What is the recommended treatment for a postpartum patient presenting with psychosis?

Treatment for Postpartum Psychosis

Postpartum psychosis requires immediate hospitalization with atypical antipsychotics (risperidone 2 mg/day or olanzapine 7.5-10 mg/day) as first-line treatment, combined with lithium for optimal acute management and relapse prevention. 1, 2

Immediate Assessment and Hospitalization

Risk assessment is the first priority, evaluating potential for self-harm, aggression toward the infant, and adequacy of community support to determine if inpatient care is required 1. Postpartum psychosis is a psychiatric emergency warranting acute inpatient admission, ideally to a specialized mother-baby unit where available 3, 4.

Before initiating psychiatric treatment, rule out medical causes of psychosis including:

• Thyroid dysfunction 1
• Electrolyte imbalances (particularly hypocalcemia) 1
• Infectious processes 1

First-Line Pharmacological Treatment

Atypical antipsychotics are the preferred initial agents due to superior tolerability and reduced extrapyramidal side effects, which improves medication adherence 1. The recommended starting doses are:

• Risperidone 2 mg/day 1
• Olanzapine 7.5-10 mg/day 1

Combination therapy with lithium and antipsychotics provides optimal acute treatment for postpartum psychosis 2. Evidence indicates postpartum psychosis exists on the bipolar disorder spectrum, making lithium particularly effective 2.

Treatment should be implemented for 4-6 weeks at adequate dosages before determining efficacy 5. Avoid excessive initial dosing, as this causes unnecessary side effects without hastening recovery 5.

Electroconvulsive Therapy (ECT)

ECT should be considered for severe cases, particularly when:

• Catatonic symptoms are present 6
• Rapid response is needed 2
• Suicidality exists 6
• Medication augmentation is required 6

ECT is effective and safe for women with severe postpartum psychosis, including those who are breastfeeding, with no adverse effects noted in breastfed infants 6. ECT can offer rapid treatment response where required 2.

Monitoring and Side Effect Management

Regular monitoring for medication side effects is essential, as these can impair recovery and reduce adherence 1. Key side effects to monitor include:

• Weight gain 1
• Sexual dysfunction 1
• Sedation 1

Failing to monitor and address these side effects leads to non-adherence and subsequent relapse 1, 7.

Psychosocial Interventions and Family Involvement

Families must be included in the assessment process and treatment planning, providing emotional support and practical advice 1, 5. Supportive crisis plans are essential to facilitate recovery and acceptance of treatment 1, 5.

Psychoeducation for both patient and family about the nature of postpartum psychosis, treatments, and expected outcomes is crucial 1, 7. For patients with frequent relapses or slow recovery, provide more intensive and prolonged psychoeducational interventions for families 7.

Continuity of Care and Relapse Prevention

Lithium has the best evidence for relapse prevention and prophylaxis in postpartum psychosis 2. Early detection and prompt treatment with antipsychotics and lithium, followed by maintenance treatment with lithium, is associated with favorable prognosis 2.

Ensure continuity of care with treating clinicians remaining constant for at least the first 18 months of treatment 1, 7, 5. Patients should remain in comprehensive, multidisciplinary, specialist mental healthcare throughout the early recovery period 1, 7.

Early warning signs of relapse should be thoroughly discussed with both patient and family to enable prompt intervention 1, 7, 5. Maintain vigilance for signs of relapse including depression, suicide risk, substance misuse, and social anxiety, as these can trigger relapse 7.

Once psychosis achieves sustained remission, slow reduction of antipsychotic medication should be attempted to determine minimal effective dose, but complete discontinuation significantly increases relapse risk 7. Long-term medication is strongly advised for individuals who experience frequent relapses, with studies showing five times higher relapse rates among those who discontinue medication 7.

Common Pitfalls to Avoid

• Premature discharge from specialist services increases relapse risk 1, 7, 5
• Reactive rather than preventive care approaches miss the best opportunity for enhancing outcomes 1, 7, 5
• Failing to monitor and address medication side effects leads to non-adherence and subsequent relapse 1, 7
• Discharging patients to primary care without continuing specialist involvement once acute symptoms improve increases relapse risk 7