Postpartum Psychosis – Causes, Symptoms, Treatment

Postpartum Psychosis /Psychosis implies the presence of manic symptoms, stupor or catatonia, perplexity, confusion, disorders of the will and self, delusions and/ or hallucinations. Psychiatric disorders that lack these symptoms are excluded; depression, however severe, is not included, unless there are psychotic features.

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.[rx][rx] 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.[rx] 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.

Causes of Postpartum Psychosis

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.  [rx] 
• 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.[rx][rx]
• 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.[rx]
• 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.[rx]
• have a family history of mental health illness, particularly postpartum psychosis (even if you have no history of mental illness)
• already have a diagnosis of bipolar disorder or schizophrenia
• you have a traumatic birth or pregnancy
• you developed postpartum psychosis after a previous pregnancy

Symptoms of Postpartum Psychosis

Symptoms usually start suddenly within the first two weeks after giving birth. More rarely, they can develop several weeks after the baby is born.

Symptoms can include:

• Hallucinations
• Delusions – thoughts or beliefs that are unlikely to be true
• A manic mood – talking and thinking too much or too quickly, feeling “high” or “on top of the world”
• A low mood – showing signs of depression, being withdrawn or tearful, lacking energy, having a loss of appetite, anxiety or trouble sleeping
• Loss of inhibitions
• Feeling suspicious or fearful
• Restlessness
• Feeling very confused
• behaving in a way that’s out of character
• Delusions or strange beliefs
• Hallucinations (seeing or hearing things that aren’t there)
• Feeling very irritated
• Hyperactivity
• Decreased need for or inability to sleep
• Paranoia and suspiciousness
• Rapid mood swings
• Difficulty communicating at times

Almost every symptom known to psychiatry occurs in these mothers – every kind of delusion including the rare delusional parasitosis,^[rx] delusional misidentification syndrome,^[rx] Cotard delusion,^[rx] erotomania,^[rx] and the changeling delusion,^[rx] denial of pregnancy or birth,^[rx] command hallucinations,^[rx] disorders of the will and self,catalepsy and other symptoms of catatonia, self-mutilation and all the severe disturbances of mood. In addition, the literature also describes symptoms not generally recognized, such as rhyming speech,^[rx] enhanced intellect,^[rx] and enhanced perception.

As for collections of symptoms (syndromes), about 40% have puerperal mania, with increased vitality and sociability, reduced need for sleep, rapid thinking and pressured speech, euphoria and irritability, loss of inhibition, violence, recklessness and grandiosity (including religious and expansive delusions); puerperal mania is considered to be particularly severe, with highly disorganized speech, extreme excitement and eroticism.^[rx]

Diagnosis of Postpartum Psychosis

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. The 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.[rx]

Evaluation

Postpartum psychosis has been underdiagnosed and underreported because there are no standard screening procedures in place during the prenatal and postnatal periods.[rx] 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.[rx][rx] 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 of Postpartum Psychosis

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 respond 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.

Medication

You may be prescribed one or more of the following:

• Antidepressants – to help ease systems of depression
• Antipsychotics – to help with manic and psychotic symptoms, such as delusions or hallucinations
• Mood stabilizers (for example, lithium) – to stabilize your mood and prevent symptoms recurring
• Common drugs from these classes include  – lithium, sodium valproate, lamotrigine, carbamazepine, benzodiazepines, quetiapine, olanzapine, etc.
• 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.[rx] Some studies advise the use of prophylactic lithium and other mood stabilizers,[rx] right after delivery in patients with a history of bipolar disorder.[rx] 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.
• On the other hand, the use of SSRIs – carbamazepine, sodium valproate, and short-acting benzodiazepines are considered relatively safe during breastfeeding.[rx] 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.[rx]
• 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.[rx] 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.[rx][rx][rx] 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.
• Psychological therapy – As you move forward with your recovery, your GP may refer you to a therapist for cognitive behavioral therapy (CBT). CBT is a talking therapy that can help you manage your problems by changing the way you think and behave. Most women with postpartum psychosis make a full recovery as long as they receive the right treatment.

Differential Diagnosis

Following psychiatric [rx] 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

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.

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