By Lexi Ilgner-McEvoy – Midwife, Leeds Teaching Hospitals NHS Trust
and Lucy Flatley – Midwifery Lecturer, School of Healthcare, University of Leeds @lucycflatley
Postpartum mood disorders are of major clinical and public health concern in the United Kingdom, where suicide is the leading cause of maternal death. The most recent MBRRACE-UK report highlighted a statistically significant increase in maternal deaths from psychiatric causes1lthough postpartum psychosis is rare with an incidence estimated at 1-2 in 1000 births, it is a severe psychiatric disorder2,3,4. It is characterised by a dramatic onset and rapid deterioration of acute mania or depression with psychosis within the first few weeks of childbirth4.
Despite diverse efforts to provide distinct pathophysiology relating to the link between birth and psychosis, the fundamental disease processes underpinning postpartum psychosis remain contentious2. Genetic, hormonal, and immunological influences have all been linked5. Nonetheless, the particular processes involved in the development of these episodes, as well as the possible relevance of additional triggering variables, remain poorly understood5.
A credible but under investigated contender for triggering postpartum psychosis is sleep loss. Sleep deprivation, a powerful precipitant of mania and elevated mood states, is a common occurrence in the perinatal period6. Sleep is fundamental for the operation of the central nervous system and is arguably the most significant psychophysiological process for brain function and mental health7 and may have a substantial influence in the development of psychosis8.
Indeed, a small body of literature indicates that sleep loss may be a powerful precipitant of postpartum psychosis and these findings have crucial clinical implications for prevention and treatment of this dangerous disorder8,9,10. Studies suggest that the elevated sensitivity to the mania inducing effects of sleep loss for women with bipolar disorder cannot be denied and it could be concluded that sleep loss is a more potent trigger in women who are already biologically predisposed to the disorder. This not only assists in the identification of women for whom obstetric staff may need to pay particular attention to the protection of sleep, but potentially aids with challenging decisions regarding medication use during the perinatal period. Despite being a credible hypothesis, the limited availability of contemporary research on this subject matter presents challenges in determining whether a history of sleep loss is a clinically meaningful predictor of developing postpartum psychosis and highlights the need for further research before reaching definitive conclusions.
While clinical guidelines suggest little about sleep facilitation as a treatment option for women at risk of postpartum psychosis, Osborne’s11 clinical guide for obstetric providers, recognises sleep as a crucial factor, emphasising the need to ask women about sleep disturbance. Furthermore, NICE clinical guidance frequently accessed by midwives12, recommends discussing sleep deprivation with parents in the postnatal period but the link to postpartum psychosis is not discussed. This highlights a potential gap for staff education surrounding the importance of sleep.
Early detection and treatment of sleep impairment is critical. Increasing awareness of the link between sleep deprivation and the postpartum psychosis may aid healthcare professionals in discussions with women and encourage the implementation of strategies to promote sleep such as stimulus reduction, daytime delivery where possible and reducing the number of visitors in the postnatal period. That being said, the difficulties of facilitating sleep in an obstetric unit should not be underestimated. There are obvious challenges during labour, however ensuring adequate sleep on the postnatal ward may also be problematic. Women have consistently reported lower satisfaction with postnatal care compared to other areas of maternity13. Midwives have also reported concerns with postnatal care relating to demanding workloads and inadequate staffing levels14. This highlights barriers to the delivery of enhanced postnatal care for vulnerable women. Further investment in postnatal care and perinatal mental health services as per the recommendations of Better Births15 could make a meaningful difference to the care women receive in this crucial time.
- Knight M, Bunch K, Patel R, Shakespeare J, Kotnis R, Kenyon, S and Kurinczuk, J. 2022. Saving Lives, Improving Mothers’ Care Core report: Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018-20. Oxford: National Perinatal Epidemiology Unit.
- Bergink V, Rasgon N. and Wisner KL. 2016. Postpartum Psychosis: Madness, Mania, and Melancholia in Motherhood. American Journal of Psychiatry. 173(12); 1179-1188.
- Gressier F, Lacaze de Cordova I, Glatingy E, Glangeaud-Freudenthal, N. and Sutter-Dally A. 2020. Handbook of Perinatal Clinical Psychology. [Online]. Abingdon, Oxfordshire: Routledge. [Accessed 24 May 2022]. Available from: https://www.taylorfrancis.com/chapters/edit/10.4324/9780429351990-20/postpartum-psychosis-bipolar-disorders-mother-baby-unit-florence-gressier-ingrid-lacaze-de-cordova-elisabeth-glatigny-nine-glangeaud-freudenthal-anne-laure-sutter-dallay
- Perry A, Gordon-Smith K, Di Florio A, Craddock N, Jones L. and Jones I. 2021a. Mood episodes in pregnancy and risk of postpartum recurrence in bipolar disorder: The Bipolar Disorder Research Network Pregnancy Study. Journal of Affective Disorders. 294: 714-722
- Perry A, Gordon-Smith K, Di Florio A, Craddock N, Jones L. and Jones I. 2021b. Phenomenology, Epidemiology and Aetiology of Postpartum Psychosis: A Review. Brain Sciences. 11(1): 47
- Sharma V. 2003. Role of sleep loss in the causation of puerperal psychosis. Medical hypotheses. 61(4): 477-481
- Baglioni C, Nanovska S, Regen W, Spiegelhalder K, Feige B. and Nissen C. 2016. Sleep and Mental Disorders: A Meta-Analysis of Polysomnographic Research. Psychology Bulletin. 142(9): 969-990.
- Lewis KJS, Di Florio A, Forty L, Gordon-Smith K, Perry A, Craddock N, Jones L. and Jones I. 2018. Mania triggered by sleep loss and risk of postpartum psychosis in women with bipolar disorder. Journal of Affective Disorders. 225; 624-629
- Sharma V, Smith A. and Khan M. 2004. The relationship between duration of labour, time of delivery, and puerperal psychosis. Journal of Affective Disorders. 83(2): 215-220
- Bilszta JLC, Meyer D. and Buist AE. Bipolar affective disorder in the postnatal period: investigating the role of sleep. Bipolar Disorders. 12(5): 568-578
- Osborne LM. 2018. Recognizing and Managing Postpartum Psychosis: A Clinical Guide for Obstetric Providers. Obstetrics and Gynecology Clinics of North America. 45(3): 455-468
- 2021. Postnatal care. [NG194]. [Online] https://www.nice.org.uk/guidance/ng194/resources/postnatal-care-pdf-66142082148037 [Accessed 2/12/22].
- Turner L, Culliford D, Ball J, Kitson-Reynolds E. and Griffiths P. 2022. [In Press]. The association between midwifery staffing levels and the experiences of mothers on postnatal wards: Cross sectional analysis of routine data. Women and Birth. [Online]. Available from: https://www.sciencedirect.com/science/article/pii/S1871519222000312
- Morrow J, McLachlan H, Forster D, Davey M. and Newton M. 2013. Redesigning postnatal care: exploring the views and experiences of midwives. Midwifery. 29(2): 159-166
- Cumberlege J. 2016. Better Births: Improving outcomes of maternity services in England – A Five Year Forward View for maternity care. [Online]. London: NHS England. [Accessed 12 December 2022]. Available from: https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf