Postpartum psychosis

Postpartum psychosis
Incidence of psychoses among Swedish first-time mothers
Classification and external resources
Specialty	psychiatry
ICD-10	F53.1
ICD-9-CM	648.4

Postpartum psychosis (or puerperal psychosis) is a term that covers a group of mental illnesses with the sudden onset of psychotic symptoms following childbirth.

A typical example is for a woman to become irritable, have extreme mood swings and hallucinations, and possibly need psychiatric hospitalization. Often, out of fear of stigma or misunderstanding, women hide their condition.^[1] Although there are factors that contribute to an increased risk of developing postpartum psychosis, such as an underlying bipolar disorder, or a previous postpartum psychosis, any pregnant woman is potentially at risk. This illness can take the woman, her family and her medical providers completely by surprise.^[2] Two steps that can be taken to mitigate this risk are 1. The taking of a thorough, detailed history prior to giving birth by a competent professional, and 2. Education of medical care professionals, expectant women and their families.

In the group of illnesses that fall under "postpartum psychosis" there are at least a dozen organic psychoses, which are described under another heading "organic pre- and postpartum psychoses".^[3] The relatively common non-organic form, still prevalent in Europe, North America and throughout the world, is sometimes called puerperal bipolar disorder, because of its close link with manic depressive (bipolar) disorder;^[4] but some of these mothers have atypical symptoms (see below), which come under the heading of acute polymorphic (cycloid) psychosis (schizophreniform in the US).^[5] Puerperal mania was first clearly described by the German obstetrician Friedrich Benjamin Osiander in 1797,^[6] and a literature of over 2,000 works has accumulated since then. These psychoses are endogenous, heritable illnesses with acute onset, benign episodic course and response to mood-normalizing and mood-stabilizing treatments. The inclusion of severe postpartum depression under postpartum psychosis is controversial: many clinicians would allow this only if depression was accompanied by psychotic features (see below).

The onset is abrupt, and symptoms rapidly reach a climax of severity. Manic and acute polymorphic forms almost always start within the first 14 days, but depressive psychosis may develop somewhat later. In some cases, psychosis can develop during pregnancy.

Symptoms

Some women have typical manic symptoms, such as euphoria, overactivity, decreased sleep requirement, loquaciousness, flight of ideas, increased sociability, disinhibition, irritability, violence and delusions, which are usually grandiose or religious in content; on the whole these symptoms are more severe than in mania occurring at other times, with highly disorganized speech and extreme excitement. Others have severe depression with delusions, auditory hallucinations, mutism, stupor or transient swings into hypomania. Some switch from mania to depression (or vice versa) within the same episode. Atypical features include perplexity, confusion, emotions like extreme fear and ecstasy, catatonia or rapid changes of mental state with transient delusional ideas; these are so striking that some authors have regarded them as a distinct, specific disease, but they are the defining features of acute polymorphic (cycloid) psychoses, and are seen in other contexts (for example, menstrual psychosis) and in men.

Although postpartum psychosis can be severe, it is not always obvious. First, it occurs during a time that is a period of disruption for many families, so oddities may be attributed to just being tired or stressed. Second, the symptoms can wax and wane. Third, a woman may try to hide her symptoms from others. Therefore it is advisable for medical care providers to do a careful screen, not simply rely on self-reportage.

Course and treatment

Without treatment, these psychoses can last many months; but with modern therapy they usually resolve within a few months. A small minority follow a relapsing pattern, usually related to the menstrual cycle. Mothers who suffer a puerperal episode are liable to other manic depressive or acute polymorphic episodes, some of which occur after other children are born, some during pregnancy or after an abortion, and some unrelated to childbearing. Puerperal recurrences occur after at least 20% of subsequent deliveries, or over 50% if depressive episodes are included.^[7]

Severe overactivity and delusions may require rapid tranquilization by neuroleptic (antipsychotic) drugs, but they should be used with caution because of the danger of severe side effects including neuroleptic malignant syndrome.^[8] Electro-convulsive (electroshock) treatment may be effective.^[9] Mood stabilizing drugs such as lithium are also useful in treatment and possibly the prevention of episodes in women at high risk (i.e., women who have already experienced manic or puerperal episodes). The location of treatment is an issue: hospitalization is disruptive to the family, and it is possible to treat moderately severe cases at home, where the sufferer can maintain her role as a mother and build up her relationship with the newborn. This requires the presence, round the clock, of competent adults (such as the baby's maternal grandmother), and frequent visits by professional staff.^[10] If hospital admission is necessary, there are advantages in conjoint mother and baby admission. Yet multiple factors must be considered in the subsequent discharge plan to ensure the safety and healthy development of both the baby and its mother.^[11] This plan often involves a multidisciplinary team structure to follow up on mother, baby, their relationship and the entire family.

Suicide is rare, and infanticide extremely rare, during these episodes. Infanticide after childbirth is usually due to profound postpartum depression (melancholic filicide) when it is often accompanied by suicide.^[12]

Furthermore, care should be taken when attempting to get treatment for a woman with this condition because the symptoms of the illness itself can contribute to a reluctance or downright refusal of care.^[13]

Causes

Postpartum psychosis has a world-wide prevalence. Its incidence is less than 1 in 1000 deliveries.^[14] It is more common in first time mothers. The French psychiatrist Louis-Victor Marcé (1862), suggested that the link to menstruation, and especially menstrual psychosis, is important.^[15][16] Molecular genetic studies suggest that there is a specific heritable factor.^[17] There is evidence of linkage to chromosome 16.^[18]

Notable cases

Harriet Mordaunt

Harriet Sarah, Lady Mordaunt (1848–1906),^[19] formerly Harriet Moncreiffe, was the Scottish wife of an English baronet and Member of Parliament, Sir Charles Mordaunt. She was the respondent in a sensational divorce case in which the Prince of Wales (later King Edward VII) was embroiled and, after a counter-petition led to a finding of mental disorder. After a controversial trial lasting seven days, the jury determined that Lady Mordaunt was suffering from “puerperal mania”^[20] (i.e. postpartum psychosis), at the time the summons was served on her and that she was unable to instruct a lawyer in her defense. Accordingly, her husband's petition for divorce was dismissed, while Lady Mordaunt was committed to an asylum,^[21] where she spent the remaining thirty-six years of her life.

Legal status

Several nations including Canada, Great Britain, Australia and Italy recognize post partum mental illness as a mitigating factor in cases where mothers kill their children.^[22] In the United States, such a legal distinction is not currently made.^[22] Britain has had the Infanticide Act since 1922.

In 2009, Texas legislator Jessica Farrar proposed a bill that would recognize postpartum psychosis as a defense for mothers who kill their infants.^[23] Under the terms of the proposed legislation, if jurors concluded that a mother's "judgment was impaired as a result of the effects of giving birth or the effects of lactation following the birth", they would be allowed to convict her of the crime of infanticide, rather than murder.^[22] The maximum penalty for infanticide would be two years in prison.^[22]

See also

• Psychiatric disorders of childbirth
• Postpartum depression

References