During pregnancy and the postpartum stage, women are increasingly vulnerable to postpartum psychiatric illnesses. This vulnerability is especially dangerous in the age of COVID-19, as this high-risk population now battles the threat of yet another illness. As there is already evidence that respiratory viruses like prenatal influenza can increase one’s susceptibility to neuropsychiatric
diseases, researchers have now predicted an association between contracting COVID-19 and developing a postpartum psychiatric illness. This hypothesis has been preliminarily supported by a survey conducted at Boston’s Brigham and Women’s Hospital, which reported that during the pandemic, the percentage of pregnant and postpartum women experiencing significantly high levels of depression has skyrocketed from approximately 15% to 36%. With that being said, the exact relationship between the onset of the two diseases is unclear. In this 2020 case series, researchers assessed three cases of postpartum psychosis (PP) in mothers with SARS-CoV-2 infection, aiming to find underlying biological, psychological, or environmental factors that would suggest COVID-19 predisposes the onset of PP.
The three COVID positive women involved in the study had successful deliveries, though they each developed PP within a week of giving birth. Despite having PP, all neurological workups and general examinations appeared normal for these subjects. Furthermore, none of the women experienced any affective symptoms (such as depression or mania). Rather, the most common symptoms observed were delusions of persecution and reference, many of which were tied to their COVID-19 diagnoses. For example, one woman reported a suspicion that her doctors were trying to infect her and her baby with COVID-19, despite knowing she was already testing positive. Another woman experienced delusions of persecution as she believed everyone she encountered blamed her for her COVID infection. This psychosis surrounding the virus supports the association between these women’s infection and their eventual development of PP.
In addition to COVID-related delusions, certain biological processes that underlie the virus have already been flagged by researchers to potentially influence the onset of PP. One immune response in particular is called a “cytokine storm,” which is characterized by the overproduction of cytokines by monocytes in the central nervous system. This overstock of cytokines causes positive feedback in the immune system, as more and more immune cells are recruited to the site of infection within the body. However, this release of cytokines by virus-infected monocytes propagates neuroinflammation and exacerbates neuropsychiatric symptoms, increasing the likelihood one experiences a psychiatric disorder. A different study found evidence of this neurotropic effect, as postpartum mothers who experienced a recent onset of psychotic symptoms (n=106) had mean antibody levels that were significantly above that of controls (n=196) (Severance et al., 2011). This significant association between having a recent psychotic episode and heightened levels of antibodies further reinforces the potential for biological mechanisms underlying COVID-19 to predate the onset of PP.
It is also important to consider how COVID-related environmental factors, such as social isolation, influence women’s susceptibility to postpartum psychiatric disorders. Having to deliver during the pandemic is already challenging, but having to completely isolate from one’s family and newborn soon after giving birth can make this situation even more difficult. Stressful life events and lack of support from close friends and family are already predictors for developing psychiatric illnesses, so being deprived of in-person help and support during the puerperium likely contributes to rates of PP in postpartum mothers.
While the role that COVID-19 plays in the pathophysiology of PP is not yet fully understood, this study offered preliminary evidence that provides us a stronger grasp of how respiratory illnesses, like coronavirus, can predispose postpartum psychiatric illnesses. By further researching the association between the onset of the two diseases, clinicians will have a more full understanding of what contributes to women’s postpartum psychiatric states, and in turn, be better prepared to prevent and treat such diagnoses.
Written by Dhiya Sani
Subramanyam, Alka A, et al. “Postpartum Psychosis in Mothers with SARS-CoV-2 Infection: A Case Series from India.” Asian Journal of Psychiatry, Elsevier B.V., Dec. 2020.