Postpartum Psychosis: Complicated but Treatable Psychiatric Emergency

SPECIAL REPORT: SCHIZOPHRENIA/PSYCHOSIS

Postpartum psychosis is a psychiatric emergency that, if not identified and treated promptly, can have devastating consequences, including suicide and/or infanticide. It is defined as a single or recurrent episode limited to the postpartum period (birth to 1 year) with sudden onset. The clinical presentation is characterized by symptoms of mood disorder, psychosis, and/or delirium (Figure).¹

This rare disorder has an incidence of 0.89 to 2.6 in 1000 births.² The clinical presentation can vary, complicating the diagnostic process. Patients can be misdiagnosed as having primary psychosis or bipolar disorder. Some patients might not have a prior psychiatric history or may not see a psychiatrist. Hence, it is crucial to educate psychiatric care clinicians and other providers, including obstetrician- gynecologists, emergency department physicians, and primary care providers, who might encounter the patient before a psychiatric clinician does.

The trigger for postpartum psychosis is childbirth, although the etiology of this condition remains unclear. Potential causes include genetic factors, circadian rhythm disruption, sleep deprivation, immune and neuroinflammatory mechanisms, infection, and rapid decline in estrogen that occurs post partum. Some established risk factors include history of postpartum psychosis, primiparity, young age, history of bipolar disorder, and sleep loss.³

Clinical Presentation

The symptoms of postpartum psychosis typically manifest within the first 2 weeks after birth; however, in some women, symptoms may emerge several months later.¹ Onset of symptoms can be sudden and may worsen rapidly. The symptoms can wax and wane; the clinical presentation can vary significantly. A large clinical cohort study on the phenotype of postpartum psychosis identified 3 symptom profiles, including manic, depressive, and atypical symptom profiles.⁴ In this study, 34% of women exhibited manic symptoms characterized by mania and agitation. Next, 41% of women displayed a depressive profile, with depression and anxiety symptoms. Finally, 25% had the atypical profile (delirium-like appearance), which included disturbance of consciousness, disorientation, and symptoms of mood and agitation.⁴ Additionally, many patients experienced psychotic symptoms, including delusions (both paranoid and delusion of reference) centered on the infant and hallucinations (auditory and visual). In postpartum psychosis, visual hallucinations are more frequent compared with primary mood or psychotic disorder.

In most cases, earlier symptoms include anxiety, insomnia, restlessness, and irritability. This is followed by mood fluctuations, psychotic symptoms, and delirium-like picture. Due to mental health stigma, fear of losing the baby, or lack of insight, women are less likely to self-report symptoms of delirium and psychosis, which can delay care. Delayed or inadequate treatment increases the risk of suicide, neglect, and/or infanticide.⁵ Suicide methods used are more violent in the perinatal period compared with the nonperinatal period.

Some other psychiatric disorders, like obsessive-compulsive disorder (OCD), major depressive disorder with psychotic features, bipolar disorder, and primary psychosis, can have similar presentations in the postpartum period.¹ The intrusive thoughts experienced in OCD are ego-dystonic and result in feelings of shame, anxiety, and guilt, whereas the thoughts are more ego-syntonic in postpartum psychosis. Bipolar disorder can be more challenging to differentiate from postpartum psychosis, as 45% of women with bipolar disorder have a risk of postpartum episodes. Some studies include postpartum psychosis in the bipolar disorder spectrum, but 25% to 30% of women with postpartum psychosis do not have any mood disorder outside the postpartum period. A case-control study showed only a partial genetic overlap of postpartum psychosis and bipolar disorder.⁶ In general, in a primary mood disorder, symptoms usually do not wax and wane. For primary psychotic disorders, symptoms are usually present for longer and reflect symptoms of preexisting illness.¹

When postpartum psychosis is suspected, it is important to conduct comprehensive physical and neurological examinations, along with laboratory tests, to exclude physical causes. Clinical symptoms guide laboratory studies but, at a minimum, consider complete blood count, basic metabolic panel, thyroid-stimulating hormone, thyroid peroxidase antibody, ammonia levels, urinalysis, urine toxicology, and vitamin levels (B12, thiamine, folate).⁷

Treatment

Treatment of postpartum psychosis includes psychoeducation, assessment of the appropriate level of care, and pharmacotherapy. Preconception counseling, regular psychiatric care, and close monitoring are important for women who are at high risk with a history or family history of postpartum psychosis.⁸

Inpatient hospitalization is usually required, given the rapid deterioration and risk of suicide and infanticide. Ideally, inpatient units that allow the baby to be with the mother are preferred, but there are very few of those in the US. In the absence of these, consider inpatient hospitals that can allow extended visiting hours so the mother can spend time with the baby to minimize the interruption in bonding.

Pharmacological treatment depends on the clinical presentation. There are no medications approved by the FDA specifically for postpartum psychosis. Atypical antipsychotics, including quetiapine and olanzapine, are frequently used; they can help with decreased sleep, mood symptoms, and psychotic symptoms. There are also more safety data on the use of these medications during breastfeeding.¹ Lithium has been studied the most for prophylaxis of postpartum psychosis in patients with a history of postpartum psychosis. Breastfeeding is not contraindicated with the use of lithium, but close monitoring of levels for mother and baby is recommended.⁹

Concluding Thoughts

Postpartum psychosis has a complicated presentation and is often misdiagnosed or missed in patients. Patient-level factors, such as mental health stigma, fear of losing the baby, or lack of insight; provider-level factors, such as lack of awareness; and system-level factors, such as lack of appropriate mother-baby inpatient units, often lead to a delay in treatment. Providers seeing postpartum women should consider screening and educating women who are at high risk. Early identification and treatment can prevent women from experiencing severe symptoms, which can be traumatic for the mother and her family. If identified and treated appropriately, postpartum psychosis has a good long-term prognosis.

Dr Toor is an associate professor at the University of Washington.

Acknowledgment : Dr Toor would like to thank Amritha Bhat, MD, a fellow associate professor at the University of Washington.

References

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