A Review of Postpartum Psychosis

University of Pittsburgh, Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania 15213, USA.
Journal of Women's Health (Impact Factor: 2.05). 06/2006; 15(4):352-68. DOI: 10.1089/jwh.2006.15.352
Source: PubMed


The objective is to provide an overview of the clinical features, prognosis, differential diagnosis, evaluation, and treatment of postpartum psychosis.
The authors searched Medline (1966-2005), PsycInfo (1974-2005), Toxnet, and PubMed databases using the key words postpartum psychosis, depression, bipolar disorder, schizophrenia, organic psychosis, pharmacotherapy, psychotherapy, and electroconvulsive therapy. A clinical case is used to facilitate the discussion.
The onset of puerperal psychosis occurs in the first 1-4 weeks after childbirth. The data suggest that postpartum psychosis is an overt presentation of bipolar disorder that is timed to coincide with tremendous hormonal shifts after delivery. The patient develops frank psychosis, cognitive impairment, and grossly disorganized behavior that represent a complete change from previous functioning. These perturbations, in combination with lapsed insight into her illness and symptoms, can lead to devastating consequences in which the safety and well-being of the affected mother and her offspring are jeopardized. Therefore, careful and repeated assessment of the mothers' symptoms, safety, and functional capacity is imperative. Treatment is dictated by the underlying diagnosis, bipolar disorder, and guided by the symptom acuity, patient's response to past treatments, drug tolerability, and breastfeeding preference. The somatic therapies include antimanic agents, atypical antipsychotic medications, and ECT. Estrogen prophylaxis remains purely investigational.
The rapid and accurate diagnosis of postpartum psychosis is essential to expedite appropriate treatment and to allow for quick, full recovery, prevention of future episodes, and reduction of risk to the mother and her children and family.

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    • "In the majority of cases, the onset is rapid and within 2 weeks postpartum. Early symptoms include insomnia and mood fluctuation, followed by more severe mood symptoms such as mania, depression, or a mixed state, as well as psychotic and cognitive symptoms (Bergink et al., 2011; Sit et al., 2006; Spinelli, 2009). Affective phenomenology is a hallmark of the disease and therefore, postpartum psychosis is generally considered a bipolar spectrum disorder and not a primary psychotic disorder (Boyce and Barriball, 2010). "
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    ABSTRACT: Objectives: Women are at very high risk for the first onset of acute and severe mood disorders the first weeks after delivery. Tryptophan breakdown is increased as a physiological phenomenon of the postpartum period and might lead to vulnerability for affective psychosis (PP) and severe depression (PD). The aim of the current study was to investigate alterations in tryptophan breakdown in the physiological postpartum period compared to patients with severe postpartum mood disorders. Methods: We included 52 patients (29 with PP, 23 with PD), 52 matched healthy postpartum women and 29 healthy non-postpartum women. Analyzes of serum tryptophan metabolites were performed using LC-MS/MS system for tryptophan, kynurenine, 3-hydroxykynurenine, kynurenic acid and 5-hydroxyindoleacetic acid. Results: The first two months of the physiological postpartum period were characterized by low tryptophan levels, increased breakdown towards kynurenine and a downstream shift toward the 3-OH-kynurenine arm, away from the kynurenic acid arm. Kynurenine was significantly lower in patients with PP and PD as compared to healthy postpartum women (p=0.011 and p=0.001); the remaining tryptophan metabolites demonstrated few differences between patients and healthy postpartum women. Limitation: Low prevalence of the investigated disorders and strict exclusion criteria to obtain homogenous groups, resulted in relatively small sample sizes. Conclusion: The high kynurenine levels and increased tryptophan breakdown as a phenomenon of the physiological postpartum period was not present in patients with severe postpartum mood disorders. No differences were observed in the levels of the 'neurotoxic' 3-OH-kynurenine and the 'neuroprotective' kynurenic acid arms between patients and healthy postpartum women.
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    • "In particular, small signals are augmented and amplified to have large effects. There is a wealth of literature on the triggers of mania and established precipitants include sleep deprivation [29], recreational use of stimulant drugs [30], antidepressants [31] [32], corticosteroids [31], anabolic steroids [32], falling in love [30] and childbirth [33]. In the presence of a de-afferented neuronal pathway , the effect of a pleasurable stimulus from falling in love or recreational stimulants could be greatly amplified. "
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    ABSTRACT: Bipolar disorder, characterised by extreme cyclical variations in mood between depression and mania, is a common, debilitating and sometimes fatal psychiatric condition with an unclear aetiology. In this paper we propose a hypothesis for the development of bipolar disorder through which neuroplastic changes in response to an index depressive episode leads to the amplification of subthreshold pleasurable stimuli that then drive conversion into a manic state. This 'pleasure deafferentation hypothesis' is reached through a discussion of the neuroscientific basis of deafferentation at the level of the neuron and its role in the development of various neurological and psychiatric phenomena before a case for deafferentation as applied to bipolar disorder is justified and its implications discussed.
    Medical Hypotheses 09/2015; DOI:10.1016/j.mehy.2015.09.023 · 1.07 Impact Factor
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    • "Today, 1–2 in every 1000 women experience psychotic or manic symptoms in the first 4 weeks after childbirth and are diagnosed with postnatal psychosis, also known as postpartum or puerperal psychosis (Austin & Highet 2011, American Psychiatric Association 2013, Essali et al. 2013). Postnatal psychosis is characterized by the rapid onset of hallucinations, delusions, confused thinking and mood swings and is a risk factor for maternal suicide and infanticide (Brockington 1996, Sit et al. 2006, Heron et al. 2008, Oates 2008, Doucet et al. 2009, Posmontier 2010, Oates & Cantwell 2011, Glover et al. 2014). It is treated with antipsychotic and mood stabilizers; however, admission is often required to prevent harm to the woman or to any other person, including the child (Doucet et al. 2009, Posmontier 2010). "
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    ABSTRACT: Aim: This study analysed historical healthcare records to investigate how women diagnosed with mania or psychosis and admitted to two mental health facilities in Australia following childbirth, were described in the late Victorian (1885 to 1895) and inter-war period (1925 to 1935). Background: Although historians have examined the history of mental health systems in Australia, there is no published scholarship that considers the healthcare records of these women. This was a unique opportunity to explore these documents. Design: An historical study examining healthcare records. The data collection occurred in 2012. Methods: Women admitted to mental health facilities with a diagnosis of psychosis or mania were identified in the admission registers found in the State Record Office of New South Wales and, if available, their healthcare record was transcribed verbatim. The records were imported into NVivo 10 for content analysis to determine the range and scope of information. A further textual analysis was conducted to see if the woman’s diagnosis was congruent with the outcome of her admission. Results/Findings: 155 cases were identified across the two periods. Although, demographic data and the description of the women on admission were remarkably similar, 17% of women were physically, rather than mentally, ill and died soon after admission. The findings demonstrate the importance of current practices such as taking a comprehensive healthcare assessment and the use of antibiotics and sanitary measures during labour and in the postnatal period. Conclusion: Historical investigations of healthcare records provide legitimacy for current healthcare practices.
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