Essential Reads: Recognizing Postpartum Psychosis

Because postpartum psychosis is a relatively rare event, we do not have as much information on this illness as we have on postpartum depression.  In addition, most of the literature we have on postpartum psychosis is not new.  A few years back, the American Journal of Psychiatry published an excellent review.  Another useful resource was published in the Obstetric Clinics of North America.  Both citations are at the end of this post.

Both of those articles are certainly worth reading, but here are the most important things covered in these articles:

• According to studies of psychiatric admissions, the incidence of 1st-onset postpartum psychosis varies from 0.25 to 0.6 per 1,000 births. This represents a decrease from previous estimates.

• Postpartum psychosis is more common in first-time mothers. It is postulated that the onset of postpartum psychosis is related to physiological changes after birth (e.g., hormonal, immunological, circadian rhythm), which trigger illness in genetically vulnerable women. Some cases of psychosis after delivery may be attributed to  autoimmune thyroiditis, infection, N-methyl-d-aspartate-encephalitis or inborn errors of metabolism.

• The absolute prevalence of postpartum psychosis is low; however, if we look at relative risk,  during the first month after the birth of a child, a woman’s risk of first-onset of affective psychosis is 23 times higher than any other time during that woman’s life.

• Postpartum psychosis typically has its onset between 3 and 10 days after delivery.  However, postpartum illness in women with bipolar disorder is often earlier, during pregnancy or immediately after delivery.

• Early or prodromal symptoms include insomnia, mood reactivity, and irritability, with subsequent emergence of mania, depression, or mixed symptoms. Disorganized, unusual behavior and obsessive thoughts related to the infant frequently occur.  Postpartum psychosis often has a delirium-like presentation, with symptoms of  disorientation, derealization, and depersonalization.

• Postpartum psychosis is associated with an increased risk of both suicide and infanticide. Delusions of altruistic homicide (often in conjunction with maternal suicide) may occur.

• Postpartum manic episodes tend to be briefer, with a duration of 1 month, as compared to 2.5 months for patients with mixed or depressed episodes.  Shorter episodes are associated with a better long term prognosis.

• A woman who has experienced one episode of postpartum affective psychosis has a 50%-80% chance of experiencing another severe psychiatric episode, usually within the bipolar spectrum.  In 20%-50%  of women, affective psychosis is limited to the postpartum period.

• Postpartum psychosis is a psychiatric emergency requiring immediate psychiatric evaluation and typically inpatient hospitalization.  In the medical literature, less than 30 studies describe the treatment of postpartum psychosis.  Lithium is consistently shown to be effective as monotherapy or as an adjunct in the acute treatment of postpartum psychosis.  Benzodiazepines and antipsychotics are used to promote sleep, target psychotic symptoms, and stabilize mood.  Patients treated with lithium monotherapy had lower rates of relapse compared with those receiving antipsychotic monotherapy.

• The most robust risk factors for postpartum psychosis are a history of bipolar disorder and/or a history of postpartum psychosis after a previous pregnancy.  Postpartum prophylaxis is indicated in these high-risk populations. For women with histories of postpartum psychosis, prophylaxis using either lithium or antipsychotics immediately after delivery was highly effective in preventing recurrence.  In all studies using prophylactic treatment with lithium, women with bipolar disorder had significantly lower rates of postpartum relapse.  In other studies of women with bipolar disorder, valproate failed to demonstrate significant prophylactic benefits, and olanzapine prophylaxis was equivocal.

Although physicians first described women with severe psychiatric symptoms after childbirth hundreds of years ago, our understanding of postpartum psychosis remains incomplete.  Other than a history of bipolar disorder or psychotic illness prior to delivery, we have not yet been able to identify factors which can reliably predict which women are at greatest risk for postpartum psychosis.  This underscores the importance of educating all women and health care providers regarding the symptoms of postpartum depression and psychosis, so that early identification of the symptoms can lead to prompt initiation of treatment.  

Ruta Nonacs, MD PhD

Bergink V, Rasgon N, Wisner KL.  Postpartum Psychosis: Madness, Mania, and Melancholia in Motherhood.  Am J Psychiatry. 2016 Sep 9.