Identifying and treating postpartum psychosis with Dr. Susan Hatters Friedman

Susan Hatters Friedman, MD, returns to the MDedge Psychcast to join host Lorenzo Norris, MD, to discuss postpartum psychosis.

Dr. Hatters Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry at Case Western Reserve University in Cleveland. She also is professor of pediatrics and reproductive biology, and adjunct professor of law at Case Western. In addition, Dr. Hatters Friedman and colleagues recently wrote an article published in Current Psychiatry examining this topic, Postpartum psychosis: Protecting mother and infant.

Timestamps:

• This week in psychiatry (01:09)
• Interview (05:07)
• Dr. RK (22:07)

Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

Overview of postpartum psychosis

• Postpartum psychosis is a medical emergency with a fulminant development occurring within 1-4 weeks after delivery.
• Onset is usually 3-10 days postpartum, and women experience a spectrum of symptoms from psychosis to dysphoric mania and confusion. Many women who experience postpartum psychosis do not have a past psychiatric history, although they might go on to develop bipolar disorder.
• Symptoms change quickly, with risks of devastating consequences. A woman with postpartum psychosis might minimize or even conceal her symptoms to avoid being separated from her child or out of fear that her child will be taken away. Collateral information is extremely important.
• A woman is at the greatest risk of developing a mental illness in the period around childbirth. The rate of postpartum depression is 1 in 9, and the baseline rate of postpartum psychosis is 1/500. Women with bipolar disorder (which may be undiagnosed until the postpartum psychosis) or a previous episode of postpartum psychosis are at highest risk of postpartum psychosis.

Prevention and intervention

• Clinicians must be proactive with their psychoeducation about pregnancy, contraception, and the natural course of mental disorders during pregnancy and postpartum. If a patient with bipolar disorder is of childbearing age, the clinician should consider having her on medications that are relatively safe during pregnancy. In 2011, 45% of pregnancies in the United States were unintended; thus, preconception counseling is necessary.
• Medications for bipolar disorder can help prevent postpartum psychosis. Other preventive measures include using sleep strategies after childbirth, such as arranging support to assist at night and weighing the risks of breastfeeding. Breastfeeding can lead to sleep deprivation, which in turn, increases the risk of decompensation.
• If a woman wants to breastfeed, the psychiatrist should be in touch with the pediatrician and plan for breastfeeding by having the mother on medications that are safe for breastfeeding.
• Involuntary hospitalization might be required if the postpartum psychosis puts the mother or child at imminent risk of harm. Family and nonpsychiatrists on the health care team might be resistant to psychiatric hospitalization because it would mean separating the mother from the child.
• Psychiatrists can broach resistance by explaining the details of a thorough risk assessment and emphasizing that, while bonding is important, the hospitalization is meant to prevent the worst outcomes of suicide or infanticide.

Review of key points

• Postpartum psychosis can present with mood symptoms or delirium, so those signs should make a clinician vigilant for postpartum psychosis.
• The symptoms of postpartum psychosis change rapidly with escalating danger, such as infanticide and suicide, so collateral from family and speedy treatment are essential.
• Focused early collaboration and education with team member such as ob.gyns. and pediatricians help make future interventions go more smoothly.

References

Friedman SH et al. Postpartum psychosis: Protecting mother and infant. Curr Psychiatr. 2019 Apr 1;18(4):13-21.

Sit D et al. A review of postpartum psychosis. J Womens Health (Larchmt). 2006 May;15(4):352-68.

Harlow BL et al. Incidence of hospitalization for postpartum psychosis and bipolar episodes in women with and without prior prepregnancy or prenatal psychiatric hospitalizations. Arch Gen Psychiatry. 2007;64(1):42-8.

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