Obstetric Characteristics and Management of Patients with Postpartum Psychosis in a Tertiary Hospital Setting

Postpartum Psychosis: A Review of Risk Factors, Clinical Picture, Management, Prevention, and Psychosocial Determinants

Postpartum psychosis is rare, but is a serious clinical and social problem. On its own, it is not included in DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) or ICD-10 (International Statistical Classification of Diseases and Related Health Problems) as a disease entity, and current diagnostic criteria equate it with other psychoses. This poses a serious legal problem and makes it difficult to classify. The disorder is caused by a complex combination of biological, environmental, and cultural factors. The exact pathophysiological mechanisms of postpartum psychosis remain very poorly understood. There is a need for further research and increased knowledge of the medical sector in the prevention and early detection of psychosis to prevent stigmatization of female patients during a psychiatric episode. It is necessary to regulate its position in the DSM5 and ICD-10. Attention should be paid to the social education of expectant mothers and their families. This article aims to review the current status of risk factors, prevention, and management of postpartum psychosis.

Maternal mental health screening and management by health workers in southwestern Uganda: a qualitative analysis of knowledge, practices, and challenges

BACKGROUND

Maternal mental health (MMH) problems, such as perinatal depression, maternal anxiety, suicide ideation and puerperal psychosis among others, have a significant impact on maternal morbidity and mortality, as well as the health and development of children. One in every four pregnant women and one in every five postpartum women in low-income countries, suffer from maternal mental health (MMH) problems. Despite this, MMH screening, diagnosis, and reporting remain scanty in Uganda. Consequently, this study aimed to investigate the knowledge, practices, and impediments that maternity care workers face when screening and managing women with maternal mental health disorders in health facilities in south-western Uganda.

METHODS

In-depth interviews were conducted with 22 health-care professionals who work in maternity care departments in primary and tertiary healthcare facilities in southwestern Uganda to investigate their medical knowledge, clinical practices, and challenges related to the screening and management of maternal mental health problems. Using qualitative content analysis, distinct categories and subcategories were found.

RESULTS

Medical staff especially midwives lacked specialized training in screening and managing women with maternal mental health problems They screened and managed MMH problems solely based on history and physical examination, and they referred nearly every mother displaying signs of mental illness because they felt ill-prepared to handle them. On the other hand, medical staff with some level of specialized training in mental health particularly staff working in mental health units, were more likely to use a mental health screening tool in addition to history and physical examination; and to treat any women exhibiting signs and symptoms of maternal mental problems without referring them. Lack of in-service training on maternal mental health, poorly coordinated referral systems, reluctance of mentally ill to visit medical facilities, scarcity of mental health specialists, and shortage of relevant medications were identified as the major challenges. Age, experience level, or gender had no effect on screening or management practices.

CONCLUSIONS

The results suggest that specialized training in mental health, and particularly maternal mental health, is essential for the effective screening and management of maternal mental health conditions in South Western Uganda.

Burden of severe maternal peripartum mental disorders in low- and middle-income countries: a systematic review

Peripartum severe mental disorders (PSMDs) encompass schizophrenia, affective psychosis, and psychotic and non-psychotic forms of bipolar disorders. PSMDs are well documented in high-income countries. However, much less is known about the prevalence of PSMDs in low- and middle-income countries (LMICs). The aim was to review the available literature systematically and estimate the prevalence of PSMDs among women in LMICs. We searched the Ovid MEDLINE, Embase, PsycINFO, CINAHL and Maternity and Infant Care databases systematically from the date of inception to Dec 31, 2020, for English-language publications with data on the prevalence of PSMDs among women in World Bank-defined LMICs. Selection of studies, extraction of data and assessment of study quality were each undertaken independently by at least two of the investigators. A total of five studies (completed in three countries spanning two continents) met the inclusion criteria. Five studies reported cumulative incidence of postpartum psychosis (ranging from 1.1 to 16.7 per 1000 births). We found no studies on the prevalence of severe mental disorder during pregnancy in these settings. Marked heterogeneity in methodology precluded meta-analysis. These findings indicate that PSMDs occur at a similar prevalence in low- and middle-income to high-income countries. However overall, there is a paucity of high-quality evidence from these settings. There is a need for rigorous studies with standardized methods to increase knowledge of the nature, prevalence, and determinants of PSMDs among women in resource-constrained LMICs to inform policies, service development, program planning and health professional training.

Antipsychotics in Postpartum Psychosis

BACKGROUND

Psychotic episodes in the postpartum period are life-threatening psychiatric emergencies, requiring urgent medical attention and admission to a psychiatric hospital.

AREAS OF UNCERTAINTY

Although the postpartum psychosis (PPP) is the most severe psychiatric disorder associated with parturition, there is little information about what interventions are most effective. Because there are no specific guidelines for the treatment of PPP, the aim of the present review was to examine the available evidence regarding the treatment of PPP.

DATA SOURCES

The PubMed database was searched based on the title and the abstract, using the key words "postpartum psychosis," "postpartum psychosis antipsychotics," "postpartum psychosis treatment," and "postpartum psychosis pharmacotherapy," for both interventional and observational, irrespective of language.

RESULTS

A number of 14 publications met the study criteria, including case reports and case series. The antipsychotics (APs) use included both first generation APs, such as haloperidol and chlorpromazine, and second generation APs, mainly, olanzapine, quetiapine, and risperidone. The most frequently used AP was olanzapine. Olanzapine and quetiapine seem to be the most acceptable during breastfeeding. Proposed treatment algorithms for the successful management of PPP are discussed.

CONCLUSIONS

The existing studies to date do not allow to draw a definitive conclusion regarding which treatment is the most effective or the most adequate. Existing evidence suggests that APs alone or in combination are responsible for sustained remission and that treated PPP has a higher pace of improvement of the mental status, with a rapid discharge from the hospital. Clinical studies to compare the efficacy and safety of different APs in the PPP are needed to provide guidance on treatment interventions.

Delusional ideation during the perinatal period in a community sample

BACKGROUND

Despite the prevalence of mental health problems during the perinatal period, little research has examined psychotic symptoms in a community sample across pregnancy and the postpartum. Exposure to environmental risk factors, and immigration in particular, are associated with increased risk for psychotic disorders. The current investigation examined whether psychosocial risk and immigrant status would predict levels of delusional ideation across the perinatal period when controlling for depression, anxiety, and demographic factors.

METHODS

A community sample of 316 pregnant women was assessed at 12-14 and 32-34weeks gestation during routine clinic visits, and at 7-9weeks postpartum during a home visit. Measures included self-report ratings of psychosocial risk (e.g., history of mental health problems or abuse, stressful life events, lack of social support), pregnancy-related anxiety, depressive symptomatology, and delusional ideation.

RESULTS

There was less delusional ideation during the postpartum period than during early pregnancy. Across all time points, levels of delusional ideation were lower than in the general population. Analyses using multilevel modeling indicated significant fixed-effects for the variables time, age, partnership, being religious and prenatal anxiety, but not depressive symptomatology, on delusional ideation. Immigrant status moderated the effect of psychosocial risk such that greater psychosocial risk predicted more symptoms of delusional ideation among immigrants, but not non-immigrants.

CONCLUSION

Psychosocial risk factors place immigrant women at an increased likelihood for experiencing delusional ideation during the perinatal period.