Continuing Education Activity

Postpartum psychosis is an acute illness of multifactorial origin and is considered a psychiatric emergency. In this activity, the common presentations, diagnosis, and treatment options for postpartum psychosis are reviewed. This activity also outlines the role of interprofessional team members in increasing awareness and decreasing latency between onset and diagnosis of this condition to improve treatment outcomes in patients experiencing postpartum psychosis.

Objectives:

• Review the potential risk factors for developing postpartum psychosis.
• Describe the typical presentation of a patient with postpartum psychosis.
• Explain the pharmacological and nonpharmacological treatment options and the indications for immediate admission to the hospital in a patient with postpartum psychosis.
• Explain the importance of improving communication and collaboration between interprofessional teams to enhance the delivery of care in postpartum psychosis.

Introduction

Childbirth is considered a major physical, emotional, and social stressor in a woman’s life. Following days to weeks after childbirth, most women experience some mental disturbance like mood swings and mild depression (also known as post-baby blues), but a few can also suffer from PTSD, major depression, or even full-blown psychosis.[1][2] This change in maternal behavior and thought process is due to several bio-psycho-social factors. There are physical and hormonal changes, lack of sleep and exhaustion, and the beginning of a new role and commitment in caring for a newborn, which is both physically and emotionally challenging. Postpartum psychosis is the severest form of mental illness in that category characterized by extreme confusion, loss of touch with reality, paranoia, delusions, disorganized thought process, and hallucinations.[3] It affects around one to two per one thousand females of childbearing age and usually happens immediately within days to the first six weeks after birth. Although rare, it is considered a psychiatric emergency that warrants immediate medical and psychiatric attention and hospitalization if the risk of suicide or filicide exists.

Etiology

Postpartum psychosis has a complex multifactorial origin. Risk factors include a history of bipolar disorder,  history of postpartum psychosis in a previous pregnancy, family history of psychosis or bipolar disorder, history of schizoaffective disorder or schizophrenia, and discontinuation of psychiatric medications during pregnancy. The overall prevalence is higher in patients suffering from affective disorders like bipolar one, two, and first-time pregnancy with a previous family or personal history of bipolar one disorder is considered the single most important risk factor.[4] Lack of sleep and hormonal fluctuations after birth, especially the rapidly falling levels of estrogen, may also pose a risk; previous postulations proposed that treatment with estradiol may be beneficial as an adjunctive treatment for women with psychosis in schizophrenia.[5][6] However, a subsequent study found a minimal benefit of prophylactic estradiol administration in pregnant females with a history of bipolar one, bipolar two, and schizophrenia to prevent relapse in the postpartum period.[7] In one study conducted on parous women with bipolar disorder, sleep loss triggering episodes of mania was considered to be an essential marker to determine predisposition to developing postpartum psychosis. The conclusion was that women who reported sleep deprivation leading to manic episodes were twice as likely to have experienced an episode of postpartum psychosis at some point in their lives.[8]

Epidemiology

With an estimated global prevalence of 0.089 to 2.6 per 1000 births, postpartum psychosis classifies as an illness with a low incidence rate. However, it carries the potential for serious medical and social consequences, including the risk of suicide and filicide, if not promptly detected and treated.[9] While first-time pregnancies in women with a history of affective mood disorders, specifically bipolar one disorder are considered the single most important risk factor, almost fifty percent of cases reported in first-time mothers are without any previous psychiatric hospitalization history. Moreover, observation shows that the latter group of patients had nearly ten times higher incidence rate during the first couple of months postpartum.[10] Other factors like advanced maternal age and low birth weight of the baby (less than one hundred fifty grams ) are also considered possible contributing factors while maternal diabetes and high birth weight of the baby (more than four thousand five hundred grams) appear to be protective against puerperal psychosis in first-time mothers during the first ninety days. Negative pregnancy and birthing outcomes like congenital malformations, preterm birth (less than thirty-two weeks), and fetal/infant death also increase the risk of psychoses and major depressive disorders in not just first-time mothers but in all mothers.

History and Physical

When a patient presents with symptoms of psychosis and recent history (days to few weeks) of giving birth a  careful and thorough history and neuropsychiatric evaluation is required to expedite correct diagnosis, treatment, and recovery. It is essential to rule out a previous personal or family history of psychiatric illness. Prenatal and perinatal health records should undergo an evaluation to rule out medical comorbidities, organic causes, and a complicated obstetrical history like preeclampsia and eclampsia or negative birth outcomes. The clinician should note whether the patient with a psychiatric history who was previously stable on psychiatric medications was compliant with her prescribed psychiatric medications throughout the pregnancy as often medications are discontinued before or during pregnancy.

Substance abuse, medication history, and a history of any other recent major stressors or traumatic events merit attention. The care team should also evaluate the patient’s social support network, including the role and responsibilities of her partner and other available caregivers in the family. Symptoms of puerperal psychosis include confusion, lack of touch with reality, disorganized thought pattern and behavior, odd effect, sleep disturbances, delusions, paranoia, appetite disturbances, a noticeable change in the level of functioning from baseline, hallucinations, and suicidal or homicidal ideation. Safety of the patient and newborn is of utmost importance, and thus, immediate hospitalization is warranted if there is a risk of harm to either one.[11]

Evaluation

Postpartum psychosis has been underdiagnosed and underreported because there are no standard screening procedures in place during the prenatal and postnatal periods.[12] While generally more focus is placed on the mother and baby’s physical health and recuperation during and after pregnancy, primary care providers should have questionnaires directly assessing the patient’s mood and feelings of well-being throughout pregnancy and postpartum. EPDS (Edinburgh postnatal depression scale) and MDQ (mood disorder questionnaire) are quick and effective screening tools to identify signs of depression and mania in populations at risk.[13][14] This evaluation can greatly help in risk assessment for future psychiatric illness in the critical puerperal time zone. Following a thorough history and complete physical examination, the following initial labs help identify organic causes of psychosis.

• A complete blood count (CBC)
• Electrolytes
• Blood urea nitrogen (BUN)
• Blood glucose
• Creatinine
• Vitamin B12
• Folate
• Thiamine
• Calcium
• Thyroid function tests
• Liver function tests or LFTs
• Urinalysis
• Urine drug screen
• Urine/blood cultures for patients with fever
• CT/ MRI brain

The above lab tests help to rule out medical conditions and organic causes that may present as psychosis. Examples include hypo and hypernatremia, hypo and hyperglycemia (insulin shock and diabetic ketoacidosis), abnormal liver function tests (hepatic encephalopathy), and hypo and hyperthyroidism (thyroid storm in Graves disease). Other examples are uremia, substance abuse, hypercalcemia (in hyperparathyroidism), urine and blood cultures to rule out infection and CT, and MRI to see for a possibility of a stroke, especially in women with a history of pregnancy-induced hypertension, preeclampsia, and eclampsia.

Treatment / Management

Timely identification of the illness is of utmost importance as it is a psychiatric emergency. Postpartum psychosis usually has a sudden onset but is a brief and limited illness that responds rapidly to treatment. Mothers who are at risk for harm to themselves or the baby require immediate hospitalization. There are no current guidelines to manage postpartum psychosis, and the management depends on the cause. Once organic causes have been ruled out, medications to control acute psychosis may be started. These include mood stabilizers, atypical antipsychotics, and antiepileptic drugs. Common drugs from these classes include lithium, sodium valproate, lamotrigine, carbamazepine, benzodiazepines, quetiapine, olanzapine, etc.

Although prophylactic treatment for women with bipolar disorder throughout pregnancy is a recommendation for women at high risk of relapse, benefits and risks merit careful discussion.[15][16] Lithium has been a standard treatment option for bipolar depression and postpartum right after delivery in patients with a history of bipolar disorder or previous isolated episodes of postpartum psychosis. The use of lithium during pregnancy is controversial as it bears a significant risk for congenital malformations, namely Ebstein anomaly and low fetal birth weight.[17] Some studies advise the use of prophylactic lithium and other mood stabilizers,[18] right after delivery in patients with a history of bipolar disorder.[19] Suggestions are that if the patient was previously stable on lithium (discontinued during pregnancy) that it be restarted as soon as the patient delivers to prevent relapse.

For women with a previous history of postpartum psychosis, the recommendation is high therapeutic target level lithium prophylaxis (zero points eight to one mmol/liter) to prevent future episodes. In that case, lithium blood levels should be obtained twice a week for at least the first two weeks postpartum. Women should abstain from breastfeeding while taking lithium as it is eliminated in breast milk and may cause higher exposure levels in infants as their metabolic systems and mechanisms of drug excretion are underdeveloped.[17] On the other hand, the use of SSRIs, carbamazepine, sodium valproate, and short-acting benzodiazepines are considered relatively safe during breastfeeding.[20] Not only does breastfeeding lead to lack of sleep and exhaustion to the mother (which can further exaggerate her symptoms) but, oxytocin, the hormone that regulates breastfeeding, also causes insomnia in breastfeeding mothers. That is why it is important to discuss the pros and cons of breastfeeding with the patient and her family.[21]

Electroconvulsive therapy (ECT) is recognized as a means of treatment with a tremendous benefit in patients with psychosis related to schizophrenia and schizoaffective disorder refractory to antipsychotic pharmacotherapy.[22] ECT is also considered a safe and effective intervention in patients with acute relapse or exacerbation of psychosis in the postpartum period with the risk of minimal complications.[23][24][25] Patients with a history of bipolar disorder stable on mood stabilizer medications before pregnancy who discontinue medications during pregnancy have an elevated risk of developing a relapse in the perinatal or postnatal period. Almost all classes of medications used as maintenance therapy pose a risk of congenital malformations and other neural complications to the developing fetus especially during the first twelve weeks of development.

The patient and the family must make an informed decision, carefully weighing the risks and benefits of medication management during pregnancy. Of the main pharmacological options, lithium has a 2.8% rate of causing major congenital malformations, valproate is highest at 5 to 8%, and carbamazepine 2 to 6%.[26] As for atypical and typical antipsychotics, the risk for causing major congenital malformations is unclear as there are no significant studies during pregnancy. Non-pharmacologic treatment like psychotherapy is a good adjuvant treatment alongside psychopharmacology and ECT has a track record as a safe and effective means of treating an acute episode during pregnancy alongside or without psychiatric medications.[27]

Differential Diagnosis

Following psychiatric [28] and medical causes should be considered and ruled out through careful history, appropriate lab investigations, and radiological studies when a patient comes in with a history of recent childbirth (days to few weeks) and symptoms of psychosis such as delusions, hallucinations, paranoia, confusion, agitation, lack of touch with reality, sleep disturbance and thoughts of suicide or filicide. 

The psychiatric differential may include:

• Bipolar 1 relapse (current and past history of low and high moods plus family history)
• Unipolar major depression with psychotic features with postpartum onset
• OCD and schizophrenia or schizophreniform disorder (past treatment history and medication non-compliance)
• Hyperthyroidism-thyroid storm as in Graves disease (thyroid function tests), fever due to these conditions: infections such as sepsis, meningitis, encephalitis, (complete blood count/ESR /differential, lumbar puncture)
• Diabetic ketoacidosis (fasting blood glucose, HbA1C, history of glucose tolerance during pregnancy)
• Substance misuse (drug screen for drugs of abuse)
• Uremia (kidney function tests, BUN, creatinine)
• Hepatic encephalopathy (LFTs, AST, ALT, hepatitis screen if a history of exposure or disease, alkaline phosphatase, bilirubin direct/indirect, lipase)
• Vitamin B12 deficiency
• Thiamine deficiency
• Hypercalcemia
• Pregnancy-induced hypertension and stroke due to preeclampsia or eclampsia (CT/MRI to rule out stroke)
• Metabolic or nutritional causes (electrolytes)
• Immunological causes like SLE
• Certain drugs like corticosteroids, antivirals (acyclovir and interferon), antibiotics (gentamicin, vancomycin, isoniazid), anticholinergic medicines like atropine, benztropine, and sympathomimetic stimulants like amphetamine, ephedrine, and theophylline

Prognosis

Postpartum psychosis is a severe mental crisis that warrants immediate medical attention. Although considered a psychiatric emergency, most patients respond to treatment and demonstrate fast recovery and remission.[29][30] However, having one episode of postpartum psychosis predisposes the patient to another episode with a future pregnancy. Patients with a history of bipolar disorder are predisposed to developing a relapse during and after pregnancy and should be carefully evaluated and counseled regarding the risk in future pregnancies.

Complications

Postpartum psychosis is a rare occurrence but may lead to undesirable outcomes. The proper identification of risk markers would enhance the ability to prevent and manage the condition. If left untreated, it can result in tragic consequences like suicide or filicide. It is a period of tremendous stress for the partner and other family members involved in taking care of the patient and has notable psychosocial implications.

Deterrence and Patient Education

Like any other mental illness, postpartum psychosis not only affects the mother and the infant but has an equal impact on families and caregivers. It is crucial for the treatment team to be able to understand the magnitude of physical and emotional stress the partner and other family members are going through and address all their questions and concerns in an empathetic manner.[31] Patients should be screened for signs of mental illness during pregnancy and after childbirth. Women planning to get pregnant, who are predisposed to developing postpartum psychosis should be counseled and informed about the illness course and outcomes and the risks associated with the disease and treatment options available so they can arrive at an informed decision.

Enhancing Healthcare Team Outcomes

Regular screening for signs of mental illness during pregnancy and after childbirth should be protocol. Social services, nurses, and other relevant departments may be involved to assess the situation and provide support and assistance if needed; reporting to clinicians whenever there is evidence suggesting a lack of improvement. When a patient seeks prenatal or postnatal care, primary care providers should pay attention to the entire bio-psycho-social model and not just the patient's physical and medical issues related to pregnancy. EPDS (Edinburgh postnatal depression scale) and MDQ (mood disorder questionnaire) are quick and effective screenings to identify telltale signs of possible mental illness in women during and after pregnancy.

Postpartum psychosis requires an interprofessional team approach, including physicians, specialists, mental health professionals, specialty-trained nurses, and pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level 5]