British

Journalof Psychiatry
(1988),
152,799—806

Non-Psychotic Psychiatric Disorder After Childbirth

A Prospective Study of Prevalence, Incidence, Course and Nature
PETERJ. COOPER,ELIZABETHA. CAMPBELL,ANN DAY, HELENKENNERLEYand ALISON BOND

The psychiatric state of 483 women was examined antenatally and at 3, 6, and 12
months postpartum. Comprehensive assessments were made of all women antenatally
and of subgroups of the full sample postnatally. Psychiatric state was assessed using
the G,eneralHealth Questionnaire, the Present State Examination and the Montgomery
and Asberg Depression Rating Scale. In terms of PSE criteria, the point prevalence
of non-psychotic psychiatric disorder antenatally was found to be 6.0%; and postnatally
it was estimated to be 8.7% at 3 months, 8.8% at 6 months and 5.2% at 12 months
after delivery. These prevalence rates were compared to the rate in a general population
sample of non-puerperal women and found to be no greater. In a subgroup of the full
sample, the incidence of psychiatric disorder in the year following delivery was
estimated to be 15.1 %, which is close to a figure previously reported for women in the
community. The onset of psychiatric disturbance was soon after delivery in most
instances; and, for the majority, the episode of disturbance lasted for 3 months or less.
The distribution of PSECatego classes and syndromes among the antenatal and postnatal
samples were found to be similar to those in the non-puerperal comparison sample. Thus,
the prevalence, incidence, and nature of non-psychotic psychiatric disorder in the 12
months following delivery do not appear to distinguish it from such disorders arising at
other times.

In recent years there has been considerable interest
in non-psychotic psychiatric disorders in the puer
perium. Early studies of depression in the puerperium
suffered from a number of methodological limita
tions. Some relied on the judgements of general
practitioners about the presence of depression,
without any clear operational criteria or standardised
procedures (Ryle, 1961; Tod, 1964; Blair eta!, 1970;
Dalton, 1971). Thus there was considerable variation
in the diagnostic criteria employed. In addition, since
standardised procedures of assessment were rarely
used, a systematic account of phenomenology was
not provided. Interpretation of the findings of this
early work is further compromised by the use of
small and non-random samples, variation in the
timing of assessment after delivery, and the absence
of comparative data.
An early study which sought to overcome some
of these difficulties was reported by Pitt (1968). In
a prospective study of a large random sample
assessed by questionnaire and interview, the inci
dence of depression in the 6—8weeks after delivery
was found to be 10.8°lo.This rate Pitt reported to
be approximately six times greater than expected. He
also noted that the depressions were ‘¿atypical' in
nature, in that other neurotic symptoms, such as
anxiety and irritability, were prominent.
Since Pitt's (1968) seminal paper, a number of
studies have been reported in which standardised
methods of assessment were used. Widely varying
prevalence rates have emerged. Studies using self
report questionnaires have reported the rate of mild
to severe depressive symptoms to be 13% (Manly
et a!, 1982) using the Beck Depression Inventory
(Beck eta!, 1961); and 22% (Hayworth et a!, 1980)
using the Zung Depression Scale (Zung, 1965).
Similar variability exists in studies which employed
standardised interview methods of assessment. For
example, O'Hara eta! (1984) found a prevalence rate
of 12% for major or minor depression 2 months after
delivery using an interview adapted from the Schedule
for Affective Disorders and Schizophrenia (Endicott
& Spitzer, 1978); and Paykel et a! (1980) found a
prevalence rate of 20010for mild clinical depression
6 weeks after delivery using the Raskin Three Area
Depression Scale (Raskin eta!, 1970). Three British
studies which used the Standardised Psychiatric
Interview (Goldberg eta!, 1970) found the prevalence
rate of psychiatric disorder to be 13% 3—5months
postpartum (Cox et a!, 1982), 16% 6 weeks after
childbirth (Watson et a!, 1984), and 17% 3 months
postpartum (Kumar & Robson, 1984). A problem
in interpreting these findings is that no comparative
data have been provided which would allow a

799
800
judgement of whether these figures represent an
elevated rate of psychiatric disorder. A further
limitation of these studies is their relatively small
sample size. This makes it difficult to examine the
phenomenological features of identified psychiatric
disorders and their duration and course.
The difficulties in interpreting the findings of
studies concerned with the nature and frequency of
psychiatric disorder in the puerperium can only be
overcome by a large prospective survey of pregnant
women. Ideally, such a survey should be conducted
with the women assessed up to 12 months after
delivery, to enable course and duration to be
established. This is important because it has been
suggested that the rate of psychiatric disorder may
be high both early and late in the postpartum year
(Kendell et a!, 1976); and because it has been
suggested that many of the psychiatric disorders
arising after childbirth run a chronic course (Pitt,
1968). A study was conducted to meet these
objectives. The principal aims were to establish the
prevalence and incidence of psychiatric disorder in
the year following delivery; to determine the onset
and course of these disorders; and to describe their
clinical features.
Method
Sample
The sample was recruited from the appointments diary of
the antenatal clinic of the John Radcliffe Hospital
Oxford, and from the delivery booking diary of the General
Practitioner Unit at the same hospital. Women
included if they resided in Oxford City and were expected
to deliver during the 9-month recruitment period.
secondwomanidentifiedwasapproachedfor interviewonce
consent from her general practitioner had been obtained.
The women then received a letter from the research team
and were interviewed in their homes. The antenatal
interview took place on average 6 weeks before
woman's expected date of delivery. There were 630 women
initially selected for the study. Of these, 52 declined to
participate; general practitioners asked for 7 to be excluded;
51 were excluded because they were soon to move out of
the area and 23 because of their difficulties with the English
language; 9 women were contacted too late to be inter
viewed; and 5 had a miscarriage. This left a final sample
of 483.
A comparison sample was provided for this study by Dr
Paul Surtees of the MRC Unit for Epidemiological Studies
inPsychiatry
inEdinburgh.Thissamplewas derivedfrom
a community sample of Edinburgh women (Surtees et al,
1983). A random sample of 576 women was interviewed
and psychiatric disorder was assessed using both Present
State Examination Index of Definition (PSE ID) criteria
and the ResearchDiagnosticCriteria (RDC; Spitzeret al,
1978). For the purposes of deriving a comparison
COOPER ET AL
for the present study, a subset of women was selected using
the following criteria: (a) age 16—40
years; (b) not currently
pregnant; and (c) no pregnancy or delivery in the previous
12months. Thus a comparison sample of 313 non-puerperal
women was derived. Surtees et al (1983) not only used the
same definition of psychiatric disorder as was used in the
present study (PSE ID@5), but also the same occupational
classification system for establishing social class (Goldthorpe
& Hope, 1974).The puerperalsampleand thenon-puerperal
comparison sample were very similar with respect to mean
age (27.2 and 28.8 years respectively),parity (4301oand 49°lo
primiparious respectively), and social class (39°loof both
samples being working class).
Measures
Antenatally a structured interview was administered to all
women to establish background and demographic variables,
gynaecological and obstetric history, attitude to the current
pregnancy, psychiatric history, psychosexual functioning,
and the level of social and material resources. The
occurrence of stressful life events and the presence of
chronic social difficulties during the preceding 12 months
was assessed using the Interview for Recent Life Events
(Paykel et al, 1969; Paykel, 1983). Psychiatric state was
assessedusing the 60-itemGeneral Health Questionnaire
(GHQ; Goldberg, 1972),the Present State Examination
(PSE; Winget al, 1974),and the Montgomeryand Asberg
DepressionRatingScale(MADRS;Montgomery&Asberg,
1979). At the postnatal interviews the main measures were
re-administered.Full obstetricdata wereobtained for each
woman from the computerised Oxford Obstetric Data
System. All the interviewers had extensive experience using
the PSE in previous studies. Reliability was ensured by
in holding regular meetings of all the raters where tape
recordedPSE interviewswereplayedand problematicitems
were discussed.
Every
Procedure
The aims of the study required that a large sample be
examined. However, interviewing all women on all
postnatal occasions would have involved considerable
each redundancy. Therefore, after certain groups had been
extracted (see below), a two-stage sampling procedure was
used postnatally, with all the women screened periodically
using the GHQ, and all ‘¿probable
cases' (GHQ@ 12) then
interviewed using the PSE.
The sample was initially assessed in the last trimester of
pregnancy and then re-assessed on three occasions in the
year following delivery: at 3,6, and 12 months postpartum.
Table I illustratesthe overallinterviewingscheme.The full
sample was interviewed antenatally. Three months after
delivery, a ‘¿random
sample' of 112(i.e. 23°lo
of the original
483) was approached for interview, of whom 6 (5.4°lo)either
refused or could not be contacted and the rest (n = 106) were
interviewed. The remaining 371 women were sent the
60-item GHQ. Of these questionnaires, 354 (95%) were
returned satisfactorily completed: 13 women had moved
and were not traced in time and 4 wished to be excluded
sample from the study. Of the 354 who returned the GHQ, 90
 PSYCHIATRIC DISORDERAFTER CHILDBIRTH 801
TABLE I
Interview scheme

AntenatalPostnatal3
monthsGroups months6 months12
interviewedFull sampleRandom sample sample
All GHQ probable All GHQ probable All GHQ probable
cases cases cases
Subsample of GHQ —¿ Subsample of GHQ
probable non-cases— probable non-cases
3-month PSE casesRandom
3- and 6-month PSE
casesTotal

ofinterviews483243107225
number

(25.4%) were found to be ‘¿probable

cases' and were cohabiting, 1% separated or divorced, and 5% single.
approached for interview; only one refused to be seen. Regarding employment, 53% were in paid employment or
Of the 264 GHQ ‘¿probablenon-cases' a subsample of 49 had recently stopped work. Using the Oxford Obstetric Data
was approached for interview, and again only one refused System, the sample was compared in terms of these
to be seen. demographic variables and in terms of parity with the
Six months after delivery, all those who had been mothers delivering in the John Radcliffe Hospital during
@ identified as PSE ‘¿cases'
(ID 5) at 3 months were the study period but not included in the present survey. No
approached for interview. Of these, one refused and seven differences were found.
were unavailable. The GHQ was sent to the remaining 452
women and 415 questionnaires (92%) were returned Obstetric history
satisfactorily completed. There were 88 (21%) GHQ
For 33°loof the women, the pregnancy was their first.
‘¿probablecases', who were all approached for interview,
Termination of one or more pregnancies was reported by
and 84 (96%) agreed to be seen. Twelve months after
12%, one or more miscarriages by 20%, and a stillbirth
delivery, all the women who had been identified as PSE
by 2%. Primiparous women comprised 43°lo.There were
‘¿cases'
at either of the previous postpartum assessments
7l% who reported that the current pregnancy was planned;
were approached for interview and 90°loagreed; two refused
and two had moved. The ‘¿random sample' of 112 was 190/othat it was unplanned but that they were pleased; and
10% that it was unplanned and that they were initially
approached for interview again, of whom 102 (91%) were
seen. The remaining 338 women were sent the GHQ, of displeased. Medical help in order to conceive had been
whom 321 (95%) returned it satisfactorily completed. This sought by 34 women (7.10/o),of whom 22 (4.6°lo)
had been
referred to a specialist clinic.
included women who had been part of the interviewed
sample of 3-month postpartum GHQ ‘¿probable
non-cases',
42 of whom again were GHQ ‘¿probable
non-cases' (all of Psychiatric history
whomwerere-interviewed).The 49(15.1010)
whowerenew Beforethe current pregnancy,33women(6.801o)
had either
GHQ ‘¿probable
cases' were approached for interview and attended a psychiatric out-patient clinic or been admitted
47 (96%) agreed to be seen. to a psychiatric hospital; and 129 (27%) reported that they
had at some stage consulted their general practitioners for
emotional problems. During the course of the current
Results pregnancy, two women (0.401o)were referred to a psychia
trist and 30(6.2%) consulted their general practitioners for
Characteristics of the sample emotional problems.
Social and demographic
Point prevalence of psychiatric disorder
The average age of the sample was 27.2 years (s.d. = 5.5),
with a range 16-41 years. Social class was determined using Table II shows the distribution of the puerperal sample by
the occupational ranking method of Goldthorpe & Hope PSE Index of Definition.
(1974). This was based on the woman's partner's Antenatal
occupation. If she had no partner it was based on her own
occupation. The sample was split into two groups on the Using PSE ID level 5 as a cut-off for clinically significant
basis of ranking: 61¾of the women were middle class psychiatricdisturbance, it can be seen that 6.0% (i.e. 29)
(ranks 1—22)and 39% were working class (ranks 23—36). were ‘¿cases'
antenatally. For the general population sample,
As to marital status, 94% of the women were married or only information about the proportion below cut-off
802 COOPER ET AL
TABLE II
Distributions by PSE Index of Definition

monthsGeneralsamplepostnatal
Antenatal3 months6 months12
sample'postnatal'postnatal'population2samplesample(n=483)(n=460)(n=442)(n=462)(n=313)Index

%Number%Definition1273
ofNumber %Number %Number %Number

60.42 56.5203 44.1167 37.8279

26.3 31.9 34.2 10.4
21428
3127 26 5.4147 44 9.6151 48 10.948 99 21.42
2.6524 5.826 5.737 8.412
3.9258.065 5.027 5.928 6.318
1.361.970 1.012 2.611 2.56
0.000.080 0.01 0.20 0.00
0.00 0.00 0.00 0.000.0
1. These distributions are derived from the PSE data of interviewed subjects, together with data extrapolated from the subsample of
GHQ ‘¿probable non-cases' who were also administered the PSE.
2. This sample is derived from data collected in Edinburgh (Surtees et al, 1983). While it would have been preferable to use data from
an Oxford sample, no such information existed and it was not practicable to obtain it. The Edinburgh sample was used because it was
the most suitable comparison group available.

was available. The proportion of those with an ID of 5 or
more in the general population was not significantly be PSE ‘¿cases'
different from that in the antenatal puerperal sample
(@2@3.60,d.f.=l).
Postnatal
At each of the three postnatal assessments, the point
prevalence of psychiatric disorder was estimated. These
estimates were derived from three sources: (a) the number
of PSE ‘¿cases'
among the GHQ ‘¿probablecases'; (b) the
45 GHQ ‘¿probable
estimated number of PSE ‘¿cases'
among the GHQ ‘¿probable
non-cases' (calculated from the established false negative
PSE ‘¿cases'.
amongthe ‘¿randominterviewed
rate);and (c)the numberof PSE ‘¿cases'
sample' (at 3 and 12 months).
Three months postnatal. Among the random sample of
106 subjects interviewed, eight (7.5%) were PSE ‘¿cases'. P<0.OOl).
Among the 89 GHQ ‘¿probable
cases' interviewed, 21 (24%)
were PSE ‘¿cases'.
Finally, among the 48 GHQ ‘¿probable Incidence of psychiatricdisorder
non-cases' interviewed,two were PSE ‘¿cases'.
The latter
figure represents a false negative rate for the GHQ of 4.2%.
From this rate an estimatecan be derivedof a further nine
PSE ‘¿cases'
amongthe 216GHQ ‘¿probable non-cases'who
were not interviewed.The PSE data from the 48 GHQ
‘¿probable
non-cases' were used to provide an estimate of
the Index of Definition distribution for the full 264 GHQ
‘¿probable
non-cases', and this estimate contributed to the
distribution shown in Table II. Therefore, the estimated
point prevalence at 3 months postpartum was 8.7% (i.e.
40 out of 460), which is no different from the point
prevalence for the general population sample (x2= 0.2,
d.f.=l).
Six months postnatal. Of the 31 women who had been
found to be PSE ‘¿cases'
at the 3-month postnatal interview,
8 of the 24 who were assessed remained ‘¿cases'
at 6 months;
15 (l8°lo)of the 84 GHQ ‘¿probable
cases' were found to
at interview.From the false negativerate
of the GHQ, it can be estimated that 14 of the 327 GHQ
‘¿probable
non-cases' were PSE ‘¿cases'.
The estimated point
prevalence rate at 6 months postpartum was therefore 8.801o
(i.e. 39 out of 442), which again is no different from that
in the general population sample (,@2 0.1, d.f. = 1).
Twelve months postnatal. One year after delivery, four
groups were interviewed (see Table I). In the subsample of
non-cases' interviewed there were no
Extrapolations were made from the other
groups, as at 3 and 6 months, and the estimated
point prevalence at 12 months was found to be 5.2% (i.e.
24 out of 462). This is a significantly lower rate than that
found in the general population sample (x@=14.9, d.f. =1,
The two-stage sampling procedure does not allow an
estimate of the annual incidence of psychiatric disorder
from the full sample. The inception rate of psychiatric
disorder in the year following delivery was therefore
examined among the randomly selected group of 112
womenassessedantenatally.At 3 months postpartum, 106
women(95¾)were assessedby interview;and 102(9l01o)
were seen again 12 months postpartum. At the 6-month
postpartum assessment, those identified by the GHQ as
‘¿probable
cases' were also interviewed. A ‘¿case'
of new onset
3 monthspostpartumwasdefmedas a ‘¿case'
whohad been
a ‘¿non-case'
antenatally. Sixmonths postpartum, a ‘¿case'
of newonset wasdefinedas a ‘¿case'
who had been a ‘¿non
case' 3 months postpartum. Twelve months postpartum,
a ‘¿case'
of newonset wasdefinedas a ‘¿case'
who had been
a ‘¿non-case'
at both the 3-monthand 6-monthpostpartum
 PSYCHIATRIC DISORDERAFTER CHILDBIRTH 803
TABLE III
Distributions of the postnatal PSE ‘¿cases'
by PSE Catego
25 class (%)‘
S
20
a PSE Catego
o class3 months months months population2
10
=31)N (n =31)6 (n =23)12 (n =23)General
(n

0
o
HHHHHH@
i
@Hfl
2 3 4 5 6
Months postpa'tum
7 8 9 10 11
Neuroticdepression29484842R

Retardeddepression26432626A

Anxiety3992632MMania330000
FIG. 1 Time of onset of postpartum psychiatric disorder (n = 55).
Obsessions3000
assessments. The proportion of ‘¿cases'
of new onset at each
of the threepostpartumassessmentswasfoundto be 7.7%, 1. The proportions are based on the Catego classes of subjects
positively identified at each assessment as a PSE ‘¿case'.
5.2°loand 2.2°lo
respectively.On this basis, the annual 2. Derived from Surtees et a! (1983).
incidence can be estimated as 15.101o. 3. This patient was not suffering from mania. The clinical diagnosis
was one of depression with occasional periods of elevated mood.
The rating of 1 on PSE symptom 41 (expansive mood and ideation)
Onset and duration of psychiatric disorder produced a certainty rating of + for syndrome 12 (HM —¿
hypomania) and thus a Catego class of M.
At each assessmentan estimatewasmade of the onset and
duration of any episode of identified psychiatric disturbance
arisingafterdelivery.
There were 53 women positively
identified postnatally as a ‘¿case'
on the PSE, and two of each occasion the identified ‘¿cases'in the puerperal
thesehad two separate onsets. As can be seenfrom Fig. 1, samplewerevirtually
all
ofdepression
oranxiety;
andthis
nearlyhalfthe identifiedcaseshad an onsetwithin3 months was also the case in the comparative general population
of delivery;and onlya quarter had an onsetbetween6 and sample. There were no significant differencesbetween
12monthspostpartum.Thedurationof identifieddisorders the puerperal sample and the general population sample
is shown in Fig. 2. It is apparent that two-thirds of the cases when the proportions within different Catego classes
had a duration of 3 months or less. were compared. In particular, the puerperal sample had
similar proportions of depressed cases to the comparison
Nature of psychiatric disorder group at 3 months (X2=0.6l,d.f.
= 1),6 months
(X2=2.99, d.f.= 1) and 12 months (x@=O.04, d.f.= 1)
The nature of the psychiatric disorders identified at each postpartum.
of the four assessmentswas examined by means of the Table IV shows the distribution of PSE ‘¿cases'
by
distribution of the PSE ‘¿cases'
by PSE Catego class and PSE syndromes at each assessment,togetherwith the
syndrome. comparable available data from the generalpopulation
Table III shows the distribution by Catego class of the sample. It can be seen that in the great majority of the
PSE ‘¿cases'
identified at each assessmentand the ‘¿cases' postnatal PSE ‘¿cases'the syndromes were the non
in the general population sample. It can be seen that on specific neurotic syndromes of worrying (WO), tension
(TE), and irritability (IT); and the specific neurotic
syndrome of simple depression (SD). When the frequency
of individual syndromes was compared for the post
30 natal ‘¿cases'
and the ‘¿cases'
in the comparison group,
no significant differences were found for any of the
25

I
syndromes for the 3-month and 12-month postnatal data.
20 A few differences did exist between the comparison group
and the 6-month postnatal ‘¿cases': among the puerperal
: 15 group, a greater proportion of cases had simple depression
a (@=4.l3, d.f.=l, P<0.0l) and loss of interest and
5 10
concentration (x@= 13.2, d.f. =1, P<0.001); and a smaller

@
5

0
1 2 3
H@I@
4 5 6
Months
7 8 9 10 11 12
proportion had generalised anxiety (x2on5.24, d.f. on1,
P<0.05)
P<0.05).
the low
and
These
rate
situational

of
syndromal
Catego
anxiety
differences
class A
(x@= 5.6,

in
simply
the
d.f. = 1,
reflect
6-month
postpartum sample shown in Table III; and the
FIG. 2 Duration of postpartum psychiatric disorder (n = 55). corresponding relatively high proportion of classes N
S psychiatrically disturbed at 12 months postpartum. and R.
804
Distributions of the postnatal PSE ‘¿cases'
PSE syndrome3
=31)SDSimple
depression771008777ONObsessional
symptoms1344GAGeneral
anxiety55174852SASituational
anxiety61355771HMHypomania300—DEDepersonalisation6134—EDPathological
guilt45617058IRIdeas
reference39262229TETension77917877LELack
of
energy35484832WOWorry9010010081ITIrritability81967077SUSocial
of
unease71577071ICLoss
concentration61916139HYHypochondriasis34410ODSomatic
of interest and
features of depression58787864
1. The proportions are based on the syndromes of women positively identified at each assessment as PSE ‘¿cases'.
2. Derived from Surtees et a! (1983).
3. Data not available in comparable form.
Discussion
A large sample of puerperal women was psychiatric
ally assessed regularly using measures of established
reliability and validity. This allowed some of the
methodological problems of earlier studies to be
overcome. In order to maximise sample size, a two
stage procedure was used postnatally to identify cases
of psychiatric disorder. A similar procedure has been
used in earlier epidemiological surveys (Duncan
Jones & Henderson, 1978; Vazquez-Barquero
1986). The method of case detection used was
conservative in that the majority of the GHQ
‘¿probable
cases' interviewedwerefoundtobe ‘¿non
cases' on the PSE. Only two women who were GHQ
‘¿probable
non-cases', from a total of 95 interviews,
were identified as PSE ‘¿cases'.
While this means that
a few cases of postpartum psychiatric disorder
not have been detected in the study, by extrapolating
from the interview data it was still possible to make
estimates of prevalence; and a sufficiently large
number of cases was systematically assessed to allow
a description of the duration, course and nature of
psychiatric disorder following childbirth.
The rate of psychiatric disorder antenatally was
similar to that reported by Kumar & Robson (1984)
and by Watson eta! (1984). The rates of psychiatric
disorder at the assessments made 3 and 6 months
after delivery were very similar to each other and to
COOPER ET AL
TABLE IV
by PSE syndromes (¾)'
monthsGeneralpostnatalpostnatalpostnatalpopulation2‘cases'‘cases'‘cases'(n
months6 months12
=31)(non 23)(non 23)(n
the rate in the general population sample. However,
the prevalence rate a year after delivery was somewhat
lower than at the other two postpartum assessments;
and it was significantly lower than the rate found in
the general population comparison sample. It is not
altogether clear why this difference arose. It should be
noted that the false negative rate for the GHQ was
zero at this assessment, whereas it had been found to
be 4.201oat an earlier assessment. Given the relatively
small number of GHQ ‘¿probablenon-cases' inter
et a!, viewed one year postpartum, this absence of false
negatives could have been a chance finding. If the
rate of false negatives previously found had continued
at 12 months, this would have given an estimated
prevalence of 7.6% at this time, a figure very close to
the prevalence rate found in the comparison sample.
Compared with previously reported point preva
would lence rates of postpartum psychiatric disorder (e.g.
Cox et a!, 1982; Kumar & Robson, 1984), the rates
found in this study are lower and close to the rates
observed in the general population. It is likely that
this inconsistency relates to differences in the
methods of assessments and case definition. Both
previous British studies cited used the Standardised
Psychiatric Interview (SPI; Goldberg et a!, 1970),
whereas the PSE was used in the present study. The
criteria used in the PSE for establishing the presence
of a symptom are rather more stringent than those
used in the SPI; and it seems likely that the SPI
 PSYCHIATRIC DISORDER AFTER CHILDBIRTH 805
would include disorders as being of clinical severity (Spitzer et a!, 1978), Surtees and colleagues (1986)
which would not reach the PSE's threshold. found the proportion of cases with a duration of less
It was not possible to calculate incidence for the than 6 months to be somewhat smaller than that
whole sample because of the sampling procedure found in the present study.
used; but it was possible to calculate incidence for The nature of non-psychotic psychiatric disorder
the randomly selected subgroup of over 100 women. occurring in the postpartum period has most usually
The annual incidence of 15.1% found is roughly been described as being depressive. When the cases
what other postpartum studies have reported for the of psychiatric disorder found in the present study
2—3 months after delivery only, and the rate were compared with those in the general population
is therefore considerably lower than previously sample in terms ofPSE Catego classes, the proportions
reported. The incidence rate for the 3-months post with anxiety were similar, and likewise for depression.
partum period was only 7% in the present study. Not There was, therefore, no excess of depressive disorders
many direct comparisons with other studies are as compared with other neurotic disorders in the
possible concerning the incidence of postpartum postpartum year, except 6 months after delivery. Pitt
psychiatric disorder, because of the different measures (1968) has referred to depression arising after delivery
used and differences in the timing of assessments. as being ‘¿atypical',
with certain distinctive features.
Pitt (1968) reported a l0.8°lo incidence rate for Comparison of the distribution by PSE syndromes
neurotic depression within 6 weeks of delivery; and of the cases identified postnatally and the general
Kumar & Robson (1984) a 14% rate for the first population cases did not substantiate this view.
3 months after delivery and an annual incidence rate There is considerable evidence that women are at
of 27%. Watson et a! (1984) reported an incidence a particularly high risk for admission for a major
of 7.8% in the first 6 weeks postpartum. It is psychiatric disorder following childbirth (Pugh eta!,
apparent therefore that there is considerable varia 1963; Paffenbarger, 1964, 1982; Dean & Kendell,
tion, related, presumably, to sample selection, sample 1981;Kendell, 1985).The predominant contemporary
size and methods of assessment. view on the status of such disorders is that they are
It is of interest to compare the incidence rate of simply ordinary functional disorders precipitated by
psychiatric disorder found in the present study with childbirth, with no material distinctive features
the incidence of psychiatric disorder for women found (Kendell et a!, 1981). The results of the present
in other epidemiological community surveys. Surtees community study suggest that there is no such increased
et a! (1986), on the basis of a community survey risk for non-psychotic psychiatric disorder for women
conducted in Edinburgh, calculated an incidence rate in the 12 months postpartum period. The prevalence
of 126/1000 per year for women aged 18—65.As they and incidence rates of disorder were found to be
point out, this study is “¿the first to calculate an similar to those of non-puerperal women in the same
inception rate among the general population using age range. There was also no evidence to support the
a longitudinal cohort design and standardised view that non-psychotic psychiatric disorder occurring
diagnostic methods―. Although the comparison is after childbirth has any distinctive clinical features.
not ideal, it is probably the best available comparison
figure; and it is close to the incidence rate of Acknowledgements
151/1000 per year found in the present study. A
similar inception rate was reported by Brown & We are grateful for the support of Professor Michael Odder and
Dr Dennis Oath throughout the conduct of this study; and indebted
Harris (1978) in their Camberwell community survey. to Dr Paul Surtees and his colleagues at the MRC Unit for
In their study, when both definite and borderline Epidemiological Studies in Psychiatry for providing the comparative
cases of all types were included, a rate of 148.5/1000 data. We should also like to thank Professors R. Acheson,
per year was obtained. Thus the incidence rate found 0. Klerman,E. Paykel, and M. Weissmanand DrsC. Kumar,
A. Stein and P. Surtees for commenting on earlier drafts of the
in the present study seems to be very close to the manuscript. We are grateful to the Mental Health Foundation and
incidence rate among women in the general population. the Oxford Regional Health Authority for their support.
There was a tendency for the onset of psychiatric
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*peter J. Cooper, DPhil,DipPsych,Research Fe!!ow (currently Lecturer in Psychopathology, University of

Cambridge),ElizabethA. Campbell,MA, MPhil,DPhi1, ResearchFellow(currently Lecturerin Clinical
Psychology, University of Surrey), Ann Day, Research Administrator, Helen Kennerley, DPhi1,Research
Psychologist (currently Clinical Psychologist, Warneford Hospital, Oxford), Alison Bond, MA, Research
Assistant; Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford

9Correspondence: Department of Psychiatry, University of Cambridge, Addenbrooke's Hospital, Cambridge CB2 2QQ
Non-psychotic psychiatric disorder after childbirth. A prospective
study of prevalence, incidence, course and nature.
P J Cooper, E A Campbell, A Day, H Kennerley and A Bond
BJP 1988, 152:799-806.
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