Postpartum PsychosisPostpartum Psychosis

Postpartum (or puerperal) psychosisPostpartum (or puerperal) psychosis is a term that covers a is a term that covers a group of mental illnesses with the sudden onset of psychotic group of mental illnesses with the sudden onset of psychotic symptoms following childbirth. In this group there are at least a symptoms following childbirth. In this group there are at least a dozen organic psychoses, which are described under another dozen organic psychoses, which are described under another heading "heading "organic pre- and postpartum psychosesorganic pre- and postpartum psychoses".".[1][1] The The relatively common non-organic form, still prevalent in Europe, relatively common non-organic form, still prevalent in Europe, North America and throughout the world, is sometimes called North America and throughout the world, is sometimes called puerperal bipolar disorder, because of its close link with manic puerperal bipolar disorder, because of its close link with manic depressive (bipolar) disorder;depressive (bipolar) disorder;[2][2] but some of these mothers have but some of these mothers have atypical symptoms (see below), which come under the heading atypical symptoms (see below), which come under the heading of acute polymorphic (cycloid) psychosis (schizophreniform in the of acute polymorphic (cycloid) psychosis (schizophreniform in the US).US).[3][3] Puerperal mania was first clearly described by the Puerperal mania was first clearly described by the German obstetrician Osiander in 1797,German obstetrician Osiander in 1797,[4][4] and a literature of over and a literature of over 2,000 works has accumulated since then. These psychoses are 2,000 works has accumulated since then. These psychoses are endogenous, heritable illnesses with acute onset, benign endogenous, heritable illnesses with acute onset, benign episodic course and response to mood-normalizing and mood-episodic course and response to mood-normalizing and mood-stabilizing treatments. The inclusion of severe postpartum stabilizing treatments. The inclusion of severe postpartum depression under postpartum psychosis is controversial: many depression under postpartum psychosis is controversial: many clinicians would allow this only if depression was accompanied clinicians would allow this only if depression was accompanied by psychotic features (see below).by psychotic features (see below).

SymptomsSymptoms Some patients have typical manic symptoms, such as euphoria, Some patients have typical manic symptoms, such as euphoria,

overactivity, decreased sleep requirement, loquaciousness, flight of overactivity, decreased sleep requirement, loquaciousness, flight of ideas, increased sociability, disinhibition, irritability, violence and ideas, increased sociability, disinhibition, irritability, violence and delusions, which are usually grandiose or religious in content; on the delusions, which are usually grandiose or religious in content; on the whole these symptoms are more severe than in mania occurring at whole these symptoms are more severe than in mania occurring at other times, with highly disorganized speech and extreme other times, with highly disorganized speech and extreme excitement. Others have severe depression with delusions, verbal excitement. Others have severe depression with delusions, verbal hallucinations, mutism, stupor or transient swings into hypomania. hallucinations, mutism, stupor or transient swings into hypomania. Some switch from mania to depression (or vice versa) within the Some switch from mania to depression (or vice versa) within the same episode. Atypical features include perplexity, confusion, same episode. Atypical features include perplexity, confusion, emotions like extreme fear and ecstasy, catatonia or rapid changes emotions like extreme fear and ecstasy, catatonia or rapid changes of mental state with transient delusional ideas; these are so striking of mental state with transient delusional ideas; these are so striking that some authors have regarded them as a distinct, specific that some authors have regarded them as a distinct, specific disease, but they are the defining features of acute polymorphic disease, but they are the defining features of acute polymorphic (cycloid) psychoses, and are seen in other contexts (for example, (cycloid) psychoses, and are seen in other contexts (for example, menstrual psychosis) and in men.menstrual psychosis) and in men.

Course and treatmentCourse and treatment Without treatment, these psychoses can last many Without treatment, these psychoses can last many

months; but with modern therapy they usually resolve months; but with modern therapy they usually resolve within a few weeks. A small minority follow a relapsing within a few weeks. A small minority follow a relapsing pattern, usually related to the menstrual cycle. Mothers pattern, usually related to the menstrual cycle. Mothers who suffer a puerperal episode are liable to other manic who suffer a puerperal episode are liable to other manic depressive or acute polymorphic episodes, some of depressive or acute polymorphic episodes, some of which occur after other children are born, some during which occur after other children are born, some during pregnancy or after an abortion, and some unrelated to pregnancy or after an abortion, and some unrelated to childbearing. Puerperal recurrences occur after at least childbearing. Puerperal recurrences occur after at least 20% of subsequent deliveries, or over 50% if depressive 20% of subsequent deliveries, or over 50% if depressive episodes are included.episodes are included.[5][5]

Severe overactivity and delusions may require rapid Severe overactivity and delusions may require rapid tranquilization by neuroleptic (antipsychotic) drugs, but they tranquilization by neuroleptic (antipsychotic) drugs, but they should be used with caution because of the danger of severe should be used with caution because of the danger of severe side effects including the neuroleptic malignant syndrome.side effects including the neuroleptic malignant syndrome. [6][6] Electro-convulsive (electroshock) treatment is highly effective.Electro-convulsive (electroshock) treatment is highly effective. [7][7] Mood stabilizing drugs such as lithium are also useful in Mood stabilizing drugs such as lithium are also useful in treatment and possibly the prevention of episodes in women at treatment and possibly the prevention of episodes in women at high risk (i.e., women who have already experienced manic or high risk (i.e., women who have already experienced manic or puerperal episodes). The location of treatment is an issue: puerperal episodes). The location of treatment is an issue: hospitalization is disruptive to the family, and it is possible to treat hospitalization is disruptive to the family, and it is possible to treat moderately severe cases at home, where the sufferer can moderately severe cases at home, where the sufferer can maintain her role as a mother and build up her relationship with maintain her role as a mother and build up her relationship with the newborn. This requires the presence, round the clock, of the newborn. This requires the presence, round the clock, of competent adults (such as the baby's maternal grandmother), competent adults (such as the baby's maternal grandmother), and frequent visits by professional staff.and frequent visits by professional staff.[8][8] If hospital admission If hospital admission is necessary, there are advantages in conjoint mother and baby is necessary, there are advantages in conjoint mother and baby admission. Yet multiple factors must be considered in the admission. Yet multiple factors must be considered in the subsequent discharge plan to ensure the safety and healthy subsequent discharge plan to ensure the safety and healthy development of both the baby and its mother.development of both the baby and its mother.[9][9] This plan often This plan often involves a multidisciplinary team structure to follow-up on mother, involves a multidisciplinary team structure to follow-up on mother, baby, their relationship and the entire family.baby, their relationship and the entire family.

Suicide is rare, and infanticide extremely rare, during Suicide is rare, and infanticide extremely rare, during these episodes. It does occur, as illustrated by the these episodes. It does occur, as illustrated by the famous cases summarized below. Infanticide after famous cases summarized below. Infanticide after childbirth is usually due to profound postpartum childbirth is usually due to profound postpartum depression (melancholic filicide) when it is often depression (melancholic filicide) when it is often accompanied by suicide.accompanied by suicide.[10][10]

CausesCauses These are world-wide disorders. Their incidence has These are world-wide disorders. Their incidence has

been carefully measured by state-of-the-art been carefully measured by state-of-the-art epidemiological studies, and is somewhat less than epidemiological studies, and is somewhat less than 1/1,000 deliveries.1/1,000 deliveries.[11][11] They are more common in first They are more common in first time mothers. As recognized by Marcé (1962), the link to time mothers. As recognized by Marcé (1962), the link to menstruation, and especially menstruation, and especially menstrual psychosismenstrual psychosis, is an , is an important clue to the cause.important clue to the cause.[12][12][13][13] Molecular genetic Molecular genetic studies suggest that there is a specific heritable factor.studies suggest that there is a specific heritable factor.[14][14] There is evidence of linkage to chromosome 16. There is evidence of linkage to chromosome 16.[15][15]

Famous casesFamous cases Melanie Blocker-StokesMelanie Blocker-Stokes Melanie Blocker-Stokes, of Melanie Blocker-Stokes, of ChicagoChicago, IL, committed , IL, committed

suicide by jumping from a building on June 11, 2001. In suicide by jumping from a building on June 11, 2001. In February 2001 she gave birth to a healthy baby girl. In February 2001 she gave birth to a healthy baby girl. In the weeks following the birth of her daughter, she the weeks following the birth of her daughter, she developed severe depression, in which (4 weeks after developed severe depression, in which (4 weeks after the birth) she stopped eating and drinking and could no the birth) she stopped eating and drinking and could no longer swallow. She thought her neighbors had all closed longer swallow. She thought her neighbors had all closed their blinds because they thought she was a bad mother their blinds because they thought she was a bad mother (a postpartum depressive psychosis).(a postpartum depressive psychosis).[16][16] She was in She was in and out of Chicago area hospitals several times over and out of Chicago area hospitals several times over period of a few months. Her death led to the proposal of period of a few months. Her death led to the proposal of the Melanie Blocker-Stokes Postpartum Depression the Melanie Blocker-Stokes Postpartum Depression Research and Care Act (H.R. 846 and S. 450), intended Research and Care Act (H.R. 846 and S. 450), intended to expand research into the condition.to expand research into the condition.[17][17]

Andrea YatesAndrea Yates Main article: Main article: Andrea YatesAndrea Yates Andrea Yates methodically Andrea Yates methodically drowneddrowned her 5 children in a her 5 children in a bathtubbathtub in in

her her Clear Lake CityClear Lake City, , HoustonHouston, , TexasTexas house on June 20, house on June 20, 20012001. Her . Her mental health began to deteriorate with the birth of each of her mental health began to deteriorate with the birth of each of her children, combined with other external stressors. She attempted children, combined with other external stressors. She attempted suicide twice and was hospitalized twice in a psychiatric facility in suicide twice and was hospitalized twice in a psychiatric facility in 1999 after delivering her fourth child. Yates was warned against 1999 after delivering her fourth child. Yates was warned against having any more children, but conceived approximately 7 weeks having any more children, but conceived approximately 7 weeks later. 3 months after the birth of her fifth child and shortly after the later. 3 months after the birth of her fifth child and shortly after the death of her father, she began to rapidly degenerate. She was death of her father, she began to rapidly degenerate. She was hospitalized twice more, and eventually released with orders that hospitalized twice more, and eventually released with orders that she should not be left alone. During an hour when her husband had she should not be left alone. During an hour when her husband had left for work and her mother-in-law was scheduled to arrive, she left for work and her mother-in-law was scheduled to arrive, she killed all five of her children. She was consequently committed to a killed all five of her children. She was consequently committed to a high-security psychiatric hospital. high-security psychiatric hospital.

Her case attracted a great deal of media attention, particularly to the Her case attracted a great deal of media attention, particularly to the concept of serious mental illness following (and also caused by) concept of serious mental illness following (and also caused by) childbirth. Some of this coverage proved to be problematic and childbirth. Some of this coverage proved to be problematic and misleading. For example, the misleading. For example, the National Organization for WomenNational Organization for Women (NOW) initially incorrectly noted on their website that Yates had (NOW) initially incorrectly noted on their website that Yates had suffered from postpartum suffered from postpartum depressiondepression. The . The Individualist FeministsIndividualist Feminists quickly pointed out that Yates suffered from postpartum psychosis, quickly pointed out that Yates suffered from postpartum psychosis, a more serious and much less common disorder, and that the a more serious and much less common disorder, and that the clinical definition of postpartum depression does not list infanticide clinical definition of postpartum depression does not list infanticide as a symptom.as a symptom.[18][18][19][19] This misrepresentation of Yates' illness This misrepresentation of Yates' illness stigmatizedstigmatized a large number of mothers and made them less likely to a large number of mothers and made them less likely to seek professional help for fear of being seen as a threat to their seek professional help for fear of being seen as a threat to their children and consequently being committed. NOW promptly revised children and consequently being committed. NOW promptly revised their statement to indicate postpartum psychosis.their statement to indicate postpartum psychosis.[20][20][21][21]

Legal statusLegal status Several nations including Canada, Great Britain, Several nations including Canada, Great Britain,

Australia and Italy recognize post partum mental illness Australia and Italy recognize post partum mental illness as a mitigating factor in cases where as a mitigating factor in cases where mothers kill their childrenmothers kill their children..[22][22] In the United States, such In the United States, such a legal distinction is not currently made.a legal distinction is not currently made.[22][22] Britain has Britain has had the had the Infanticide ActInfanticide Act since 1922. since 1922.

In 2009, Texas legislator In 2009, Texas legislator Jessica FarrarJessica Farrar proposed a bill proposed a bill that would recognize postpartum psychosis as a defense that would recognize postpartum psychosis as a defense for mothers who kill their infants.[23] Under the terms of for mothers who kill their infants.[23] Under the terms of the proposed legislation, if jurors concluded that a the proposed legislation, if jurors concluded that a mother's "judgment was impaired as a result of the mother's "judgment was impaired as a result of the effects of giving birth or the effects of lactation following effects of giving birth or the effects of lactation following the birth", they would be allowed to convict her of the the birth", they would be allowed to convict her of the crime of infanticide, rather than murder.[22] The crime of infanticide, rather than murder.[22] The maximum penalty for infanticide would be two years in maximum penalty for infanticide would be two years in prison.[22]prison.[22]