Recognizing Postpartum Psychosis

By: Dr. Michael Araco

It is important that women suffering from postpartum psychosis receive medical help at the earliest opportunity. This does not always happen, unfortunately, as many are unaware they have become unwell and their loved ones may not recognise the symptoms.  Postpartum psychosis is far less common than depression, but new mothers and their families should know what to look out for.

Symptoms of postpartum psychosis

Psychosis is a severe mental illness that is often described as a "loss of touch with reality".  If the first episode of psychosis occurs shortly after a birth, this is termed postpartum psychosis.  Psychosis may be mild, or if severe, may incapacitate a mother leaving her unable to care for herself or her baby.  The key features of postpartum psychosis include:

· Delusional beliefs. Delusions are fixed, false beliefs that are unshakeable and not amenable to reason. They may be paranoid beliefs or they be of a grandiose nature (ie the mother may have an unusually high opinion of herself or perceive her abilities as super-uman).

· Hallucinations. Hearing voices is not uncommon with postpartum psychosis.

· Personality changes and abnormal thinking. Women with postpartum psychosis may not be able to organise their thoughts. Conversations may become odd and difficult to follow.

· Lack of insight. Frequently people with psychosis are unaware they have become unwell. This can present a problem for friends and family who are unable to convince them to get help. Sometimes, arguments may ensue, but usually after treatment the mother can retrospectively acknowledge their illness.

· Appetite disturbance.

· Suicidal or homicidal thoughts. These are not uncommon and highlight the urgency with which these women need treatment.

What causes postpartum psychosis?

There is no single trigger. Some experts believe the changing hormone levels may be implicated in the onset of both postpartum psychosis and depression. Women who have a pre-existing mental illness, such as bipolar disorder or schizophrenia, are at higher risk. Abusers of illicit substances, particularly cannabis, are thought to be at greater risk than the general population.  The increased stress commonly associated with a new birth is likely to further contribute.

Is this the same illness as the "baby blues"?

No. Baby blues, or "ups and downs" are common for the first two weeks postpartum and usually resolves. Ongoing, persistent, low mood may be diagnosed as postpartum depression. Both postpartum psychosis and depression are severe medical conditions that warrant medical attention.  While postpartum depression is usually treated with an antidepressant (commonly a serotonin reuptake inhibiting class drug), postpartum psychosis is best treated with antipsychotic class medications.

Is there effective treatment for postpartum psychosis?

Yes. Medications have been available to treat psychosis since the 1960s. They have improved enormously during this time. Most women who have psychosis postpartum are treated with oral medications although women who are very unwell or unwilling to take tablets may require injectable drugs. Two commonly used choices are Risperidone and Olanzapine.  It is important treatment is started at the earliest opportunity.  In much the same was as diabetes and high blood pressure cause less complications if caught early, the longer a woman is left untreated the less effective medication may be.

Prior or concurrently with initial treatment, expect the treating doctor to do a physical examination and possibly order some tests.  These commonly involve basic blood tests, screening for an organic medical illness that may better explain the psychosis.  For example, the doctor will want to exclude a systemic infection, severe renal disease, or untreated thyroid disease.  A neurological screen, including a computerised brain scan (or CAT scan), may also be used to exclude an abnormal brain mass or malignancy. 

The tragic story of Andrea Yates

The story of Mrs. Yates was widely publicised in Houston, Texas late 2001. According to reports at the time, Andrea was the devoted mother of five children she home-schooled. She was first diagnosed with postpartum psychosis after the birth of her first child in 1994. Andrea experienced psychosis, including hearing voices commanding her to stab her baby. She had attempted suicide twice, driven by these voices. Prior to the birth of her fifth child, Andrea had previously had two hospitalisations for treatment.

Sadly Andrea drowned her five children in a bathtub during June 2001. At the time she was experiencing severe postpartum psychotic symptoms. One psychiatrist reported she was mute, and walked the house like a "caged" animal.

Andrea's story became a case study highlighting the importance of vigilance for mental illness in postpartum mothers. A number of factors were thought to have contributed to this event, including her history of mental illness, the possibly limited response of family members, her isolation, and the discontinuation of her antipsychotic medication.

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