A 38-year-old woman is brought to the emergency department by her husband due to depression and difficulty caring for their 3-week-old son. The husband came home from work and found the patient staring at the television and mumbling to herself while the baby cried in his crib in a soiled diaper. He says that she has already lost all her pregnancy weight and frequently cries for no apparent reason. The patient is exhausted because the baby keeps her up all night. She admits to hearing voices sometimes but insists on going home and says, "Everything will be okay if I just get some sleep." The patient has a history of bipolar disorder; she did not take medication during the pregnancy due to concerns about effects on the fetus. On mental status examination, the patient is alert and speaks slowly and softly. Her mood is depressed and her affect is blunted. At one point, she stares into space and mumbles something before turning to the doctor and saying, "I am a terrible mother; I should not have brought a baby into this world." The patient does not have suicidal ideation or intent. Which of the following is the most appropriate course of action?
Postpartum blues, depression & psychosis | |||
Postpartum | Postpartum depression | Postpartum psychosis | |
Prevalence | 40%-80% | 8%-15% | 0.1%-0.2% |
Onset | 2-3 days (resolves within 14 days) | Typically within 4-6 weeks (can be up to 1 year) | Variable: days to weeks |
Symptoms | Mild depression, tearfulness, irritability | ≥2 weeks of moderate to severe depression, sleep or appetite disturbance, low energy, psychomotor changes, guilt, concentration difficulty, | Delusions, hallucinations, thought disorganization, |
Management | Reassurance & monitoring | Antidepressants, psychotherapy | Antipsychotics, antidepressants, mood stabilizers; hospitalization (do not leave mother alone with infant due to risk of infanticide) |
In addition to depressive symptoms, this patient has auditory hallucinations and bizarre behavior (staring into space and mumbling), raising concern for postpartum psychosis. This disorder most commonly occurs within the first weeks after birth and can present with delusions (eg, believing that the baby is evil or does not belong to the mother), hallucinations (eg, command hallucinations to kill the baby or kill herself), thought disorganization, and/or bizarre behavior. Postpartum psychosis is often seen in conjunction with other psychiatric disorders, most commonly bipolar disorder (as in this patient).
Although it is rare in comparison with postpartum blues and postpartum depression, postpartum psychosis is a medical emergency, with an increased risk of both suicide and infanticide. Most patients should be hospitalized to ensure safety, as with this patient who is actively hallucinating and expressing remorse for bringing a baby into the world, which places her at high risk of harming herself or the baby. If necessary, involuntary hospitalization should be pursued. Antipsychotic medication should be started, with treatment of the underlying mood disorder (eg, addition of mood stabilizers or antidepressants) if necessary.
(Choices A, C, D, and E) Outpatient treatment would be unsafe at this point due to the risks of infanticide and suicide. Treatment with mood stabilizers, antidepressants, and/or antipsychotics would be appropriate on an inpatient basis. Outpatient treatment with an antidepressant and/or psychotherapy would be appropriate for a patient with postpartum depression without psychotic features.
(Choice F) Reassurance that symptoms are self-limited would be appropriate only if the patient had postpartum blues, a common mood disturbance characterized by mild depression and mood lability, not psychosis.
Educational objective:
Postpartum psychosis is a medical emergency characterized by delusions, hallucinations, and disorganized thoughts or behavior often accompanied by mood symptoms. Due to the high risk for suicide/infanticide, most patients require hospitalization to ensure safety.