Compared with antiepileptics, less information is available about the use of atypical antipsychotics in pregnancy and lactation. Antipsychotics’ potential advantage in women at risk for PPP is that these agents may help prevent or treat both manic and psychotic symptoms.
In a small, naturalistic, prospective study, 11 women at risk for PPP received olanzapine alone or with an antidepressant or mood stabilizer for at least 4 weeks after delivery. Two (18%) experienced a postpartum mood episode, compared with 8 (57%) of 14 other at-risk women who received antidepressants, mood stabilizers, or no medication.20
When you discuss breast-feeding, consider possible risks to the neonate as well as potential sleep interruption for the mother. If a mother has a supportive partner, the partner might be put in charge of night-time feedings in a routine combining breast-feeding and bottle-feeding. In some cases you may need to recommend cessation of lactation.21
Table 3
Treating postpartum psychosis: Consider 3 components
| Component | Recommendations |
|---|---|
| Hospitalization vs home care | Hospitalize in most cases because of emergent severe symptoms and fluctuating course; base decision on risk evaluation/safety issues for patient and infant After discharge, visiting nurses are useful to help monitor the mother’s condition at home |
| Psychoeducation | Educate patient, family, and social support network; address risks to mother and infant and risks in future pregnancies |
| Medication | When prescribing mood stabilizers and/or antipsychotics, consider:
|
Managing PPP
Early symptoms. Because of its severity and rapid evolution, PPP often presents as a psychiatric emergency. Monitor atrisk patients’ sleep patterns and mood for early signs of psychosis.22 Watch especially for hypomanic symptoms such as elevated or mixed mood and decreased judgment, which are common early in PPP.13
A mother with few signs of abnormal mood, good social support, and close follow-up may potentially be safely managed as an outpatient. Initial evaluation and management of PPP usually requires hospitalization, however, because of the risks of suicide, infanticide, and child maltreatment.23
Hospitalization. Mother-infant bonding is important, but safety is paramount if a mother is psychotic—especially if she is experiencing psychotic thoughts about her infant. If possible, the infant should remain with family members during the mother’s hospitalization. Supervised mother-infant visits are often arranged, as appropriate.
Mood-stabilizing medications, including antipsychotics, are mainstays of treatment.24 In some cases, conventional antipsychotics such as haloperidol may be useful because of a lower risk of weight gain or of sedation that could impair a mother’s ability to respond to her infant. Electroconvulsive therapy often yields rapid symptomatic improvement for mothers with postpartum mood or psychotic symptoms.25
Discharge planning. Assuming that the mother adheres to prescribed treatment, discharge may occur within 1 week. Plan discharge arrangements carefully (Table 4).28 A team approach can be very useful within the outpatient clinic. In the model of the Perinatal Psychiatry Clinic of Connections in suburban Cleveland, OH, the mother’s treatment team includes perinatal psychiatrists, nurses, counsellors, case managers (who do home visits), and peer counselors.
Outpatient civil commitment, in which patients are mandated to accept treatment, is an option in some jurisdictions and could help ensure that patients receive treatment consistently.
Table 4
Discharge planning for safety of mother and infant
| Notify child protective services (CPS) depending on the risk to the child. Case-by-case review is needed to assess whether the infant should be removed. CPS may put in place a plan for safety, short of removal. The plan may require that the woman continue psychiatric care |
| Meet with the patient and family to discuss her diagnosis, the risks, the importance of continued medication adherence, and the need for family or social supports to assist with child care |
| Consider engaging visiting nurses or doulas to provide help and support at home |
| Schedule frequent outpatient appointments for the mother after discharge |
| Consider family therapy after the mother has improved because of her risk for affective episodes outside the postpartum28 |