What is Postpartum Psychosis?
Childbirth is known to be a significant event in a woman’s life, causing physical, emotional, and social changes. After giving birth, most women may go through emotional ups and downs and mild depression, commonly referred to as post-baby blues. However, a few women may experience severe conditions like Post-Traumatic Stress Disorder (PTSD), severe depression, or even serious mental health issues known as psychosis.
Various factors contribute to these changes in a new mother’s behavior and thought process. These include physical and hormonal changes, a lack of sleep paired with exhaustion, and the new commitment to taking care of a newborn, which can be both physically and emotionally demanding.
Postpartum psychosis, the most severe form of mental illness after childbirth, can cause extreme confusion, a disconnection from reality, paranoid feelings, false beliefs, disorganized thinking, and even hallucinations.
This condition affects one to two women out of a thousand who are of childbearing age and typically occurs within the first six weeks after birth. Though it’s rare, postpartum psychosis is considered an emergency in mental health care. Immediate medical and mental health attention is necessary, and hospitalization might be required if there’s a risk of the mother harming herself or her baby.
What Causes Postpartum Psychosis?
Postpartum psychosis, a severe mental illness that can affect new mothers, can be caused by several factors. These include having a history of bipolar disorder, having had postpartum psychosis in past pregnancies, having family members with psychosis or bipolar disorder, having disorders like schizoaffective or schizophrenia, and stopping psychiatric medications during pregnancy.
People who suffer from emotional disorders such as bipolar one and two are generally more likely to develop postpartum psychosis. However, the biggest risk of all is being a first-time mother who either personally or within her family has a history of bipolar one disorder.
Changes in your body after having a baby, such as lack of sleep and hormone levels dropping rapidly (especially estrogen), can also increase your risk. Some research has suggested that giving estrogen to women who have psychosis in schizophrenia might help. But, later studies found that giving estrogen ahead of time to pregnant women who had bipolar one, bipolar two, or schizophrenia didn’t really prevent them from having a relapse after giving birth.
A specific study has also pointed out the significance of sleep loss in predicting postpartum psychosis. This study found that women with bipolar disorder who have manic episodes triggered by lack of sleep are twice as likely to develop postpartum psychosis in their lifetime.
Risk Factors and Frequency for Postpartum Psychosis
Postpartum psychosis is a condition that doesn’t occur frequently, with about 0.089 to 2.6 cases for every 1000 births worldwide. But, it’s very important to address it swiftly because it can lead to severe health risks and social problems, such as suicide and harm to the child. The biggest risk factor is if a woman has a history of serious mood disorders, specifically bipolar disorder, during her first pregnancy. Interestingly, about half of the postpartum psychosis cases in first-time mothers happen in women who have never been hospitalized for mental health issues before. This group tends to have a higher occurrence rate in the first few months after giving birth.
- Other factors, like the mother being older and the baby being born small (less than 150 grams), may also increase the risk.
- On the other hand, if the mother has diabetes or if the baby is born quite large (more than 4500 grams), this seems to lower the risk of postpartum psychosis.
- Negative experiences during pregnancy and childbirth, such as birth defects, premature birth (less than 32 weeks), and the death of the baby, can also increase the risk of psychosis and major depression.
- This doesn’t just affect first-time mothers, but all mothers.
Signs and Symptoms of Postpartum Psychosis
When a new mother shows signs of psychosis shortly after giving birth, it’s vital to quickly determine the right diagnosis and start treatment. This occurs with a detailed check of the individual’s psychiatric and health history, with particular attention to any past or family mental health problems, as well as health issues during pregnancy. It’s also important to know if the woman was taking any prescribed psychiatric medications during pregnancy, as these are often stopped before or during this time.
Other key considerations include any history of drug misuse, medications currently taken, and any recent stressful or traumatic events. The doctor should also examine the woman’s social support, including the involvement and duties of her partner and other potential caregivers in the family.
Symptoms of postpartum psychosis can include confusion, being out of touch with reality, scattered thought patterns and behavior, unusual emotional responses, problems with sleeping, delusions, paranoia, changes in appetite, noticeable changes from normal behavior, hallucinations, and thoughts about suicide or harming others.
If there’s a risk of harm to the mother or baby, immediate hospitalization may be required for their safety.
- Confusion
- Altered reality perception
- Scattered thoughts and behavior
- Unusual emotional responses
- Sleep problems
- Delusions
- Paranoia
- Change in appetite
- Noticeable changes from normal behavior
- Hallucinations
- Suicidal or harmful thoughts
Testing for Postpartum Psychosis
Postpartum psychosis is a condition that affects some women after childbirth, but it’s often not diagnosed or reported as frequently as it should be. This is mainly because there are no set methods for checking for it during and after pregnancy. Although doctors typically focus more on the physical health of the mother and baby during this time, they should also pay attention to the mother’s mental health.
One way to do this is with questionnaires that ask about the mother’s mood and overall well-being throughout her pregnancy and after childbirth. Two questionnaires that are particularly good at catching signs of depression and mania, which could be signs of postpartum psychosis, are the Edinburgh Postnatal Depression Scale (EPDS) and the Mood Disorder Questionnaire (MDQ). If used properly, they can help doctors identify women who might be at risk of developing mental health issues after giving birth.
In addition to these questionnaires, doctors may also want to do a comprehensive medical history and physical examination. There are also a variety of tests they might run, including:
– Complete Blood Count (CBC)
– Electrolytes
– Blood Urea Nitrogen (BUN)
– Blood Glucose
– Creatinine
– Vitamin B12, Folate, Thiamine, and Calcium
– Thyroid Function Tests
– Liver Function Tests
– Urinalysis
– Urine Drug Screen
– Urine/blood cultures (for patients with fever)
– CT/ MRI Brain Scan
These tests are important for ruling out other physical causes that might be mistaken for psychosis. For instance, chemical imbalances in the blood, abnormal liver function, thyroid issues, and various infections can all mimic the symptoms of postpartum psychosis. A CT scan or MRI can also reveal if a woman has had a stroke, which is especially important to know for women with a history of high blood pressure during pregnancy, preeclampsia, or eclampsia.
Treatment Options for Postpartum Psychosis
Postpartum psychosis is a severe mental health condition affecting some mothers after childbirth. The main priority is to quickly identify the illness because it’s considered a psychiatric emergency. Despite its sudden and often intense onset, postpartum psychosis is typically a short-lived condition that responds well to prompt treatment. If a mother is at risk of harming herself or her baby, she needs to be hospitalized immediately.
There aren’t any official guidelines on how to manage postpartum psychosis, so the treatment approach depends on the cause. Once health professionals have ruled out any physical causes, they might start treatment for psychosis, using various types of medications. These medications can include mood stabilizers, unconventional antipsychotics, and antiepileptic drugs.
For women with bipolar disorder who are at high risk of relapse, being treated throughout the pregnancy is a common suggestion. However, the benefits and risks need careful consideration. One of those treatments is lithium, which has been used for years to treat bipolar depression. However, it’s also associated with certain birth defects and low birth weight. Another suggestion is starting lithium and other mood stabilizers after delivery for patients who have had bipolar disorder. If the patient was stable on lithium before pregnancy and then stopped using it during, it should be restarted as soon as the patient delivers to prevent a recurring episode.
For women who’ve previously had postpartum psychosis, the recommendation is to monitor lithium at specific levels in the bloodstream (0.8 to 1 mmol/liter) to prevent future episodes. In this case, blood levels of lithium should be checked twice a week for at least the first two weeks postpartum. While lithium can be found in breast milk and potentially pose a higher exposure risk for infants, other medications such as SSRIs, carbamazepine, sodium valproate, and short-acting benzodiazepines, are relatively safe during breastfeeding. Important discussions around the merits and challenges of breastfeeding, such as lack of sleep and exhaustion, need to be had with the patient and her family.
Electroconvulsive therapy (ECT) is a treatment for severe mental disorders and is considered safe and effective for psychosis treatment postpartum as well. Patients with bipolar disorder who stopped their mood stabilizing medications during pregnancy are at an elevated risk of a relapse either during or after the pregnancy. Almost all types of medications for long-term therapy pose some risk of congenital malformations and other complications for the developing baby, especially in the first twelve weeks of the pregnancy. This makes informed decision-making about medication use during pregnancy extremely important.
Certain medications such as lithium, valproate, and carbamazepine can increase the rate of major congenital malformations. The potential risks associated with typical and atypical antipsychotics are still unclear. In this complex scenario, non-drug treatments like psychotherapy can be beneficial, and ECT is generally considered safe and effective for treating acute episodes during pregnancy, with or without the use of other psychiatric medications.
What else can Postpartum Psychosis be?
When a patient comes in presenting symptoms of psychosis, such as delusions, hallucinations, paranoia, confusion, agitation, a separation from reality, disrupted sleeping patterns, and thoughts of harm towards themselves or their child, particularly following recent childbirth, doctors need to carefully examine their history and carry out a range of tests. These tests could include lab investigations and radiological studies to identify or rule out a range of potential psychiatric and medical causes.
The potential psychiatric causes could include:
- Bipolar 1 relapse: Indicators could be a current or past history of fluctuating moods and a family history of the condition.
- Unipolar major depression with psychotic features following childbirth
- OCD and schizophrenia or schizophreniform disorder: Signs could be a history of past treatment and non-adherence to medication.
There are also a range of potential medical scenarios to consider, such as:
- Hyperthyroidism or thyroid storm as in Graves disease: Thyroid function tests would be necessary.
- Infections such as sepsis, meningitis, or encephalitis: A CBC/ESR /differential, lumbar puncture could be used.
- Diabetic ketoacidosis: Indicators could be fast blood glucose, HbA1C or a history of glucose tolerance during pregnancy.
- Substance abuse: Drug screening would be necessary.
- Uremia: Tests involving kidney functions, BUN, creatinine would be used.
- Hepatic encephalopathy: Checking LFTs, AST, ALT, hepatitis screening if the patient has a history of exposure or disease, alkaline phosphatase, bilirubin direct/indirect, lipase would be needed.
- Vitamin B12 deficiency, Thiamine deficiency, or Hypercalcemia
- Pregnancy-induced hypertension and stroke because of preeclampsia or eclampsia: A CT/MRI scan could rule out a stroke.
- Metabolic or nutritional causes: Tests involving electrolytes would be used.
- Immunological causes such as SLE
- Possible responses to certain drugs like corticosteroids, antivirals (acyclovir and interferon), antibiotics (gentamicin, vancomycin, isoniazid), and anticholinergic or sympathomimetic stimulants like atropine, benztropine, amphetamine, ephedrine, and theophylline.
All of these possibilities need to be thoroughly examined in order to arrive at an accurate diagnosis.
What to expect with Postpartum Psychosis
Postpartum psychosis is a serious mental health issue that needs urgent medical attention. Even though it’s seen as a psychiatric emergency, the good news is that most patients respond well to treatment and recover quickly. But it’s crucial to note that if you’ve suffered from one episode of postpartum psychosis, you’re more likely to experience another one during a future pregnancy.
Also, if you have a history of bipolar disorder, you’re at a higher risk of experiencing a relapse during and after pregnancy. That’s why it’s so important for you to be thoroughly evaluated and counseled about this risk if you’re planning future pregnancies.
Possible Complications When Diagnosed with Postpartum Psychosis
Postpartum psychosis, which is relatively rare, can lead to severe outcomes if not dealt with properly. The right direction in recognizing the warning signs can help us prevent or better handle this condition. If it’s ignored, it could lead to heart breaking outcomes such as self-harm or harm to the child. This is an exceedingly stressful time not only for the patient but also for their partner and family who are providing care, and it can have significant emotional and social impacts.
Worrying Side Effects of Postpartum Psychosis:
- Suicide
- Child harm (filicide)
- Intense stress for caregivers
- Emotional and social consequences for the family
Preventing Postpartum Psychosis
Postpartum psychosis, like other mental health conditions, can deeply affect not only the new mother and baby, but can also significantly impact the wellbeing of family members and caregivers. It’s really important that the healthcare professionals providing treatment grasp just how much physical and emotional stress this can place on a partner and other family members. They should compassionately answer all questions and address any concerns related to this condition.
Health checks during pregnancy and following the birth of the baby should include looking for any signs of mental health issues. If a woman who is planning to have a baby has a higher chance of developing postpartum psychosis, it is very important that she receive information and counseling about what to expect from the illness, the possible outcomes, potential risks, and treatment options. This will help her to make an informed decision about her health and wellbeing.
