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Postpartum Psychosis

Learning Objectives

Learning

Objectives

  • Able to recognize that postpartum psychosis is a medical emergency
  • Understand the treatment options for postpartum psychosis in Northern BC
  • Able to differentiate between postpartum depression and postpartum psychosis
  • To understand who is at an increased likelihood of developing postpartum psychosis
  • Understands the role of the nurse when treating postpartum psychosis
  • Understanding the different presentations of postpartum psychosis
  • Identify diagnostic criteria

Overview

How common is it?

It occurs in every 0.89-2.6 per 1000 births (Madora et al., 2023)

When is it typically seen?

Difference between Postpartum Psychosis and Depression

General Overview

  • Sudden onset that usually occurs without any warning
  • It occurs most often within the first two weeks after birth, but it can appear anytime in the first year postpartum (Postpartum Support International, n.d.)
  • Both are serious mood disorders
  • Postpartum depression is nonpsychotic depressive episode and more commonly seen
  • Postpartum psychosis is manic or affective psychotic episodes that occur temporarily with childbirth. It is less common and harder to diagnose
  • (Doucet et al., 2009)

What is Postpartum Psychosis?

  • A severe mental illness and a psychiatric emergency that can happen without any warning (Royal College of Psychiatrists, 2018)
  • It is an emergency due to high rates of suicide and infanticide (Madora et al., 2023)
  • It can cover several terms including:

- Mania

- Psychosis

- Psychotic Depression

- Mixed affective state

-(Madora et al., 2023)

Risk Factors

Bio

Psycho

  • MDD during pregnancy/history of MDD

  • Anxiety during pregnancy

  • Prementstral dysphoric disorder

  • Stress during prenatal period
  • (Hazelgrove et al., 2021)

  • Rapid decrease of hormones progesterone and estrogen after the delivery of the placenta, greatly affecting the brain

  • Sudden decrease in sleep

post burth

  • Going off psychiatric medications during pregnancy
  • (Upadhyaya et al., 2014)

Risk Factors

Social

  • Lack of social support

  • Marital difficulties

  • Younger marital age
  • (Upadhyaya et al., 2014)

Symptoms

Depressive Symptoms

Manic Symptoms

Symptoms

  • Anxiety/panic
  • Delusions and hallucinations
  • Agitation
  • Feelings of guilt
  • Loss of appetite
  • Loss of enjoyment
  • Thoughts of self-harm, suicide or harming the child
  • Insomnia
  • Hypochondria
  • Stressors regarding health factors
  • PTSD
  • Flashbacks, memories, nightmares

  • Can look different for everyone
  • Manic symptoms less common and harder to diagnose
  • Manic episodes can be distinguished as "good symptoms"
  • Intrusive thoughts, delusions, auditory and visual hallucinations, detachment from reality, bizzare thinking and behvaiour, confusion
  • PSYCHIATRIC EMERGANCY

Kleiman, K. (2022). Therapy and the Postpartum Woman: Notes on Healing Postpartum Depression for Clinicians and the Women Who Seek their Help (1st ed.). Routledge. https://doi.org/10.4324/9781003248477

Nall, R. (2018). Depressive psychosis: Causes, symptoms, and diagnosis. Healthline.https://www.healthline.com/health/depression/major-depression-with-psychotic-features

Important Considerations

Diagnosis

Criteria for

Diagnosis

  • Take into account if the client has had PPP or other psychiatric disorders in the past
  • Difficult to distinguish hypomania from elevated mood and reduced sleep that comes with a new baby

(American Psychiatric Association, 2013)

  • No standardized set of questions, screening tools, labwork for diagnosis due to symptom variability, however all are used to rule out another diagnosis (Spinelli, 2021)
  • Edinburgh post-natal depression scale to rule out PPD
  • Infanticide: command hallucinations to kill the infant or delusions that the infant is possessed (American Psychiatric Association, 2013)
  • New occurrence of the following symptoms within 6 weeks postpartum (Bergink et al., 2016):

1. Mania/mixed episodes with or without

psychotic symptoms

2. Depression with psychotic features

3. Psychosis without mood symptoms

Diagnosis

Process

Lab Work

  • Comprehensive Matebolic Panel
  • CBC
  • TSH
  • TPO antibodies
  • Ammonia level and urinalysis

Bergink et al., 2016)

Interdisciplinary Team Members

Family usually 1st to notice changes

(Timms, 2018)

Interdisciplinary Team

  • Psychiatrists needed to assess and diagnose
  • Midwives
  • Nurse Practitioner
  • Mental health crisis team (community)
  • Family doctor

(Timms, 2018)

  • What about nurses??
  • Educating, Screening, Advocating, Supporting

Doula

Treatment Options

  • Doula - provides postpartum support and education for mothers surrounding proper nutrition, adequate sleep and importance of respite care (Sobczack et. al., 2023)
  • Indigenous doula available to patients by contacting the liason

Pharmacotherapy

  • Women often get a combination of a benzodiazepine, antipsychotic, and lithium prescribed for treatment
  • Benzodiazepines and hypnotics useful for insomnia which is a cause of post-partum psychosis (Jairaj et al., 2023)
  • Antipsychotics as they are beneficial for the treatment of acute psychosis
  • Lithium and mood stabilizers are another class of medication used for both prophylaxis and for acute treatment

Treatment

Options

ECT

  • An important treatment as pharmacological interventions or other forms of therapy may not be effective for all patients (Grover et al., 2018)
  • It works fast thus reducing the chance of patients harming themselves or others
  • Amount a person must go to ECT sessions depends on how severe a patient’s symptoms are

Early Psychosis Intevention

  • 6 centres across BC
  • Prince George responsible for entire NH region
  • For those experiencing their first psychotic break

Services they provide:

Resources in

Northern

Health

Role of the Nurse

At EPI

  • Coordinate services
  • Administer routine antipsychotics
  • Frequently assess patient using MSE
  • Provide education to families and patients

Assessment

Client/family education

Group

Support

Case

Management

Medication

Management

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Bergink, V., Rasgon, N., & Wisner, K. L. (2016). Postpartum psychosis: Madness, mania, and melancholia in motherhood. American Journal of Psychiatry, 173(12), 1179–1188. https://doi.org/10.1176/appi.ajp.2016.16040454

Doucet, S., Dennis, C. L., Letourneau, N. & Blackmore, E. R. (2009). Differentiation and clinical implications of postpartum depression and postpartum psychosis. Journal of Obstetrics, Gynecology, & Neonatal Nursing, 38(3), 269-279. https://doi.org/10.1111/j.1552-6909.2009.01019.x.

Edinoff, A. N., Sathivadivel, N., McNeil, S. E., Ly, A. I., Kweon, J., Kelkar, N., Cornett, E. M., Kaye, A. M., & Kaye, A. D. (2022). Antipsychotic Use in Pregnancy: Patient Mental Health Challenges, Teratogenicity, Pregnancy Complications, and Postnatal Risks. Neurology international, 14(1), 62–74. https://doi.org/10.3390/neurolint14010005

Friedman, S. H., Reed, E., & Ross, N. E. (2023). Postpartum psychosis. Current Psychiatry Reports, 25(2), 65–72. https://doi.org/10.1007/s11920-022-01406-4

Gordon-Smith, K., Perry, A., Di Florio, A., Forty, L., Fraser, C., Casanova Dias, M., Warne, N., MacDonald, T., Craddock, N., Jones, L., & Jones, I. (2020). Symptom profile of postpartum and non-postpartum manic episodes in bipolar I disorder: a within-subjects study. Psychiatry research, 284, 112748. https://doi.org/10.1016/j.psychres.2020.112748

Grover, S., Sahoo, S., Chakrabarti, S., Basu, D., Singh, S. M., & Avasthi, A. (2018). ECT in the Postpartum Period: A Retrospective Case Series from a Tertiary Health Care Center in India. Indian journal of psychological medicine, 40(6), 562–567. https://doi.org/10.4103/IJPSYM.IJPSYM_105_18

Jairaj, C., Seneviratne, G., Bergink, V., Sommer, I. E., & Dazzan, P. (2023). Postpartum psychosis: A proposed treatment algorithm. Journal of Psychopharmacology (Oxford, England), 37(10), 960–970. doi:10.1177/02698811231181573

Kleiman, K. R. (2022). Therapy and the postpartum woman: notes on healing postpartum depression for clinicians and the... women who seek their help. ROUTLEDGE. https://doi.org/10.4324/9781003248477

Madora, M. J., Knopf, H. S., Prakash, M., Kim, J., Medavaram, M. R. & Vaughn, R. L. (2023). Postpartum psychosis or something else? The Primary Care Companion for CNS Disorders, 25(1). https://doi.org/10.4088/PCC.22nr03269

Nall, R. (2018). Depressive psychosis: Causes, symptoms, and diagnosis. Healthline.https://www.healthline.com/health/depression/major-depression-with-psychotic-features

Postpartum Support International. (n.d.). Postpartum psychosis. https://www.postpartum.net/learn-more/postpartum-psychosis/

Sobczak, A., Taylor, L., Solomon, S., Ho, J., Kemper, S., Phillips, B., Jacobson, K., Castellano, C., Ring, A., Castellano, B., & Jacobs, R. J. (2023). The Effect of Doulas on Maternal and Birth Outcomes: A Scoping Review. Cureus, 15(5), e39451. https://doi.org/10.7759/cureus.39451

Rommel, A. S., Molenaar, N. M., Gilden, J., Kushner, S. A., Westerbeek, N. J., Kamperman, A. M. & Bergink, V. (2021). Long-term outcome of postpartum psychosis: A prospective clinical cohort study in 106 women. International Journal of Bipolar Disorders, 9(31), 1-10. https://doi.org/10.1186/s40345-021-00236-2

Royal College of Psychiatrists. (2018). Postpartum psychosis. https://www.rcpsych.ac.uk/mental-health/mental-illnesses-and-mental-health-problems/postpartum-psychosis#:~:text=Postpartum%20psychosis%20(or%20puerperal%20psychosis,1%2D2

Spinelli, M. (2021). Postpartum psychosis: A diagnosis for the DSMV. Archives of Women’s Mental Health, 24(5), 817–822. https://doi.org/10.1007/s00737-021-01175-8

Steven L. D., Biswarup M. G., Jordan C. S., & Victoria C. Psychotic Depression: Diagnosis, Differential Diagnosis, and Treatment. Psychother Psychosom 13 April 2021; 90 (3): 160–177. https://doi.org/10.1159/000511348

Timms, P. (Ed.). (2018, November). Postpartum psychosis for carers: Royal College of Psychiatrists. www.rcpsych.ac.uk. https://www.rcpsych.ac.uk/mental-health/mental-illnesses-and-mental-health-problems/postpartum-psychosis-in-carers

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