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Maternal Bonding in Women at Risk of Postpartum Psychosis

The role of psychiatric symptoms and parenting stress

Postpartum psychosis: which are the symptoms and which women are more at risk


Postpartum psychosis is the most severe mental illness that can occur in the postpartum period, so that it is considered a psychiatric emergency and requires urgent treatment and, in most cases, hospitalisation. Postpartum psychosis usually develops very soon after childbirth and symptoms include elation, depression, with rapid fluctuations, as well as psychotic symptoms (delusions and hallucinations), often centred on the baby, and disorganized behaviour.


Luckily, contrary to postpartum depression, postpartum psychosis is relatively rare, occurring in 1–2 per 1000 deliveries in the general population. However, some women are more at risk to develop this illness, and these are women with a diagnosis of bipolar disorder, schizoaffective disorder and those who have already experienced postpartum psychosis with a previous delivery.


Although these women are more at risk to develop the illness, we know very little about why some women considered at risk become unwell after delivery while others remain completely well. Some of the most significant risk factors reported in the studies include sleep deprivation, having experienced psychiatric symptoms during pregnancy and being a first-time mother. However, many other factors remain to be investigated. The little amount of research in postpartum psychosis is in contrast with the numerous known risk factors for antenatal and postnatal depression.


I am a postdoctoral researcher working in perinatal psychiatry at the Institute of Psychiatry, Psychology and Neuroscience and I have talked about risk factors for antenatal depression in a previous piece. We need to better understand which factors increase a mother's risk of developing postpartum psychosis.


As we have recently read in my fellow colleague Katie’s blog, our research (the Psychiatry Research and Motherhood Study — the PRAM Study) has studied a number of possible risk factors. Our aim is to eventually identify, early on -in pregnancy, which women are more likely to develop an episode so that preventive interventions can be put in place. Our research has found that maternal experience of childhood maltreatment, high perceived stress and cortisol are important risk factors.


Mother-infant relationship


As much as we know little on why some women considered at risk of postpartum psychosis will eventually become unwell after delivery while others will remain completely well, we know even less about the mother-infant relationship in women at risk of/with postpartum psychosis.


This is surprising considering that we know that postnatal depression can represent a risk for the mother-infant relationship and infant development, particularly when the illness is severe and persists over time, with no treatment provided. Considering the severity of postpartum psychosis, it is essential to establish whether this illness can also have negative effects on the mother-infant relationship so that interventions can be put in place to protect the dyad in the long term.


Maternal perceived bonding towards the infant is an important aspect of the mother-infant relationship as it is the emotional response towards the baby i.e., how the mother feels towards and in the relationship with the baby. It is very much subjective as it represents how the woman perceives herself as a mother, her baby and their relationship.


We know that maternal bonding does not start when the baby is born, but much before then -when the mother is pregnant. It is during this time that the mother starts to develop a relationship with her baby, which is comprised of her feelings, thoughts and behaviours directed to the fetus. This relationship represents the basis of the mother’s future relationship with her child, although, of course, it will also be shaped by lots of other factors that will come about postnatally, including maternal mental illness, the involvement of the father, maternal experiences of being parented during childhood, social support, social and environmental circumstances, parenting stress.


Our study


And this is where my work comes in. I have a particular interest in the mother-infant relationship and infant development in the first years of life. Since 2013 I have worked on the PRAM Study, which recruited a group of women at increased risk of postpartum psychosis and followed them (and their children) from pregnancy to 12 months postpartum.


As part of this study, we investigated maternal emotional bonding towards the baby during the perinatal period in women at risk of postpartum psychosis and in those at risk who then become unwell (with depressive, manic or psychotic symptoms) in the early postpartum period (within 4 weeks after delivery). This work was recently published in the Journal of Affective Disorders.


So, what did we find?


We found that women at risk of postpartum psychosis who became unwell within 4-weeks after delivery reported a more negative affective experience towards their infants (i.e., more negative feelings) during pregnancy, compared to women at risk who remained well during that time.


However, these differences in bonding evident in pregnancy were not present anymore in the postpartum period. Indeed, in the first 12-months postpartum, women at risk of postpartum psychosis who became unwell within 4-weeks after delivery reported similar bonding to women at risk who had stayed well during that time. However, women at risk of postpartum psychosis as a group i.e. regardless of whether they had developed an episode within 4-weeks postpartum showed a more negative affective experience towards their babies compared to healthy control women (women not considered at risk of postpartum psychosis), and this remained the same throughout the first year postpartum.


What do these results mean? The role of maternal psychiatric symptoms


We found that this difference in bonding between pregnancy and postpartum was explained by the same underlying mechanism-maternal psychiatric symptoms-which had a negative impact on bonding. In other words, psychiatric symptoms affected the emotional relationship women experienced towards their babies, both in pregnancy and in the postpartum period.


The more the psychiatric symptoms experienced, the more negative was the quality of the emotional bonding. This finding is in line with what we would have expected as we know that mood symptoms impact the woman’s feelings towards herself, her environment, and her relationships, and therefore, also the relationship with the baby. Also, this confirms previous studies in depression that have shown that bonding during the perinatal period is affected by symptoms of depression, even if they are only sub-clinical (they don’t reach the level necessary for a diagnosis).


Let me explain this in more detail.


In pregnancy, women at risk of postpartum psychosis who then went on and developed a postpartum episode already experienced more psychiatric symptoms than those who then stayed well postnatally and this negatively affected the bonding women experienced towards their unborn babies. However, by 8-weeks and 12-months postpartum, when bonding was evaluated, other women at risk of postpartum psychosis who had stayed well within 4-weeks postpartum, developed psychiatric symptoms.


Therefore, by this time, women at risk of postpartum psychosis with and without an early postnatal relapse were not so clearly identifiable as before in terms of the levels of psychiatric symptoms, while women at risk of postpartum psychosis reported as a group more symptoms than healthy control women. As a result of the effect of psychiatric symptoms on bonding, in the postpartum period, women at risk as a group reported a more negative bonding quality compared to controls.


The role of parenting stress


Another important finding of the study was that parenting stress, the stress the woman experiences in her role as the mother, for example feeling inadequate as a mother, restrictions on other life dimensions, conflict with a partner, a child not meeting expectations, child perceived as difficult to manage etc. was higher in women at risk of postpartum psychosis compared to women not at risk, and this remained the same throughout the first year postpartum.

Interestingly, the more stress women experienced in their parenting role, the more negative was their bonding with their baby, a finding that has previously been reported in depression. Indeed, we found that parenting stress, similarly to psychiatric symptoms, was an important predictor of the quality of bonding women reported towards their babies.

Therefore, in summary, we found that both psychiatric symptoms and parenting stress negatively affected the emotional relationship women experienced towards their babies. Of course, it is important to mention that this was not the case for all women at risk. Indeed, not all of them experienced psychiatric symptoms, high levels of parenting stress nor a more negative emotional bonding towards their babies. As in every study, we talk about a percentage of women, not all of them.

Why these results are important

We know that both psychiatric symptoms and parenting stress can have an impact not only on the mother-infant relationship but also on the infant development in the long term. Therefore, these findings tell us that it is absolutely important to think of preventive interventions from pregnancy throughout the first postpartum year to support women at risk of postpartum psychosis to reduce parenting stress, as well as psychiatric symptoms and to improve the emotional bonding with their babies, specifically in view on the fact that bonding and parenting stress remained the same during the first year postpartum. We expect that supporting women to improve their mood symptoms and reduce parenting stress will have positive effects not only on their emotional bonding towards their babies but also on the quality of the mother-infant interaction and on the development of the infant in the long term.



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