Catatonic features noted in patients with post-partum mental illness
Dr Tiao-Lai Huang, Department of Psychiatry, Chang Gung Memorial Hospital, 123, Ta-Pei Road, Niao-Sung, Kaohsiung 833, Taiwan. Email: firstname.lastname@example.org
Abstract The purpose of the present study was to investigate the prevalence, distribution of psychiatric diagnoses, and treatment responses of patients with post-partum mental illness at an emergency unit at Chang Gung Memorial Hospital at Kaohsiung in Taiwan. During a 1 year period a total of 636 Taiwanese women received psychiatric consultation on their visits to the emergency room. Fifteen of these were noted to have post-partum mental illnesses. All subjects were followed up for a minimum of 3–6 months. The prevalence of patients with post-partum mental illness at an emergency unit at Chang Gung Memorial Hospital at Kaohsiung was 2.4% (15/636). The distribution of psychiatric diagnoses according to Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) criteria included eight cases of major depressive disorders (53.3%), three cases of bipolar I disorder (20%), three cases of schizophrenia (20%), and one case of psychotic disorder due to a general medical condition (6.7%). Four subjects manifested catatonic features. Of these four, three had complete remission in catatonic symptoms after receiving intramuscular injection of lorazepam. The fourth subject died of multiple medical diseases. The treatment results suggest that most of the clinical presentations in patients with post-partum mental illness could be relieved by antipsychotics, mood stabilizers or antidepressants. In addition, it was found that intramuscular injection of lorazepam was also effective in patients with catatonic features and post-partum depression or psychosis.
During the post-partum period women are more vulnerable to a wide variety of psychiatric disorders,1,2 from the brief and mild symptoms of the ‘baby blues’ to the most severe episodes of puerperal psychosis. The prevalence of baby blues, post-partum depression, and puerperal psychosis is 50–70%,3–5 10–15%,5–8 and 0.1–0.2%,9 respectively.
Childbirth is a period during which rapid and significant biological, psychological, and social changes occur. A rapidly changing hormonal environment after delivery may influence the emergence of mood disorders.3,10–13 Psychosocial variables such as the stress of the peripartum period and adjustments to child-care responsibilities, also appear to play an important role in post-partum psychiatric disorders.10,13
Most women with puerperal psychosis develop symptoms within the first 2–4 weeks after delivery and are more commonly associated with confusion and delirium than non-puerperal psychotic mood disorder,14 while depression more commonly develops insidiously over the first 6 post-partum months.14 Patients with post-partum mental illness might have more severe symptoms than those in the ordinary outpatient clinics. Sometimes we found patients with catatonic features. However, the studies on catatonia after delivery are rare.15
In the present paper we investigate the prevalence, psychiatric diagnoses and treatment responses of patients with severe post-partum mental illness at an emergency unit at Chang Gung Memorial Hospital at Kaohsiung in Taiwan. In addition, we also report the catatonic features in patients with post-partum mental illness and the treatment responses.
A total of 636 women were recruited from the psychiatric consultations at the emergency unit at Chang Gung Memorial Hospital in Kaohsiung from January 2001 to December 2001. The distribution of clinical psychiatric diagnoses included 45 cases of psychotic disorder due to general medical conditions, 131 cases of schizophrenia, 16 cases of drug-induced extrapyramidal syndrome (EPS), 18 cases of brief psychotic disorder, 58 cases of bipolar I disorder, 149 cases of major depressive disorder, 35 cases of anxiety disorder, 15 cases of drug dependence and 173 cases of others psychiatric diagnoses.
Of these cases, 15 women whose onset of psychiatric illness was related to post-partum period constituted our subjects. The diagnosis of post-partum psychiatric illness was based on Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) criteria16 and was confirmed by two psychiatrists. All medical records including special charts for initial visit and outpatient service records, physical and neurological examinations, basic laboratory data, and imaging study findings were reviewed. We followed up these cases for the diagnoses and the treatment responses for at least 3–6 months. The patients were then grouped into four diagnostic categories consisting of major depressive disorder, bipolar I disorder, schizophrenia, and psychotic disorder due to a general medical condition for comparison and discussion.
The patient data and psychiatric symptoms of these 15 subjects are given in Table 1. Their ages ranged from 21 to 38 years, with a mean age of 26.7 ± 4.5 years.
Table 1. Patient data, psychiatric symptoms, EEG and brain CT findings
| 1||25||1st||10 days||Catatonic features, déjà vu, retardation, derealization, anterograde amnesia,||Yes||Normal||Normal||Major depressive disorder|
| 2||33||2nd|| 2 weeks||Catatonic features, depressed mood, fatigue, retardation||Yes||ND||ND||Major depressive disorder|
| 3||38||5th|| 3 days||Catatonic features, delusion of persecution, auditory hallucination||Yes||Probably abnormal||Normal||Schizophrenia, catatonic type|
| 4||29||1st|| 1 week||Catatonic features, poor intake, disorientation, insomnia, auditory and visual hallucination||Yes||ND||ND||Psychotic disorder due to general medical conditions|
| 5||27||1st|| 4 weeks||Elevated mood, racing thought, buying spree, poor concentration||No||ND||ND||Bipolar I disorder, manic episode|
| 6||26||1st|| 9 days||Elevated mood, inflated self-esteem, hypertalkativity, insomnia||No||ND||ND||Bipolar I disorder, manic episode|
| 7||26||1st|| 3 days||Self-talking, thought insertion, auditory and visual hallucination, disorganized speech||Yes||Normal||ND||Bipolar I disorder, manic episode|
| 8||22||1st|| 3 weeks||Suicidal ideation, depressed mood, anxiety, guilt, low self-esteem||No||Normal||Normal||Major depressive disorder|
| 9||26||1st|| 3 weeks||Depressed mood, guilt, low self-esteem||No||ND||ND||Major depressive disorder|
|10||29||1st|| 4 weeks||Depressed mood, loss of interest, poor concentration||Yes||ND||ND||Major depressive disorder|
|11||23||1st|| 3 weeks||Infanticide idea, suicidal ideation, depressed mood, worthlessness||No||ND||ND||Major depressive disorder|
|12||21||1st|| 3 weeks||Suicidal ideation, depressed mood, loss of interest, guilt||No||ND||ND||Major depressive disorder|
|13||26||3rd|| 2 weeks||Infanticide idea, depressed mood, loss of interest, anxiety, suicidal ideation||No||ND||ND||Major depressive disorder|
|14||21||1st|| 3 weeks||Self-talking, avolition, slow response, silly smile||No||Normal||ND||Schizophrenia, paranoid type|
|15||28||4th|| 3 weeks||Violent tendency, auditory hallucination, delusion of persecution||No||Normal||ND||Schizophrenia, paranoid type|
The chief complaints of patients who were sent to the emergency room included suicidal ideation, violent behavior (harming their infants or husbands), elevated mood, psychosis and mutism (Table 1).
The profiles of psychiatric diagnoses in the patients were as follows: eight cases of major depressive disorder (53.3%), three cases of bipolar I disorder, manic episode (20%), three cases of schizophrenia (20%), and one psychotic disorder due to a general medical condition (6.7%). Among these 15 subjects, 11 (73.3%) were primiparous while the other four (26.7%) were multiparous (2nd, 3rd, 4th, and 5th parity, respectively). Durations of onset after delivery were as follows: <2 weeks in seven cases (46.7%); and between 2 and 4 weeks in eight cases (53.3%).
The ratio of patients with post-partum depression to female patients with major depression at the emergency unit was 5.4% (8/149). Puerperal psychosis included bipolar I disorder, schizophrenia and psychotic disorder due to a general medical condition. The ratios of patients with post-partum onset of bipolar I disorder, schizophrenia and psychotic disorder due to a general medical condition to female patients with puerperal psychosis at the emergency unit were 5.2% (3/58), 2.3% (3/131), and 2.2% (1/45), respectively.
Most of the clinical presentations in patients with post-partum mental illness could be relieved by antipsychotics (e.g. haloperidol 5–10 mg/day), mood stabilizers (e.g. lithium 400–600 mg/day), or antidepressants (e.g. fluoxetine 20 mg/day).
Of the 15 subjects, four manifested catatonic features including stupor, mutism, immobility, and negativism (cases 1–4), and one presented derealization, déjà vu, anterograde amnesia, and misidentification (case 4). Three of them (two with major depression, one with schizophrenia) received intramuscular injection of lorazepam and had complete remission of catatonic symptoms after 30–60 min. The remaining subject (psychotic disorder due to a general medical condition) died of pneumonia, sepsis and adult respiratory distress syndrome on the fourth day of her hospital stay. She did not receive treatment of intramuscular injection of lorazepam during the whole course.
The distribution of diagnoses in the present study included eight cases of major depressive disorder (53.3%), three cases of bipolar I disorder (20%), three cases of schizophrenia (20%), and one psychotic disorder due to a general medical condition (6.7%) after 3–6 months follow up. It came close to the findings of Davidson and Robertson's follow-up study.11
The DSM-IV defined post-partum onset as episodes occurring within 4 weeks after delivery.16 However, the literature has inconsistently defined time of onset as between 4 weeks and 6 months following delivery.17,18 The shorter period of 4 weeks may reflect the organic etiology of rapid hormone changes contributing to vulnerability to psychiatric disorders, while the longer 6 months may indicate the major role of psychosocial factors in triggering post-partum psychiatric disorders.19,20 In the present study we collected patients according to DSM-IV criteria, and found that the duration of onset after delivery was <2 weeks in seven cases (46.7%) and between 2 and 4 weeks in eight cases (53.3%).
The ratio of patients with post-partum depression to female patients with major depression at emergency unit at Chang Gung Memorial Hospital at Kaohsiung was 5.4% (8/149). This prevalence was within the ranges reported in other studies (5–20%).5–8,21–24
Several previous studies indicated that guilt occurs more frequently in cases of post-partum depression and suicidality is less common.25 In the present study, among patients with post-partum depression from the emergency room, 3/8 (37.5%) experienced severe feelings of guilt and 4/8 (50%) had suicidal ideation. A marked percentage of women with post-partum depression have ambivalent or negative feelings toward the infants and even ego-dystonic thoughts of harming their infants;26 however, in the present study only two subjects presented infanticide ideas (cases 13, 14) and one subject was noted with violence to her husband (case 15). Severe post-partum psychiatric disorders may disrupt the mother's interactions with her spouse, with the infant, and with other family members,27,28 and may increase risk for later maternal depression and for child behavior problems.29
In addition, in the acute state some patients could simultaneously express mixed symptoms of consciousness change (e.g. delirium), motor abnormality (e.g. catatonia), thought and mood disturbances.30 In the present study, two patients with major depressive disorder (cases 1, 2) had catatonic features such as stupor, mutism, immobility, and negativism. After the motor signs of catatonic features were relieved by intramuscular injection of lorazepam, these two patients could eat, walk, talk and respond to our orders. We also found that one of them had derealization, anterograde amnesia, déjà vu, and delusion of misidentification (case 1). Two days later all the aforementioned symptoms subsided and the patient presented only symptoms of major depression.
The depressive symptoms were improved under the treatment of fluoxetine (20 mg/day) in all patients with major depression.
In the present study two patients had vivid visual or auditory hallucinations (cases 3, 4). One had schizophrenia and the other had psychotic disorder due to a general medical condition. The patient with schizophrenia (case 3) received intramuscular injection of lorazepam and had complete remission of catatonic symptoms after 30–60 min. In contrast, the patient with psychotic disorder due to a general medical condition (case 4) died of multiple medical diseases including pneumonia, sepsis and adult respiratory distress syndrome on the fourth day of her hospital stays. She did not receive lorazepam injection during the whole course.
All patients with post-partum psychosis were able to maintain a stable condition under the treatments of antipsychotics (e.g. haloperidol 5–10 mg/day) for schizophrenia and mood stabilizers (e.g. lithium 200–600 mg/day) for bipolar I disorder.
According to previous reports there is more disorientation or confusion in post-partum episodes, as compared with non-post-partum episodes.14 This is probably due to the significant physiological changes (e.g. hormonal change), during the post-partum period.3,10–13 In the present study, nearly half of the subjects (6/15) initially manifested disorientation or a confusional state (Table 1).
Several studies suggested that electroencephalography (EEG) is useful for differential diagnosis between epileptic activity, especially non-convulsive status epilepticus, and catatonia.31–33 In the present study EEG were performed in six subjects, of which five (case 1, 7, 8, 14, 15) had negative findings (Table 1). The remaining subject (case 3) had probable abnormal findings but her brain computed tomography (CT) disclosed no prominent brain lesions.
Catatonia has been noted in post-partum illness but it has been reported only rarely.15 In the present study, it was not rare and appeared in four subjects (4/15). Previous studies have reported responses to lorazepam in variable catatonia.34–38 In the present study we further reported that intramuscular injection of lorazepam was also effective in patients with catatonic features and post-partum psychiatric disorders.
Catatonia is a syndrome rather than a disease, and is associated with variable etiologies, presentations, and courses.39–43 If left untreated the complications of the medical diseases might be fatal.44 In the present study, the patient (case 4) who died of multiple medical diseases that included pneumonia, sepsis and adult respiratory distress syndrome was noted to be healthy and free from any physical problems before the episode of post-partum psychiatric disorder. We can conclude that patients might die of the complications of catatonia. If intramuscular injection of lorazepam had been used earlier, it is possible that this patient might have had a chance to live.
The present study is a small case series on post-partum mental illness. Other limitations included referral bias and incomplete data in EEG and brain CT studies. The catatonic features and post-partum onset specifier tend to be underrecognized, therefore it is possible that the actual prevalence of catatonia in post-partum mental illness may be underestimated.
Our study has noted the presence of catatonic features in some patients with post-partum psychiatric illnesses. Most of the clinical presentations in patients with post-partum mental illness could be relieved by antipsychotics, mood stabilizers or antidepressants. In addition, intramuscular injection of lorazepam was also effective in patients with catatonic features and post-partum depression or psychosis.
Thanks to all residents in the department of psychiatry at Chang Gung Memorial Hospital at Kaohsiung for alerting us when receiving patients with catatonic features in the emergency room.