The majority of puerperal psychotic episodes are of affective type with mania [1], specifically a cognitive disorganization psychosis which is not observed in women with nonchildbearing affective psychosis [9]. Its manifestations include cognitive impairment, bizarre behavior, thought disorganization, lack of insight, delusions of reference, delusions of persecution, and greater levels of homicidal and suicidal ideations and behavior [9]. Delusions and hallucinations are said to be Schneiderian, which is defined as thought broadcasting and feeling of being controlled by an outside force [10].

The mean time of onset of symptoms is within two to three weeks after giving birth [2]. Psychotic episode starts with complaints of fatigue, insomnia, and restlessness. Tearfulness and emotional lability may also be observed. Manifestation become worse, with patient presents with suspiciousness, confusion, incoherence, irrational statements, and obsessive concerns about the health and welfare of the infant [2]. Majority have delusional ideas related to their infant, like someone is planning to kill the baby or the baby is harmed by the breastmilk [11]. In 28-35% of cases, delusions that the infant is dead or defective may be observed [2] [4], while 9% had infanticidal thoughts [4]. Patients may also deny giving birth and invoke reasons such as virginity and being unmarried [2].

A thorough history must be obtained. Since the primary psychiatric diagnosis to consider in postpartum psychosis is bipolar disorder, history of the disorder, either personal or family, must be determined [4]. Thoughts of dying, feeling of life not worth living, active plans to kill herself or the baby, access to weapons, and suicidal attempts in the past must also be elicited and must be taken seriously [4].

Laboratory investigations may be requested to exclude organic causes of acute psychosis [4]. Cerebrovascular events such as stroke due to preeclampsia may be excluded by careful history, blood pressure measurement, and CT or MRI [4]. Sepsis can be detected by CBC, urine culture, and, in cases of meningitis or encephalitis, lumbar puncture or cranial CT [4]. Metabolic or nutritional causes may also present with psychosis-like signs and symptoms [4]. Electrolytes such as sodium, fasting blood sugar, calcium, serum Vitamin B12, RBC folate, and thiamine levels may be requested [4]. Normal BUN and creatinine level will rule out uremic encephalopathy, while liver function tests (AST, ALT, alkaline phosphate, LDH, direct and indirect bilirubin) may exclude hepatic etiology [4]. Thyroid function tests can rule out Graves disease [4]. History of medication and drug screening may point to drug use as the primary cause of psychosis [4].

To screen for depression and mania/hypomania, the Edinburgh Postnatal Depression Scale (EPDS) and the Mood Disorder Questionnaire (MDQ) may be employed. EPDS is a self-rating tool used to uncover the presence of persistent low mood, anhedonia, guilt, anxiety, and thoughts of self-harm, while MDQ may be used to elicit past and present symptoms of high or irritable mood, racing thoughts, pressured speech, and manic or hypomanic symptoms [4]. Confusion, threats of harming herself or other people, difficulty caring her children, or poor self-care elicited in these screening tools must prompt the physician to refer the patient to a psychiatrist immediately [4].

No clinical guidelines specific to the management of postpartum psychosis is existing, and no universal recommendations can be made [1] [4]. The management should be individualized and discussed with the patient and her family, including the choices as well as the side effects of medications. The management of postpartum psychosis must involve education of patient about the illness, ruling out organic causes, initiation of pharmacologic and supportive therapy, and constant assessment of patient’s function and safety status [4].

Patients with suicidal or homicidal ideations should be brought to an emergency department as soon as possible [4]. Insomnia if present should be treated aggressively [3]. Organic causes must be ruled out first prior to the diagnosis of postpartum psychosis [4].

Drug treatment is needed to manage the psychotic and mood-related symptoms of psychosis, and should be initiated once organic causes are ruled out [4]. Although monotherapy is more preferred, some patients may require more than one drug to achieve satisfactory resolution of symptoms. These drugs are often started at the lowest starting dose and titrated slowly to the response dose to minimize side effects [4]. Assessment of patient’s function and safety status must be done repeatedly. This includes exploring the adherence to regimen and checking for signs of side effects which may necessitate dose adjustment [4].

Lithium and antipsychotic medications are considered the treatment of choice in the management of postpartum psychosis [2]. Patients with known cyclic mood illness or with family history of bipolar disorder may benefit from lithium [4]. Lithium has a very narrow window between the therapeutic and toxic windows, hence renal and thyroid functions should be assessed after five days. Drug level should be tested every 6-12 months after stabilization [4]. Side effects include tremor, sedation, renal dysfunction, weight gain, nausea, and vomiting. While data contradicting breastfeeding while in lithium is lacking [1], the infant should be strictly monitored for signs of toxicity, such as poor hydration, sedation, poor feeding, and weight gain [13]. Patients should also avoid drugs that alter fluid balance and renal excretion of lithium, such as thiazides, nonsteroidal anti-inflammatory drugs, and angiotensin-converting enzyme inhibitors [4].

Antiepileptic drugs are also used in the management of postpartum psychosis, particularly carbamazepine and valproic acid which are compatible with breastfeeding (4). Carbamazepine is used primarily in the treatment of mania, while valproic acid is indicated for bipolar illness. Other antiepileptic drugs approved for bipolar illness include oxcarbazepine for bipolar mania and lamotrigine for maintenance therapy of bipolar depression [4].

Atypical antipsychotic agents like olanzapine, risperidone, quetiapine, and ziprasidone are also used in managing acute psychosis and bipolar mania. Those with primary diagnosis of schizophrenia may also benefit from these drugs. Patients however must be advised to modify their diet and exercise regularly while taking any of these drugs to minimize the adverse metabolic side effects [4]. Extrapyramidal side effects should also be monitored as these are increased among patients with with affective disorders like postpartum psychosis. These drugs are also deemed safe for the infant while breastfeeding, though strict monitoring of the baby should also be done [4].

Electroconvulsive therapy, though becoming a mainstream treatment option recently [4] due to its effective treatment of puerperal psychosis [1], must be considered if conventional therapeutic options are ineffective. It provides instant resolution of symptoms in patients with acute psychosis. This option is ideal for patients who are unresponsive to several drugs, patients who are eager to have rapid resolution of symptoms, those who developed adverse drug events with conventional drug options, and those requiring fast and effective resolution of symptoms due to gross impairments in self-care, cognition, and judgment that may affect their safety and well-being [4].

Estrogen replacement as a treatment of postpartum psychosis was also shown to be therapeutic [7] although more proof is needed to establish its efficacy. Antidepressants are also used in combination with lithium (2), but some discourage its use due to possible rapid cycling or mixed states [3].

Educating the patient and her family about the illness and the management is essential because it improves the therapeutic alliance and strengthens the decision making process of the patient about the treatment and her feelings of improvement and mastery over the illness [4].

Supportive psychotherapy is effective adjunctive treatments for acute postpartum psychosis, and usually directed at helping the patient accept the mothering role [2] [4]. This includes incorporating parenting skills, early infant interventions, family-focused therapy, cognitive behavioral therapy, or interpersonal psychotherapy [13]. Contact with infant usually helps the patient to recover, but this should be supervised [2]. Support from the husband and family members is also essential [2], for example in allowing the patient to recover postdelivery from sleep loss, a precipitant of mania and psychosis [4].

There is a high rate of recovery among patients from acute postpartum psychosis [2], especially if the symptoms present less than one month postdelivery [4]. A good premorbid adjustment and a supportive family also result to a more favorable outcome [2].

This prognosis however is true only in the short-term [1]. Despite this excellent prognosis, patients are still at risk of subsequent puerperal and nonpuerperal episodes of psychosis. [1]. Patients should be informed and counselled of this risk of recurrence. Long-term stabilizing medication as well as other options to reduce the risk of recurrence must also be discussed [1]. However, contrary to the practice of most physicians, women should not be told not to bear children again [1].

There is generally an increased risk of manic or psychotic mood disorder during the puerperium [1]. Postpartum psychosis has a close relation with mood disorders [2]. In fact, most studies concluded that it is an episode of a mood disorder, usually a bipolar disorder and occasionally of major depressive disorder [2]. Since bipolar disorder has a relapsing and remitting presentation, most patients seem well prior to episode, not detected antenatally, and not in contact with mental health services, thereby failing to recognize the risks of having psychosis after delivery [1]. It was also suggested that this manic episode postpartum can be explained by the fact that women with bipolar disorder discontinue taking medication such as lithium prior to conception or during pregnancy because of fear over toxicity to the fetus [1].

Family history of bipolar disorder also increases the risk of postpartum psychosis. It was observed in 74% of mothers with bipolar disorder and a first degree relative who had postpartum psychosis, compared to only 30% of bipolar women without any family history [4]. Some authors suggest that this correlation imply that postpartum psychosis is actually a marker of a familial bipolar disorder, and that genetic factors increase the vulnerability of woman of having the episode [1].

The next best established risk factor after personal and family history of mood disorder is the parity [1]. 50-60% of the cases occur after the first obstetric delivery [2]. The risk of recurrence among patients is also high; there is a 50% chance of having the same episode after subsequent deliveries [4].

Other factors considered to increase the risk of postnatal psychosis are obstetric complication [1] [5], cesarian section [1], younger age [5], and absence of husband during peripartum stage [5]. Environmental stressors such as marital discord are also linked to psychosis [4], although data on its association with domestic violence is lacking [6].

Postpartum psychosis has a prevalence of 1-2 per 1000 childbirths [1] [2] [3]. However, its actual incidence may be higher since only the number of admissions is recorded, and a number of women opt to be treated at home [1]. 5% of the patients acted on their suicidal ideation while 4% of them committed infanticide [2]. The mean age of onset is 26.3, the age at which most women have their first or second child [4].

The onset of postpartum psychosis is widely thought to be brought by abrupt hormonal changes in a genetically vulnerable woman [2]. The lack of evidence associating psychosocial factors, and the fact that major physiological changes occur immediately postpartum strengthen this belief on the role of biological, especially hormonal, factors in the manifestation of psychosis [1]. Psychotic episode is likely triggered by abnormal response due to genetic or familial susceptibility, in the sudden but normal changes in hormonal level particularly estrogen and progesterone in a person with no gross endocrine abnormality [1] [3]. This concept, despite widely accepted, is still subject to investigation.
Another possibility of triggering psychosis revolves around the fact that most patients have actually bipolar illness prior to pregnancy. Due to concerns over toxicity of antipsychotic drugs to the fetus, such as lithium, patients usually discontinue taking their medications [1].

The physical stress brought by delivery deprives the patient sleep, and this lack of sleep, a known trigger of mania in bipolar disorder, is also thought to be responsible for puerperal triggering of illness [8]. This aspect, however, still lacks studies and attention among investigators [1].

The NICE guideline of 2014 recommends screening for known risk factors among antenatal women, and that protocols must be in place for those at risk of developing postpartum psychosis, including risk assessments and management plan [12]. Pregnant women with previous history of bipolar disorder or with family members with history of either bipolar disorder or postpartum psychosis must be informed of the risk and should be educated on the symptoms they must recognize such as mood swings, confusion, strange beliefs, and hallucinations particularly in the first two to four weeks postpartum [4]. Before delivery, at-risk patients are advised to consult with psychiatrist to discuss treatment options and possible prophylactic management.

For women with bipolar disorder who are taking lithium prior to pregnancy, they should be discouraged from abruptly discontinuing the medication [4]. Those with history of bipolar disorder who discontinued taking lithium during pregnancy are advised to resume taking the drug immediately after delivery. Women with past postpartum psychosis may also benefit from immediate treatment of lithium postdelivery [4]. The effect of lithium in the fetus is not well-founded by evidence [1], hence discussion with a psychiatrist regarding this prophylactic treatment may be necessary.

Postpartum psychosis, also known as puerperal or postnatal psychosis, is a severe mental illness and considered an emergency [1] [2] [3] which requires inpatient psychiatric treatment to ensure the safety not only of the patient but also of her infant [3]. Strictly speaking, it is a term reserved for severely affective psychosis, either manic, depressive or schizoaffective forms, of acute onset in a previously well woman, regardless of psychiatric history [1]. Patients present with depression, delusions, and thoughts of harming either herself or her infant, which must be monitored as they may act on their suicidal or infanticidal ideations [2]. Since the prevention and management of more common obstetric complications such as hemorrhage and infection greatly improved in the past years, this leaves suicide, usually associated with postpartum psychosis, as one of the leading causes of maternal mortality in developed countries [1].

Postpartum psychosis is usually characterized by bizarre behavior, delusions, and feeling of being controlled by outside forces, as well as suicidal and infanticidal ideations. Symptoms usually present two to four weeks after giving birth. The present belief is that this illness is brought by abrupt but normal hormonal changes after delivery in genetically susceptible individuals. This is considered an emergency warranting inpatient management and monitoring. Adherence to medication and family support are effective in the management of postpartum psychosis. Most medications used like lithium, antiepileptic drugs, and atypical antipsychotic drugs are safe during breastfeeding, but infant must be strictly monitored. Patients usually recover in a matter of days, although there is a high risk of recurrence even during nonpregnant periods. Most patients who develop postpartum psychosis have history of bipolar disorder and with family members with the same history, hence at-risk women can be identified even prior to pregnancy and be given with prophylactic treatment to avoid having psychosis postdelivery.

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