Postpartum psychosis: A proposed treatment algorithm

New treatments: Opportunities and challenges

Across the spectrum of perinatal mental illness, there exist a variety of effective treatments. However, the available treatments are not always matched to the presentation, resources, constraints, or values of each patient. Furthermore, provider, local, and systemic factors complicate access to current treatment options. New and emerging approaches offer the potential of more effective treatment for specific perinatal psychiatric disorders. From neuroactive steroid medications to accelerated psychotherapy interventions, recent innovations have demonstrated enhanced efficacy on a faster timeline. Optimally, these developments will also lower barriers to care but this is not necessarily true. We review novel and upcoming interventions across perinatal mental illness and place them in the context of existing treatments and common challenges.

Postpartum Psychosis as a Precursor to Schizophrenia: A Comprehensive Review

Postpartum psychosis (PP) is a rare and severe mental health disorder occurring shortly after childbirth, characterized by symptoms such as delusions, hallucinations, and intense mood swings. This review examines the potential link between PP and the later development of schizophrenia, a chronic psychiatric condition that typically emerges in late adolescence or early adulthood. By reviewing existing literature and analyzing epidemiological and clinical data, this review aims to clarify whether PP can be a precursor to schizophrenia. Findings suggest that while the transition from PP to schizophrenia is not inevitable, there is an increased risk, with some studies indicating that a subset of women with PP may develop a chronic psychotic disorder later on. This underscores the importance of early detection, ongoing monitoring, and targeted interventions. The review emphasizes the need for improved diagnostic practices and preventive measures to better manage PP and its potential long-term effects. Enhanced understanding of this relationship can inform more effective treatment strategies and support better mental health outcomes for new mothers. Future research should focus on refining risk assessment tools, exploring underlying mechanisms, and developing comprehensive management approaches to address the challenges associated with PP and its potential progression to schizophrenia.

A Rare Case of Arnold Chiari Malformation Type 1 Presenting With Features of Catatonia

The Arnold Chiari malformation is a congenital neurological condition. It occurs due to a defect in the cerebellum. Our patient is a 19-year-old postpartum female who presented to our ER with headaches, crying spells, reduced interaction, poor self-care, and neglect of her newborn for the past five days. Before the onset of her presenting symptoms, the patient had complained of a severe headache in the back of the head and dizziness. Her baseline investigations were normal. On examination, the patient was noticed to have a fixed gaze, ambiguity, mutism, and rigidity. So, she was diagnosed with catatonia, a differential diagnosis of mental and behavioral disorders associated with pregnancy, childbirth, and puerperium, and was treated with medications appropriately. As her headache showed minimal relief with adequate analgesic measures, neuroimaging was done, which showed Arnold Chiari malformation type I with hydrocephalus. A liaison was made with the neurology team, who confirmed the diagnosis and advised her on the decompression procedure. Her family refused to undergo the procedure. Once she showed minimal improvement in her symptoms, her family members requested her discharge. In our case, the Arnold Chiari malformation type I presented with features of catatonia, unlike the usual reported presentation of depression and anxiety. This case highlights the need for a thorough evaluation of any patient presenting with catatonia.

Genetic and Epigenetic Factors Associated with Postpartum Psychosis: A 5-Year Systematic Review

Purpose: Postpartum psychosis (PPP) is a serious mental health illness affecting women post-parturition. Around 1 in 1000 women are affected by postpartum psychosis, and the symptoms usually appear within 2 weeks after birth. Postpartum mental disorders are classified into 3 main categories starting from the least to most severe types, including baby blues, postpartum depression, and postpartum psychosis. Materials and Methods: In this systematic review, genetic and epigenetic factors associated with postpartum psychosis are discussed. A PRISMA flow diagram was followed, and the following databases were used as main sources: PubMed, ScienceDirect, and Scopus. Additional information was retrieved from external sources and organizations. The time period for the articles extracted was 5 years. Results: Initially, a total of 2379 articled were found. After the stated criteria were applied, 58 articles were identified along with 20 articles from additional sources, which were then narrowed down to a final total of 29 articles. Conclusions: It can be concluded that there is an association between PPP and genetic and epigenetic risk factors. However, based on the data retrieved and examined, the association was found to be greater for genetic factors. Additionally, the presence of bipolar disorder and disruption of the circadian cycle played a crucial role in the development of PPP.

Hormones, psychotic disorders, and cognition in perinatal women: a mini review

Previous scientific evidence has shown a relationship between hormones and the onset and relapse of perinatal psychotic disorders (PPD) in women during pregnancy, childbirth, and the postpartum period. In healthy women the interaction between hormones and cognitive changes has been confirmed mainly in memory, attention, and executive function during pregnancy and postpartum, which respond to adaptive demands related to parenting tasks. In women with psychotic episodes there is a significant impairment in several cognitive functions, but studies of the perinatal period are limited. The objective of this mini review is to analyze the main findings to identify whether hormonal changes interact with the onset of PPD and cognitive impairment in perinatal women. The studies included samples of women with psychosis, risk of developing psychosis, bipolar psychosis, schizoaffective psychosis, and psychotic symptoms, during pregnancy and postpartum. Findings contributed to knowledge about five hypotheses regarding the relationship between hormones in the perinatal period and the appearance of PPD. Nevertheless, this review did not find reports of evidence of a relationship between hormonal production and cognitive function among women with clinically diagnosed PPD, suggesting a research gap. Clinical implications of assessing hormonal production and cognitive function in PPD are discussed. Although the evidence identified is scarce and heterogeneous, the findings call for further research with clinical samples on the role of hormones in perinatal psychotic disorders, especially as they relate to the study of cognition. This will promote more consistent evidence and understanding of PPD etiopathology that can guide early and effective multidisciplinary interventions.

Postpartum Psychosis as a Consequence of Thyroiditis Versus Relapse: A Diagnostic Dilemma

Thyrotoxicosis can exhibit overlapping symptoms of psychosis in the general population. Each of these pathologies has well-established workups and management. Rare presentations of thyroiditis and psychosis in the postpartum state have been seen in case studies mostly, but data on the prevalence of postpartum psychosis in association with postpartum thyroiditis are not available. Here, we present a unique case of a patient with a history of bipolar disorder who originally presented with postpartum thyroiditis that was worked up and managed appropriately. However, on follow-up, the patient was found to have progressed into prominent psychosis. Both thyroiditis and psychosis were managed individually with full remission upon discharge and is doing well today. The co-occurrence of postpartum psychosis and thyroiditis presents a unique challenge for timely diagnosis and management. We present a case of a young woman initially diagnosed with postpartum thyroiditis needing further management of postpartum psychosis due to persistent symptoms. Clinical presentation supported with a prior history of mood disorder increases the likelihood of these diagnoses together.

The ambulatory treatment of postpartum psychosis in Israel

Postpartum psychosis is a severe psychiatric disorder that occurs following childbirth. Due to its severity, postpartum psychosis is generally treated in an inpatient hospital setting. In this original contribution, we present the ambulatory treatment of postpartum psychosis and advocate that an ambulatory setting can be feasible under the right circumstances. In this article, we provide an overview of the Israeli legal system and its implications when treating maternal mental illness. We present the process by which we treat a woman with postpartum psychosis in an ambulatory setting. We provide a case example of the successful treatment of postpartum psychosis in an ambulatory setting and list general strategies to utilize. We demonstrate that an ambulatory approach to postpartum psychosis is not only possible, but also has significant benefits. We suggest that the ambulatory treatment of postpartum psychosis was developed in Israel as a direct result of its liberal legal system. Specifically, because of the legal system's value on patient autonomy, acute psychiatric illnesses such as postpartum psychosis are at times treated in outpatient settings. Additionally, we posit that Israel's unique culture provides the framework to support its implementation. We review the challenges of the treatment in the case example as well as other anticipated challenges that may arise with a broader application of this approach. Our hope is that this novel presentation will lead to more nuanced and holistic treatment of postpartum psychosis.