Postpartum Psychosis in a Young VA Patient: Diagnosis, Implications, and Treatment Recommendations

Antipsychotic and Other Psychotropic Medications

Choice of an antipsychotic and other psychotropic medications to treat postpartum psychosis is based on the patient’s breastfeeding status. The benefits of treatment should be weighed against the risks of a breastfeeding infant’s exposure to the medication. Because postpartum psychosis is a psychiatric emergency, the benefits of the medication are considered to outweigh any potential adverse effect to the breastfeeding infant exposed to the medication. Risks of untreated postpartum psychosis to the infant include rejection of the infant, poor parental relationships, suicide, infanticide, long-term failure to bond with the child, delayed infant development, and failure to thrive.²⁹ Also, many mothers—including the patient in this presentation—decide that the benefits of treatment outweigh those of breastfeeding and choose to feed their infant with formula. Even if the patient chooses to bottle-feed her infant, consider administering medications that are considered safer for breastfeeding because the patient may need to continue the psychotropic during later pregnancies to prevent future psychotic episodes.³⁰ All psychotropic medications pass into breast milk.²⁹ Studies on the long-term effect of these medications on the infant are limited, but experts tend to recommend olanzapine, quetiapine, and risperidone over aripiprazole and ziprasidone.^21,31-33

Lithium often is used to treat postpartum psychosis. Studies examining risk to the infant after long-term exposure to lithium through breast milk have not been conducted, but the American Academy of Pediatrics discourages its use during breastfeeding because of concerns about toxicity in the infant.^34-36

Sleep regulation is important to treat bipolar disorder and to prevent future episodes.^2,20,21 To ensure safety of the infant and mother before discharge, family education is imperative to establish close follow-up, adequate sleep, and reduction of stressors.^7,10 Separation from the infant might be necessary after discharge, and someone should monitor the infant at all times until the outpatient mental health provider confirms that all psychotic symptoms have resolved.^7,10 Successful treatment of postpartum psychosis requires close communication among the mental health provider, the pediatrician, and the obstetrician or women’s health provider.¹⁰ Because a close-knit team approach after discharge from the acute psychiatric unit is necessary, the care of such a patient and her child provides an educational opportunity for individuals working in integrated care clinics.

Conclusion

Postpartum psychosis is a psychiatric emergency requiring immediate treatment to prevent dire outcomes such as suicide or infanticide. Treatment considerations include the cost-benefit analysis of breastfeeding and the toxicity of psychotropic medications when ingested by the infant via breast milk. A close relationship has been demonstrated between postpartum psychosis and bipolar disorder.

Preferred treatment regimens include lithium and an antipsychotic. Educate the family as a unit about the diagnosis and treatment, the importance of adequate sleep for treatment and prophylaxis, and the decision on whether to discontinue breastfeeding despite its well-known benefits for mother and infant. Stabilization is a multifaceted process and needs to be reinforced with a solid plan for support and follow-up appointments. Because of the higher risk of relapse, educate patients about prophylactic treatment during subsequent pregnancies and monitor for development of bipolar disorder in the future.