Oct 9, 2019
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.
- 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
- 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
- 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
Friedman SH et al. Postpartum psychosis: Protecting mother and
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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