Authors: Muthukumar Kannabiran, Rowan Pearson, Gopinath Narayan
Publication date: 03 Mar 2007
Muthukumar Kannabiran, Rowan Pearson, and Gopinath Narayan discuss
Perinatal psychiatry is the branch of psychiatry dealing with the management of mental health disorders in the antenatal and postnatal period. It is considered by many to be a relatively new specialty. Mental health problems after childbirth have been long recognised. The first treatise on postnatal mental illness was written by a French psychiatrist Louis Victor Marcé in 1858 ( [Link] ).
The need for perinatal mental health services
The World Health Organization's study on the global burden of disease lists depression as the second leading cause of disability in market economies and the leading cause of disability worldwide,  and the Confidential Enquiry into Maternal and Child Health (CEMACH) states that, “Psychiatric illness was the most common cause of indirect maternal death and the largest cause of maternal death overall.” 
It is well established that the prevalence of mental illness is increased in women after childbirth and that untreated perinatal psychiatric disorders can prolong maternal morbidity and interfere with maternal bonding. In women with pre-existing psychiatric disorders, this period carries an increased risk of relapse. Women with a history or a family history of bipolar disorder or puerperal psychosis are at high risk of developing puerperal psychosis, which can have a sudden onset. The need for early recognition and treatment to avoid possible disastrous consequences for the mother, baby, and family cannot be overemphasised (see box for recent guidelines).
Perinatal mental health problems have been in the media spotlight recently, as celebrities have been discussing their own experiences of postnatal depression, and following the backlash after Tom Cruise criticised Brooke Shields for taking antidepressants for postnatal depression. The suicide of Dr Daksha Emson (a 34 year old psychiatrist) and the death of her 3 month old daughter was a shocking reminder of the devastating effects of puerperal psychosis. 
What are the psychiatric disorders seen in the perinatal period?
Traditionally, mental health disorders in the perinatal period have been classified as postnatal blues, postnatal depression, and puerperal psychosis (box). The SIGN 60 guidelines (further information box) define these terms as:
Postnatal (baby) blues. A brief episode of misery and tearfulness that affects at least half of all women after delivery, especially of first babies
Postnatal depression. Any non-psychotic depressive illness of mild to moderate severity occurring during the first postnatal year. It occurs in 10-15% of women after childbirth
Puerperal psychosis. Puerperal psychosis is a mood disorder accompanied by features such as loss of contact with reality, hallucinations, severe thought disturbance, and abnormal behaviour, affecting one to two per thousand women.
A week in the life of a perinatal psychiatrist
Perinatal psychiatrists manage psychiatric disorders in the antenatal and postnatal periods, and their work varies from day to day. It consists of outpatient clinics with assessment and follow-up of patients referred to the service. In our service, we have regular reviews of the inpatients as well as mothers attending the day hospital. We provide information to general practitioners (GPs) on the use of psychotropic drugs in pregnancy and while breast feeding. We also perform urgent assessments of pregnant women or mothers who have recently given birth, when a medical team or a GP have concerns. Some mother and baby units conduct parenting assessments for social services. We have an important role in educating patients, carers (who are often the partners), and the public about mental health issues in the perinatal period.
How do we do it?
The organisation of perinatal mental health services varies across the country. Some services have mother and baby units, offering joint admission to the mother and her baby, with facility to supervise the baby at all times. Other services consist of community teams, which may work alongside adult mental health teams. Day hospitals are available in a few trusts. In areas where the service is not available, liaison psychiatrists provide the necessary expertise.
In addition to doctors and nurses, teams consist of social workers, nursery nurses, physiotherapists, and occupational therapists. We work closely with GPs, midwifes, and health visitors, as well as with obstetricians and paediatricians.
Common terms used in perinatal psychiatry
“Postnatal blues” and “postnatal depression” have been used as generic terms for all psychiatric disorders in this period. This can be potentially misleading and life threatening, reducing the awareness of severe psychotic or mood disorders in the perinatal period and causing delay in recognition and treatment. Although we have used the traditional terms in this article, the consultation document from the National Institute for Health and Clinical Excellence (NICE; further information box) encourages the use of formal diagnostic categories because of the lack of an evidence base for use of the terms “postnatal blues,” “postnatal depression,” or “puerperal psychosis.”
What are the qualities needed to work in perinatal psychiatry?
You need to be compassionate and patient, as with any branch of psychiatry. A working knowledge of obstetrics is useful and you should be willing to update your knowledge constantly, especially about psychopharmacology in the context of pregnancy and breast feeding.
What are the benefits of working in perinatal psychiatry?
This is a developing area and you will be part of a small group of specialists. With new services being set up around the country, you have an opportunity to be involved in shaping new services, as well as the chance to choose which part of the country to work in. As the outcomes of most perinatal disorders after treatment are good, it is a rewarding specialty to work in.
What are the challenges of working in this area?
Because of the obvious difficulties in conducting clinical drug trials in pregnant or breastfeeding mothers, there is a lack of quality evidence for prescribing for antenatal and postnatal psychiatric disorders. Though new services are being established, some areas may suffer from a paucity of resources. There is a constant need to educate and inform, to promote awareness of these disorders and of the help available.
Training requirements and opportunities
Perinatal psychiatry was a special interest group within the Royal College of Psychiatrists until recently, when it became a section of the college.
One of the recommendations of the inquiry into Dr Emson's suicide is that the perinatal psychiatry group should have full training status within the college.  At present there are no dedicated training schemes for perinatal psychiatry and it is not possible to obtain a certificate of completion of training in the specialty. Initial exposure can be gained as part of the psychiatric rotation as a senior house officer in perinatal psychiatry. If you wish to pursue this as a career, a one year placement as a specialist registrar would be helpful. It is still unclear as to how this will change after Modernising Medical Careers.
Useful websites and organisations
Confidential Enquiry into Maternal and Child Health: [Link]
National Service Framework for Children, Young People and Maternity Services: [Link]
Royal College of Psychiatrists' perinatal section— [Link]
Scottish Intercollegiate Guidelines Network-60 (SIGN 60): [Link]
The Marcé Society: [Link]
The Association for Postnatal Illness: [Link]
NICE's antenatal and postnatal mental health: consultation, full guideline: [Link]
Doctors specialising in other fields such as obstetrics have found that a placement in perinatal psychiatry provides valuable experience. The CEMACH report states, “the relevant Royal Colleges should ensure that perinatal psychiatry is included in their curricula and requirements for continuous professional development.” 
Perinatal psychiatry continues to grow as a specialty, because of the increasing recognition of its role. It is a fulfilling and challenging area to work in.
Competing interests: At the time of submission, all three authors were working in perinatal mental health.
- Murray CJL, Lopez AD, eds. The global burden of disease and injury series, volume 1: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020 . Cambridge, MA: Harvard School of Public Health on behalf of WHO and the World Bank, Harvard University Press, 1996.
- Royal College of Obstetricians and Gynaecologists. Confidential enquiries into maternal deaths (2001). Why mothers die 2000-2002 . London: RCOG, 2001. [Link] (accessed 12 Oct 2006).
- Royal College of Psychiatrists. Independent inquiry into the care and treatment of Daksha Emson . London: RCP, 2003. [Link] and [Link] (accessed 12 Oct 2006).
Muthukumar Kannabiran locum staff grade
Rowan Pearson associate specialist
Gopinath Narayan lead clinician Perinatal Mental Health Service, Leeds email@example.com