journal wanted to include this study during its press conference because it contains current information that can help clinicians in their day-to-day practice.

"A lot of what we publish is 5, 10 years down the road, but sometimes we have something that has significance today. It can have an impact now, especially in an area that's critically underserved, and any guidance that we can give is a benefit," said Roy.

"With awareness and earlier detection, the outcomes across the board are better. Answering, 'Is there anything that we can do to try to move the discussion further upstream?' is going to be a benefit for the field."

The study was funded by a grant from the National Institute of Mental Health. Dr Bauer has disclosed no relevant financial relationships. Disclosures from the other study authors are listed in the original article. Michael Roy has disclosed no relevant financial relationships.

American Psychiatric Association (APA) 2018. Presented May 7, 2018.

Am J Psychiatry. Published online May 7, 2018. Abstract

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