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Postpartum Psychiatric Illness
Postpartum
Psychiatric Illness
A Picture Puzzle

Edited by James Alexander Hamilton

and Patricia Neel Harberger

li
UNIVERSITY OF PENNSYLVANIA PRESS Philadelphia
Copyright © 1992 by James Alexander Hamilton
Patricia Neel Harberger

Library of Congress Cataloging-in-Publication Data

Postpartum psychiatric illness : a picture puzzle / edited by James Alexander Hamilton
and Patricia Neel Harberger.
p. cm.
Includes bibliographical references and index.
ISBN 0-8122-3137-6 (cloth). — ISBN 0-8122-1385-8 (paper)
1. Postpartum psychiatric disorders. I. Hamilton, James Alexander, 1907-
II. Harberger, Patricia Neel.
[DNLM: 1. Mental Disorders. 2. Puerperal Disorders. 3. Puerperium—
psychology. WQ 500 P858]
RG850.P67 1992
618.7'6—dc20
DNLM/DLC
for Library of Congress 91 -30386
CIP
Contents

List of Illustrations ix
List of Tables xi
Preface xiii
Acknowledgments xvii
Introduction xix

Part I: The Qualities of Postpartum Psychiatric 1

Illness

1. Patterns of Postpartum Illness 5

James Alexander Hamilton
2. The Issue of Unique Qualities 15
James Alexander Hamilton
3. The Problem of Terminology 33
James Alexander Hamilton, Patricia Neel Harberger,
and Barbara L. Parry
4. Cries for Help 41
Patricia Neel Harberger, Nancy Gleason Berchtold,
and Jane Israel Honikman

Part II: Recognition, Treatment, a n d Support 61

5. Prediction, Recognition, and Prevention 65

Elizabeth K. Herz
6. Recent Clinical Management Experience 78
Ricardo J. Fernandez
7. Maternity Blues: A Model for Biological Research 90
Jan L. Campbell
vi Contents

8. T h e Mother and Baby Unit: An Important Approach 102

to Treatment
Joan Sneddon
9. T h e Integrated Care of Hospitalized Women with 115
Postpartum Psychiatric Illness
Deborah A. Sichel and Jeanne Watson Driscoll
10. T h e Provision of Services for Postpartum Mental 126
Illness in the United Kingdom
Ian Brockington
11. Rituals and Support: An Anthropological View of 137
Postpartum Depression
Laurence Dean Kruckman

Part III: The Organic Matrix 149

12. Endocrinology of the Postpartum Period 153

Robert B. Filer
13. T h e Hypothalamic-Pituitary-Adrenal Axis and Mood 164
Disorders Related to Pregnancy
Roger Smith and Bruce Singh
14. Endocrine Function and Hormonal Treatment of 176
Postpartum Psychosis
Junichi Nomura and Tadaharu Okano
15. Psychiatric Manifestations in Patients with Postpartum 191
Hypopituitarism
J. C. Davis and Μ. T. Abou-Saleh
16. Reproductive-Related Depressions in Women: 200
Phenomena of Hormonal Kindling?
Barbara L. Parry
17. Prophylactic Measures 219
James Alexander Hamilton and Deborah A. Sichel

Part IV: Unfinished Business 235

18. Toward the Diagnosis of Postpartum Psychotic 239

Depression
Bernhard Pauliekhoff
 Contents vll

19. Major Postpartum Depression 250

Galina M. Gorodetsky, Richard H. Trapnell, and
James Alexander Hamilton
20. Infanticide and the Law in England and Wales 257
R. Kumar and Maureen Marks
21. Postpartum Psychosis, Infanticide, and Criminal 275
Justice
Daniel Maier Katkin
22. Postpartum Disorders and the Law 282
Susan A. Hickman and Donald L. LeVine
23. Medical Insurance Litigation Problems of Postpartum 296
Patients
Mark D. DeBofsky
24. Husband Support: A Neglected Aspect of Postpartum 305
Psychiatric Illness
Robert Hickman
25. Information and Its Applications 313
James Alexander Hamilton, Patricia Neel Harberger,
and Robert M. Atkins

Appendix: The Words of Marce 325

Contributors 343
Index 347
Illustrations

FIGURES
4.1. The continuum of postpartum emotional reactions 44
4.2. "Gordon's Iceberg" 53
4.3. The pathway to false solutions 54
14.1. Onset of postpartum psychosis 178
14.2. Serum-bound Cortisol levels in antenatal and 180
postpartum periods
14.3. Clinical course of Case 1 181
14.4. Clinical course of Case 2 182
14.5. Clinical course of Case 3 184
14.6. Clinical course of Case 4 185
14.7. Clinical course of Case 5 186
14.8. Metrizamide CT-cisternography of Case 5 187
18.1. Post-delivery time intervals marking the onset of 241
psychosis
20.1. Homicide rates for England and Wales (1925-86) 267

PLATES
Plates I—XV. Facsimiles of two works by Dr. Louis Victor 328
Marce
Tables

Table 4.1. Prenatal suggestions 42

Table 4.2. Seven simple postnatal suggestions 43
Table 4.3. Symptoms suggestive of postpartum 47
psychiatric illness
Table 9.1. Problems, objectives, interventions, and 118
responsibilities
Table 14.1. Thyroid function in postpartum psychosis 179
Table 18.1. Age of onset of 200 cases of postpartum 241
psychosis
Preface

For psychiatric illness after childbirth, most of the twentieth century

was a time of inactivity and denial. If textbooks of psychiatry or obstet-
rics mentioned postpartum illness at all, the topic was dismissed quickly
with a pronouncement that these conditions were examples of the
same varieties of mental disorder as those that occurred without rela-
tionship to childbirth. Pregnancy, delivery, or the responsibilities of
child care were regarded as stresses that activated latent tendencies
toward mental illness. Even the word "postpartum" and its synonyms
were regarded as archaic, when used to qualify a psychiatric diagnosis.
The prevailing view stood in contrast to a strong nineteenth-century
position that held that postpartum psychiatric disorders were unique
in many ways. Scores of scholarly papers explored the unique features.
Many believed that the study of these features would yield clues to the
etiology and treatment of postpartum disorders.
In 1980, the pendulum began to move back toward the nineteenth-
century interest when Ian Brockington, then at Manchester, England,
called an international conference on postpartum disorders. World-
wide interest in these matters was kindled, and a substantial amount of
new information was disclosed. Out of this conference came the Marce
Society, an international scientific organization to advance knowledge
about postpartum illness. Scientific interest was mobilized.
During most of the twentieth century, postpartum illness was an
affliction about which people did not talk. It was a condition without
an identity. Many women who experienced postpartum disorders be-
lieved themselves stigmatized by a degrading disease. Then, as infor-
mation began to emerge, support groups were created to provide
information, guidance, and encouragement for the suffering women
and their families. One support group led to another; the movement
spread widely. Prominent coordinating organizations are Depression
after Delivery, Postpartum Support International, and Post and Ante-
natal Depression Association (PANDA), in Australia. Some support
xlv Preface

groups arose from the initiative of women who had recovered from
postpartum illness, while others were lead by health professionals.
Popular interest and the need for women to be informed were well
served by Carol Dix's 1985 book, The New Mother Syndrome (Double-
day). T h e positive reception of this book is attested by the fact that it
has gone through several editions and its scope has been extended by
translations.
Early in the 1980s the media began to sense that new information,
new attitudes, and new treatment possibilities were developing in the
field of postpartum illness. Both scientific meetings and support group
activities were covered with increasing interest and sophistication. Sci-
entific papers and the media began to converge on a few central
themes: mild postpartum symptoms, if not more severe disorders, are
of fairly frequent occurrence; there may be much more to postpartum
illness than a vagary of the mind; these conditions are not reflections of
mental incompetence or character weakness; most patients recover
completely; appropriate treatment and support hastens recovery; and
responsibility must be borne by family members, health care profes-
sionals, and a variety of societal institutions, not the new mother alone.
Rare but devastating consequences of severe postpartum illness are
suicide and infanticide. T h e media began to cover infanticide cases and
the law enforcement actions that followed them. One of these tragedies
took place in York, Pennsylvania. This well-informed and civic-minded
community was shocked by the event and equally shocked by the lack
of information that met questions of why and how this event could
have happened. In 1987, the York Task Force Studying Postpartum
Stress and Depression was organized and set about a systematic inves-
tigation. York Hospital took an important role in the task force. A
support group was initiated. Then York Hospital and the Infant Men-
tal Health Coalition of York organized a joint medical and public
conference which was held at the hospital in April 1988. T h e interest
displayed at the conference encouraged the hospital to stimulate the
creation of a book on postpartum illness. World leaders in many as-
pects of the problem were asked to write chapters, and they did so with
unanimity.
This book is an outgrowth of that conference and represents the
work of thirty-one authors who have made major contributions to
research, treatment, and thinking in this field. T h e authors are from
different specialty fields and different continents. At this stage of inter-
est revival, and rapid accumulation of information, it is to be expected
that different opinions and interpretations will be found. T h e editorial
policy encouraged the expression of individual thinking. As new infor-
 Preface xv

mation is put with the old, and when new research is brought forth and
evaluated, wide areas of agreement have become apparent.
The mystery that has shrouded the phenomenon of psychiatric
illness after childbirth is disappearing. In its place is emerging a picture
of an illness that can be fairly well defined and for which effective
methods of prevention and treatment are available today. Clues exist
that point toward treatment possibilities which could reduce signifi-
cantly the duration and severity of postpartum psychiatric illness.
Acknowledgments

T h e editors are indebted to many who made this book a labor of love: to
our beloved families: James Harberger; Quincy, Lincoln, and Seneca
Harberger; and Marjorie Hamilton who encouraged us and made
many sacrifices so that we might remain committed and complete this
valuable project; to the authors who have been generous with their
time and tolerant of our demands; to the York Task Force Studying
Postpartum Stress and Depression; to Patricia Smith, our editor at the
University of Pennsylvania Press who has been consistently supportive;
to Maryann Zaremska, the medical librarian at Saint Francis Memorial
Hospital in San Francisco, to Barbara Bevan, its former director, and
Beth Evitts, its current director; to Shirley Cooper, Virginia Grove, Gail
Diehl, and Diane Robinson of the York Hospital Hoover Library for
their enthusiastic assistance; to Glenn Cannon, Alex Burger, Rod
Pabst, and Gloria Heard of the Media Services Department of York
Hospital for their critical assistance with our art work; to Erma Det-
tinger in the York Hospital mailroom who guided our perpetual flow of
correspondence from the East Coast to the West Coast and vice versa; to
Betty Altland who typed, beautifully, the chapters over and over; and to
the York Hospital Auxiliary, an 1,800-member group without which
the hospital would be poorer in many ways. The auxiliary made an
unprecedented grant to our book production project, for which we are
most grateful. There are many impediments to completing a project of
this magnitude. One of the persons most responsible for helping to
overcome these impediments and gain early and continued support
was Dr. David R. Fink, Jr., Director of Education—Department of
Medical Affairs, York Hospital. We gratefully acknowledge Dr. Fink's
unhesitating encouragement and his role in providing a critical stim-
ulus to insure continued progress on the book.
Introduction

The 1980s have witnessed an explosion of knowledge regarding post-

partum illness, and a parallel expansion of interest on the part of both
the public and many individuals in the health professions. When this
book was proposed in 1988, the editors examined questions that were
asked by many thoughtful and interested people. These questions
appeared to fall into four categories, which became the four parts of
the book. Part I examines many unique qualities of postpartum illness
and describes the main syndromes that appear. Part II presents the
best of current treatment methods. Part III examines in detail evidence
implicating organic changes during the puerperium in the etiology of
postpartum illness. Part IV looks at problems that exist because post-
partum psychiatric illness has been virtually overlooked by modern
science. The question of what should be done to catch up is asked, and
some of the answers are suggested.
Parts I and III present evidence from a variety of sources suggesting
that postpartum psychiatric syndromes implicate a range of patho-
physiology which is fairly extensive and extended in time. Looked at as
individual variables, a very complex phenomenon is suggested.
These data can be viewed as a dynamic mechanism that induces
many changes in the reproductive and endocrine systems during the
puerperium. With this approach, many clinical details, organic trends,
and irregularities begin to take on the outline of a model, or a picture
puzzle as it is being assembled.
One does not put a picture puzzle together in an instant. Similarly,
the details of postpartum illness and its physiology cannot be coalesced
readily into a short description. This book tries to indicate the pre-
sumptive outline of the picture, present as many details as possible,
and then fit these details into the overall picture. The picture is looked
at from different perspectives and thus involves some purposeful repe-
tition.
Finally, in Chapter 25, when the picture is fairly advanced, its plau-
xx Introduction

sibility is questioned. T h e nearly complete picture is used to set u p

critical tests of its validity. If the tests validate the picture, effective
treatments could be available in the near future. If the tests disprove
the picture, pursuit of other inquiries is encouraged.
Each of the four parts has its own introduction. T h e introduction to
Part IV suggests the diversity of problems that arise when an area of
knowledge falls behind. Humanitarian problems exist along with the
scientific ones. All of these problems can be solved. Their solution has
been hastened by the acknowledgment of postpartum illness.
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