Postpartum Psychosis


Article Author:
Sehar Raza


Article Editor:
Syed Raza


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
7/6/2019 5:25:07 PM

Introduction

Childbirth is considered a major physical, emotional, and social stressor in a woman’s life. Following days to weeks after childbirth, most women experience some mental disturbance like mood swings and mild depression (also known as post-baby blues), but a few can also suffer from PTSD, major depression, or even full-blown psychosis.[1][2] This change in maternal behavior and thought process is due to several bio-psycho-social factors. There are physical and hormonal changes, lack of sleep and exhaustion, and the beginning of a new role and commitment in caring for a newborn, which is both physically and emotionally challenging. Postpartum psychosis is the severest form of mental illness in that category characterized by extreme confusion, loss of touch with reality, paranoia, delusions, disorganized thought process, and hallucinations.[3] It affects around one to two per one thousand females of childbearing age and usually happens immediately within days to the first six weeks after birth. Although rare, it is considered a psychiatric emergency that warrants immediate medical and psychiatric attention and hospitalization if the risk of suicide or filicide exists.

Etiology

Postpartum psychosis has a complex multifactorial origin. Risk factors include a history of bipolar disorder,  history of postpartum psychosis in a previous pregnancy, family history of psychosis or bipolar disorder, history of schizoaffective disorder or schizophrenia and discontinuation of psychiatric medications during pregnancy. The overall prevalence is higher in patients suffering from affective disorders like bipolar one, two, and first-time pregnancy with a previous family or personal history of bipolar one disorder is considered the single most important risk factor.[4] Lack of sleep and hormonal fluctuations after birth, especially the rapidly falling levels of estrogen, may also pose a risk; previous postulations proposed that treatment with estradiol may be beneficial as an adjunctive treatment for women with psychosis in schizophrenia.[5][6] However, a subsequent study found a minimal benefit of prophylactic estradiol administration in pregnant females with a history of bipolar one, bipolar two, and schizophrenia to prevent relapse in the postpartum period.[7] In one study conducted on parous women with bipolar disorder, sleep loss triggering episodes of mania was considered to be an essential marker to determine predisposition to developing postpartum psychosis. The conclusion was that women who reported sleep deprivation leading to manic episodes were twice as likely to have experienced an episode of postpartum psychosis at some point in their lives.[8]

Epidemiology

With an estimated global prevalence of 0.089 to 2.6 per 1000 births, postpartum psychosis classifies as an illness with a low incidence rate. However, it carries the potential for serious medical and social consequences, including the risk of suicide and filicide, if not promptly detected and treated.[9] While first-time pregnancies in women with a history of affective mood disorders, specifically bipolar one disorder are considered the single most important risk factor, almost fifty percent of cases reported in first-time mothers are without any previous psychiatric hospitalization history. Moreover, observation shows that the latter group of patients had nearly ten times higher incidence rate during the first couple of months postpartum.[10] Other factors like advanced maternal age and low birth weight of the baby (less than one hundred fifty grams ) are also considered possible contributing factors while maternal diabetes and high birth weight of the baby (more than four thousand five hundred grams) appear to be protective against puerperal psychosis in first-time mothers during the first ninety days. Negative pregnancy and birthing outcomes like congenital malformations, preterm birth (less than thirty-two weeks) and fetal/infant death also increase the risk of psychoses and major depressive disorders in not just first-time mothers but in all mothers.

History and Physical

When a patient presents with symptoms of psychosis and recent history (days to few weeks) of giving birth a  careful and thorough history and neuropsychiatric evaluation is required to expedite correct diagnosis, treatment, and recovery. It is essential to rule out a previous personal or family history of psychiatric illness. Prenatal and perinatal health records should undergo an evaluation to rule out medical comorbidities, organic causes, and a complicated obstetrical history like preeclampsia and eclampsia or negative birth outcomes. The clinician should note whether the patient with a psychiatric history who was previously stable on psychiatric medications was compliant with her prescribed psychiatric medications throughout the pregnancy as often medications are discontinued before or during pregnancy.

Substance abuse, medication history, and a history of any other recent major stressors or traumatic events merit attention. The care team should also evaluate the patient’s social support network, including the role and responsibilities of her partner and other available caregivers in the family. Symptoms of puerperal psychosis include confusion, lack of touch with reality, disorganized thought pattern and behavior, odd effect, sleep disturbances, delusions, paranoia, appetite disturbances, a noticeable change in the level of functioning from baseline, hallucinations and suicidal or homicidal ideation. Safety of the patient and newborn is of utmost importance, and thus, immediate hospitalization is warranted if there is a risk of harm to either one.[11]

Evaluation

Postpartum psychosis has been underdiagnosed and underreported because there are no standard screening procedures in place during the prenatal and postnatal period.[12] While generally more focus is placed on the mother and baby’s physical health and recuperation during and after pregnancy, primary care providers should have questionnaires directly assessing patient’s mood and feelings of well being throughout pregnancy and postpartum. EPDS (Edinburgh postnatal depression scale) and MDQ (mood disorder questionnaire) are quick and effective screening tools to identify signs of depression and mania in populations at risk.[13][14] This evaluation can greatly help in risk assessment for future psychiatric illness in the critical puerperal time zone. Following a thorough history and complete physical examination, the following initial labs help identify organic causes of psychosis.

  • A complete blood count(CBC)
  • Electrolytes
  • Blood urea nitrogen (BUN)
  • Blood glucose
  • Creatinine
  • Vitamin B12
  • Folate
  • Thiamine
  • Calcium
  • Thyroid function tests
  • Liver function tests or LFTs
  • Urinalysis
  • Urine drug screen
  • Urine/blood cultures for patients with fever
  • CT/ MRI brain

The above lab tests help to rule out medical conditions and organic causes that may present as psychosis. Examples include hypo and hypernatremia, hypo and hyperglycemia (insulin shock and diabetic ketoacidosis), abnormal liver function tests (hepatic encephalopathy), and hypo and hyperthyroidism (thyroid storm in Graves disease). Other examples are uremia, substance abuse, hypercalcemia (in hyperparathyroidism), urine and blood cultures to rule out infection and CT, and MRI to see for a possibility of a stroke, especially in women with a history of pregnancy-induced hypertension, preeclampsia, and eclampsia.

Treatment / Management

Timely identification of the illness is of utmost importance as it is a psychiatric emergency. Postpartum psychosis usually has a sudden onset but is a brief and limited illness which responds rapidly to treatment. Mothers who are at risk for harm to themselves or the baby require immediate hospitalization. There are no current guidelines to manage postpartum psychosis, and the management depends on the cause. Once organic causes have been ruled out, medications to control acute psychosis may be started. These include mood stabilizers, atypical antipsychotics, and antiepileptic drugs. Common drugs from these classes include lithium, sodium valproate, lamotrigine, carbamazepine, benzodiazepines, quetiapine, olanzapine, etc.

Although prophylactic treatment for women with bipolar disorder throughout pregnancy is a recommendation for women at high risk of relapse, benefits and risks merit careful discussion.[15][16] Lithium has been a standard treatment option for bipolar depression and postpartum right after delivery in patients with a history of bipolar disorder or previous isolated episodes of postpartum psychosis. Use of lithium during pregnancy is controversial as it bears a significant risk for congenital malformations, namely Ebstein anomaly and low fetal birth weight.[17] Some studies advise the use of prophylactic lithium and other mood stabilizers,[18] right after delivery in patients with a history of bipolar disorder.[19] Suggestions are that if the patient was previously stable on lithium (discontinued during pregnancy) that it be restarted as soon as the patient delivers to prevent relapse.

For women with a previous history of postpartum psychosis, the recommendation is high therapeutic target level lithium prophylaxis (zero points eight to one mmol/liter) to prevent future episodes. In that case, lithium blood levels should be obtained twice a week for at least the first two weeks postpartum. Women should abstain from breastfeeding while taking lithium as it is eliminated in breast milk and may cause higher exposure levels in infants as their metabolic systems and mechanisms of drug excretion are underdeveloped.[17] On the other hand, the use of SSRIs, carbamazepine, sodium valproate, and short-acting benzodiazepines are considered relatively safe during breastfeeding.[20] Not only does breastfeeding lead to lack of sleep and exhaustion to the mother (which can further exaggerate her symptoms) but, oxytocin, the hormone that regulates breastfeeding, also causes insomnia in breastfeeding mothers. That is why it is important to discuss the pros and cons of breastfeeding with the patient and her family.[21]

Electroconvulsive therapy (ECT) is recognized as a means of treatment with a tremendous benefit in patients with psychosis related to schizophrenia and schizoaffective disorder refractory to antipsychotic pharmacotherapy.[22] ECT is also considered a safe and effective intervention in patients with acute relapse or exacerbation of psychosis in the postpartum period with the risk of minimal complications.[23][24][25] Patients with a history of bipolar disorder stable on mood stabilizer medications before pregnancy who discontinue medications during pregnancy have an elevated risk of developing a relapse in the perinatal or postnatal period. Almost all classes of medications used as maintenance therapy pose a risk of congenital malformations and other neural complications to the developing fetus especially during the first twelve weeks of development.

The patient and the family must make an informed decision, carefully weighing the risks and benefits of medication management during pregnancy. Of the main pharmacological options, lithium has a 2.8% rate of causing major congenital malformations, valproate is highest at 5 to 8%, and carbamazepine 2 to 6%.[26] As for atypical and typical antipsychotics, the risk for causing major congenital malformations is unclear as there are no significant studies during pregnancy. Non-pharmacologic treatment like psychotherapy is a good adjuvant treatment alongside psychopharmacology and ECT has a track record as a safe and effective means of treating an acute episode during pregnancy alongside or without psychiatric medications.[27]

Differential Diagnosis

Following psychiatric [28] and medical causes should be considered and ruled out through careful history, appropriate lab investigations and radiological studies when a patient comes in with a history of recent childbirth (days to few weeks) and symptoms of psychosis such as delusions, hallucinations, paranoia, confusion, agitation, lack of touch with reality, sleep disturbance and thoughts of suicide or filicide. 

The psychiatric differential may include:

  • Bipolar 1 relapse (current and past history of low and high moods plus family history)
  • Unipolar major depression with psychotic features with postpartum onset
  • OCD and schizophrenia or schizophreniform disorder (past treatment history and medication non-compliance)
  • Hyperthyroidism-thyroid storm as in Graves disease (thyroid function tests), fever due to these conditions: infections such as sepsis, meningitis, encephalitis, (complete blood count/ESR /differential, lumbar puncture)
  • Diabetic ketoacidosis (fasting blood glucose, HbA1C, history of glucose tolerance during pregnancy)
  • Substance misuse (drug screen for drugs of abuse)
  • Uremia (kidney function tests, BUN, creatinine)
  • Hepatic encephalopathy (LFTs, AST, ALT, hepatitis screen if a history of exposure or disease, alkaline phosphatase, bilirubin direct/indirect, lipase)
  • Vitamin B12 deficiency
  • Thiamine deficiency
  • Hypercalcemia
  • Pregnancy-induced hypertension and stroke due to preeclampsia or eclampsia (CT/MRI to rule out stroke)
  • Metabolic or nutritional causes (electrolytes)
  • Immunological causes like SLE
  • Certain drugs like corticosteroids, antivirals (acyclovir and interferon), antibiotics (gentamicin, vancomycin, isoniazid), anticholinergic medicines like atropine, benztropine, and sympathomimetic stimulants like amphetamine, ephedrine, and theophylline

Prognosis

Postpartum psychosis is a severe mental crisis that warrants immediate medical attention. Although considered a psychiatric emergency, most patients respond to treatment and demonstrate fast recovery and remission.[29][30] However, having one episode of postpartum psychosis predisposes the patient to another episode with a future pregnancy. Patients with a history of bipolar disorder are predisposed to developing a relapse during and after pregnancy and should be carefully evaluated and counseled regarding the risk in future pregnancies.

Complications

Postpartum psychosis is a rare occurrence but may lead to undesirable outcomes. The proper identification of risk markers would enhance the ability to prevent and manage the condition. If left untreated, it can result in tragic consequences like suicide or filicide. It is a period of tremendous stress for the partner and other family members involved in taking care of the patient and has notable psychosocial implications.

Deterrence and Patient Education

Like any other mental illness, postpartum psychosis not only affects the mother and the infant but has an equal impact on families and caregivers. It is crucial for the treatment team to be able to understand the magnitude of physical and emotional stress the partner and other family members are going through and address all their questions and concerns in an empathetic manner.[31] Patients should be screened for signs of mental illness during pregnancy and after childbirth. Women planning to get pregnant, who are predisposed to developing postpartum psychosis should be counseled and informed about the illness course and outcomes and the risks associated with the disease and treatment options available so they can arrive at an informed decision.

Enhancing Healthcare Team Outcomes

Regular screening for signs of mental illness during pregnancy and after childbirth should be protocol. Social services, nurses, and other relevant departments may be involved to assess the situation and provide support and assistance if needed; reporting to clinicians whenever there is evidence suggesting lack of improvement. When a patient seeks prenatal or postnatal care, primary care providers should pay attention to the entire bio-psycho-social model and not just the patient's physical and medical issues related to pregnancy. EPDS (Edinburgh postnatal depression scale) and MDQ (mood disorder questionnaire) are quick and effective screenings to identify telltale signs of possible mental illness in women during and after pregnancy.

Postpartum psychosis requires an interprofessional team approach, including physicians, specialists, mental health professionals, specialty-trained nurses, and pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level V]


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Postpartum Psychosis - Questions

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The day after delivery, a mother develops confusion, disorientation, and loss of touch with reality. Which of the following is the most likely diagnosis?



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What is not true about postpartum psychosis?



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A 28-year-old woman presents 1 month after the delivery of her newborn son. She is feeling very low and has lost interest in daily activities. Sometimes, she just bursts into tears. Recently, she reports hearing voices telling her to kill the baby to make the world a better place. Which of the following statements is true about the most likely diagnosis?



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A nurse is caring for a client with a diagnosis of postpartum psychosis. Which of the following is important for the nurse to know related to this disorder? Select all that apply.



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A 27-year-old primigravida comes for a prenatal consultation. She is a veteran who is recently back from a tour and has a history of post-traumatic stress disorder. Her cousin had an episode of postpartum psychosis after delivering her first child. The patient is concerned about her mental health and wants to find out if she too is at risk of developing postpartum psychosis during or after pregnancy. Which of the following conditions is most likely to be associated with postpartum psychosis?



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A 28-year-old GTPAL (gravida, term, preterm, abortions, and living) of 3-2-0-1-2 female presents the office with a reported loss of interest in everyday activities. She delivered a viable infant one week ago. She lives at home with her husband and 2-year-old child. She has a history of postpartum depression with her first child. The patient is not currently taking a prenatal vitamin daily. She states that she hears voices and that she believes they want to harm her baby. Which of the following is the next best step in the management of this patient?



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A 22-year-old previously healthy female, primipara is brought to the emergency department on 4th-day postpartum with complaints of confusion, lack of sleep, anxiety, agitation, and loss of touch with reality. She complains about seeing ghosts of her dead relatives in the nursery. She does not trust anyone holding the baby as she believes that everyone, including her husband, is trying to kidnap the baby. She has no previous psychiatric history, and there is no history of mental illness in the family. Her medical and obstetrical history is uneventful. On examination, her vitals are normal. The neurological exam is also within limits. The psychiatric evaluation shows disheveled appearance, confusion, agitation, and hallucinations. There is no suicidal or homicidal ideation. Routine labs are all within normal limits, and urine toxicology screen is negative. What is the most likely diagnosis?



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A 24-year-old primipara is brought to the emergency department on 4th-day postpartum with complaints of confusion, lack of sleep, anxiety, and loss of touch with reality. She complains about seeing ghosts of her dead relatives everywhere. She believes the baby has demonic powers and feels scared to touch or go near the baby. She has a previous history of bipolar one disorder for which she was taking medications until the start of pregnancy when she discontinued all her medications. Her mother also suffers from bipolar disorder, and one of her cousins from her maternal side has schizophrenia. Her sister, who had diabetes type 1, passed away recently. Her medical and obstetrical history is otherwise uneventful. On examination, her vitals are normal. The neurological exam is within limits, and psychiatric evaluation shows disheveled appearance, confusion, agitation delusions, paranoia, and hallucinations. CBC shows elevated eosinophils, while electrolytes are all within normal limits. The urine toxicology report is negative. What is the most likely cause of her psychosis?



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A 24-year female primipara is brought to the emergency department on 5th-day postpartum with complaints of confusion, lack of sleep, anxiety, and loss of touch with reality. She complains about seeing ghosts of her dead relatives everywhere. She believes the baby has demonic powers and feels scared to touch or go near the baby. She has a previous history of bipolar one disorder for which she was taking medications until the start of pregnancy when she discontinued all her medications. Her mother also suffers from bipolar disorder, and one of her cousins from her maternal side has schizophrenia. Her sister, who had diabetes type 1, passed away recently. Her husband is in the army touring Afghanistan, and she has no one at home to care for her. Her medical and obstetrical history is uneventful. On examination, her vitals are normal. The neurological exam is within normal limits. The psychiatric evaluation shows disheveled appearance, confusion, agitation, delusions, paranoia, and hallucinations. She plans to kill herself with the knife in the kitchen drawer when she reaches home. CBC (complete blood count) is normal, electrolytes are all within normal limits, and urine toxicology is negative. What is the best initial step in the management of this patient?



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A 19-year-old previously healthy female, primipara is brought to the psychiatric clinic three months after giving birth with complaints of confusion, lack of sleep, anxiety, agitation, crying spells, feelings of hopelessness, loss of appetite, extreme exhaustion, and inability to concentrate for the past two and a half months. She thinks she is failing the role as a good mother and is not taking care of her baby the way she should. She has lost over 20 pounds in the last two months and is unable to have a restful sleep at night. Her husband is very supportive, and her mother also lives close by and is proactive in helping her with the baby. She has no previous psychiatric history, but she has a cousin with a history of bipolar disorder who suffered from postpartum psychosis years ago after her first delivery. The patient feels scared that she may end up like her cousin and may start having hallucinations and psychosis-like her. Her medical and obstetrical history is uneventful. On examination, her vitals are normal. The neurological exam is also within limits. There is no suicidal or homicidal ideation. CBC, electrolytes are all within normal limits. What is the most likely diagnosis?



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A 19-year female primipara is brought to the emergency department on 3rd day postpartum with complaints of confusion, lack of sleep, anxiety, and loss of touch with reality. She complains about seeing aliens everywhere and smelling burnt plastic. She is also experiencing back and flank pain, burning pain during micturition, chills and has been unable to eat anything since this morning due to nausea and vomiting. She has no previous history of mental illness, but her mother suffers from bipolar disorder, and one of her cousins from the maternal side has schizophrenia. Her medical and obstetrical history is uneventful. On examination, she has a fever of 103.8 F, pulse 110/minute, and respiratory 30/minute. The neurological exam is within limits. The psychiatric evaluation shows disheveled appearance, confusion, disorientation, agitation, delusions, paranoia, and hallucinations. CBC shows elevated white blood cell count with marked neutrophilia. Urinalysis shows bacteria and elevated white blood cell count. Blood and urine cultures are sent out. A urine toxicology screen is negative. What is the most likely cause of her psychosis?



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Postpartum Psychosis - References

References

Ayers S,Wright DB,Thornton A, Development of a Measure of Postpartum PTSD: The City Birth Trauma Scale. Frontiers in psychiatry. 2018     [PubMed]
Slomian J,Honvo G,Emonts P,Reginster JY,Bruyère O, Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Women's health (London, England). 2019 Jan-Dec     [PubMed]
Jones I,Chandra PS,Dazzan P,Howard LM, Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet (London, England). 2014 Nov 15     [PubMed]
Di Florio A,Jones L,Forty L,Gordon-Smith K,Blackmore ER,Heron J,Craddock N,Jones I, Mood disorders and parity - a clue to the aetiology of the postpartum trigger. Journal of affective disorders. 2014 Jan     [PubMed]
Kulkarni J,de Castella A,Fitzgerald PB,Gurvich CT,Bailey M,Bartholomeusz C,Burger H, Estrogen in severe mental illness: a potential new treatment approach. Archives of general psychiatry. 2008 Aug     [PubMed]
Davies W, Understanding the pathophysiology of postpartum psychosis: Challenges and new approaches. World journal of psychiatry. 2017 Jun 22     [PubMed]
Kumar C,McIvor RJ,Davies T,Brown N,Papadopoulos A,Wieck A,Checkley SA,Campbell IC,Marks MN, Estrogen administration does not reduce the rate of recurrence of affective psychosis after childbirth. The Journal of clinical psychiatry. 2003 Feb     [PubMed]
Lewis KJS,Di Florio A,Forty L,Gordon-Smith K,Perry A,Craddock N,Jones L,Jones I, Mania triggered by sleep loss and risk of postpartum psychosis in women with bipolar disorder. Journal of affective disorders. 2018 Jan 1     [PubMed]
VanderKruik R,Barreix M,Chou D,Allen T,Say L,Cohen LS, The global prevalence of postpartum psychosis: a systematic review. BMC psychiatry. 2017 Jul 28     [PubMed]
Valdimarsdóttir U,Hultman CM,Harlow B,Cnattingius S,Sparén P, Psychotic illness in first-time mothers with no previous psychiatric hospitalizations: a population-based study. PLoS medicine. 2009 Feb 10     [PubMed]
Wesseloo R,Burgerhout KM,Koorengevel KM,Bergink V, [Postpartum psychosis in clinical practice: diagnostic considerations, treatment and prevention]. Tijdschrift voor psychiatrie. 2015     [PubMed]
Rai S,Pathak A,Sharma I, Postpartum psychiatric disorders: Early diagnosis and management. Indian journal of psychiatry. 2015 Jul     [PubMed]
Wesseloo R,Kamperman AM,Munk-Olsen T,Pop VJ,Kushner SA,Bergink V, Risk of Postpartum Relapse in Bipolar Disorder and Postpartum Psychosis: A Systematic Review and Meta-Analysis. The American journal of psychiatry. 2016 Feb 1;     [PubMed]
Bergink V,Bouvy PF,Vervoort JS,Koorengevel KM,Steegers EA,Kushner SA, Prevention of postpartum psychosis and mania in women at high risk. The American journal of psychiatry. 2012 Jun;     [PubMed]
Poels EMP,Bijma HH,Galbally M,Bergink V, Lithium during pregnancy and after delivery: a review. International journal of bipolar disorders. 2018 Dec 2;     [PubMed]
Cohen LS,Sichel DA,Robertson LM,Heckscher E,Rosenbaum JF, Postpartum prophylaxis for women with bipolar disorder. The American journal of psychiatry. 1995 Nov;     [PubMed]
Austin MP, Puerperal affective psychosis: is there a case for lithium prophylaxis? The British journal of psychiatry : the journal of mental science. 1992 Nov;     [PubMed]
Austin MP,Mitchell PB, Use of psychotropic medications in breast-feeding women: acute and prophylactic treatment. The Australian and New Zealand journal of psychiatry. 1998 Dec;     [PubMed]
Pirec V, What Can Happen When Postpartum Anxiety Progresses to Psychosis? A Case Study. Case reports in psychiatry. 2018;     [PubMed]
Kumagaya DY, Acute electroconvulsive therapy in the elderly with schizophrenia and schizoaffective disorder: A case series. Asia-Pacific psychiatry : official journal of the Pacific Rim College of Psychiatrists. 2019 May 20;     [PubMed]
Grover S,Sahoo S,Chakrabarti S,Basu D,Singh SM,Avasthi A, ECT in the Postpartum Period: A Retrospective Case Series from a Tertiary Health Care Center in India. Indian journal of psychological medicine. 2018 Nov-Dec;     [PubMed]
Bergink V,Rasgon N,Wisner KL, Postpartum Psychosis: Madness, Mania, and Melancholia in Motherhood. The American journal of psychiatry. 2016 Dec 1;     [PubMed]
Rundgren S,Brus O,Båve U,Landén M,Lundberg J,Nordanskog P,Nordenskjöld A, Improvement of postpartum depression and psychosis after electroconvulsive therapy: A population-based study with a matched comparison group. Journal of affective disorders. 2018 Aug 1;     [PubMed]
Epstein RA,Moore KM,Bobo WV, Treatment of bipolar disorders during pregnancy: maternal and fetal safety and challenges. Drug, healthcare and patient safety. 2015;     [PubMed]
Miller LJ, Use of electroconvulsive therapy during pregnancy. Hospital     [PubMed]
Holford N,Channon S,Heron J,Jones I, The impact of postpartum psychosis on partners. BMC pregnancy and childbirth. 2018 Oct 23;     [PubMed]
Clark CT,Sit DK,Driscoll K,Eng HF,Confer AL,Luther JF,Wisniewski SR,Wisner KL, DOES SCREENING WITH THE MDQ AND EPDS IMPROVE IDENTIFICATION OF BIPOLAR DISORDER IN AN OBSTETRICAL SAMPLE? Depression and anxiety. 2015 Jul;     [PubMed]
Sit D,Rothschild AJ,Wisner KL, A review of postpartum psychosis. Journal of women's health (2002). 2006 May;     [PubMed]
Burgerhout KM,Kamperman AM,Roza SJ,Lambregtse-Van den Berg MP,Koorengevel KM,Hoogendijk WJ,Kushner SA,Bergink V, Functional Recovery After Postpartum Psychosis: A Prospective Longitudinal Study. The Journal of clinical psychiatry. 2017 Jan;     [PubMed]
Bergink V,Burgerhout KM,Koorengevel KM,Kamperman AM,Hoogendijk WJ,Lambregtse-van den Berg MP,Kushner SA, Treatment of psychosis and mania in the postpartum period. The American journal of psychiatry. 2015 Feb 1;     [PubMed]
Smith-Nielsen J,Matthey S,Lange T,Væver MS, Validation of the Edinburgh Postnatal Depression Scale against both DSM-5 and ICD-10 diagnostic criteria for depression. BMC psychiatry. 2018 Dec 20;     [PubMed]

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The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of PA-Hospital Medicine. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

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