Commentary

Postpartum psychosis and ill-advised discharge


 

Muslim Bangladeshi female presents

The patient is a 31-year-old married Muslim Bangladeshi female homemaker admitted to an inpatient unit in a private hospital in a large urban area in the northeastern United States because of postpartum psychosis. She recently had immigrated to the United States and spoke no English. She lived with her husband, his parents, and his siblings in a city neighborhood predominantly comprised of South Asian immigrants. Her sole source of financial support was her husband, who worked as a cab driver. Both patient and her husband were uninsured. They identified strongly with their religion and culture of origin.

Key questions

Communication was a challenge and was accomplished using an interpreter, who was not always available. The patient did not seem to respond to treatment, and there was a question about the possibility that she was “cheeking” her medications. Her husband requested her discharge against medical advice, despite her still showing signs of psychosis. He appeared ambivalent about outpatient follow-up.

What is the duty of care in this situation, given the complexities inherent in a cross-cultural situation, the presence of communication barriers, the question of patient and infant safety, the husband’s role (given the understanding that his actions were probably culturally sanctioned and consistent with his role), issues regarding financing their current and follow-up care, and their ambivalence toward follow-up care?

Family perspective

Working with a qualified medical interpreter is imperative, and hospitals and health care providers who accept federal funds are obliged to provide language assistance services under Title VI of the Civil Rights Act of 1964.

First, it is important to accurately assess the woman’s psychosis, including risk of self-harm, risk of harming the infant or others, and capacity to care adequately and safely for the infant.

Second, the team should assess the patient’s and husband’s beliefs about the illness, hospitalization, and treatment. For some Muslim patients, the daily practice of Islam may necessitate the separation of sexes, meaning that female nurses and physicians might be optimal. Accessing professional spiritual or pastoral care in meeting the patient’s and family’s religious needs should be considered. Additional cultural practices that might help increase the acceptability of inpatient psychiatric care for the family include practices regarding diet, dress, hygiene, and prayer. The husband also might want to stay and sleep in the patient’s room during her hospitalization.

Dr. Ellen Berman

Dr. Ellen Berman

It also might be challenging for some North American therapists to understand and focus on the entire family as a functioning unit, rather than seeing the issues as only between husband and wife. Learning about how “normal family functioning” is defined, especially in terms of roles, hierarchy, and intimacy, is critical to supporting this mother and baby. Cultivating “cultural humility” in working with patients and families from diverse backgrounds is extremely important.

During the hospitalization as the patient improves, a plan for care needs to be developed with the patient and her family. This plan should include adequate support of the mother and her baby. The husband should bring his parents and siblings to an initial meeting early during the hospitalization, being mindful of addressing any HIPAA-related issues. This will allow for a uniform understanding of the patient’s illness and treatment. At this meeting, all family members should express their concerns, worries, beliefs, and perceived barriers to optimal care. If the family members feel listened to, they are more likely to feel understood and adhere to recommendations.

Dr. Alison M. Heru

Dr. Alison M. Heru

At the initial meeting and subsequent ones, the following questions might be helpful to ask to gather information in negotiating a mutually acceptable treatment plan:

1. What is the family’s understanding of her illness? What do they think may have caused it? How do they understand postpartum psychosis? Do they think there is a role for medication? Are any other alternative healing modalities being considered or used?

2. Who is caring for the baby now? Is the baby healthy? Does the family understand how the mother’s illness affects the baby? Can the family provide adequate care for the baby?

3. How are decisions made in the family? Are there any other issues in the family, such as ill health in a parent?

4. Was this an arranged marriage? How long have they known the patient? Do they care for her? What is the family’s attitude toward her?

5. Besides the mother-in-law, are there other adult females (for example, her husband’s sisters and his brothers’ wives) living in the household? How old is the mother-in-law? Who runs the household? Who does all the work? If possible, it will be important to interview anyone else in the household. How long have the couple and the family been in the United States? Did they all come at the same time?

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