Postpartum Psychosis

Postpartum psychosis is a severe mental illness starting within days to weeks of birth, with delusions, hallucinations, mania, confusion and loss of insight. It affects 1 to 2 per 1000 births, and usually presents within the first 2 weeks. It matters because it is a psychiatric emergency with risk of suicide and harm to the infant, and it is often the first episode of bipolar disorder.

• Risk factors: bipolar disorder, previous postpartum psychosis, schizoaffective disorder, family history of bipolar disorder or postpartum psychosis, first birth, sleep loss, obstetric complications, thyroid disease.
• Recurrence after later births is about 30 to 50 percent without prevention.
• Organic causes must be excluded in every woman with new confusion.

Women have rapid onset of elated or irritable mood, reduced need for sleep, racing thoughts, hallucinations, delusions about the baby (for example that the baby is possessed or has died), disorganised behaviour, confusion and rapidly changing mood. Some are depressed, perplexed or catatonic.

• Fluctuating confusion, disorientation and bizarre behaviour.
• Statements or behaviour that put the infant or the woman at risk.
• Differential diagnosis: eclampsia, sepsis and meningitis, thyrotoxicosis, hypocalcaemia, hypoglycaemia, cerebral venous thrombosis, HIV related psychosis, autoimmune encephalitis, substance or alcohol withdrawal, Sheehan syndrome, severe postpartum depression with psychotic features, postpartum obsessive compulsive symptoms, schizophrenia.
• Complications: suicide, infanticide, harm to the infant through neglect, exhaustion, relapse and bipolar disorder, loss of custody, post-psychotic depression.

The approach is urgent psychiatric assessment with exclusion of organic illness and a risk assessment for the woman and the infant.

• History from the woman and family; mental state examination; risk assessment of suicide, harm to the baby and capacity to care; Edinburgh Postnatal Depression Scale item on self-harm.
• Blood pressure, temperature, glucose, urine dipstick for protein, malaria rapid test, HIV test, full blood count, urea, creatinine, electrolytes, calcium, liver enzymes, thyroid function.
• Blood culture and lumbar puncture if fever, neck stiffness or reduced consciousness; CT or MRI head with venography if focal signs, severe headache or seizures.
• Drug and alcohol history.

The principle is immediate admission, ideally with the baby in a mother and baby unit, with antipsychotic treatment and constant protection of the infant.

• Supportive: admit under psychiatric care; one to one observation; the infant is never left alone with an acutely ill mother and is cared for by a trusted adult; sleep protection; calm low stimulation environment; maintain fluids and nutrition; family education; safeguarding review; continue breastfeeding only if the woman is well enough and drugs are compatible.
• Pharmacological: acute agitation: haloperidol 2.5 to 5 mg oral or IM, repeated after 1 hour (maximum 20 mg daily), or lorazepam 1 to 2 mg oral or IM 8-hourly for up to 3 days (maximum 4 mg daily); antipsychotic: olanzapine 5 to 10 mg oral at night increased to 20 mg daily, or quetiapine 50 mg oral at night increased by 50 to 100 mg daily to 300 to 600 mg daily (maximum 800 mg), or risperidone 1 mg oral at night increased to 2 to 4 mg daily; mania or bipolar disorder: lithium carbonate 400 mg oral at night increased to reach a level of 0.6 to 1.0 mmol/L (12 hours after the dose), with level, creatinine and thyroid function checked weekly at first; benztropine 1 to 2 mg oral twice daily for dystonia from haloperidol; any treatable cause (for example ceftriaxone 2 g IV 12-hourly for meningitis) is treated at once.
• Procedures: electroconvulsive therapy for severe, catatonic, suicidal or treatment resistant illness, or when drugs cannot be used.
• Special groups: breastfeeding women prefer olanzapine or quetiapine at the lowest dose with infant sedation, feeding and weight checked, and avoid lithium unless the infant is monitored for level, kidney and thyroid function; avoid abrupt stopping of drugs in women with a previous episode; women with seizures, eclampsia or severe hypertension need those causes treated first.
• Red flags: suicidal or infanticidal thoughts, command hallucinations about the baby, refusal to feed or drink, catatonia, fever with rigidity, severe agitation, confusion with raised blood pressure.
• Follow-up: daily review in hospital; continue antipsychotic for at least 12 months after recovery, and lithium or another mood stabiliser if bipolar disorder is diagnosed; review weekly after discharge for 4 weeks; plan prevention before a later pregnancy with lithium 400 mg oral at night started immediately after birth; screening for post-psychotic depression at 3 months.