Treatment of postpartum psychosis
- Jennifer Payne, MD
Jennifer Payne, MD
- Associate Professor of Psychiatry
- Johns Hopkins School of Medicine
During the postpartum time period, women are at an increased risk of the onset or recurrence of psychiatric illness, including mood, anxiety, and psychotic disorders. Postpartum psychosis (or puerperal psychosis) typically presents with rapid onset of psychotic symptoms including hallucinations and delusions, bizarre behavior, confusion, and disorganization that may appear to be delirium.
The syndrome is most often seen in patients that have been or will be diagnosed with bipolar disorder, but can also less frequently occur in women with major depression with psychosis, schizophrenia, or schizoaffective disorder. A small subset of women experience isolated postpartum psychosis that does not progress to mood or psychotic episodes outside the postpartum time period .
The treatment of postpartum psychosis is reviewed here. The epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis of postpartum psychosis are reviewed separately. The clinical manifestations, differential diagnosis and initial management of psychosis in adults are also reviewed separately. The epidemiology, clinical manifestations, assessment, diagnosis, and treatment of other mental disorders occurring peripartum are also reviewed separately. (See "Postpartum psychosis: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Clinical manifestations, differential diagnosis, and initial management of psychosis in adults" and "Mild to moderate postpartum unipolar major depression: Treatment" and "Severe postpartum unipolar major depression: Treatment" and "Postpartum unipolar major depression: General principles of treatment" and "Bipolar disorder in postpartum women: Treatment" and "Obsessive-compulsive disorder in pregnant and postpartum women".)
Postpartum psychosis constitutes a medical emergency, generally requiring rapid identification and intervention. Ensuring safety and initiating medications for psychosis, agitation, and insomnia are the initial priorities of clinical management. Important next steps include evaluation and testing to exclude other medical causes of psychosis, and diagnosing/starting treatment for an underlying psychiatric disorder [2-6].
Postpartum psychosis is typically treated with a combination of antipsychotic medication and a mood stabilizer. Benzodiazepines and antidepressants are used to treat insomnia or depression, respectively, when present. Pharmacotherapy in this population needs to be considered in the context of the mother's status regarding breastfeeding. Adjunctive psychotherapy can be useful and includes psychoeducation, support, coordination of care, and encouraging treatment adherence.
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- PSYCHOSIS AND AGITATION
- Choice of antipsychotic
- Other antipsychotics
- Antipsychotic maintenance
- UNDERLYING MENTAL DISORDER
- Bipolar disorder
- - Choice of mood stabilizer
- Schizoaffective disorder
- ANTIPSYCHOTIC RESISTANCE
- ADJUNCTIVE PSYCHOTHERAPY
- SUMMARY AND RECOMMENDATIONS