Postnatal psychosis: a psychiatric emergency

Taking her new baby home is the happiest day for a mother. She’s prayed for a healthy baby and hope for a straighforward birth for nine months. Then suddenly, she gets the urge to kill him. Kamelia Kountcheva investigates this real psychiatric emergency.

Introduction

This is one of the more severe effects of the rare and acute psychiatric disorder, postnatal psychosis, and despite the fact that it only affects two in every thousand births, it can be devastating to an unassuming new mother and her family.

Medical professionals outside the field of psychiatry must be sure to acquaint themselves with the illness and monitor patients over the first few months following childbirth…¹

The condition

Postnatal psychosis, also known as postpartum psychosis or puerperal psychosis, is a term that covers a group of mental illnesses with sudden onset of psychotic symptoms following childbirth. It is thought to be closely related to manic depressive (bipolar) disorder.²

The causes of this illness are unclear but literature suggests that there are two aspects involved: genetics and the endocrine system.¹

The illness appears to be heritable, as women with bipolar disorder have a 25 percent chance of developing it, and for those who have bipolar disorder and a personal or family history of postpartum psychosis, the risk of developing it again shoots up to 50 percent.¹

Therefore, healthcare staff must inquire about past incidences of mental disorders in the woman and her family, as well as any mental problems following any previous childbirths.

Di Florio et al called for multidisciplinary teams to keep in close contact with a mother at risk well into the postnatal period and even if she is seemingly well.¹

The other influential factor is the sharp change and sudden imbalance in the hormone levels in a woman’s body post labour. At this time in their lives, women are thought to be more susceptible to developing a mental illness than at any other.³

Severe depression is one symptom of postnatal psychosis, alongside mania, delusions, hallucinations, confusion, bewilderment and perplexity. Psychosis will usually occur within the first few days after childbirth, or more uncommonly, it can also occur a few weeks after childbirth.²

The Royal College of Psychiatrists state that it can take six to 12 months or more to fully recover from postpartum psychosis. However, the most severe symptoms tend to last two to 12 weeks, and the vast majority of women will recover fully.²

The threat

The quick onset and severity of the symptoms can pose a great threat to a mother and her baby, as it may be difficult to catch early. Psychosis can make the woman behave irrationally and in combination with a lapsed insight into her illness, she may cause harm to herself and her baby.⁴

A 2012 BBC Newsnight programme followed the stories of three mothers suffering from postnatal psychosis, detailing the feelings they experienced, including fear of stigma and of having their babies taken away.³ Their accounts can help midwives and health workers empathise and diagnose the condition more effectively.

However many who become ill do make a full recovery and the horror stories comprise only a handful of cases.⁵ Where the condition is not as acute, there may still be deleterious effects of some of the symptoms of psychosis on the infant.⁶

The shortcomings and the next steps

The rarity of the disorder has impacted on both medical practice and popular culture. It is not well known outside of the field of psychiatry and in the experience of some sufferers, it was not addressed by midwives during pregnancy consultations or in any pregnancy reading materials.⁵

Additionally, unlike postnatal depression, this is not a disorder which features on TV or on the radio, and is not something discussed by celebrity icons. Mothers are unaware of it and medical staff are fearful of scaremongering, both of which result in poor preparation for the potential onset of postnatal psychosis.

UK Blogger, Naomi, urges healthcare staff to be more open about it and ensure that it stops being a taboo subject.⁵

The Editor-in-chief of TOG, Jason Waugh, also noted the lack of information given to pregnant women, and said of the review: “It is … vital that all women are made aware of the condition and its signs and symptoms.”

Sit et al say that “rapid and accurate diagnosis of postpartum psychosis is essential to expedite appropriate treatment.”⁴

It should be a part of a midwife’s training to become acquainted with postnatal psychosis and make prospective parents aware of the possibility of developing this disorder. Early diagnosis is essential in order to manage it with minimal risk to the mother and baby, to which end, midwives should also reassure expectant mothers that there is no stigma, shame or risk of losing their child if they come forward seeking help.

Dr Ian Jones, Reader in Perinatal Psychiatry, Cardiff University and co-author of the TOG review said: “Postpartum psychosis is a true psychiatric emergency and it is vital that is recognised early and treated immediately. Admission to hospital is usually necessary and women should ideally be offered a specialist mother and baby unit where the best treatment options can be established.”

Author

Kamelia Kountcheva, Assistant Editor, Journal of Anaesthesia Practice.

References

1. Di Florio A, Smith S, Jones I. Postpartum psychosis. The Obstetrician & Gynaecologist 2013; http://dx.doi.org/10.1111/tog.12041
2. BBC, 2012. Postpartum psychosis: Affected parents speak out. [online] Available at: http://www.bbc.co.uk/news/health-19323695 [Accessed August 22, 2013]
3. Royal College of Psychiatrists [online] Available at: http://www.rcpsych.ac.uk/expertadvice/problemsdisorders/postpartumpsychosis.aspx [Accessed: August 22, 2013]
4. Sit, D., Rothchild, A. J., Wisner, K. L. 2006. A review of postpartum psychosis. Journal of Women’s Health. Volume 15, Number 4. Available online: http://www.liebertpub.com/media/pdf/JWH_15_4_p352-368.pdf [Accessed: 22 August, 2013]
5. Unknown. 2012. Postpartum psychosis: mental illness after childbirth should not be taboo. _Naomi_’s blog, [blog] 1st November, Available at: www.time-to-change.org.uk/blog/postpartum-psychosis-mental-illness-after-childbirth [Accessed: 22 August 2013].
6. Murray, L. and Cooper, P. J. 1997. Effects of postnatal depression on infant development. Archives of Disease in Childhood. 77:99-101
7. BBC Radio 4, 2009. Postnatal Depression. Am I Normal? Episode 2 of 4. [online] Available at: www.bbc.co.uk/programmes/b00htn08 [Accessed: 23 August, 2013].
8. Davis, A. 10 Celebrities Who Battled Postpartum Depression. Health Magazine. [online] Available at www.health.com/health/gallery/0,,20448173,00.html [Accessed: 23 August, 2013].

Articles