Postpartum Psychosis

Primer

Postpartum psychosis is a perinatal mental disorder that begins exclusively after childbirth. It is a disorder linked closely with postpartum depression.

Epidemiology
  • PPP affects affects 1-2 per 1,000 women.[1][2]
Prognosis
  • The prognosis for patients with PPP is somewhat poor. Follow up studies up to 10 years later have shown that up to 40% of the women had not retained full working capacity due to ongoing psychiatric symptoms.[3] Recurrent episodes of psychosis are also common, both postpartum and non-puerperal psychosis (not pregnancy-related). Postpartum psychosis is associated with high rates of both suicide and infanticide.[4]
  • If symptoms occur within 4 weeks of delivery, the prognosis is better.[5]
  • Infanticide is associated with postpartum psychotic episodes, and mothers may experience command hallucinations to kill the infant or delusions that the infant is possessed.
  • Once a woman has had a postpartum episode with psychotic features, the risk of recurrence with each subsequent delivery is between 30% and 50%.
Comorbidity
  • Bipolar disorder is both a comorbidity and risk factor for PPP (see below).
Risk Factors
  • PPP has a clear biological trigger caused by childbirth.
  • The single strongest risk factor for PPP is a personal history of bipolar disorder. Around 20-30% of parous women with diagnosed bipolar disorder experience PPP.[6] Interestingly, however, only 1/3 of women who present with PPP will have a prior psychiatric history. Regardless, the association of PPP with bipolar disorder is so strong that it should be considered a bipolar diagnosis until proven otherwise.[7]
  • Other risk factors include sleep loss, a family history of bipolar disorder, and prior episodes of PPP. Other studies have found a higher risk for PPP in primiparous (first pregnancy) women.[8]

DSM-5 Diagnostic Criteria

The onset of PPP is typically sudden, and usually occurs within the first 2 weeks postpartum.[9]

Signs and Symptoms

Patients will typically have disorganization, confusion, pepersonalization, insomnia, irritability, abnormal thought content (including delusions or hallucinations), and an abnormal mood (including mania or agitation, or depression, or a mixed presentation). About one-third (34%) of cases are characterized by mania and/or agitation, with irritability being much more common than elevated mood. Around another 40% of cases are predominantly characterized by depression and/or anxiety, while the remaining 25% have an atypical or mixed profile.[10]

Screening Tools and Scales

There is no standardized questions or screening tool for postpartum psychosis due to the wide range of signs and symptoms. Asking patients about a personal or family history of bipolar disorder, sleep disturbances post-childbirth, and for suicidal or infanticidal ideation is important.

Pathophysiology

Rapid changes in estrogen and progesterone in the 24 hours following childbirth is thought to play a role in the development of most postpartum psychiatric disorders. However, this remains poorly understood. Certain women may have a particular vulnerability to hormonal fluctuations that increases their risk for psychosis.[11] Other etiologies may include biological triggers such as immune dysregulation.

Differential Diagnosis

  • Baby blues
    • The baby blues affect 85-90% of women. This is a self-limited syndrome of tearfulness, mood lability (up or down), and/or feeling overwhelmed. However, there are no serious effects on the woman’s overall function. It usually occurs within days of birth and is resolves within 2 weeks. Baby blues are unrelated to psychiatric history, and requires no specific intervention beyond usual supportive care.
  • Postpartum depression
    • Postpartum depression is characterized by clinically significant low mood, anhedonia, and/or suicidality. It has a peripartum onset, meaning it can begin in the third trimester all the way until 4 weeks postpartum
  • Generalized anxiety disorder
    • Generalized anxiety is characterized by excessive worries across multiple domains in life and overlaps with postpartum depression
  • Obsessive-compulsive disorder
    • Postpartum obsessive-compulsive disorder (OCD) can be difficult to differentiate from PPP. There higher risk of onset and flare of OCD during times of reproductive changes. It is important for clincians to distinguish between intrusive thoughts (obsessions) common in OCD and the delusions that define PPP.
  • Delirium
    • Any fluctuating level of conciousness should alert the clinician to rule out delirium (most commonly caused by infection surrounding delivery and childbirth). Cognitive testing can be helpful to differentiate this.
  • Autoimmune encephalitis
    • Case reports have indicated the rare but possible event that the psychosis is caused by an underlying autoimmune encephalitis
  • Sheehan’s syndrome
    • Sheehan's is an adrenal-pituitary insufficiency caused by severe blood loss (hypovolemia), which can present with neuropsychiatric symptoms such as psychosis.[12]
  • Autoimmune disorders
    • Underlying autoimmune disorders (i.e. - neuropsychiatric symptoms of lupus) can also be triggered during the peripartum period and contribute to psychosis.[13]
  • Substance use disorders
    • Common substance intoxications and withdrawal (e.g. - alcohol) should be ruled out
  • Medication-related adverse events (i.e. - steroid-induced mania)

Investigations

Common investigations include basic metabolic panel, complete blood count, urinalysis, urine toxicology screen, TSH, free T4, and TPO antibodies.

Physical Exam

A complete physical and neurological examination should be performed. If neurological symptoms present, brain imaging and work up for limbic encephalitis may be warranted.

Treatment

PPP is considered a psychiatric emergency, and requires immediate hospitalization and treatment. Due to ethical considerations and rarity of the condition, well-designed studies are difficult to do. Various effective treatments include antipsychotics, benzodiazepines, mood stabilizers (in particular lithium), hormones, propranolol, and electroconvulsive therapy (ECT).

Pharmacotherapy

Treatment Recommendations for Acute Postpartum Psychosis

Step 1 Benzodiazepine (lorazepam 0.5-1.5 mg TID)
Step 2 Antipsychotic (high potency preferred, haloperidol 2-6 mg or olanzapine 10-15 mg)
Step 3 Lithium (to achieve serum level of 0.8-1.2 mmol/L)
Step 4 Taper benzodiazepine and antipsychotic once symptom remission achieved
Maintenance • Continue lithium monotherapy for 9 months (can lower to achieve serum level of 0.6-0.8 after symptom remission if severe side effects)
• For future pregnancies, begin prophylactic lithium monotherapy during pregnancy or immediately postpartum

Lithium, Pregnancy, and Breastfeeding

Although there are risks to using lithium in both pregnancy and breastfeeding, those risks are much lower than previously thought and for many women, the benefits of treatment will outweigh the risks of untreated PPP (e.g. - suicide, infanticide, poor mother-child bonding, and subsequent impact on child development).

Psychosocial

Although pharmacological management is the main treatment, psychosocial supports including in particular sleep hygiene and general family and caregiver support is important.

Guidelines

Perinatal Mental Health Guidelines

Guideline Location Year PDF Website
BC Best Practice Guidelines for Mental Health in the Perinatal Period Canada 2014 PDF Link
American College of Obstetricians and Gynecologists (ACOG) Psychotropic Medication Guidelines USA 2008 PDF • Link (AAFP)
• Link (ACOG)
American Psychiatric Association (APA) and ACOG Depression Guidelines USA 2009 - Link
National Institute for Health and Care Excellence (NICE) UK 2014, 2020 - Link
British Association for Psychopharmacology (BAP) UK 2017 PDF Link
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Australia, New Zealand 2018 PDF Link

Resources

For Patients
For Providers
Articles
Research

References

1) Osborne, L. M. (2018). Recognizing and managing postpartum psychosis: a clinical guide for obstetric providers. Obstetrics and Gynecology Clinics, 45(3), 455-468.
2) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
3) Videbech, P. B., & Gouliaev, G. H. (1996). Prognosis of the onset of postpartum psychosis. Demographic, obstetric and psychiatric factors. Ugeskrift for Laeger, 158(21), 2970-2974.
4) Spinelli, M. G. (2009). Postpartum psychosis: detection of risk and management. American Journal of Psychiatry, 166(4), 405-408.
5) Sit, D., Rothschild, A. J., & Wisner, K. L. (2006). A review of postpartum psychosis. Journal of women's health, 15(4), 352-368.
6) Di Florio, A., Forty, L., Gordon-Smith, K., Heron, J., Jones, L., Craddock, N., & Jones, I. (2013). Perinatal episodes across the mood disorder spectrum. JAMA psychiatry, 70(2), 168-175.
7) Osborne, L. M. (2018). Recognizing and managing postpartum psychosis: a clinical guide for obstetric providers. Obstetrics and Gynecology Clinics, 45(3), 455-468.
8) Di Florio, A., Jones, L., Forty, L., Gordon-Smith, K., Blackmore, E. R., Heron, J., ... & Jones, I. (2014). Mood disorders and parity–a clue to the aetiology of the postpartum trigger. Journal of affective disorders, 152, 334-339.
9) Kendell, R. E., Chalmers, J. C., & Platz, C. (1987). Epidemiology of puerperal psychoses. The British Journal of Psychiatry, 150(5), 662-673.
10) Kamperman, A. M., Veldman‐Hoek, M. J., Wesseloo, R., Robertson Blackmore, E., & Bergink, V. (2017). Phenotypical characteristics of postpartum psychosis: A clinical cohort study. Bipolar Disorders, 19(6), 450-457.
11) Bloch, M., Schmidt, P. J., Danaceau, M., Murphy, J., Nieman, L., & Rubinow, D. R. (2000). Effects of gonadal steroids in women with a history of postpartum depression. American Journal of Psychiatry, 157(6), 924-930.
12) Shoib, S., Dar, M. M., Arif, T., Bashir, H., Bhat, M. H., & Ahmed, J. (2013). Sheehan's syndrome presenting as psychosis: A rare clinical presentation. Medical journal of the Islamic Republic of Iran, 27(1), 35.
13) Jafri, K., Patterson, S. L., & Lanata, C. (2017). Central nervous system manifestations of systemic lupus erythematosus. Rheumatic Disease Clinics, 43(4), 531-545.