Postpartum psychosis: Revisiting the phenomenology, nosology, and treatment

Abstract

• The heterogeneity of postpartum psychosis poses diagnostic challenges. • Although generally considered a rare entity, more than 16% of women with bipolar disorder have a manic, mixed or psychotic episode after childbirth. • There is paucity of data on the identification of women at risk of having postpartum psychosis. • Managing the predisposing, precipitating, perpetuating, and protective factors has the potential to improve the short- and long-term prognosis of postpartum psychosis. To review the phenomenology, nosology, and treatment of postpartum psychosis. Using the keywords postpartum, puerperal, psychosis, bipolar, mania, depression, classification, nosology, phenomenology, diagnosis, suicide, infanticide, and treatment, four electronic databases, MEDLINE/PubMed (1966–2020), PsycINFO (1806–2020), EMBASE (1980–2020), and the Cochrane Database of Systematic Reviews were searched. We also searched the reference lists of articles identified to find articles of interest. There is a lack of consensus about the diagnostic criteria. Although it is usually considered a rare entity, as many as 16% of women with bipolar I disorder have mood or psychotic episodes that meet the contemporary definition of postpartum psychosis. There is a paucity of data on the identification of women at risk of having postpartum psychosis. Atypical antipsychotics and lithium are commonly recommended for acute treatment of postpartum psychosis, however, there are no randomised trials of drugs in the acute treatment of manic/mixed or depressive episodes with psychosis in the postpartum period. This is not a systematic review but rather a selective appraisal of the literature. Controversies surrounding its phenomenology and nosology have probably prevented consensus about its management. Accurate diagnosis of postpartum psychosis is crucial for suicide risk assessment and prediction, and treatment planning. As much as possible clinicians should consider applying the DSM-5 nomenclature to characterize disorders subsumed under the umbrella of postpartum psychosis. A nuanced approach that takes into consideration the predisposing, precipitating, perpetuating, and protective factors could potentially improve the short- and long-term prognosis of postpartum psychosis.