Modern health care is problematic for patients suffering from psychiatric emergencies. But for women suffering from postpartum psychosis, the combination of misinformation and fragmented care is distinctly dangerous.
Without biomarkers, the sensitivity of psychiatric diagnoses relies on detailed evaluations, serial visits, and collateral information. If systems of care are not designed around this rubric, the diagnostic tool will not work. Moreover, the variable interpretation of laws governing confidentiality and autonomy can unintentionally impede care. In other medical emergencies resulting in diminished capacity to weigh the risks and benefits of treatment, surrogate decision-makers are quickly enlisted to help. But due to the complex history of mental health, psychiatric patients do not enjoy such a luxury. And because psychosis is neurotoxic, disease progression is the steep price that many psychiatric patients pay for autonomy and confidentiality. Imagine requiring a faxed release of information and a probable cause hearing to treat a patient with status epilepticus! Such requirements would be seen as scandalous for any acute ailment other than acute psychosis.
Because postpartum psychosis is elusive and our health care systems are not always designed around the principles of diagnostic finesse, we must ensure that we understand what separates this illness from other perinatal maladies. Postpartum psychosis is not a complication of postpartum depression. While several etiologies can be proposed, most cases represent undiagnosed bipolar I disorder. Unlike typical, unrelenting psychotic episodes, postpartum psychosis waxes and wanes, just like delirium. During one encounter, the mother is well; an hour later, she firmly believes that she is a supernatural deity and the only way to salvation is to jump off a cliff. It is during these moments that patients get prematurely discharged and their families relax. Because these are primarily manic or mixed episodes of bipolar I disorder, the patient may have a decreased need for sleep. This is different from insomnia. In insomnia, the patient is tired and exhausted. With a decreased need for sleep, the patient has an unusually high level of energy despite sleep deprivation. Another distinctive feature of psychosis is anosognosia. Most patients with psychosis do not know they are ill. When they do, their insight is intermittent or incongruent with the seriousness of the symptoms.
In contrast, perinatal depression is akin to what we normally encounter in the spectrum of depressive disorders. Symptoms may include depressed mood, lack of interest, sleep changes, appetite changes, hopelessness, and sometimes thoughts of not wanting to be alive. It impacts up to 20 percent of women around pregnancy and represents a very common obstetrical complication. More importantly, there is no anosognosia and there are no signs of psychosis.
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Another term that is often misunderstood is “intrusive thoughts,” so much so that women may disclose subclinical psychotic phenomena using this terminology since it’s more palatable than “hallucinations.” While hallucinations and delusions are inherently intrusive, we often reserve “intrusive thoughts” to denote traits of obsessive-compulsive disorder (OCD), another common and mostly benign perinatal mental health condition. The perinatal transition represents prime time for intense fears surrounding contamination, illness, and accidental death. Like perinatal depression, OCD does not involve anosognosia, signs of psychosis, or intent to cause harm.
Using terms like postpartum depression and postpartum psychosis interchangeably for any perinatal mental health condition alienates patients with common disorders and delays care for patients with psychosis. Moreover, using the wrong terms can translate into using the wrong treatments. For example, serotonergic medications can be useful in several psychiatric conditions, but they can be harmful in postpartum psychosis. Likewise, prescribing multiple agents at once can dilute the importance of adherence to the correct medication. Lithium, antipsychotics, and a good delirium workup are often the first tools in treatment-naive patients with postpartum psychosis. Because postpartum psychosis is an emergency, treatment plans require a hospitalization that is long enough to ensure tolerability, response, coordination, and a truly viable disposition plan.
Compared to prior centuries, we have made leaps in destigmatizing mental health. But we must continue to be diligent in our education and advocacy, hoping for a design that better aligns with the needs of our psychiatric population.
Disclaimer
The opinions expressed are my own and are shared in my personal capacity as a physician. They do not reflect the views or positions of any employer, health system, academic institution, professional organization, government agency, or other affiliated entity.
Patricia De Marco Centeno is a board-certified psychiatrist specializing in consultation-liaison psychiatry, and she currently serves as a psychopharmacology consultant at the California Department of State Hospitals. She received additional training in reproductive mental health through the University of Southern California at the Maternal Wellness Clinic at Los Angeles County Medical Center.
De Marco has helped establish perinatal mental health programs at large health systems in Orange County, California, and facilitated the development of local protocols for the screening, assessment, and treatment of women during pregnancy, postpartum, and fertility treatment. She formerly served as behavioral health medical director for the County of Orange, where she helped oversee Medicaid-based mental health services for patients living with serious mental illness.
Her research spans controlled substance disclosure among psychiatric outpatients, quality of life in anorexia nervosa, and the management of mental illness in obstetric inpatients, with work appearing in the Journal of Psychiatric Practice and Eating Disorders and presented at the American Psychiatric Association Annual Meeting. She coauthored Beyond the Birth Plan, a workshop offered through the Maternal Mental Health Program at Hoag Hospital, and has spoken on expert panels addressing women’s health, hormones and mental health, and mental health leadership for audiences convened by Hoag Hospital, Cigna, and the Young Presidents’ Organization. Her commentary has appeared in the Los Angeles Times Daily Pilot and Parenting OC, and her expertise has been cited in Parents.com and TheEveryMom.com. She shares updates on LinkedIn.
