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Post-Partum Psychosis
Post-partum psychosis is also referred to as puerperal psychoses or mental and peripartum psychosis. It is a serious mental health disorder and acute emergency that is associated with pregnancy, childbirth, and the postnatal period. It is reported to affect 1-2 for every 1000 child births worldwide t and mostly occurs within the first 2-4 weeks post-delivery. However, it is currently unrecognized by diagnostic systems. It is a condition that is predominated by affective components. It is commonly used in the clinical context to describe a diverse constellation of symptoms with a sudden onset after childbirth. Most presentations fulfill the criteria for diagnosis of major depressive disorder with psychotic symptoms, mania, or schizoaffective disorders. Organic psychotic illnesses especially those with infective causes also occur especially in Low- and Middle-Income Countries (LMIC). In Nigeria, it affects 2-3 for 1000 childbirths higher than the rate reported in high income countries.
The change that occurs due to hormonal, physical, psychological, and social changes in the life of a new mother is what usually predisposes them to post-partum psychosis. This follows the Bio-Psycho-Social pattern of most mental illnesses.
The signs and symptoms of post-partum psychoses can be gradual or sudden. Most of the mothers start with post-partum blues, then post-partum depression, and subsequently develop psychotic symptoms if those mentioned above are not well taken care of. However, some present with manic symptoms or frank psychotic symptoms from the start. The most common presenting symptoms include; low mood or elated mood, poor sleep, agitation, irritability, confusion, neglect or harm to the child, suicidality, homicidal tendencies, delusions, hallucinations, and gross abnormal behaviors.
Mental state examination findings may include; an unkempt woman, poorly dressed, might be uncooperative and restless. Mood can be depressed or elated depending on the theme of the psychoses, affect might or might not be congruent with the mood. There could be delusions, hallucinations, depersonalizations, and/or derealization. There could be poor cognition, especially in organic psychoses, poor judgment, and lack of insight. Previous history of mental illness is a very important risk factor.
1. Young age: less than 25 as at the time of giving birth
2. Lack of a supportive partner
3. Severe sleep deprivation
4. Rapid hormonal changes around the birth
5. Prior history of postpartum psychosis in previous pregnancies
6. Poverty
7. Previous history of mental illness (Bipolar disorder or major depression with psychosis, schizophrenia)
8. Family history of psychosis or bipolar disorder
9. Unplanned pregnancy
10. First delivery
11. Noncompliance or stoppage of prior psychiatric medications during pregnancy
12. Postpartum Heamorrage
13. Those who undergo Caesarian section surgery
Differential diagnoses include; delirium, bipolar disorder, major depressive disorder not related to childbirth, substance use disorder, schizophrenia, thiamine deficiency, vitamin B12 deficiency, uremia, diabetic ketoacidosis, hepatic encephalopathy and immunological diseases like systemic lupus erythematosus (SLE).
Diagnosis of pot-partum psychosis is clinical; however, differential diagnosis needs to be ruled out to exclude organicity. Baseline investigations such as complete blood count, serum electrolytes, urea and creatinine, blood glucose levels, urinalysis, liver function tests, and brain CT/ MRI can all be done depending on the presentation. Psychological investigations to assess the severity of depressive, manic, and psychotic symptoms can be carried out. Suicidality and violence risk assessments are also worth performing. Social investigations to assess family dynamics and look at her social support base and also possible stressors in the home environment can also be done.
The treatment of post-partum psychosis follows the bio-Psycho-Social approach like all other psychiatric illnesses. Postpartum psychosis is a mental health emergency, hence, the first thing to do once diagnosis is established is to admit the mother with the child in a mother-baby unit where the baby will stay with the mother under strict supervision. The safety of the mother and child is essential in treatment consideration. Client needs close monitoring and urgent treatment. Second generation antipsychotic medications such olanzapine, risperidone, aripiprazole are safe to use and are recommended as the first line of management. Anti-depressants and mood stabilizers (Lithium) can be used as well. Correction of anemia, vitamin deficiencies and treatment of other underlying conditions that might be picked should be carried out. Electro-convulsive therapy can be used in severe or treatment refractory cases. Some key behavioural intervention include psychoeducation, CBT and peer support group.
When the client is stable and ready for discharge, frequent follow-ups are recommended until 1-year post-partum. This is however individualized depending on type of illness, severity, financial resources and proximity to the mental health facility.
Post-partum psychosis has no single cause and hence total prevention is difficult. However, treatment of those with already existing mental illnesses, good family and social support play key roles in preventing it. Early presentation and adequate treatment help prevent complications. Those with previous history of post-partum psychosis should be placed under close monitoring.
In conclusion, post-partum psychosis is a severe mental illness which requires prompt treatment in a mental health facility. Prompt treatment helps to prevent complications that could occur due to the illness. Good family and social support during pregnancy and puparium plays a significant role in prevention.
A 19-year-old primipara presented with history of aggression and neglect of her baby. She claims voices are telling her that this world is cruel and she should kill herself and the child to escape the hardships of the world. She lives in a rural community and did not have any antenatal visits. She has no pre-existing physical or mental illnesses. She is married to an elderly man who doesn’t believe in helping out in house chores. She lives in a different settlement from her parents and they only went to visit her following the delivery. Her affect was labile, she had hallucinations, and persecutory delusion with suicidal and homicidal thoughts. She lacked insight and had poor judgement. She was immediately admitted, the Bio-psychosocial method of management was used. She spent one month on admission and was discharged for follow-up in two weeks. She however did not come back for follow-up despite proper psychoeducation before discharge
1. Modern Management of Perinatal Psychiatric Disorders (Second edition) Henshaw Carol Cox John Barton Joanne Modern Management of Perinatal Psychiatric Disorders (Second edition).
2. Shorter Oxford Textbook of Psychiatry Paul Harrison, 6th edition.
3. Review of psychiatry Praveen Tripathi, 7th edition.
4. Kaplan and Sadock’s comprehensive textbook of Psychiatry 9th edition.
5. African textbook of psychiatry by Professor David Musyimi Ndetei.
6. Vanderkruik R, Barreix M, Chou D, Allen T, Say L, Cohen LS et al,.The global prevalence of postpartum psychosis: a systematic review. BMC Psychiatry 2017; 17: 1427-7.
Author's details
Reviewer's details
Post-Partum Psychosis
Post-partum psychosis is also referred to as puerperal psychoses or mental and peripartum psychosis. It is a serious mental health disorder and acute emergency that is associated with pregnancy, childbirth, and the postnatal period. It is reported to affect 1-2 for every 1000 child births worldwide t and mostly occurs within the first 2-4 weeks post-delivery. However, it is currently unrecognized by diagnostic systems. It is a condition that is predominated by affective components. It is commonly used in the clinical context to describe a diverse constellation of symptoms with a sudden onset after childbirth. Most presentations fulfill the criteria for diagnosis of major depressive disorder with psychotic symptoms, mania, or schizoaffective disorders. Organic psychotic illnesses especially those with infective causes also occur especially in Low- and Middle-Income Countries (LMIC). In Nigeria, it affects 2-3 for 1000 childbirths higher than the rate reported in high income countries.
The change that occurs due to hormonal, physical, psychological, and social changes in the life of a new mother is what usually predisposes them to post-partum psychosis. This follows the Bio-Psycho-Social pattern of most mental illnesses.
1. Modern Management of Perinatal Psychiatric Disorders (Second edition) Henshaw Carol Cox John Barton Joanne Modern Management of Perinatal Psychiatric Disorders (Second edition).
2. Shorter Oxford Textbook of Psychiatry Paul Harrison, 6th edition.
3. Review of psychiatry Praveen Tripathi, 7th edition.
4. Kaplan and Sadock’s comprehensive textbook of Psychiatry 9th edition.
5. African textbook of psychiatry by Professor David Musyimi Ndetei.
6. Vanderkruik R, Barreix M, Chou D, Allen T, Say L, Cohen LS et al,.The global prevalence of postpartum psychosis: a systematic review. BMC Psychiatry 2017; 17: 1427-7.
Content
Author's details
Reviewer's details
Post-Partum Psychosis
Background
Post-partum psychosis is also referred to as puerperal psychoses or mental and peripartum psychosis. It is a serious mental health disorder and acute emergency that is associated with pregnancy, childbirth, and the postnatal period. It is reported to affect 1-2 for every 1000 child births worldwide t and mostly occurs within the first 2-4 weeks post-delivery. However, it is currently unrecognized by diagnostic systems. It is a condition that is predominated by affective components. It is commonly used in the clinical context to describe a diverse constellation of symptoms with a sudden onset after childbirth. Most presentations fulfill the criteria for diagnosis of major depressive disorder with psychotic symptoms, mania, or schizoaffective disorders. Organic psychotic illnesses especially those with infective causes also occur especially in Low- and Middle-Income Countries (LMIC). In Nigeria, it affects 2-3 for 1000 childbirths higher than the rate reported in high income countries.
The change that occurs due to hormonal, physical, psychological, and social changes in the life of a new mother is what usually predisposes them to post-partum psychosis. This follows the Bio-Psycho-Social pattern of most mental illnesses.
Further readings
1. Modern Management of Perinatal Psychiatric Disorders (Second edition) Henshaw Carol Cox John Barton Joanne Modern Management of Perinatal Psychiatric Disorders (Second edition).
2. Shorter Oxford Textbook of Psychiatry Paul Harrison, 6th edition.
3. Review of psychiatry Praveen Tripathi, 7th edition.
4. Kaplan and Sadock’s comprehensive textbook of Psychiatry 9th edition.
5. African textbook of psychiatry by Professor David Musyimi Ndetei.
6. Vanderkruik R, Barreix M, Chou D, Allen T, Say L, Cohen LS et al,.The global prevalence of postpartum psychosis: a systematic review. BMC Psychiatry 2017; 17: 1427-7.
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