Discussion
Postpartum psychosis can present with a prodromal phase consisting of fatigue, insomnia, restlessness, tearfulness, and emotional lability, making early identification difficult. Later, florid psychotic symptoms can include suspiciousness, confusion, incoherence, irrational statements, obsessive concern about the infant’s health, and delusions, including a belief that the baby is dead or defective. Some women might deny that the birth occurred or feel that they are unmarried, virginal, or persecuted.1 More concerning symptoms include auditory hallucinations commanding the mother to harm or kill the infant and/or herself. Symptoms often begin within days to weeks of birth, usually 2 to 3 weeks after delivery but can occur as long as 8 weeks postpartum.1 Several cases of infanticide and suicide have been documented.1 The risk of experiencing another psychotic episode in subsequent pregnancies can be as high as 50%.4-6 Regardless of symptom severity at onset, postpartum psychosis is a psychiatric emergency and must be treated as such.
Bipolar Disorder and Postpartum Psychosis
A close relationship exists between postpartum psychosis and development of bipolar disorder. A postpartum psychotic episode often is the harbinger of bipolar illness.7 About two-thirds of women who have an episode of postpartum psychosis will experience an underlying affective disorder within a year of childbirth.1,8 It is unclear what triggers the psychotic episode, but it has been theorized that major systemic shifts in hormone levelsor trauma of delivery could instigate development of symptoms.1,9
Risk factors include obstetric complications; perinatal infant mortality; previous episodes of bipolar disorder, psychosis, or postpartum psychosis; family history of bipolar disorder or postpartum psychosis; sleep deprivation; increased environmental stress; and lack of partner support.10 The strongest risk factor for developing postpartum psychosis is a personal or family history of bipolar disorder or a related psychotic disorder.11 This risk factor is identified in about 40% to 50% cases of postpartum psychosis.11
Treatment
Standard treatment for postpartum psychosis includes an antipsychotic and often lithium and benzodiazepines.1,7,10,11 This treatment approach differs slightly from treating a patient with a nonpostpartum psychotic illness, who generally would not receive mood stabilizers, such as lithium. Including a mood stabilizer for postpartum psychosis is warranted because of the association between postpartum psychosis and bipolar disorder, which is treated with a mood stabilizer.
Prevalence
Postpartum psychosis is identified in 1 to 2 per 1,000 childbirths. In women who have had an earlier episode of postpartum psychosis or have a diagnosis of bipolar disorder, the rate is up to 100 times higher.1 Kendell and colleagues found that psychiatric admissions occurred at a rate 7 times higher in the 30 days after birth than in the prepregnancy period, suggesting that metabolic factors might be involved in triggering postpartum psychotic symptoms.12 An abrupt hormonal loss occurs at childbirth; hormones peak 200-fold during gestation and decline rapidly within a day after birth.9 Despite the severity of symptoms in postpartum psychosis, these patients tend to have a better prognosis than that of women with psychotic episodes not related to pregnancy.4
Patients with bipolar disorder have the highest risk of psychotic episodes during the postpartum period, with a study reporting 260 episodes of psychosis per deliveries among women with bipolar disorder.13 Studies such as this suggest that episodes of postpartum psychosis might be a variant or atypical presentation of an underlying bipolar disorder or a predisposition to developing the disorder.14 In a study that compared 58 patients with postpartum psychosis with to 52 individuals with nonchildbearing-related psychosis, manic symptoms were more common among the postpartum group.15 Family studies have shown that the risk of psychiatric illness among first-degree relatives of women with postpartum psychosis is 10% to 50%, which is higher than in the general population.14
Brockington and colleagues found that patients with postpartum psychosis had more mood lability, distractibility, and confusion than those with psychosis unrelated to pregnancy.15 Patients with postpartum psychosis were more likely to have impaired sensorium, bizarre quality of delusions, and memory loss. Psychosis with onset after childbirth included high levels of thought disorganization, delusions of reference, delusions of persecution, and greater levels of homicidal ideation and behavior.16 This study also reported symptoms such as visual, tactile, and olfactory hallucinations and a presentation similar to that of delirium.
Chandra and colleagues found that 53% of women with postpartum psychosis had delusions about the infant, including beliefs that someone would harm or kill the baby or that the baby would be harmed by their breast milk.17 Compared with women with bipolar disorder, Oostheuizen and colleagues found that women with postpartum psychosis had delusions of control, such as feeling under the influence of an overpowering force that controlled their actions.18 Infanticidal thoughts are common among patients with postpartum psychosis, and about 4% of women committed infanticide.1
Rapid stabilization and treatment are important because postpartum psychosis is considered a psychiatric emergency.7 Potential consequences of delayed diagnosis and treatment include harm or death of the infant by infanticide and death of the mother by suicide. A thorough physical examination is important to rule out metabolic or neuroendocrine causes of psychosis other than postpartum hormonal shifts. These could include causes of altered mental status: stroke, pulmonary embolism, amniotic fluid emboli, Sheehan syndrome, thyroid disorders, electrolyte abnormalities, acute hemorrhage, sepsis, and substance toxicity or withdrawal.10 A complete blood count, full chemistry, thyroid function tests, antithyroid antibody tests, calcium, vitamin B12, and folate should be measured.7,10
Initial treatment should include antipsychotics and often mood stabilizers such as lithium. Managing insomnia aggressively is also necessary for initial stabilization and to prevent a repeat manic episode if the patient develops bipolar disorder.2 Many experts argue that sleep loss in combination with other risk factors might be the final common pathway for development of postpartum psychosis in women predisposed to this disorder.19,20
Treating insomnia in an outpatient setting includes teaching sleep hygiene practices and relaxation techniques. Although these methods to regulate sleep could be encouraged during the emergent inpatient stabilization of a patient with postpartum psychosis, pharmacologic approaches are necessary for acute mania and psychosis. Concern about possible dependence on benzodiazepines and other sedating sleep aids are valid; however, the benefit of acute stabilization of psychotic symptoms outweighs the potential risk of dependence.
Typically, first-line treatment is an antipsychotic, and second-generation antipsychotics generally are preferred over first-generation antipsychotics because of their more benign adverse effect profile.21,22 There are no controlled trials that compare antipsychotics with placebo or other interventions for postpartum psychosis. Therefore, use of atypical antipsychotics is based on randomized trials demonstrating efficacy in reducing psychosis in bipolar disorder, depression with psychotic features, and schizoaffective disorder.23,24 Once the patient is treated with an antipsychotic, further use of psychotropic medications, such as lithium or other mood stabilizers, should be based on the patient’s clinical presentation. For example, the patient in this case study primarily had manic symptoms consistent with bipolar disorder, making lithium or another mood stabilizer an appropriate choice.
Bergink and colleagues demonstrated positive outcomes with a treatment algorithm involving sequential use of benzodiazepines to improve sleep, an antipsychotic to decrease acute manic symptoms, lithium to stabilize mood based on symptoms, and electroconvulsive therapy if other treatments were not successful.25 Case studies document that administering estrogen led to recovery from postpartum psychosis, although patients often relapsed when estrogen was stopped.26 Electroconvulsive therapy has shown promising results, especially in patients who do not respond to antipsychotic medications or lithium.27,28