Treatment of Postpartum Psychosis
The treatment of postpartum psychosis requires prompt intervention with atypical antipsychotics (such as risperidone 2 mg/day or olanzapine 7.5-10.0 mg/day) as first-line pharmacological therapy, often combined with mood stabilizers like lithium, and consideration of electroconvulsive therapy (ECT) for severe or treatment-resistant cases. 1, 2
Initial Assessment and Management
- Postpartum psychosis typically presents within the first 1-4 weeks after childbirth and requires immediate psychiatric evaluation to ensure safety of both mother and baby 3
- Inpatient psychiatric admission is essential to ensure safety, perform physical and neurological examinations, and exclude organic causes for acute psychosis 4
- Risk assessment should evaluate potential for self-harm, aggression, or harm to the infant, determining whether the level of community support is sufficient or if inpatient care is required 1
- Before initiating treatment, rule out physical illnesses that can cause psychosis, including thyroid dysfunction, electrolyte imbalances, and infectious processes 1
Pharmacological Treatment
- Atypical antipsychotics are preferred first-line agents due to better tolerability and reduced extrapyramidal side effects, which improves medication adherence 1
- Initial target doses should be risperidone 2 mg/day or olanzapine 7.5-10.0 mg/day, with adjustments based on response and tolerability 1
- Mood stabilizers, particularly lithium, should be considered as they are effective for both treatment and prevention of recurrence in women with postpartum psychosis 2, 4
- Avoid excessive initial dosing of antipsychotics as this leads to unnecessary side effects without hastening recovery 5
- Regular monitoring for medication side effects such as weight gain, sexual dysfunction, and sedation is essential as these can impair recovery and reduce adherence 1
Electroconvulsive Therapy (ECT)
- ECT should be considered as a primary treatment option for severe postpartum psychosis, particularly when rapid symptom resolution is needed or when patients are unresponsive to pharmacotherapy 6, 4
- Evidence suggests ECT is highly effective for postpartum psychosis and should be the treatment of choice for some patients, especially those with severe symptoms or safety concerns 6
Psychosocial Interventions
- Supportive crisis plans are essential to facilitate recovery and acceptance of treatment 1
- Families should be included in the assessment process and treatment plan, providing emotional support and practical advice 1
- Psychoeducation for both patient and family about the nature of postpartum psychosis, treatments, and expected outcomes is crucial 1
- Specialized mother-baby psychiatric units are recommended when available, as they allow for treatment while maintaining the mother-infant relationship 7
Continuity of Care and Relapse Prevention
- Ensure continuity of care with treating clinicians remaining constant for at least the first 18 months of treatment 1
- Patients should remain in comprehensive, multidisciplinary, specialist mental healthcare throughout the early recovery period 1
- Early warning signs of relapse should be thoroughly discussed with both patient and family to enable prompt intervention 1, 8
- For women with a history of postpartum psychosis, prophylactic treatment with lithium immediately postpartum has been shown to be highly effective in preventing relapse 4
Common Pitfalls to Avoid
- Delaying treatment can lead to worsening symptoms and increased risk to both mother and infant 3
- Premature discharge from specialist services increases relapse risk 8
- Failing to monitor and address medication side effects can lead to non-adherence and subsequent relapse 1
- Reactive rather than preventive care approaches miss the best opportunity for enhancing outcomes 1
- Neglecting the needs of the partner and family members, who require support and education throughout the treatment process 7