Post-partum psychiatric care in India: the need for integration and innovation

Brockington emphasises the need for clinicians and researchers to recognise that post-partum psychiatric syndromes go beyond the traditionally accepted triad. There are several distinct clinical conditions that have now been recognised, each with different aetiologies, course, methods of diagnosis and management.

In this regard, research in post-partum psychiatric disorders in India, though limited, has followed two parallel streams. Community-based studies have focussed mainly on post-partum depression (PPD), while hospital-based studies have focussed mainly on clinical descriptions of post-partum psychosis. The last few years have seen an increase in epidemiological data on PPD in India (1, 2). These studies have been extremely important in estimating the prevalence and identifying risk factors for the disorder and have also highlighted specific cultural and social factors that increase risk for the disorder in India.

Two prospective studies on pregnant women, in the states of Goa and rural South India, detected depressive disorder in 23% and 16% respectively, with depression persisting six months after child birth in 11-14% of women (1, 2). While the risk factors found in both the studies replicate some of those already established in Western countries (poor marital relationship, antenatal depression), the finding of culture specific risk factors enhances their relevance. Gender based factors emerged as being highly important, with intimate partner violence, unhappiness about the gender of the child, poverty and having a living female child being identified as risk factors both for the occurrence of PPD and for chronicity. Maternal education, on the other hand, appeared to be a protective factor. Both the above studies have highlighted the importance of social factors, specifically poverty and female gender of the infant.

It must be emphasised here that both these studies were carried out in states of India where antenatal and postnatal services are among the best in the country. The National Family Health Survey-2 (3) from India has reported that nearly 34% of pregnant women do not receive even a single antenatal check up and only 35% of deliveries are conducted in health facilities. In some states up to 65% mothers did not get even one antenatal check up. Both antenatal and postnatal check ups were reported to be less among low-income women and those who had low literacy levels, both of which have been identified as risk factors for depression.

The findings of these studies, in the light of national health indicators of maternal health, inform us regarding the need for mental health care in the community to be integrated with other programs, including those on economic growth, alcohol services for men, and those addressing gender specific issues. A purely biomedical approach is unlikely to prevent the occurrence or chronicity of these disorders, given the fact that most mediators do not seem to be biomedical in nature. Mental health professionals, however, have an important role in working closely with maternal and child health workers and offering consultative and training services in early detection and referral.

Severe mental illness (SMI) in the post-partum is another important but neglected area, with most studies in India being descriptive (4). Inadequate post-partum care contributes to organic factors in precipitating or worsening psychosis.

There are very few studies that have assessed mother-infant interaction patterns, including harm to the baby and neglect, which according to Brockington are important consequences of post-partum psychosis (5). Despite India having low resources for some mental health facilities, newer antipsychotics, mood stabilisers and antidepressants are available at reasonable cost (6). A large number of women with SMI will be on psychotropic medication and need special services for preconception counselling and safe use of drugs in the post-partum. Parenting assessments and family planning issues need to be integrated into the routine care of women with SMI. All this will require special effort and training of mental health personnel.

It has been established that joint admissions in specialised mother-baby units are the preferred context for handling post-partum women with SMI with their babies. Mother-baby units are expensive and need specialised personnel. In a resource scarce country such as India, while tertiary care centres can offer specialised services including clinical care, research and training, more cost effective ways of delivering services for mothers with SMI need to be identified. This might include domiciliary care by trained nurses, volunteers or trained peers or even a female relative under supervision.

The challenge that post-partum psychiatry faces in India is to translate research findings into practice by working closely with other agencies, adapting established modes of care to local needs and resources and finding innovative care delivery methods both in the hospital and the community.