What is Postpartum Psychosis?

Ruth Mielke, DNP, RN, CNM

Introduction

Every few years, a news story brings attention to the devastating condition called postpartum psychosis (PPP). Sadly, this has happened again with the death of three children in Massachusetts at the end of January 2023. Lindsay Clancy is charged with homicide and multiple counts of strangulation, assault, and battery. Her defense claims she was overmedicated with 13 different psychiatric medications in recent months. Her three children were ages eight months to five years old. Lindsay also severely harmed herself by jumping from a window. According to news reports, Lindsay is an RN and worked in labor and delivery.

Postpartum psychosis (PPP) is a rare disorder affecting one to two women per 1,000. It is a perinatal mental disorder that is closely linked to postpartum depression. It is a psychiatric emergency that endangers the mother and her children. It requires immediate hospitalization and treatment. PPP is one of the least understood and most dangerous psychiatric disorders. There is a general lack of knowledge about this illness. More specific gaps in knowledge include how to recognize it and how to treat it. PPP is often missed due to a lack of knowledge and the stigma perinatal psychiatric disorders carry.

Definition

Postpartum psychosis (PPP) has a distinct pattern of symptoms. The onset of symptoms is usually sudden and typically occurs within the first two weeks of giving birth. Early warning signs include mood fluctuations, irritability, anxiety, and insomnia. PPP is different than "baby blues," postpartum depression, or postpartum anxiety, but the initial warning signs may be similar. Psychotic symptoms are the most dramatic evidence of PPP, but women also have mood changes that may include mania, depression, or mixed symptoms. Clinical features of PPP include:

Delirium-like alteration in consciousness
Disorganization
Confused
Depersonalization
Delusions – often about the child or childbirth
Disoriented
Hallucinations
Insomnia
Catatonia
Severe depression
Hyperactivity
Paranoia

Risks

Childbirth is the biological trigger for postpartum psychosis. Studies are unclear about whether pregnancy-related medical factors predict an increased risk for PPP. Some studies show no correlated risk factors, while others show some specific risks, including having a history of bipolar disorder, a family history of bipolar disorder, previous postpartum psychosis, lack of sleep, and giving birth to the first child (primiparity).

The most substantial risk factor for PPP is a personal history of having bipolar disorder. In addition, most women that have PPP as their first psychiatric event will eventually be diagnosed with bipolar disorder. Because of this strong association, PPP should be considered a bipolar disorder and treated as such. It is important to note that PPP runs in families.

Certain women may be more vulnerable to rapid changes in estrogen and progesterone following delivery. Still, there is little evidence to support the role of these changes in the development of postpartum psychosis. Recent evidence regarding the origins of PPP points to immune system dysregulation. There are increased rates of autoimmune thyroiditis, failure of normal T cell elevation, significant up-regulation of immune-related genes, and increased monocyte-to-non-monocyte ratio in women with PPP. One of the greatest areas of biological research regarding PPP is focused on the significant changes in the number and type of T cells and Natural Killer cells in women with PPP.

Screening

Screening for postpartum psychosis is essential, but unfortunately, there are no standardized screening tools. There are tools such as the Edinburgh Postnatal Depression Scale (EPDS) that screen for symptoms of depression and anxiety, but it does not assess for psychosis. Considering the lack of screening tools, the following questions are important for patients and their families:

Does the patient have any history of previous psychiatric disorders?
If she has a psychiatric history, did she present with mania, depression, or both?
Does the patient have a family history of bipolar?
Is there a current history of substance use?
Does the mother have any thoughts of hurting herself or her baby?

In addition to screening questions, there are critical physical assessments, including a complete physical exam, a neurological exam, and lab work to include:

Complete metabolic panel
Complete blood count
Urinalysis
Urine toxicology screen
Ammonia level
Thyroid labs: thyroid stimulating hormone, free T4, and TPO antibodies
Brain imaging if neurological symptoms

Diagnosis

The diagnosis of postpartum psychosis can be confused with the diagnosis of postpartum obsessive-compulsive disorder (OCD). It is essential to differentiate the delusions characteristic of PPP from the intrusive and frightening thoughts of OCD. Other differential diagnoses for PPP include postpartum depression, delirium, anxiety disorder, Sheehan's syndrome, autoimmune flare, and reaction to substance use.

Treatment

It is imperative to understand that postpartum psychosis is a psychiatric emergency. It requires inpatient hospitalization and treatment. Unfortunately, in the United States, no psychiatric units permit the baby to stay with the mother for treatment. This barrier prevents many families from seeking the necessary treatment. Another obstacle is that the average inpatient stay for PPP is only ten days due to insurance coverage.

Treatment for postpartum psychosis includes the use of antipsychotic medications and mood stabilizers. Family and social support are also necessary for recovery. In addition, sleep care interventions are vital, as a prominent feature of PPP is insomnia. Ensuring patient and child safety is the priority in treatment.

Prognosis

The prognosis for women with postpartum psychosis is poor. Suicide and infanticide are associated with psychotic episodes when the woman is experiencing a break from reality. The delusions feel very real. There is approximately a 5% suicide rate and a 4% infanticide rate associated with these delusions. Recurrent episodes of psychosis are common both in future postpartum periods and non-pregnancy-related psychosis. The risk of recurrence of PPP with each subsequent delivery is between 30-50%. Ten years later, up to 40% of women could not reach total working capacity due to continued psychiatric symptoms.

Conclusion and Call to Action

Nurses may encounter women experiencing undiagnosed postpartum psychosis in the emergency room, the pediatrician's office, the OBGYN office, or the community. Anyone facing a woman with possible PPP should call 911 or refer the patient to the emergency department. An immediate psychiatric consult is necessary if the patient is inpatient.

In addition to identifying symptoms of postpartum psychosis, nurses can educate women and families regarding warning signs while pregnant. Nurses can act by expanding community awareness of this devastating psychiatric condition. They can also support legislation that expands access to care and treatment for PPP and other postpartum mental health disorders. As a medical community, all providers can work to remove the stigma around PPP.

Now, back to the tragic story of Lindsay Clancy. If she had postpartum psychosis, did her healthcare providers recognize her diagnosis? Was she treated appropriately? Is it right to charge her criminally for the death of her children? There are so many profound and disturbing questions left unanswered. As healthcare professionals, may we all hold this family in our hearts and do all we can to prevent further similar tragedies by knowing the symptoms of postpartum psychosis and demanding improved treatment in our flawed healthcare system.

References/Resources

Recognizing and Managing Postpartum Psychosis: A Clinical Guide for Obstetric Providers: National Library of Medicine

Lindsay Clancy, Duxbury mother accused of killing kids, arraigned on murder, strangulation charges: WCVB Boston

Livestream: Arraignment for Lindsay Clancy, Duxbury mom accused of killing her children: Boston.com

Postpartum Psychosis: PsychDB