Review of: Jairaj C et al, J Psychopharmacol 2023;37(10):960–970

Study Type: Literature review

Postpartum psychosis (PPP) is a serious mental illness that lacks official recognition in DSM-5. This paper pulled together peer-reviewed English-language studies to review what is known about PPP and propose a treatment algorithm.

The prevalence of PPP is around 1–2 cases per 1,000 births. The strongest risk factors for PPP are bipolar disorder and a history of PPP, but having a first-degree relative with bipolar disorder also increases the risk. Currently there are no validated PPP screeners available, but the Mood Disorder Questionnaire (MDQ) has been used.

Patients at risk should be offered pre-conception counseling, ideally from a specialist in perinatal mental health. For patients with a history of PPP, researchers recommend prophylaxis with antipsychotics or lithium after delivery.

Patients with PPP can develop symptoms very quickly—within hours—though they most commonly develop between 3 and 10 days postpartum. Early symptoms include insomnia, anxiety, and mood fluctuations. Later, confusion, disorganized behavior, and mood changes are common. 

Persecutory delusions, delusions of reference, visual hallucinations, and catatonia are also common. Visual hallucinations and delirium-like symptoms are more common with PPP than other psychoses.

When diagnosing PPP, rule out postpartum blues and postpartum depression, which can present in similar ways. Infections, delirium, eclampsia, postpartum thyroiditis, autoimmune encephalitis, Sheehan syndrome (postpartum pituitary disorder), and metabolic derangement should also be on your radar. Lastly, rule out medication- or substance-induced psychosis with a urine drug screen.

Other recommended labs include full blood count, metabolic profile, thyroid profile, serum calcium levels, B12, folate, and thiamine. Rule out thyroiditis with antithyroid peroxidase antibodies and autoimmune encephalitis with anti-NMDA antibodies and imaging. Elevated C-reactive protein, a marker for inflammation, is also linked to PPP.

PPP is a psychiatric emergency that often warrants hospitalization. Researchers recommend three medications: lithium, a second-generation antipsychotic, and short-term benzodiazepines to manage catatonia, agitation, or insomnia. Neonatologists should be consulted about lithium. For breastfeeding patients, olanzapine and lorazepam are recommended due to their safety profile in lactation. ECT is an option when a rapid response is needed or when medication doesn’t work. The choice to breastfeed should be individualized, because it can affect medication selection—namely, lithium—and the sleep deprivation can exacerbate PPP.

Researchers found no studies of antidepressants or psychosocial interventions in PPP. Brexanolone and zuranolone, though approved for postpartum depression, also lack evidence in psychotic patients. They do suggest that individual and couples therapy may help both the patient and the couple work through the emotions and relationship challenges that an episode of PPP can bring.

CARLAT TAKE

PPP is a life-threatening condition that requires early screening and intervention, along with inpatient treatment. This algorithm puts lithium, antipsychotics, and short-term benzodiazepines first line, with ECT reserved for refractory cases or those requiring a rapid response.