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Understanding postpartum psychosis.

Conception, pregnancy, childbirth and the postpartum period are a time of enormous change for all women from a biological, psychological and social perspective. For approximately one to two in 1,000 women, the rapid onset of psychotic symptoms as seen in postpartum psychosis (PP) exacerbate this further (Kendall, 1987).

It is important that all healthcare professionals and pregnant women are aware of this potentially catastrophic illness. Prompt detection and intervention can prevent potentially tragic outcomes and hasten recovery: with the right treatment at the right time, most women will make a full recovery (Meltzer, 1985).

WHAT IS POSTPARTUM PSYCHOSIS (PP)?

PP is a severe mental illness that affects mothers shortly after delivery. It is characterised by psychotic symptoms. PP is a psychiatric emergency.

Psychosis is the experience where it is impossible to distinguish between what is real and what is not. Hallucinations can occur in all sensory modalities. Individuals may perceive auditory hallucinations, such as hearing voices. Frequently individuals with psychosis will experience delusional ideas. These are firmly held ideas, not in keeping with their previous beliefs and are seldom shared by others. These experiences can be persecutory in nature-such as a belief that people may harm them or their baby--or grandiose, where they feel they are 'chosen' and that their baby has special gifts.

In PP these psychotic symptoms will occur within the first few days or weeks after delivery, and for some can happen within hours (Heron, 2007). There is a rapid alteration in presentation. Completely well mothers can deteriorate with prominent psychotic symptoms within hours on the same day. There is a 'kaleidoscopic' presentation where symptoms will rapidly alter during the course of a day, altering from one moment to the next (Brockington, 1996).

Frequently there is a mood component. Some mothers present as elated with lots of energy and racing thoughts, often with grandiose delusional beliefs. For others there may be marked depressive symptoms, with feelings of hopelessness, worthlessness and uselessness, which may be delusional in nature. Commonly there is a mixture of these two presentations with mothers feeling despairing, but having excessive energy and racing thoughts: a mixed affective presentation.

An overriding feature for many mothers with PP is a feeling of perplexity, where everything is confusing. It is difficult to make sense of day-today events. Decisions, judgements and actions can be grossly impaired (Heron, 2008). These symptoms are also seen in women who are delirious. It is important to exclude an organic cause for a delirium (such as infection or medication) before a diagnosis of PP is made.

In PP no organic cause can be found.

HOW CAN WE TREAT IT?

Once a diagnosis is made, the priority is to keep mother and baby safe. Often mothers need to be admitted to an inpatient psychiatric unit. Ideally, mothers should be admitted together with their baby to a psychiatric mother and baby unit (Cantwell, 2011; NICE, 2014). This is the safest option and enables mothers, during lucid intervals, to continue to care for their baby, preventing the distress of separation for both mother and baby.

The mainstay of treatment is medication. Women will receive the same medication as individuals suffering from a major mood disorder with psychotic symptoms. This treatment could include benzodiazepines, antipsychotics, antidepressants, mood stabilisers such as lithium and electro-convulsive treatment (ECT). There is a very good prognosis, but active treatment is required. (SIGN, 2012; NICE, 2014).

Longer-term support is essential, helping mothers to recover from the acute phase, to regain their self-esteem and to build their confidence as mothers. Often it can take mothers two or three years before returning to their pre-morbid level of functioning.

Support can be found in the community from mother and baby groups. Specialist support and information is also essential. Action on Postpartum Psychosis (APP) is the largest support network for mothers and their families affected by PP and offer educational materials and a PP peer support service delivered by trained peer supporters (www.app-network.org).

WHO IS MOST AT RISK?

One to two in 1,000 (0.1-0.2 per cent) of women in the general population are at risk of developing PP. This can occur without warning, often where there is no personal or family history of mental illness. (Kendall, 1987; MunkOlsen, 2006).

Certain women are at higher risk of PP, specifically women with an existing diagnosis of bipolar affective disorder (BPAD) who have an increased risk of between 25-50 per cent. This risk increases to 60 per cent where the mother has had PP previously. This increases further to 70 per cent where the mother has had a previous episode of PP and there is a family history of PP (Robertson, 2005). This means that we can start to identify women who are at high risk of post-partum episodes prior to their time of greatest risk (Jones, 2005; Doyle, 2012).

RISK REDUCTION AND PREVENTION

All pregnant women need to be made aware that PP exists, that it can be treated, and that full recovery is possible. Women at high risk of PP should be identified and informed fully about the potential risks. This will enable women to make informed decisions about how they would like to be treated.

The use of medication in the later stages of pregnancy can reduce the risk of an episode for high-risk mothers to approximately 10 per cent (Cohen et al, 1995). Making decisions about taking medication during pregnancy and breastfeeding are emotive ones for all mothers. These decisions should be made in collaboration between the perinatal psychiatrist, the mother and her family, and other healthcare professionals involved.

A comprehensive plan should be put in place to reduce the risks. We know that the highest risk is in the first two weeks after delivery. Constant support and monitoring by family, friends and healthcare professionals is essential at this time. Sleep is important, and reducing any interference with sleep is beneficial. Partners and family members can give practical support allowing sleep to be a priority. Education can be given about the early symptoms, and a crisis plan designed which can be activated should signs of relapse commence (Heron, 2008). This may include a home treatment team or an admission to a mother and baby unit. (RCOG, 2011; Doyle, 2012).

The recent publication of the National Institute for Health and Clinical Excellence (NICE) clinical guidelines for antenatal and postnatal mental health again has highlighted the importance of these services (NICE, 2014). The Maternal Mental Health Alliance has recently commissioned an economic report assessing the importance of investing in maternal mental health services (Bauer, 2014). More awareness is needed about PP to optimise outcomes (Heron, 2012).

Case Study

Name: Andrea, 34.

Ethnic origin: White/British

County: Warwickshire, UK.

Occupation: Computer Aided Design (CAD) Technician.

Personal status: Married 10 years. Home owner Stable comfortable life. Planned pregnancy. No personal or family history of mental illness.

Number of children: 1

Year of PP episode: 2006

'I had a smooth pregnancy with few challenges. I went to antenatal classes, exercised and read baby books so I felt happy, well prepared and full of expectation. The birth went well but I couldn't have the pain relief I'd planned, so I found it traumatic. I was exhausted, felt out of sorts and overwhelmed but I'd established breast-feeding and everything seemed OK.

At home I was busy with childcare and chores and was feeling very anxious and fearful. A midwife I'd not met before visited a few days later, she didn't ask me how I was feeling mentally or if I was sleeping. Four days after the birth, without sleep, the confusion, extreme anxiousness and terror mounted. It happened suddenly and severely, within hours. I wasn't making sense, couldn't think straight and couldn't string a sentence together I repeated random words over and over that made sense only to me. I held my phone but couldn't work out how to call for help. I was frantic, manic and couldn't walk or talk and was barely functioning.

'I was rushed to A&E and taken back to the maternity ward. I believed I was in labour again and the contractions were frightening and very real. I believed I could talk through my eyes so with urgency I glared into my mum's face to tell her what HAD to be said. I was sedated and treated with antipsychotic medication and finally slept. I was in a single room with my baby, with a crisis team member outside my door 24/7.

A midwife told me I had postnatal depression but I wasn't depressed so my paranoia grew. I was diagnosed with postpartum psychosis, which I had never heard of, so was scared and desperate for information.

'For weeks, I had delusions and scribbled notes frantically. My thoughts raced so fast I developed a stutter I couldn't read or watch TV and was terrified by people moving or speaking too fast. I couldn't process thoughts quickly enough to understand. I was learning how to care for my baby at the same time as trying to survive myself. I was scared we'd be separated.

'I was monitored at home by crisis and early intervention teams. A few weeks later, severe, depression developed. I was given antidepressants along with the anti-psychotic medication. I was numb, rarely left the house and lost touch with my friends. I cared for my baby but couldn't bond with him. After months of thinking and planning, I attempted suicide.

'It was two years before I could stop taking the medication and a further year before I felt back to my normal self again. I now have a great bond with my son but chose not to have more children.'

References

Action on Postpartum Psychosis. www.app-network.org Bauer A, Parsonage M, Knapp M, et al, (2014). The costs of perinatal mental health problems. London School of Economics& Centre for Mental Health Brockington I (1996). Motherhood and mental health. Oxford University Press, Oxford

Cantwell R, Clutton-Brock T, Cooper G, et al (2011). Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom British Journal of Obstetrics and Gynaecology. 118(Suppl 1):1-203.

Cohen LS, Sichel DA, Robertson LA, Heckscher E, Rosenbaum J (1995). Postpartum prophylaxis for women with bipolar disorder. Am. J. Psychiatry. 152: 1641-1645.

Doyle K, Heron J, Berrisford G et al (2012). The management of bipolar disorder in the perinatal period and risk factors for postpartum relapse. European Psychiatry 27: 563-569 Heron J, Robertson Blackmore E, McGuinness M (2007). No 'latent period' in the onset of bipolar affective puerperal psychosis. Archives of General Psychiatry. 64: 42-48.

Heron J, McGuinness M, Robertson Blackmore E (2008). Early postpartum symptoms in puerperal psychosis. British Journal of Obstetrics and Gynaecology. 115: 348-353.

Heron J, Gilbert N, Dolman C et al (2012). Information and support needs during recovery from postpartum psychosis. Archives of Women's Mental Health. 15(3): 155-165

Jones I, Craddock N (2005). Bipolar disorder and childbirth: the importance of recognising risk. British Journal of Psychiatry 186:453-4

Kendell RE, Chalmers JC, Platz C (1987). Epidemiology of puerperal psychoses. British Journal of Psychiatry 150: 662-673.

Meltzer ES & Kumar R (1985). Puerperal mental illness, clinical features and classification: a study of 142 mother-and-baby admissions. British Journal of Psychiatry. 147: 647-654.

Munk-Olsen T, Laursen TM, Pedersen CB (2006). New parents and mental disorders: a population based register study. Journal of the American medical Association. 286(21): 2582-2589.

NICE Guidelines (2014). Antenatal and postnatal mental health: clinical management and service guidelines. NICE Clinical Guidelines. 192.

Robertson E, Jones I, Haque S et al (2005). Risk of puerperal and non-puerperal recurrence of illness following bipolar affective puerperal (post-partum) psychosis. British Journal of Psychiatry. 186: 258-259.

Royal College of Obstetricians and Gynaecologists (2011). Management of women with mental health issues during pregnancy in the postnatal period: Good practice No 14. London. Available from url: http://www.rcog.org.uk/files/rcog-corp/ ManagementWomenMentalHealthGoodPractice14.pdf SIGN (2012). Management of perinatal mood disorders. Scottish Intercollegiate Guidelines Network. 127

DR GILES BERRISFORD

MBChB MSc FRCPsych

Consultant Perinatal Psychiatrist

Chair of Action on Postpartum Psychosis

ANDREA LAMBERT

Peer Support Co-ordinator

Action on Postpartum Psychosis

DR JESSICA HERON

Senior Research Fellow in Perinatal Psychiatry

University of Birmingham
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Title Annotation:CLINICAL FEATURE
Author:Berrisford, Giles; Lambert, Andrea; Heron, Jessica
Publication:Community Practitioner
Article Type:Disease/Disorder overview
Date:May 1, 2015
Words:2040
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