Postpartum psychosis
Postpartum psychosis is a serious mental illness and psychiatric emergency. Treatment should be sought immediately if symptoms develop or are suspected, because of the potential risks to the mother and baby.
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Definition
Postpartum psychosis is a serious mental illness and psychiatric emergency. The risk of developing postpartum psychosis in the general population is one to two in 1000 (Royal College of Psychiatrists, 2018a). However, in women with a diagnosis or family history of bipolar affective disorder or postpartum psychosis, the risk of developing the condition is one in two (Royal College of Psychiatrists, 2018a).
Treatment should be sought immediately if symptoms develop or are suspected, because of the potential risks to the mother and baby. Suicide is a leading cause of death in the perinatal period (Knight et al, 2023), and women with postpartum psychosis often choose more violent methods of suicide, indicating fatal intent (Chin et al, 2022). Postpartum psychosis can also increase the risk of infanticide, which occurs in 1–4.5% of cases (Friedman et al, 2023).
There are several risk factors for postpartum psychosis, with a previous history of mental
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Symptoms
The International Classification of Diseases 10 (World Health Organization, 2019) defines postpartum psychosis as the onset of psychotic and mood symptoms at any time within 6 weeks of giving birth, including:
- hallucinations – seeing, hearing, feeling, smelling or tasting things that are not there
- delusions – strongly held thoughts, beliefs or suspicions that are not seen as real by others
- mania – experiencing high levels of physical and mental energy, overactivity, restlessness, rapid thoughts and speech or agitation
- depression – low mood, feeling tearful, lacking energy, poor sleep or appetite
- anxiety
- confusion or feeling perplexed
Postpartum psychosis is thought to be a mood disorder, similar to bipolar disorder (Jairaj et al, 2023). Osborne (2018) reported that when symptoms begin to develop, the onset is usually rapid (a matter of hours) and the symptoms highly changeable. Early symptoms include:
- insomnia
- anxiety
- irritability
- minor mood changes (Osborne, 2018)
Psychotic type symptoms present
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Aetiology
The primary cause of postpartum psychosis is childbirth, most commonly following the first birth (Royal College of Psychiatrists, 2018a). The symptoms are thought to be influenced by biological and psychological factors.
Genetic factors
Postpartum psychosis is known to run in families, suggesting a genetic component. Genetic variations in the mechanisms of serotonin transportation through the brain and a genetic link between bipolar disorder and postpartum psychosis have been found, but require further research (Davies, 2017).
Hormonal factors
An abrupt fall in oestrogen and progesterone levels following birth corresponds with the onset of postpartum psychosis (Perry et al, 2021). These hormones influence the normal function and role of serotonin and dopamine, which are strongly associated with mood and psychotic disorders (Perry et al, 2021).
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Diagnosis
There are no assessment tools for postpartum psychosis. Diagnosis can be made by doctors and nurses with advanced training, based on the symptoms above using a holistic assessment (National Institute for Health and Care Excellence, 2020). Assessment should include:
- mental health and pregnancy history
- physical health
- current presentation
- drug and alcohol use
- birth experience
- family and social history
- thorough risk assessment
Where appropriate, families and support networks should be involved. If there are concerns around risk and safety of the mother and/or child, then local safeguarding procedures should be followed (National Institute for Health and Care Excellence, 2020).
There are no universally agreed laboratory tests for diagnosis, but some tests are recommended to rule out physical cause or infection, including:
- full blood count
- metabolic profile
- thyroid function
- urinalysis (Bergnik et al, 2016)
Differential diagnoses include:
- ‘baby blues’
- postnatal depression
- postnatal obsessive-compulsive disorder
- postnatal trauma
- postnatal anxiety (Osborne, 2018)
Possible
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Treatment
Screening and prevention
Many women stop taking mental health medication when pregnant, often because of concerns around risks to the baby and pregnancy (NHS England and NHS Improvement, 2018). Women with a history or family history of bipolar disorder or postpartum psychosis can access a preconception advice appointment to ensure she is receiving the most suitable medication and support (NHS England and NHS Improvement, 2018). Optimising existing treatment, taking prophylactic antipsychotics or lithium as a mood stabiliser in pregnancy or immediately following birth can reduce the risk of developing symptoms and is advised for people who are at risk (Jairaj et al, 2023).
The National Institute for Health and Care Excellence (2020) guidelines recommend screening women following birth; this can be undertaken by any healthcare professional involved in the woman’s care. Where there is a history or current diagnosis of a severe mental illness and/or a family or
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NMC proficiencies
Nursing and Midwifery Council: standards of proficiency for registered nurses
Part 1: Procedures for assessing people’s needs for person-centred care
1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages
Part 2: Procedures for the planning, provision and management of person-centred nursing care
3. Use evidence-based, best practice approaches for meeting needs for care and support with rest, sleep, comfort and the maintenance of dignity, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions
11. Procedural competencies required for best practice, evidence-based medicines administration and optimisation
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Resources
Baldaçara L, Leite VDS, Teles ALS, Silva AGD. Puerperal psychosis: an update. Rev Assoc Med Bras (1992). 2023;69(suppl 1):e2023S125. https://doi.org/10.1590/1806-9282.2023S125
Bergink V, Rasgon N, Wisner KL. Postpartum psychosis: madness, mania, and melancholia in motherhood. Am J Psychiatry. 2016;173(12):1179-1188. https://doi.org/10.1176/appi.ajp.2016.16040454
Carr C, Borges D, Lewis K et al. Sleep and postpartum psychosis: a narrative review of the existing literature. J Clin Med. 2023;12(24):7550. https://doi.org/10.3390/jcm12247550
Chin K, Wendt A, Bennett IM, Bhat A. Suicide and maternal mortality. Curr Psychiatry Rep. 2022;24(4):239-275. https://doi.org/10.1007/s11920-022-01334-3
Davies W. Understanding the pathophysiology of postpartum psychosis: challenges and new approaches. World J Psychiatry. 2017;7(2):77-88. https://doi.org/10.5498/wjp.v7.i2.77
Friedman SH, Reed E, Ross NE. Postpartum psychosis. Curr Psychiatry Rep. 2023;25(2):65-72. https://doi.org/10.1007/s11920-022-01406-4
Hoffman C, Dunn DM, Njoroge WFM. Impact of postpartum mental illness upon infant development. Curr Psychiatry Rep. 2017;19(12):100. https://doi.org/10.1007/s11920-017-0857-8
Jairaj C, Seneviratne G, Bergink V, Sommer IE, Dazzan P. Postpartum psychosis: A proposed treatment algorithm. J Psychopharmacol. 2023;37(10):960-970. https://doi.org/10.1177/02698811231181573
Knight M, Bunch K, Felker A et al. Saving lives, improving mothers’ care: lessons learned to inform maternity care from the UK and Ireland confidential enquiries into maternal deaths and morbidity 2019-21. 2023.
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