Prevenţia suicidului în perioada post-partum

Introduction

Suicide ranks as the 10^th leading cause of death in the United States of America, accounting for 45,000 deaths per year. The number of suicides represents 1.3% of the total number of deaths. More than 500,000 people present to emergency departments each year with non-fatal, self-inflicted injuries, representing 0.5% of all annual visits, which reflects the high rate of suicide attempts relative to those who die by suicide. For every person who dies by suicide, approximately 30 people attempt suicide⁽¹⁾.

More than 90% of suicides and suicide attempts are associated with psychiatric disorders. Psychiatric illness is the strongest risk factor for suicide attempts and suicide. Among these, there are nosological entities with a high risk of suicide: major depressive disorder, bipolar disorder, panic disorder, which together account for 50% of suicides; schizophrenia, accounting for 10% of suicides; alcohol and drug use disorders, accounting for 25% of suicides; organic brain syndromes, accounting for 2% of suicides; and personality disorders, accounting for 5% of suicides⁽¹⁾.

Studies show that a high percentage of people with these disorders die by suicide: 15% of patients with major depressive disorder and bipolar disorder, 15-25% of patients with alcohol and drug use disorders, 10% of patients with schizophrenia, 20% of patients with anxiety disorders, 4-10% of patients with borderline personality disorder, and 5% of patients with antisocial personality disorder⁽¹⁾.

This article focuses on postpartum major depressive disorder (PPD), which is underdiagnosed and undertreated and which, in severe forms, leads to suicide in 20% of all postpartum deaths⁽²⁾.

Major hormonal changes during the postpartum period affect a woman’s emotional state, potentially predisposing her to postpartum mental health disorders⁽²⁾. Postpartum depression has a prenatal or postpartum onset within the first 12 months. Emotional difficulties during pregnancy and after childbirth occur in more than 80% of women, ranging from temporary baby blues to, in 10-20% of cases, PPD in developed countries and up to 7-40% in low- and middle-income countries. Compared to the baby blues, postpartum depression is more severe and has negative consequences for both the mother and the child. Postpartum depression is debilitating for the mother, and it is one of the most common complications of pregnancy. Women with severe depression neglect their personal care and exhibit generally unhealthy behavior, including poor eating habits, which affect the cognitive, emotional and behavioral development of the newborn, as well as parental relationships, marital relationships and society; PPD is a public health issue⁽²⁾.

The course of postpartum depression may involve recovery within a few months for most women; however, 30% still suffer one year after giving birth, and 40% are at risk of recurrence during the postpartum periods of future pregnancies⁽²⁾ (the risk of PPD recurrence is 27-46 times higher after the second birth)⁽⁴⁾ or during non-postpartum periods⁽²⁾ (compared to women without PPD after their first birth, women with PPD had a 6.2-6.6 times higher risk of non-postpartum affective disorder in the years following their first birth)⁽⁴⁾. Furthermore, postpartum depression can be long-lasting; women with PPD at 8 months postpartum showed increased depressive symptoms when the child was 11 years old. The chronicity and severity of postpartum depression predict the child’s later lower cognitive performance⁽⁴⁾.

There are multiple risk factors for PPD: psychological, social, genetic, hormonal and neurophysiological.

a) Psychological risk factors include a history of mental illness, poor stress coping strategies, cultural factors, prenatal depression, a lack of understanding of PPD due to cultural, ethnic or personal beliefs, a lack of understanding between spouses, and the husband’s lack of understanding of maternal postpartum depression⁽²⁾.

b) Social risk factors consist of past or recent negative life events, childhood or adolescent sexual abuse, marital or financial challenges, impaired mother-child bonding, lack of support from the husband/family, chronic stress during pregnancy⁽²⁾, young age, multiple children, low educational level, partner violence, low social support, single status, public health insurance, annual income below $20,000 and low occupational status⁽⁴⁾.

c) Genetic risk factors – there are candidate genes and potential pathways involved in PPD:

• The estrogen receptor alpha gene modulates hormonal changes during pregnancy and the postpartum period⁽²⁾.
• The serotonin transporter gene, whose lower expres­sion makes women more prone to PPD after childbirth⁽²⁾.
• Polymorphisms and variants of the monoamine oxidase A enzyme, which is involved in the oxidative deamination of the amines dopamine, serotonin and norepinephrine, have been correlated with PPD severity scores⁽²⁾.

d) Neuroendocrine dysfunction associated with PPD is caused by stress and previous adverse life events⁽²⁾:

• Sudden and dramatic changes in hormone production during the peripartum period lead to increased susceptibility to mood disorders and support the hypothesis of ovarian steroid withdrawal⁽²⁾.
• Elevated levels of stress hormones during the peripartum period lead to postpartum mood disorders⁽²⁾.
• The hypothalamic-pituitary-adrenal axis is also disrupted by stress, leading to elevated levels of cortisol, ACTH and CRH (corticotropin-releasing hormone). Elevated CRH levels are a diagnostic criterion for postpartum depression⁽²⁾.
• The antidepressant effect of estrogen is well known. Estrogen levels drop sharply after childbirth. Treatment with estrogen reduces the risk of postpartum depression⁽²⁾.
• Oxytocin is a regulator of emotions, social interactions, stress, the mother-infant relationship, childbirth, lactation and attachment. Symptoms of depression are inversely correlated with oxytocin levels during breastfeeding⁽²⁾.
• Prolactin is known to be important for lactation and maternal behavior. Some studies associate hyperprolactinemia with PPD through an unknown mechanism, while others report a lower risk of postpartum depression associated with longer duration of breastfeeding⁽²⁾.
• Thyroid hormones indicate thyroid dysfunction in major depressive disorder and during pregnancy, so thyroid dysfunction may contribute to PPD⁽²⁾.

Thus, understanding the pathophysiology of postpartum depression helps in identifying appropriate management options⁽²⁾.

Postpartum depression occurs in 13-19% of postpartum women, with risk groups including women with a history of postpartum depressive disorder, 50% of whom relapse in the next pregnancy, and women with symptoms of depression that appeared during pregnancy, with or without a history of depression, who have an increased risk of postpartum depression⁽¹⁾.

Symptoms of major postpartum depressive disorder appear within the first 2-3 months after childbirth and consist of a depressed mood, irritability, loss of interest in usual activities, anhedonia, feelings of guilt, insomnia, loss of appetite, fatigue and low energy, associated with a severe decline in functioning⁽¹⁾. Symptoms are present for at least two weeks, they represent a change from previous functioning, are not attributable to substances or another medical condition, and cause clinically significant distress⁽²⁾.

The behavior of women with PPD is characterized by anxiety; they are irritable and struggle with routine household tasks, are tearful, may experience marital problems, have sleep and appetite disturbances, harbor negative feelings toward themselves and their child, and exhibit obsessive behavior that leads to marital crises. In the most severe cases, 5-14% experience fear of harming themselves or their child. Twenty percent of postpartum deaths are due to suicide⁽²⁾.

Screening for PPD is therefore recommended, as it can help improve women’s mental and physical well-being. This is a clinical recommendation for obstetricians and primary care providers⁽²⁾.

Postpartum depression may be accompanied by comorbidities: generalized anxiety disorder, panic disorder and obsessive-compulsive disorder. The latter involves the occurrence of aggressive obsessive thoughts in 57% of women with or without postpartum onset of major depressive disorder, thoughts that involve harming the newborn in the absence of psychosis. Comorbidities lead to more severe symptoms, reduced treatment response and suicidality⁽¹⁾.

Risk factors for suicide include:

1. Psychiatric disorders, particularly those associated with a higher risk – major depressive disorder, bipolar disorder, panic disorder, schizophrenia, alcohol and substance use disorders, organic brain syndromes and personality disorders⁽¹⁾.

2. Race (higher risk among whites compared to Asians), gender (higher risk among men compared to women), age (higher risk among the elderly compared to young people) and hopelessness⁽¹⁾.

3. Loneliness (single, divorced, widowed, separated), living alone, recent personal losses (including loss of self-esteem and status, grief with a history of mental illness and without social support, and lack of engagement with mental illness, especially in men), unemployment, financial and legal difficulties and interpersonal conflicts⁽¹⁾.

4. Medical conditions that increase the risk of suicide – traumatic brain injury, epilepsy, multiple sclerosis, Huntington’s disease, organic brain syndromes, mild spinal cord injuries, hypertension, cardiopulmonary diseases, peptic ulcer, chronic kidney disease (5% of hemodialysis patients die by suicide), Cushing’s disease, rheumatoid arthritis, cancer (especially of the head, neck, gastrointestinal tract, lungs and upper respiratory tract, with severe pain) and HIV infection. The medical conditions are associated with 35-40% of suicides, rising to 70% for those aged 60 or older⁽¹⁾.

5. Family and genetic factors – the risk of suicide is doubled by a family history of suicide and psychiatric illness; this increase is driven by shared genetic predisposition, inherited psychiatric disorders and impulsive behavior, modeling or imitation within the family environment and epigenetics. It is estimated that one-third to one-half of the suicide risk is genetically mediated. Epigenetics refers to DNA methylation influenced by factors in a turbulent family environment: early parental death, parental separation, frequent moving and emotional, physical or sexual abuse, all of which increase the risk of suicide⁽¹⁾.

6. Firearms in the home – in adolescents, the risk of suicide increases 4- to 10-fold. Additionally, suicide rates among military personnel in the U.S. have risen; in 2012, the number of deaths by suicide exceeded the number of combat deaths⁽¹⁾.

7. Current and past suicidal behavior – a history of suicide attempts is a very strong risk factor for future suicide attempts and for suicide. Fifty percent die by suicide on their first attempt, and 10-20% of people who attempt suicide die by suicide. The risk of suicide following a suicide attempt is 100 times higher than in the general population in the year following the attempt, decreasing thereafter but remaining elevated for eight years. The risk may be ongoing for patients who make a detailed plan, perceive the suicide attempt as lethal, believe that death is certain, are disappointed to be alive, and must face unchanged stressors. A patient who makes a calculated, premeditated suicide attempt is at higher risk of repeating the attempt compared to a patient who makes an impulsive suicide attempt driven by anger, revenge or a desire for attention, or compared to a patient who has ingested poison⁽¹⁾.

8. Recent discharge from the hospital for a psychiatric illness⁽¹⁾.

The frequency of use of different suicide methods varies by gender. Thus, men often use firearms (in 50% of their suicides) and hanging, while women primarily use poisoning⁽¹⁾.

Several tools are available that have been designed to assess the risk factors for prenatal, perinatal and postpartum PPD and for suicide^(2,5):

• The Postpartum Depression Predictors Inventory Revised.
• The Beck Depression Inventory II.
• The Edinburgh Postnatal Depression Scale is the gold standard during pregnancy and the postpartum period.
• The Depression, Anxiety and Stress Scale measures the severity of symptoms of depression, anxiety and stress.
• The Beck Hopelessness Scale.
• The Sad Persons Scale.
• Suicide Assessment Five-Step Evaluation and Triage.
• The Patient Health Questionnaire (PHQ-9) includes questions about suicide.

Clinicians must be aware of the barriers that prevent patients who test positive on depression screening from receiving appropriate treatment. It is known that only 50% of patients with major depressive disorder are identified, and only 35% receive care within the first year of onset, because there is a lack of connection between primary care and mental health, patients hesitate to initiate treatment, patients are nonadherent to treatment, while racism and structural policies lead to inequities in care due to lack of insurance and neglect⁽⁵⁾.

Suicide is the second leading cause of death among individuals aged 10-34. Eighty-three percent of individuals who die by suicide were seen in primary care in the year prior, and 24% had no mental health diagnosis in their medical records in the month before death⁽⁵⁾.

Suicide risk screening should be completed for all patients with psychiatric illnesses seen in the emergency department or upon hospital admission⁽¹⁾.

The association between postpartum depressive disorder and child development

By impairing the mother’s functioning, PPD has a significant impact on children’s development, affecting all aspects that support their mental development: the mother’s mental health, the child’s physical health, the parent-child relationship and social factors⁽²⁾.

Postpartum depression reduces maternal sensitivity to the infant’s cues, which she neglects, leading (especially in months 4-6) to impaired intellectual development in the child due to reduced cognitive stimulation. Furthermore, PPD is associated with long-term negative cognitive effects on the preschool and school-aged children of affected mothers.  The amount of cognitive stimulation provided by mothers to their children aged 5-8 is directly linked to their performance on cognitive tests. The impact of postpartum depression on intellectual development during adolescence is lower compared to other ages; however, maternal interest and support have a strong connection with the child’s learning⁽²⁾.

Severe postpartum depressive disorder is associated with child abuse, impaired cognitive development, marital problems and even infanticide. For this reason, it is important to screen all postpartum women for postpartum depression, in order to protect their children, prevent long-term consequences for the family and prevent postpartum depressive disorder from becoming severe⁽²⁾.

The management of PPD

Because postpartum depression affects multiple aspects of the lives of the mother, the child and the family as a whole, its management must involve comprehensive interventions: psychotherapy, pharmacotherapy, lifestyle interventions and family and social support, depending on the severity of symptoms, their presentation and the patient’s needs⁽²⁾.

a) Psychotherapy is indicated for mild or moderate postpartum depression, and includes cognitive-behavioral therapy, which  modifies negative thought patterns and behaviors and reduces depressive symptoms, anxiety and stress; interpersonal therapy, which improves interpersonal relationships and social functioning; and peer support groups that provide a platform for new mothers to share coping strategies effectively, reducing feelings of isolation, promoting recovery and preventing PPD⁽²⁾.

b) Pharmacotherapy for postpartum depressive disorder during breastfeeding is indicated for moderate and severe cases, in conjunction with psychotherapy⁽²⁾. Untreated postpartum depression affects the mother’s well-being and the child’s long-term development: cognitive, emotional and behavioral⁽²⁾, and in cases of psychotic PPD, it can lead to child abuse, infanticide⁽³⁾, self-harm by the mother in 5-14% of cases⁽⁴⁾, maternal suicide, impairment of the mother-child relationship and impairment of the infant’s/child’s development⁽³⁾. Furthermore, untreated major depressive disorder leads to impaired functioning, cardiovascular events, increased mortality and exacerbation of comorbid conditions⁽⁴⁾.

All psychotropic drugs are excreted into breast milk in varying concentrations, peaking 6-8 hours after ingestion. Therefore, if breastfeeding occurs shortly before or immediately after taking the medication, the infant’s exposure is reduced. This approach is not practical for infants who feed every 2-3 hours. In premature infants or those with signs of impaired liver metabolism (hyperbilirubinemia), breastfeeding while taking medication should be postponed, because they have reduced liver capacity to metabolize medications⁽¹⁾. The use of psychotropic medications during breastfeeding should be guided by the risk of not treating the mother’s mental disorder, the safety of the medications during breastfeeding and the infant’s status (age, weight, behavior, stability)⁽¹⁾. The psychotropic medications administered during breastfeeding are presented in Table 1^(1,3).

During the postpartum period, significant changes occur in plasma levels of endocrine hormones, peptides and neuroactive steroids. The latter, along with GABA, are implicated in the pathophysiology of PPD, which has led to the investigation of synthetic neuroactive steroids and their analogs as a potential specific treatment for postpartum depression⁽²⁾.

Neuroactive steroid medications as GABA (gamma-aminobutyric acid) modulators. In August 2023, the U.S. FDA approved zuranolone as the first specific oral medication for postpartum depressive disorder. It acts as an allosteric modulator of GABA receptors, reducing depressive symptoms in postpartum women. It is well tolerated by patients, has a rapid onset of action, and a half-life of 24 hours. Caution is still warranted, however. Brexanolone is an intravenous treatment that rapidly alleviates PPD symptoms, but it is administered in a hospital setting. The half-life is 9-13 hours, so the amount transferred into breast milk to the newborn would be minimal⁽²⁾.

c) Lifestyle changes improve the condition of patients with postpartum depression, and include regular exercise, a healthy diet and adequate sleep⁽²⁾.

d) Social support involves engaging the family, partner and community resources, as well as educational interventions for men to recognize postpartum depressive disorder and improve family support and bonds. Family members and partners are also encouraged to get involved in caring for the child and managing the household, which reduces stress and provides emotional support for recovery from postpartum depression. Community services – such as home visits by professionals and local parenting groups – help alleviate feelings of isolation⁽²⁾.

e) When cases of PPD are severe or psychotic, and patients do not respond to pharmacotherapy and management, electroconvulsive therapy is recommended, as it rapidly alleviates the depressive symptoms⁽²⁾.

f) Prevention is necessary to reduce the prevalence of postpartum depression, and consists of:

• early identification of women at risk for PPD through routine screening, using the EPDS scale during pregnancy and the postpartum period;
• educating pregnant women about the symptoms of PPD to facilitate early recognition and prompt treatment;
• raising awareness among family members to identify the condition and provide support⁽²⁾.

Women at risk for postpartum affective disorders (with a history of mood disorder or postpartum depressive disorder) are administered SSRIs prophylactically after childbirth, which reduces the rates of recurrent postpartum depression⁽²⁾.

g) Patients with suicidal impulses can be treated with benzodiazepines, antidepressants, antipsychotics and mood stabilizers. The latter regulate emotions and reduce the patient’s tendency toward impulsivity and emotional overstimulation⁽⁶⁾. Additionally, psychotherapy should be used to improve problem-solving skills, so that patients can cope more effectively with life⁽⁶⁾.

Due to the risk of overdose, ATC-3 medications are prescribed for only one week, not one month, because the lethal dose is equivalent to 1-2 weeks’ worth. The lethal dose for SSRIs is equivalent to several months’ worth. Therefore, the family must be involved to monitor the patient and ensure they do not hoard the medication⁽⁶⁾.

Directly or indirectly, 80% of people who die by suicide communicate their intent, primarily to family and friends, and then to their clinician. Half of them visit their primary care physician within a month of the suicide. Even so, these individuals rarely tell their doctor about their suicidal intent: 60% told their family doctor, while 20% told a psychiatrist⁽¹⁾.

A lack of hope or negative expectations about the future is a stronger predictor of suicide risk than depression and suicidal ideation⁽¹⁾.

Half of suicidal patients visit their primary care physician in the month prior to their death for somatic complaints rather than psychiatric ones. One-fifth visit a psychiatrist in the month prior to suicide⁽¹⁾.

The suicide risk screening must be completed for all patients with psychiatric disorders seen in the emergency room or upon hospital admission using a validated screening tool. If the result is positive – that is, they have attempted suicide, spoken of suicidal ideation or intent, admitted to these when questioned, or their behavior suggested them despite their protests to the contrary –, a comprehensive evaluation is conducted⁽¹⁾.

All suicide attempts and suicidal thoughts must be taken seriously, regardless of the manner of expression, nature and objective lethality.

The comprehensive assessment of a patient with suicidal ideation or suicidal behavior includes a detailed psychiatric evaluation, specific assessment of suicidality and estimation of the suicide risk.

1. The psychiatric evaluation includes: psychiatric, medical, social and family history, which reveals the presence of risk factors for suicide; the diagnosis of conditions associated with an increased risk of suicide (major depressive disorder, psychotic disorders, substance use disorders, anxiety disorders, personality disorders); an examination of mental status, including psychiatric difficulties and cognitive function, and differential diagnosis. Data are also collected from family, friends and colleagues⁽¹⁾.

2. The assessment of suicidality includes suicide scales, questions about suicidal ideation and intent, hopelessness and depression, suicide plans and lethal methods (when, where, how), the seriousness of the intent (no longer has plans for the future), precipitating factors, and social support⁽¹⁾.

3. The assessment of suicide risk, which is equal to the lethality of the method/chance of survival, combined with the seriousness of the intent to die⁽¹⁾. Example 1: A patient may plan a suicide attempt with a low risk of potential injury – i.e., low lethality, but truly wants to die, and believes the plan will be fatal (the likelihood of survival is low). This patient has a higher risk of suicide. Example 2: A patient may plan a suicide attempt with high lethality (high probability of death), but has little desire to die and little understanding of the severity of the attempt, so the likelihood of survival is high. This patient has a lower risk of suicide⁽¹⁾.

Conclusions and recommendations

The American College of Physicians recommends screening for depression in all adults, especially those at a high risk for depression, such as postpartum women, individuals with a personal or family history of depression, and individuals with comorbid medical conditions⁽⁵⁾.

The American College of Obstetricians and Gynecologists recommends screening for perinatal and postpartum depression at least once during follow-up visits⁽⁵⁾.

Severe postpartum depressive disorder is associated with child abuse, impaired cognitive development in the child, with marital problems, infanticide and suicide. For this reason, it is important to screen all postpartum women for PPD to protect their children, prevent long-term consequences for the family and prevent postpartum depressive disorder from becoming severe⁽²⁾.

In the community, the available treatments are underutilized due to many women’s reluctance to seek psychiatric services. Stigma is one such barrier, as are those encountered in accessing psychiatric services. For this reason, collaboration is necessary among specialists in the fields of obstetrics, psychiatry, pediatrics, nursing and primary care. At the educational level, it is necessary to increase knowledge about reproductive psychiatry among psychiatry residents⁽²⁾.

Suicide risk screening must be completed for all patients with psychiatric disorders seen in the emergency room or upon hospital admission using a validated screening tool. If the result is positive – that is, if they have attempted suicide, spoken of suicidal ideation or intent, admitted to such thoughts when questioned, or if their behavior suggests such thoughts despite their denials –, a comprehensive assessment must be conducted⁽¹⁾. 

Autor corespondent:   Raluca Pretorian E-mail: pretorianraluca@yahoo.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

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