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 has featured cover stories providing expert perspectives on multiple important psychiatric issues such as the state of mental health care in the United States, the link between COVID-19 and psychosis, and the future of psychiatry. Halfway through 2022, here are some highlights from this year’s cover stories so far.

Psychosis in the Patient With COVID-19: An Emerging Psychopathology?

The link between viral infections and effects on the central nervous system has been studied with viruses such as influenza, H1N1, and previous coronaviruses, including SARS and MERS. It has been documented that like COVID-19, these viruses have been able to produce symptoms of psychosis in patients with no prior psychiatric conditions.

Recently published studies have shown that COVID-19 can cause severe neuropsychological stress-inducing psychosis in affected patients.

 The literature covering correlations between COVID-19 and psychosis has demonstrated that there has been an increase in the rate of psychotic symptoms such as paranoia, delusions of persecution, and auditory and visual hallucinations in populations with high incidence rates of COVID-19 infection.

Thought, CircRNAs, and a Neurodigital Hypothesis

If you ask a cardiologist, “Physiologically speaking, what is a heartbeat?” they can bore you to tears with details on anatomy, electrophysiology, hemodynamics, innervation, and pulmonary and peripheral circulation. But if you ask a psychiatrist the entirely pertinent question, “Physiologically speaking, what is a thought?” the truth is, we have been without a clue—until now.

Of all psychiatry’s mysteries, this is the most crucial void in our scientific knowledge: how the brain executes the higher functions that are the actual focus of psychiatric practice—the generation of thought and behavior. This knowledge gap has been responsible for psychiatry’s own split personality—historically swinging back and forth between a biological focus on the brain and a psychological focus on the mind. Just as physics sought a unified “theory of everything” to incorporate the mystery of gravity, this missing piece of science has eluded psychiatry since its inception. 

Psychiatric Care in the US: Are We Facing a Crisis?

By the end of 2021, many American adults found themselves in the worst mental state in years. According to the US Census Bureau’s Household Pulse Survey, 47% of adults reported symptoms of anxiety,

 and 1 in 5 adults disclosed suffering from a mental illness.

 Despite this, it is estimated that less than half of Americans with a mental disorder get adequate treatment.

“It has been just over a year now since the COVID-19 pandemic struck the United States full force. A year of hunkering down and Zooming in, teleworking and telepsychiatry, economic and social upheaval, and steady scientific progress. Looking back to last March, we knew this would be difficult. But we didn’t know how difficult. And we certainly didn’t know that the challenge of COVID-19 would last this long,” said Joshua A. Gordon, MD, PhD, director of the National Institute of Mental Health, in a 2021 director’s message.

Psychedelics and the Future of Psychiatry

Over the past several years, we have witnessed a psychedelic renaissance, and a growing body of evidence suggests that several psychedelic compounds hold strong therapeutic potential for a wide array of mental health conditions.

Once dismissed as dangerous and having little therapeutic potential, psychedelic drugs are gaining mainstream acceptance. Research data continue to demonstrate that, on the whole, these medicines are not only safe, but mostly well tolerated. Although more research is needed to better understand safety, especially in the context of at-risk conditions, these favorable safety profiles are enabling deeper exploration of these medicines. 

See more 2022 cover stories and download complete issues of 

. And be sure to stay up-to-date by subscribing to the 

Do you have a comment on any of these or other articles? Have a good idea for an article and want to write? Interested in sharing your perspectives? Write to us at 

Over the past 6 months, Psychiatric Times has featured expert opinions on important psychiatric issues from psychosis to psychedelics.

From the Pages of Psychiatric Times: 6 Months of Cover Stories

“Mr Jesse” is a 39-year-old African-American male with a 17-year history of schizophrenia. When he was 22, he was in a motor vehicle accident while under the influence of alcohol and suffered a head injury. Several months later, he was hospitalized for a first episode of psychosis. After discharge, he was non-adherent with his oral antipsychotic and was hospitalized within 2 months for another episode of acute psychosis. During the second hospitalization, he was started on a long-acting injectable antipsychotic. For the past 15 years, he has been maintained on the same long-acting injectable antipsychotic and is adherent with outpatient appointments. He tends to experience mild paranoia during periods of stress, but has not had any subsequent psychiatric hospitalizations.

Medication nonadherence is, unfortunately, the rule rather than the exception in patients with schizophrenia, and it is associated with poorer long-term outcomes.

 Although long-acting injectable (LAI) antipsychotics improve treatment adherence, thereby reducing illness relapses and hospitalizations, they are not extensively used.

 There is evidence that treatment with LAIs in the early stages of schizophrenia is associated with decreased hospitalizations,

 as well as suicide attempt and mortality.

 investigated whether patients with early-stage schizophrenia switched from oral to LAI antipsychotics during hospitalization had fewer emergency room (ER) visits, fewer psychiatric rehospitalizations, and lower mortality compared to patients maintained on oral agents. Study authors conducted a population-based cohort study using the Taiwan national Health Insurance Research Data and National Death Registry databases. These databases were used for the 13-year period from 2002 to 2015. They started with a base cohort of 19,183 patients aged 16 to 65 years with newly diagnosed schizophrenia (ICD-9) who received oral antipsychotics during the period of 2002 to 2005.

Thereafter, they identified a study cohort of patients who were switched to LAIs during hospitalization and had at least 6 LAI prescriptions during the year after discharge. These patients were matched 1:1 with patients continuing to receive oral antipsychotics (at least 6 times after the index date) based on age, sex, time since first antipsychotic prescription, time of the first LAI prescription, and psychiatric comorbidities. Early-stage switching to LAIs was defined as ≤ 3 years, and late-stage switching was defined as >3 years. Patients were followed from the index date to either the study end or death.

Primary study outcome measures were all-, natural-, and unnatural-cause mortality. Secondary outcomes were occurrences of medical and psychiatric rehospitalizations, psychiatric ER visits, and antipsychotic adherence during the follow-up period. The Charlson Comorbidity Index was used as a covariate. The risk of death was estimated using conditional Cox regression analyses. Hospitalizations and psychiatric ER visits were analyzed using conditional negative binomial regression analyses.

During the follow-up period (median 89 months), 678 hospitalized patients were switched to LAIs (312 early-stage and 266 late-stage), and these subjects were matched to 678 subjects on oral antipsychotics. The mean subject age at first antipsychotic exposure was 34, and 51% of the sample was male. Early-stage switch to LAIs was associated with significantly lower all-cause (HR=0.49, 95% CI 0.27-0.87) and natural-cause (HR=0.30, 95% CI 0.15-0.60) mortality. This survival advantage did not extend to patients with late-stage switch to LAIs. 

Both early- and late-switching to LAIs were associated with better medication adherence than with patients taking oral antipsychotics. Early-stage switch to LAIs was associated with significantly lower risk of rehospitalization (IRR=0.56, 95% CI 0.45-0.69), psychiatric hospitalization (IRR=0.63, 95% CI 0.50-0.81), and psychiatric ER visits (IRR=0.58, 95% CI 0.45-0.75). This advantage did not extend to patients with late-stage switch to LAIs, who surprisingly had a higher risk of psychiatric rehospitalization (IRR=1.34) than patients on oral antipsychotics.

The authors concluded that there were profound benefits of early-stage use of LAIs on decreased mortality, hospitalization, and ER visits, and increased treatment adherence in patients with schizophrenia. These benefits did not extend to patients who were switched to LAIs after 3 years of oral antipsychotic initiation. 

The primary study strength was the use of a population-based cohort with linkage to national data registers. The selection of hospitalized patients provides a reasonable indicator of illness severity. Study limitations included the potential for residual confounding; the absence of data on socioeconomic and lifestyle factors; and potential time-period effects on the adoption of LAIs.

This study demonstrates that use of LAIs in early-stage schizophrenia is associated with increased adherence and decreased psychiatric hospitalizations and ER visits. Increased use of LAIs in this population appears warranted.

is a professor in the Department of Psychiatry and Health Behavior at Augusta University in Augusta, Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for 

The author reports that he receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute.

1. Tiihonen J, Mittendorfer-Rutz E, Majak M, et al. 

Real-world effectiveness of antipsychotic treatments in a nationwide cohort of 29 823 patients with schizophrenia

Barriers to the use of long-acting injectable antipsychotics in the management of schizophrenia

3. Kane JM, Schooler NR, Marcy P, et al. 

Effect of long-acting injectable antipsychotics vs usual care on time to first hospitalization in early-phase schizophrenia: a randomized clinical trial

 [published correction appears in JAMA Psychiatry. 2020 Dec 1;77(12):1310]. 

Comparison of long-acting injectable antipsychotics with oral antipsychotics and suicide and all-cause mortality in patients with newly diagnosed schizophrenia

 [published correction appears in JAMA Netw Open. 2022 Apr 1;5(4):e2210829]. 

Long-term outcomes of early use of long-acting injectable antipsychotics in schizophrenia

Does the “early bird get the worm”? Researchers investigated long-term outcomes with an early-switch long-acting injectable antipsychotic in patients with schizophrenia using a population-based cohort.

Outcomes With Early Long-Acting Injectable Antipsychotic Use in Schizophrenia

Interim results from an open-label study of evenamide as an add-on in patients with chronic treatment-resistant schizophrenia (TRS) showed an improvement in symptoms of psychosis in the first 100 participants.

The first-of-its-kind study is an international, 6-week, open-label, randomized, rater-blinded, multi-center study examining the effects of adding evenamide—a new chemical entity (NCE) antipsychotic—to treatment for 180 participants with TRS who are moderately to severely ill (CGI-S of 4 to 6), with a baseline PANSS score between 70 and 90, predominant positive symptoms, and functional deficits, who had not been responding to prior treatment with antipsychotic medications. Researchers are evaluating the tolerability and safety of adding evenamide orally at 3 fixed doses—7.5, 15, and 30 mg bid—compared with a stable therapeutic dose of a single antipsychotic (other than clozapine) as well as conducting safety and efficacy assessments in 1- to 2-week intervals. The study is being conducted by Newron Pharmaceuticals.

Interim results for the first 100 participants showed a 12% reduction in the participants’ PANSS scores, CGI-S improvement of 0.7, and CGI-C ratings demonstrating that 77% of participants responded to the treatment.

“We are excited to present the interim results of this study, which demonstrate the potential of evenamide as an add-on therapy to antipsychotics in patients with treatment-resistant schizophrenia,” said Ravi Anand, MD, Newron Pharmaceuticals chief medical officer, in a press release. “The data presented today confirm evenamide’s potential to improve symptoms of psychosis in patients who, despite treatment with various antipsychotics, continue to experience severe symptoms of psychosis and functional disabilities. These patients represent about one third of the overall schizophrenia population and thus a significant unmet medical need.”

As part of its ongoing Phase II/III development plan for evenamide, Newron announced it will initiate a multinational, randomized, placebo-controlled study in patients with TRS during the first quarter of 2023.

 “Evenamide acts through selective attenuation of an abnormal release of glutamate and synergizing with the background antipsychotic activity,” Anand said in a press release. “The outcome of this study may change the treatment of future TRS patients when confirmed in a larger, placebo-controlled study.”

1. Newron presents encouraging interim results for evenamide in patients with treatment-resistant schizophrenia (TRS) at the 33rd CINP Hybrid World Congress of Neuropsychopharmacology. News release. Newron Pharmaceuticals. June 7, 2022. Accessed June 17, 2022. 

https://www.newron.com/news-and-media/regulatory-news/newron-presents-encouraging-interim-results-evenamide-patients

Interim study results show 77% treatment response rate among participants.

New Chemical Entity Improves Symptoms in Individuals With Treatment-Resistant Schizophrenia

 (PP) is an umbrella term for the impairing and isolating psychotic-mood symptoms experienced by a small proportion of women (1 to 2 women every 1000 deliveries) shortly after childbirth. Despite being recognized for centuries, the condition has historically been understudied. However, over the past 10 to 15 years, stimulated by a growing interest in women’s health and increasing crosstalk among biomedical practitioners in diverse fields, we are finally starting to characterize PP more comprehensively and beginning to understand its associated risk factors and biological basis (

Individuals affected by PP typically experience hallucinations, delusions (often infant-focused), mood swings, sleep problems, and cognitive disorganization/disorientation within 2 weeks of giving birth. The condition is regarded as a psychiatric emergency and is associated with an increased risk of maternal suicide and infanticide. However, with prompt medical intervention and enduring psychiatric and psychosocial support, the acute symptoms and long-term consequences associated with PP can generally be managed effectively.

Pharmacotherapeutic options for PP include antipsychotic, mood stabilizer, or sedative administration; in more extreme cases, electroconvulsive therapy may be advisable. Pharmacotherapies can be given prophylactically in pregnant women who are at high risk of developing PP. Some of the teratogenic effects of effective drugs, such as the mood stabilizer lithium, appear to be less insidious than previously suspected, particularly if treatment regimens are appropriately titrated.

 Similarly, understandable fears about persistently impaired mother-child bonding as a consequence of PP may have been overemphasized, with a new analysis showing that bonding impairments persist in fewer than 6% of affected individuals who were affected at hospital discharge.

 Valuable qualitative research is beginning to document the experiences of women with PP and to help us understand the support mechanisms through which their recovery might be aided.

Besides a previous episode of PP, by far the largest risk factor for the condition is an existing diagnosis of bipolar disorder—particularly bipolar I disorder. Between 20% and 40% of individuals with bipolar I disorder who give birth will experience PP.

 A major challenge for the future will be deciphering the factors that distinguish women with bipolar disorder who develop PP from those who do not. The 2 groups do not appear to differ with respect to their personality traits, cognitive styles, or affective temperaments,

 but women with bipolar disorder whose manic episodes are precipitated by sleep loss may be at especially high risk.

Current diagnostic classification systems do not recognize PP as an entity in its own right, but rather as a variant or subform of other mood-psychotic conditions. On the basis of its unique constellation of features, as well as its specific and definitive link to childbirth, some psychiatrists have called for this approach to be revised.

 Emerging data have indicated that, in individuals with bipolar disorder, the frequency and quality of symptoms in the postpartum and nonpostpartum periods may differ: In the former, there may be fewer manic symptoms, more depressive symptoms, greater perplexity and self-reproach, and less pressured speech and sociability.

The relationship between bipolar disorder and PP risk appears remarkably strong and relatively specific, in that personal history for other mood-psychotic spectrum conditions (eg, schizophrenia, schizoaffective disorder) appears to raise an individual’s PP risk only modestly (10% to 15% of individuals with schizophrenia-like disorders develop PP).

 Additionally, in individuals with schizophrenia, PP manifests differently than it does in individuals with bipolar disorder.

 It is also noteworthy that, for around half of all cases of PP, the affected individual has no psychiatric history; the latest analysis indicates that in such women, psychotic experiences appear to be largely limited to the postpartum period, although around one-third of previously healthy women may subsequently exhibit recurrent symptoms consistent with a bipolar disorder spectrum condition.

Numerous medical conditions may arise, or be exacerbated, in the perinatal period. These include preeclampsia (significantly elevated blood pressure and associated proteinuria typically occurring in late pregnancy) and autoimmune thyroid disorders. Preeclampsia and autoimmune thyroid disorders frequently cooccur with postpartum psychiatric symptoms, including PP. To date, little evidence is available regarding whether these conditions are causal risk factors for PP, or whether there are shared etiological factors that could predispose a woman to both PP and preeclampsia/autoimmune thyroid disorders. Although exposure to adverse life events has traditionally been more strongly associated with postpartum depression risk than with PP risk, evidence is emerging to suggest that severe childhood maltreatment, exposure to more frequent stressful life events, and elevated levels of the stress-related molecules cortisol and C-reactive protein in late pregnancy may predict PP episodes in “at-risk” women.

 However, given a previously reported lack of association between adverse early-life events and PP risk in individuals with bipolar disorder,

 the question of whether a link between the 2 variables truly exists remains to be answered definitively.

In terms of demographics, postpartum psychiatric symptom risk may be greater in younger mothers

 and in primiparous individuals (ie, those having their first child); however, this latter finding may be confounded by mitigating measures being put in place after a first PP episode.

New Research and Their Clinical Implications

There is strong reason to believe that PP risk is, in part, determined by biological factors: The prevalence and manifestations of the condition are similar across countries and cultures, and the condition is tightly linked to childbirth and its associated biological changes. Affected individuals and their relatives are at high risk of relapse or of first-onset PP, respectively.

Identifying and characterizing the biological features that underlie PP risk through increased collaborative endeavors and novel experimental approaches is important for 3 main reasons:

It will clarify the extent to which PP overlaps with, or is distinct from, other psychiatric and medical conditions. This topic feeds into debates on whether or not PP warrants its own diagnostic category.

It will enable the development and testing of predictive biomarkers. Then, individuals at particularly high risk of PP, or those at risk of transitioning to a bipolar disorder spectrum condition, can be identified and prioritized for early intervention to minimize the likelihood of long-term harm to affected individuals and their children.

It may highlight novel drug targets, stimulating the development or repurposing of even more effective and/or less toxic pharmacotherapies.

Maternal physiology changes significantly throughout pregnancy and into the postpartum period, notably with respect to immune function and circulating sex hormones. During early pregnancy, a proinflammatory state aids in successful implantation and placentation while a subsequent anti-inflammatory state protects against preterm birth and miscarriage. Predelivery, and for several months into the postpartum period, the mother’s body returns to a proinflammatory phase.

The results of multiple recent studies have suggested that in individuals with PP, this final inflammatory phase is exaggerated—potentially, in part, as a consequence of altered activity, or number, of immunosuppressive regulatory T-cells (Tregs).

 Heightened immunoreactivity may partially explain links between COVID-19 infection and apparent vulnerability to psychosis across the lifespan, including in the postpartum period.

 Whether the immunological changes seen in individuals affected by PP are a cause or a consequence of the disorder remains an open question, as does the significance of these findings. Are immune system changes fundamental to PP risk, or are they merely the most observable changes, given the accessibility of relevant tissues (ie, blood)? One route to testing this question would be to test whether anti-inflammatory drug administration further alleviates symptoms and potentiates recovery in patients.

The immediate postpartum period sees precipitous drops in circulating estrogen and progesterone levels in the new mother following expulsion of the placenta. As no consistent differences have been observed in levels of these hormones between healthy mothers and mothers with psychosis following birth, it has been proposed that at-risk mothers are somehow especially biologically sensitive to estrogen and/or progesterone depletion. Through comparing brain activity at baseline and during relevant cognitive tasks, investigators at Kings College London have shown that at-risk women who develop PP exhibit altered prefrontal cortex network activity compared with at-risk women who do not develop PP.

 White matter integrity is altered in women with bipolar disorder and may also be perturbed in PP cases. We have proposed that defective (re)myelination processes occurring in the perinatal period may underlie PP symptoms and be related to abnormal secretion of the cellular communication network factor 3 protein by Tregs.

 Cellular communication network proteins were initially implicated in PP risk through work in a new, experimentally amenable mouse model relevant to the condition, and these proteins seem to affect numerous PP-associated neurobehavioral processes, in addition to playing a role in preeclampsia pathogenesis.

Although immunological and neuroimaging markers associated with PP may be confounded by environmental exposures (eg, the patient’s comorbid medical conditions, demographics, or treatment), genetic factors associated with PP are stable; their impact upon disorder risk is not complicated by reverse causation issues. Early, limited linkage analyses in a sample of women with bipolar disorder and PP pointed to 2 candidate loci on chromosomes 16p13 and 8q24, the latter overlapping the cellular communication network factor 3 gene. Single-gene association studies examining candidates involved in stress, hormonal signaling, and serotonergic pathways have largely proved unreliable. Currently, collaborative efforts are underway to recruit and phenotype a sufficiently sized patient cohort to undertake a genome-wide association analysis in PP and to identify robust risk polymorphisms.

Although meaningful genome-wide analyses are not yet feasible, an insightful new study has used a genetics-based approach to provide evidence that first-onset PP may be biologically dissociable from bipolar disorder and therefore may represent a separate nosological entity within the bipolar disorder spectrum.

 Briefly, the researchers calculated polygenic risk scores for schizophrenia, depression, and bipolar disorder across 3 cohorts: healthy individuals, individuals diagnosed with bipolar disorder, and individuals diagnosed with first-onset PP. Interestingly, while bipolar disorder and schizophrenia polygenic risk scores completely or substantially overlapped between individuals with bipolar disorder and PP, depression polygenic risk scores were clearly higher in individuals with bipolar disorder than in individuals with PP.

In the future, testing clinical samples that are larger and better defined should allow us to more robustly identify sleep-related, cognitive, neuroimaging, and peripheral biological measures (eg, immune system–related molecules) that distinguish women who develop PP both from healthy controls and from at-risk women who do not develop PP. These measures could then be tested alone, or in combination, as predictive biomarkers. Genome-wide association analysis may help identify candidate risk genes/pathways and clarify the extent of genetic overlap with related conditions; these include other mood-psychosis spectrum disorders, other postpartum psychiatric conditions, (auto)immune disorders, and preeclampsia. Genetic epidemiology techniques, such as Mendelian randomization, may subsequently be used to highlight causal pathways and to predict rational points for intervention.

The observation that children exposed to mothers with postpartum mood disorders (including psychosis) are more likely to develop attention-deficit/ hyperactivity disorder

 indicates that further investigation into mechanisms mediating this link, including the possibility of common genetic risk factors shared between PP and neurodevelopmental disorders, may be warranted. Finally, laboratory-based approaches similar to those used to understand the neurobiology of other rare conditions may be employed. For example, the cellular/molecular phenotypes underlying PP may be examined through combined assessment of patient stem cell-derived brain cell cultures or organoids (“mini-brains”) and animal models. Such work should help reveal the biology most proximal to the behavioral and cognitive disturbances in PP and highlight amenable therapeutic targets.

is a PhD candidate in the School of Medicine at Cardiff University, Cardiff, Wales. This work was supported in part by grant MR/N0137941/1 for the GW4 BIOMED MRC DTP, awarded to the Universities of Bath, Bristol, Cardiff, and Exeter from the Medical Research Council (MRC)/UK Research and Innovation. 

 is a senior lecturer in the schools of medicine and psychology at Cardiff University, Cardiff, Wales.

The authors wish to thank Arianna di Florio, MD, PhD, for her comments on a draft of this article.

1. Fornaro M, Maritan E, Ferranti R, et al. 

Lithium exposure during pregnancy and the postpartum period: a systematic review and meta-analysis of safety and efficacy outcomes

2. Gilden J, Molenaar NM, Smit AK, et al. 

Mother-to-infant bonding in women with postpartum psychosis and severe postpartum depression: a clinical cohort study

Recovery from postpartum psychosis: a systematic review and metasynthesis of women’s and families’ experiences

4. Perry A, Gordon-Smith K, Di Florio A, et al. 

Mood episodes in pregnancy and risk of postpartum recurrence in bipolar disorder: the Bipolar Disorder Research Network Pregnancy Study

5. Perry A, Gordon-Smith K, Webb I, et al. 

Postpartum psychosis in bipolar disorder: no evidence of association with personality traits, cognitive style or affective temperaments

6. Lewis KJS, Di Florio A, Forty L, et al. 

Mania triggered by sleep loss and risk of postpartum psychosis in women with bipolar disorder

Postpartum psychosis: a diagnosis for the DSMV

8. Gordon-Smith K, Perry A, Di Florio A, et al. 

Symptom profile of postpartum and non-postpartum manic episodes in bipolar I disorder: a within-subjects study

9. Munk-Olsen T, Munk Laursen T, Mendelson T, et al. 

Risks and predictors of readmission for a mental disorder during the postpartum period

10. Jones I, Chandra PS, Dazzan P, Howard LM. 

Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period

11. Rommel AS, Molenaar NM, Gilden J, et al. 

Long-term outcome of postpartum psychosis: a prospective clinical cohort study in 106 women

12. Hazelgrove K, Biaggi A, Waites F, et al. 

Risk factors for postpartum relapse in women at risk of postpartum psychosis: the role of psychosocial stress and the biological stress system

Biological stress response in women at risk of postpartum psychosis: the role of life events and inflammation

14. Perry A, Gordon-Smith K, Di Florio A, et al. 

Adverse childhood life events and postpartum psychosis in bipolar disorder

Young women are the most vulnerable to postpartum mental illness: a retrospective cohort study in UK primary care

The role of the immune system in postpartum psychosis

Immune system alterations and postpartum mental illness: evidence from basic and clinical research

Postpartum psychosis and SARS-CoV-2 infection: is there a correlation?

19. Sambataro F, Cattarinussi G, Lawrence A, et al. 

Altered dynamics of the prefrontal networks are associated with the risk for postpartum psychosis: a functional magnetic resonance imaging study

20. Kowalczyk OS, Pauls AM, Fusté M, et al. 

Neurocognitive correlates of working memory and emotional processing in postpartum psychosis: an fMRI study

Do defective immune system-mediated myelination processes increase postpartum psychosis risk?

An analysis of cellular communication network factor proteins as candidate mediators of postpartum psychosis risk

23. Di Florio A, Yang JMK, Crawford K, et al. 

Post-partum psychosis and its association with bipolar disorder in the UK: a case-control study using polygenic risk scores

Postpartum depression and psychosis and subsequent severe mental illnesses in mothers and neurodevelopmental disorders in children: a nationwide study

Postpartum psychosis is experienced by 1 to 2 women every 1000 deliveries.

An Update on the Presentation, Nosology, and Causes of Postpartum Psychosis

The lifetime prevalence of schizophrenia and related psychotic disorders is approximately 1% of the population.

 These disorders have clear genetic and biological underpinnings

 and generally respond favorably to antipsychotic medication, particularly in reducing the hallmark positive symptoms (eg, delusions, hallucinations).

 However, even with medication, some positive symptoms persist. Furthermore, negative symptoms (eg, asociality, amotivation), which have an even greater detrimental impact on quality of life, are less impacted by medication,

 underscoring a need for additional therapeutic interventions for individuals with 

. Sociocultural factors have been shown to impact both the presentation and course of schizophrenia/psychosis. In this article, we use 3 case vignettes to illustrate how cultural factors can be considered in treatment planning and for a more holistic understanding of how to improve outcomes for individuals with schizophrenia/psychosis (

“Mr Williams” is a 40-year-old single Black man with a history of schizophrenia, although he notes, “I have been told I have everything: schizophrenia, 

, paranoia, you name it.” Mr Williams states he came in at his sister’s request because she noted he was sleeping less and talking to himself more than usual. Mr Williams explains he has been more anxious about the police in his neighborhood. This coincided with a shooting approximately 1 month ago, when a close acquaintance was shot and killed by police about 3 blocks from his home. Mr Williams says he believes the police have bugged his house and he feels energized to solve the issue. “I have been installing a new security system and filling in all the gaps in my house so no radio waves can get through.” He has also been talking more to his grandmother, who died a decade prior. He hears her voice more frequently when he is distressed, and he likes hearing from her.

Mr Williams’ statement about his many diagnoses reflects an unfortunate reality for Black men with experiences of psychosis. It has been shown that Black men tend to to be overdiagnosed with schizophrenia and underdiagnosed with bipolar disorder.

 Notably, schizophrenia tends to be more stigmatized than 

. This discrepancy in diagnosis has contributed to poorer quality of care, because these 2 diagnoses have key differences in first-line treatment.

Although Mr Williams seems to relay his experiences of disparate diagnoses to his provider as humorous, it should act as a clue to the provider that his existing diagnosis may not be accurate and that Mr Williams may not completely trust the insights of his providers. Potential follow-up questions may be: “What do you think about your diagnosis? Is there a label you prefer that reflects your difficulties with mental health?” Direct questioning about symptomology would also be needed to clarify diagnosis, but these initial questions can help create a shared language between provider and client that prioritizes the client’s understanding of the symptoms. Providers may also reflect this experience back to the client: “That might be frustrating—to be told all these different diagnoses over the years.” Acknowledgements like this can help establish a sense of trust, letting your patients know it is appropriate to acknowledge their challenges with the health care system to their providers.

Mr Williams endorses a belief that the police are recording him inside his house and has acted in response to this delusion. Providers are often told not to reinforce delusions or give them too much airtime beyond what it takes for diagnosis and assessment of severity. Unfortunately, this guidance may be overused such that providers avoid better understanding or seeing the greater context of delusions/hallucinatory symptoms. The presentation and expression of symptoms differs across ethnic groups, often due to differential experiences and environments.

In the case of Mr Williams, although the police may not be explicitly recording him in his home (although further questioning is warranted), his delusion seems triggered by real-life experiences. Black Americans are proportionally more impacted by police brutality and 

 and consequently demonstrate greater levels of suspiciousness in general.

 With this cultural consideration in mind, providers need to be especially cautious of rating something as abnormal or delusional when it is a reality for Black individuals (eg, being followed/watched in stores, being targeted for harassment at work, feeling unsafe at home, being wary of police intentions).

In addition, increased experiences of discrimination are linked to increased 

 and psychotic experiences in ethnic minorities.

 For Mr Williams, it would be helpful to acknowledge and reinforce the realities of his experience (“I am so sorry to hear about your friend. I understand why this would make you fearful of the police.”) while guiding him toward relevant solutions (“Have you talked to anyone, like your sister, about what happened? How are the other individuals in your neighborhood coping with this?”). Further conversation may help Mr Williams consider how to get familial/community support and assist him in finding spaces that feel welcoming and safe (eg, support groups, volunteering, reaching out to friends). For some patients in which the delusion is seemingly unconnected to the environment, clinicians may reinforce the patient’s experience (“What I am hearing is that you have been feeling fearful lately.”) and point to emotion-focused coping strategies instead.

In a similar vein, Mr Williams also acknowledged hearing the voice of his late grandmother, but notes that he likes hearing from her. Although hallucinations/voices can be extremely distressing, they are not always so, with some cultures or groups having higher rates of positive or benign experiences.

 In fact, there is a growing movement among those with experiences of hallucinatory voices to integrate them into daily life rather than trying to avoid them completely (ie, Hearing Voices Network), with some evidence of success.

 Providing quality care therefore involves balancing many considerations (eg, existing symptoms, adverse effects, barriers to adherence), and the distress of current symptoms should not be assumed. Follow-up questions should aim to be neutral (“What is it like to hear your grandmother’s voice? How often does this happen? Are you able to shift your focus when other things need to be done?”) to get a better sense of how it impacts Mr Williams.

“Ms Khan” is a 55-year-old divorced Sunni Muslim Pakistani woman on disability, diagnosed with 

. Outside of 3 relapses triggered by big life changes, Ms Khan mostly struggles with negative symptoms (eg, asociality, low motivation). Ms Khan scheduled a mental health appointment because she has been struggling to get out of bed. She explains, “What is keeping me in bed is a jinni holding me down. It stops me from doing my prayers and makes me lazy. I should do my wudhu and pray, but once I get out of practice, I feel guilty and avoid it.”

Ms Khan endorses a belief that the reason she is struggling to leave bed is the influence of a jinni (ie, a supernatural spirit/demon). A provider unfamiliar with Islam may automatically view this as a sign of pathology. To assess this, however, a clinician should attempt to clarify how common this type of belief is to those who are part of the community. Clinicians may do this by asking questions directly (“I am unfamiliar with jinn. Is this a common experience for other individuals you know?”) but may also need to seek consultation from the patient’s community. In this case, research suggests that many Muslims do indeed believe that physical and mental ailments (eg, sleep paralysis, depression, fever) are caused by jinn

 and subsequently endorse religious-based solutions such as wudhu (ie, ablution), prayer, and consulting an imam. However, Muslims and other religious groups tend to endorse multiple models of mental illness, often endorsing biological factors in addition to others (eg, jinn, engaging in sin, God’s will, environmental factors).

In developing suggestions, clinicians may gain more traction by acknowledging the patient’s perspective. Clinicians should still provide recommendations within their purview (eg, medication changes, therapy recommendations), while also supporting cultural practice and assisting in problem- solving (“Are there other Muslims you know to whom you can reach out for support?”).

In addition, Ms Khan would likely benefit from greater religious coping, because she indicates that being less engaged with her religious practice leads to more distress. In fact, in the United States, the majority of the general public and individuals with schizophrenia in particular endorse engaging in religious and spiritual practices and report finding these practices highly important to them.

 Religious practice is also broadly associated with better mental health.

 In the case of Ms Khan, if clinicians consider behavioral activation—for example, an emphasis on increased religious practice (eg, prayer and wudhu) and engagement with religious community (eg, going to mosque, finding Quran study groups)—this may be especially beneficial, because it already aligns with the patient’s belief system and desires.

Clinicians should be wary of 2 potential issues. First, not all religious coping is created equal, with some strategies consistently leading to less distress (eg, prayer, belief that God is supportive) and others leading to more distress (eg, believing one’s difficulties are a punishment from God, using religion to avoid problems).

 Second, emphasis on religion may not be useful if the patient endorses significant religious delusions. In these cases, focusing on other strategies (eg, light exercise, relaxation techniques) and support networks (eg, family, book club) tends to be more beneficial.

“Mr Baker” is a 60-year-old White retired male veteran who received a diagnosis of schizophrenia and lives with his long-term girlfriend. Over the past year, he has struggled to keep up with chores and relies on his girlfriend to make most of his meals. This has led to fights that escalate into his girlfriend threatening to leave him due to his “laziness, lack of caring, and craziness.” Mr Baker feels like a burden on his girlfriend and is also afraid to tell others how much he struggles with his mental health. “I always prided myself, especially with my veterans group, that I was dependable and logical. If I admit to them that I have heard voices and had to go to the hospital, I will have to admit I am a screwed-up person.”

Mr Baker has internalized the idea that mental illness is shameful, which is more common among men.

 Unfortunately, self-stigma is linked to marked increases in distress and to greater risk of suicide.

 His noted feelings of burdensomeness, therefore, could warrant a suicide risk assessment. Although psychoeducation can reduce 

, engaging with individuals openly about their experience with mental illness tends to be most effective.

 Mr Baker would likely benefit from a referral to support groups of other veterans with serious mental illness. Providers may begin suggesting these referrals by highlighting the effectiveness of therapy for others, because focusing directly on Mr Baker’s need for support may lead to defensiveness or denial: “I find a lot of veterans in your situation have really enjoyed this outpatient group we have.” Keeping it low stakes may also prove helpful: “Hey, this is a good way to get out of the house and meet some new individuals.”

There is also a high level of criticism and hostility (ie, expressed emotion) in Mr Baker’s household, which research indicates is related to higher rates of relapse for individuals with serious mental illness.

 Hostility and criticism occur in some ethnic groups at higher rates (eg, White families) than others (eg, Latinos).

 Mr Baker and his girlfriend may benefit from psychoeducation such that they can recognize that many of Mr Baker’s symptoms are related to a mental illness. This could help reduce some of the girlfriend’s frustration by shifting the blame away from her partner. This couple might also benefit from developing strategies to meet their household needs and demands in tandem with each other. Culturally informed therapy for schizophrenia (CIT-S) is a family intervention that emphasizes the family unit’s shared values, engages in psychoeducation with culture in mind, reinforces positive religious coping, and guides the family unit through communication and problem-solving techniques.

 Rather than solely focusing on Mr Baker, it equally acknowledges the needs of his girlfriend and guides both individuals through their shared difficulties.

Practices like CIT-S also highlight an important message across all 3 cases. Clinicians often see the individual (identified patient) arriving at a session as the sole therapy target. However, there is an untapped but extremely important social support network integral to the lives and well-being of individuals with schizophrenia/psychosis. It may be a family member who suggested they visit a doctor (case 1), a larger religious community that provides meaning (case 2), or a partner who provides resources (case 3). In addition to employing the aforementioned strategies and being mindful of cultural distinctions, providers benefit from relying on these social structures (eg, consultation) and encouraging their patients to be more engaged in these social supports, which ultimately could be an invaluable resource in improving the lives of patients with schizophrenia/psychosis.

is a predoctoral psychology trainee at the University of Miami in Florida.

is a professor of psychology at the University of Miami.

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Sociocultural factors have been shown to impact both the presentation and course of schizophrenia/psychosis. Learn more here. 

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