What is the treatment for postpartum psychosis?

Treatment of Postpartum Psychosis

Initiate treatment with atypical antipsychotics at low doses—specifically risperidone 2 mg/day or olanzapine 7.5-10 mg/day—as first-line pharmacological therapy, while simultaneously arranging urgent psychiatric assessment to determine if inpatient admission is required for safety. 1

Immediate Risk Assessment and Setting of Care

• Evaluate three critical safety domains: potential for self-harm, risk of aggression, and risk of harm to the infant, as these determine whether community treatment is feasible or inpatient care is mandatory 1
• Arrange inpatient psychiatric admission when significant risk of self-harm or aggression exists, as this enables close monitoring of mother-infant safety and allows for comprehensive medical workup 1, 2, 3
• Treatment in outpatient or home settings may be considered only when risks are minimal and robust community support systems are in place 2

Essential Medical Workup Before Treatment

• Rule out organic causes that mimic psychosis: thyroid dysfunction, electrolyte imbalances, infectious processes, metabolic disturbances, and other medical causes of acute confusional states 1, 2, 3
• Perform physical examination, neurological examination, and laboratory analysis during inpatient screening, as somatic comorbidity is common and must be excluded 3

First-Line Pharmacological Treatment

• Start atypical antipsychotics at the following initial target doses: risperidone 2 mg/day or olanzapine 7.5-10 mg/day, as these agents offer better tolerability and reduced extrapyramidal side effects compared to typical antipsychotics 1, 2
• Avoid large initial doses, as they increase side effects without hastening recovery 2
• Continue treatment for 4-6 weeks at adequate dosages before determining efficacy 2
• Monitor closely for medication side effects including weight gain, sexual dysfunction, sedation, and extrapyramidal symptoms, as these impair recovery and reduce adherence 1, 2

Alternative and Adjunctive Pharmacological Options

• Consider lithium as both an acute treatment option and for prophylaxis, particularly in women with history of bipolar disorder or previous postpartum psychosis, as lithium initiated immediately postpartum is highly effective for preventing relapse 4, 3
• Mood stabilizers may be used as adjunctive therapy depending on clinical presentation and underlying diagnosis 4, 3
• If atypical antipsychotics are unavailable or ineffective, haloperidol 4-6 mg/day maximum may be considered in first-episode psychosis, though atypical agents remain preferred 2

Electroconvulsive Therapy (ECT)

• ECT should be considered the treatment of choice for severe cases, particularly when catatonia is present, when rapid restoration of health is critical, or when medication augmentation is needed 5, 6
• ECT is effective and safe in postpartum psychosis, with only transient side effects in mothers and no adverse effects noted in breastfed infants 6
• Common indications for ECT include presence of catatonic symptoms, need for medication augmentation, and significant suicidality 6
• Preliminary evidence suggests ECT may be one of the most effective treatment strategies for postpartum psychosis 4, 5

Essential Psychosocial Interventions

• Include families in the assessment process and treatment planning from the outset, providing both emotional support and practical advice, as family involvement is crucial for recovery 1, 2
• Provide psychoeducation to both patient and family about the nature of postpartum psychosis, available treatments, and expected outcomes 1
• Develop supportive crisis plans to facilitate recovery and acceptance of treatment 1
• Address psychological needs that evolve over time: initially focus on ensuring safety and containment, then help the patient connect with and process their experiences, and finally assist with planning for the future including managing fear of relapse 7

Continuity of Care and Relapse Prevention

• Ensure treating clinicians remain constant for at least the first 18 months of treatment, as continuity of care is essential for optimal outcomes 1
• Keep patients in comprehensive, multidisciplinary, specialist mental healthcare throughout the early recovery period 1
• Thoroughly discuss early warning signs of relapse with both patient and family to enable prompt intervention 1
• Monitor closely for depression and ongoing suicide risk throughout treatment, as these commonly co-occur with psychosis 2
• With adequate treatment, almost all patients achieve complete remission and the prognosis is optimistic 3

Critical Pitfalls to Avoid

• Never discharge prematurely from specialist services, as this substantially increases relapse risk 1
• Do not fail to monitor and address medication side effects, as this leads to non-adherence and subsequent relapse 1
• Avoid reactive rather than preventive care approaches, which miss the best opportunity for enhancing outcomes 1
• Do not neglect to avoid extrapyramidal side effects, as these discourage future medication adherence 2