From the Guidelines
The gold standard for diagnosing postpartum psychosis is a clinical interview, with the most well-known being the Structured Clinical Interview for the DSM-IV, although this study 1 focuses on postpartum depression, the principle of a clinical interview applies broadly to psychiatric conditions, including postpartum psychosis.
Key Considerations
- The importance of cultural factors in the expression and diagnosis of postpartum mental health conditions is highlighted in the study 1, emphasizing the need for a comprehensive and culturally sensitive approach to diagnosis and treatment.
- While the study 1 discusses the use of shorter screening tools like the Edinburgh Postnatal Depression Scale (EPDS) for postpartum depression, the diagnosis of postpartum psychosis typically requires a more thorough clinical assessment due to its severity and potential risks.
- Postpartum psychosis is a severe condition that requires immediate psychiatric intervention, often involving hospitalization, and a combination of antipsychotic medications, mood stabilizers, and supportive care to manage symptoms and prevent severe outcomes like suicide or infanticide.
Treatment Approach
- Given the severity and risks associated with postpartum psychosis, treatment should prioritize rapid and effective management of symptoms, typically involving second-generation antipsychotics, mood stabilizers, and, when necessary, benzodiazepines for agitation or insomnia, as guided by the most recent clinical guidelines and expert consensus.
- Electroconvulsive therapy (ECT) may be considered for severe or treatment-resistant cases, highlighting the need for a comprehensive treatment plan that can be adjusted based on the patient's response and clinical condition.
- The involvement of mother-baby units, when available, is crucial for maintaining the mother-infant bond while ensuring the safety of both, which is a key aspect of the treatment approach for postpartum psychosis.
From the Research
Treatment Options for Postpartum Psychosis
- The treatment of postpartum psychosis is dictated by the underlying diagnosis, often bipolar disorder, and guided by symptom acuity, patient response to past treatments, drug tolerability, and breastfeeding preference 2.
- A structured treatment algorithm with the sequential addition of benzodiazepines, antipsychotics, and lithium may result in high rates of remission in patients with first-onset postpartum psychosis 3.
- Lithium maintenance may be most beneficial for relapse prevention, with patients treated with lithium having a significantly lower rate of relapse compared to those treated with antipsychotic monotherapy 3.
Pharmacological Therapy
- Pharmacological therapy is the mainstay of postpartum psychosis management in the acute phase, with evidence pointing to a combination of antipsychotics and lithium in the acute treatment 4, 5.
- Electroconvulsive therapy can offer a rapid treatment response where required, and lithium appears to have the best evidence for relapse prevention and prophylaxis in postpartum psychosis 4, 5.
Psychoeducation and Psychosocial Interventions
- Psychoeducation is essential, and psychosocial interventions used in bipolar disorder may be effective in postpartum psychosis 4, 5.
- Early detection and prompt treatment with antipsychotics and lithium, followed by maintenance treatment with lithium, is associated with a favourable prognosis in postpartum psychosis 4, 5.
Prevention and Treatment Interventions
- Studies on the prevention of postpartum psychosis have examined the effects of mood stabilizers, antipsychotics, and hormone therapy, while those examining treatment have included electroconvulsive therapy, mood stabilizers, antipsychotics, hormones, and the beta blocker propranolol 6.
- Only preliminary evidence suggests which interventions may be effective strategies to prevent (e.g., lithium) and treat (e.g., electroconvulsive therapy) postpartum psychosis, with well-designed prospective studies needed to determine the efficacy of prevention and treatment interventions 6.