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Postpartum Psychosis: Updates and Clinical Issues

Postpartum Psychosis: Updates and Clinical Issues

Risk factors for postpartum psychosisTable 1: Risk factors for postpartum psychosis
Clinical features of postpartum psychosisTable 2: Clinical features of postpartum psychosis


DSM-5 defines psychotic disorders as abnormalities in 1 or more of 5 domains: delusions, hallucinations, disorganized thinking, grossly disorganized or abnormal motor behavior, and negative symptoms. The current psychiatric nosology does not recognize postpartum psychosis as a distinct disorder. DSM-IV-TR allowed clinicians to apply the “with postpartum onset” specifier to brief psychotic disorder or to a current or most recent major depressive, manic, or mixed episode with psychotic features in MDD or bipolar disorder, if onset occurred within 4 weeks postpartum.

In preparation for DSM-5, evidence of the onset of symptoms in postpartum disorders was examined. Study findings suggest that 50% of major depressive episodes that present postpartum actually began during pregnancy. For this reason, the specifier “with postpartum onset” for depressive and bipolar disorders was replaced with the specifier “with peripartum onset” in DSM-5. The “with peripartum onset” specifier is applied if onset of mood symptoms occurs during pregnancy or within the 4 weeks following delivery. Thus, patients with postpartum psychosis with onset within 4 weeks after delivery could receive a diagnosis of current or most recent manic or depressed episode with psychotic features in depressive or bipolar and related disorders with the specifier “with peripartum onset.”

Alternatively, if a woman with postpartum psychosis meets criteria for a brief psychotic disorder, DSM-5 suggests adding the specifier “with postpartum onset” if onset is during pregnancy or within 4 weeks postpartum. Many clinicians had hoped that the postpartum or peripartum specifier would be extended to 6 months after delivery in DSM-5, since clinical experience suggests that many mood and psychotic episodes present beyond 1 month postpartum. Unfortunately, there was a paucity of evidence to support 6 months.

Epidemiology

The prevalence of postpartum psychosis in the general population is 0.1% to 0.2%, which is significantly lower than the prevalence of postpartum blues (50% to 75%) and postpartum depression (10% to 13%).1 Postpartum psychosis is one of the rarest psychiatric disorders, yet it is almost always considered a psychiatric emergency because of the rapid onset of severe maternal symptoms and the potential for a catastrophic outcome, such as infanticide or suicide.

Postpartum psychosis is the presentation of a psychotic disorder, such as schizophrenia, in 3.4% of women.2 However, women with known schizophrenia have a 25% risk of puerperal exacerbation.1 Postpartum psychosis occurs in 20% to 30% of women with known bipolar disorder.3 Moreover, in women with bipolar disorder and a family history of postpartum psychosis in a first-degree relative, the rate of postpartum psychosis is almost twice that of women with bipolar disorder without such a history (74% versus 30%).3

Cross-sectional studies have reported an association of psychiatric, social, and obstetric variables with the onset of the syndrome (Table 1).2,4 Once a woman has had an episode of postpartum psychosis, the risk of recurrence after a subsequent pregnancy can exceed 50%.5 Depressive episodes may follow the acute psychotic symptoms in many women with postpartum psychosis, and 26% of women with postpartum psychosis who received pharmacotherapy remain symptomatic 1 year after delivery.5 Studies have suggested that postpartum psychosis may be a variant of bipolar disorder and that hormonal and other physiological changes in the perinatal period may play an important role in its development. The strong link between postpartum psychosis and bipolar disorder is suggested by evidence of clinical presentation, longitudinal course, and family history.6

CASE VIGNETTE

After delivering a healthy baby by caesarean section, Ms A went home on postpartum day 4. Two days later, her husband called her physician because he was worried about her: she had been acting “strange” since coming home from the hospital; she worried about the baby’s well-being and was constantly asking her husband if the baby was OK. She became agitated and delusional, and her husband brought her to the emergency room. On first evaluation, Ms A was disorganized and extremely agitated; she was unable to focus on her current presentation or even acknowledge that she had recently delivered a baby.

The pregnancy had been planned, and there had been no complications. She had no personal psychiatric history, but the history revealed that her mother suffered from depression and that she had family members who had psychiatric issues, but details were unknown.

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