Postpartum Psychiatric Disorders (Clinical)

Overview

Definitions^[11,12,14]

• Postpartum (PP) blues: mild depressive symptoms that are transient and self-limiting Self-Limiting Meningitis in Children in the perinatal period
• PP depression PP depression Depression in postpartum women, usually within four weeks after giving birth (parturition). The degree of depression ranges from mild transient depression to neurotic or psychotic depressive disorders. Postpartum Psychiatric Disorders: depressive symptoms beginning within the 1st 12 months following childbirth and lasting for at least 2 weeks
• PP psychosis PP psychosis A psychiatric manifestation with abrupt onset after delivery that is characterized by psychotic symptoms.Symptoms are similar to those of non-obstetric psychosis. The presenting symptoms are often severe, interfere with daily activities, and require hospitalization. Postpartum Psychiatric Disorders: a psychiatric manifestation with abrupt onset after delivery that is characterized by psychotic symptoms Psychotic symptoms Brief Psychotic Disorder

Classification^[9,12]

The American Psychiatric Association (APA)’s Diagnostic and Statistical Manual, 5th edition (DSM-5)^[9] currently:

• Does not classify PP psychiatric disorders as distinct entities
• Allows providers to use the “with peripartum onset” specifier with the following diagnoses:
  • Adjustment disorder Adjustment disorder Adjustment disorder is a psychological response to an identifiable stressor. The condition by emotional or behavioral symptoms that develop within 3 months of exposure, and do not last more than 6 months. Adjustment Disorder with depressed mood 
  • Depressive disorder not otherwise specified
  • Major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder
  • Brief psychotic disorder Brief psychotic disorder Brief psychotic disorder is the presence of 1 or more psychotic symptoms lasting more than 1 day and less than 1 month. An episode is often stress-related with a sudden onset, and the patient fully returns to baseline functioning after an episode. Brief Psychotic Disorder
  • Major depressive, manic, or mixed episode in bipolar Bipolar Nervous System: Histology I or II disorders

According to the DSM-5, to use the “with peripartum onset” modifier, the onset of symptoms must occur during pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care or within 4 weeks PP (rather than within 1 year, which is commonly considered in clinical practice).

Epidemiology^[1,13,15]

• Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency:
  • PP blues PP blues Mild depressive symptoms that are transient and self-limiting in the perinatal period Postpartum Psychiatric Disorders: very common, up to 80% of pregnancies
  • PP depression PP depression Depression in postpartum women, usually within four weeks after giving birth (parturition). The degree of depression ranges from mild transient depression to neurotic or psychotic depressive disorders. Postpartum Psychiatric Disorders: often underdiagnosed, approximately 10%–25% of pregnancies 
  • PP psychosis PP psychosis A psychiatric manifestation with abrupt onset after delivery that is characterized by psychotic symptoms.Symptoms are similar to those of non-obstetric psychosis. The presenting symptoms are often severe, interfere with daily activities, and require hospitalization. Postpartum Psychiatric Disorders: rare, < 1–2 per 1000 births
• Gender Gender Gender Dysphoria: primarily occur in women
• Age: more common in women < 25 years of age

Impact

• Maternal suicide Suicide Suicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death. Suicide:^[1,13]
  • One of the leading causes of maternal mortality Mortality All deaths reported in a given population. Measures of Health Status 
  • Rates of maternal mortality Mortality All deaths reported in a given population. Measures of Health Status due to suicide Suicide Suicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death. Suicide:
    • Are similar to mortality Mortality All deaths reported in a given population. Measures of Health Status from infection
    • Exceed mortality Mortality All deaths reported in a given population. Measures of Health Status rates due to hemorrhage and hypertensive disorders
• Infanticide: approximately 300 in the US each year^[1]
• Negative effects on children^[1]: Untreated postpartum mood disorders in mothers are associated with impairments in cognitive, behavioral, and emotional development in childhood through adolescence.

Risk factors^[1,13]

• Young age (< 25 years)
• Poor social support
• Difficulties with breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding
• Cesarean sections, traumatic birth experience, or other perinatal complications
• Women with infants having health problems and/or with infants admitted to the NICU
• History of psychotic illnesses (especially anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder and depression)
• Family history Family History Adult Health Maintenance of psychiatric illnesses
• Previous episode of PP psychiatric disorder
• Stressful life events (during pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care and near delivery)
• Childcare stress (e.g., inconsolable crying infant)
• History of sexual abuse Sexual Abuse Sexual abuse and assault are major public health problems that affect many people from all walks of life, including people of all ages and genders, but it is more prevalent in women and girls, with reports of up to 1 in 3 experiencing sexual assault at some time in their life. Sexual Abuse and/or domestic violence
• Financial difficulties
• Concurrent substance abuse

Pathophysiology^[13,14]

The exact mechanisms are unclear and often multifactorial. 

• Estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy can affect the monoaminergic system ( serotonin Serotonin A biochemical messenger and regulator, synthesized from the essential amino acid l-tryptophan. In humans it is found primarily in the central nervous system, gastrointestinal tract, and blood platelets. Serotonin mediates several important physiological functions including neurotransmission, gastrointestinal motility, hemostasis, and cardiovascular integrity. Receptors and Neurotransmitters of the CNS and dopamine Dopamine One of the catecholamine neurotransmitters in the brain. It is derived from tyrosine and is the precursor to norepinephrine and epinephrine. Dopamine is a major transmitter in the extrapyramidal system of the brain, and important in regulating movement. Receptors and Neurotransmitters of the CNS) → changes in estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy influence affective and psychotic symptoms Psychotic symptoms Brief Psychotic Disorder
• Drastic changes in hormone levels are thought to be major contributing factors in PP psychiatric disorders:
  • Early PP period is characterized by a marked ↓ in both estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy and progesterone Progesterone The major progestational steroid that is secreted primarily by the corpus luteum and the placenta. Progesterone acts on the uterus, the mammary glands and the brain. It is required in embryo implantation; pregnancy maintenance, and the development of mammary tissue for milk production. Progesterone, converted from pregnenolone, also serves as an intermediate in the biosynthesis of gonadal steroid hormones and adrenal corticosteroids. Gonadal Hormones.
  • Other hormones Hormones Hormones are messenger molecules that are synthesized in one part of the body and move through the bloodstream to exert specific regulatory effects on another part of the body. Hormones play critical roles in coordinating cellular activities throughout the body in response to the constant changes in both the internal and external environments. Hormones: Overview and Types whose levels change following delivery:
    • Cortisol Cortisol Glucocorticoids
    • Melatonin
    • Oxytocin
    • Thyroid Thyroid The thyroid gland is one of the largest endocrine glands in the human body. The thyroid gland is a highly vascular, brownish-red gland located in the visceral compartment of the anterior region of the neck. Thyroid Gland: Anatomy hormone
• Genetic factors may contribute.

Key features of peripartum mood disorders^[13]

• Prominent, common features include:
  • Anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder and mood symptoms
  • Insomnia Insomnia Insomnia is a sleep disorder characterized by difficulty in the initiation, maintenance, and consolidation of sleep, leading to impairment of function. Patients may exhibit symptoms such as difficulty falling asleep, disrupted sleep, trouble going back to sleep, early awakenings, and feeling tired upon waking. Insomnia (not related to caring for the newborn Newborn An infant during the first 28 days after birth. Physical Examination of the Newborn)
• Other constitutional symptoms Constitutional Symptoms Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis may be present, especially in the immediate postpartum period Postpartum period In females, the period that is shortly after giving birth (parturition). Postpartum Complications, including changes in:
  • Sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep patterns
  • Appetite
  • Libido

Screening Screening Preoperative Care tools

There are a number of validated screening Screening Preoperative Care questionnaires that can help identify patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with or at risk for PP psychiatric disorders. However, no screening Screening Preoperative Care tool is 100% accurate in detecting PPD. There is also no universally recommended time duration in which to screen patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship. 

• Some of the most common questionnaires include:
  • Edinburgh Postnatal Depression Scale (EPDS)
  • PHQ-9 (Patient Health Questionnaire-9 (PHQ-9)
  • Postpartum Depression Screening Scale (PDSS)
• In one review study of 36 articles of postpartum depression Postpartum depression Depression in postpartum women, usually within four weeks after giving birth (parturition). The degree of depression ranges from mild transient depression to neurotic or psychotic depressive disorders. Postpartum Psychiatric Disorders screening Screening Preoperative Care tools, the PHQ-2 had the highest sensitivity (62–100%) of all the screening Screening Preoperative Care tools analyzed. 
• The EPDS EPDS Used to assess patients for PP depression specifically (as opposed to major depressive disorder in general) Postpartum Psychiatric Disorders is the most widely tested screening Screening Preoperative Care tool (71%) but had the lowest overall sensitivity of all (22–96%). 
• All the screening Screening Preoperative Care tests showed wide variations in their reported sensitivities, some of which varied based on what summed score was used as the decision point. 
• Results should always be interpreted within the clinical context (as with any screening Screening Preoperative Care test). 
• Validation by diagnostic interview for positive scores or scores which appear discordant with the clinical context is always necessary.

Edinburgh Postnatal Depression Scale Scale Dermatologic Examination ( EPDS EPDS Used to assess patients for PP depression specifically (as opposed to major depressive disorder in general) Postpartum Psychiatric Disorders)^[8,14]

• Used to assess patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship for PP depression PP depression Depression in postpartum women, usually within four weeks after giving birth (parturition). The degree of depression ranges from mild transient depression to neurotic or psychotic depressive disorders. Postpartum Psychiatric Disorders specifically (as opposed to major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder in general)
• Self-reported 10-item questionnaire
• Includes anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder symptoms, which are a prominent feature in perinatal mood disorders
• Excludes constitutional symptoms Constitutional Symptoms Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis (e.g., changes in sleeping patterns) that are common in the PP period
• Available in over 50 languages
• Screening Screening Preoperative Care tool recommended by the American College of Obstetricians and Gynecologists (ACOG),^[13] the UK National Institute for Health and Care Excellence (NICE),^[5] and the World Health Organization (WHO)^[4]

Administering the EPDS EPDS Used to assess patients for PP depression specifically (as opposed to major depressive disorder in general) Postpartum Psychiatric Disorders:^[8,14]

• Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship are asked how often they have felt certain ways about specific things in the past 7 days.
• Each item on the questionnaire has 4 possible answer choices, each of which is assigned a score from 0 to 3.
• The scores from each item are added together to determine the final score (maximum score, 30).
• Interpretation:
  • The cutoff used to identify individuals who may have major depression varies by institution/practitioner but is typically between 10 and 13.
    • A score of ≥ 11 maximizes sensitivity (81%) and specificity (88%).
    • Using a cutoff score of ≥ 13 decreases sensitivity (66%) but increases specificity (95%).
    • Using a cutoff of ≥ 10 increases sensitivity (85%; fewer false positives) but decreases specificity (84%).
  • A score other than 0 on item 10 (thoughts of harming myself) always requires follow-up.

Patient Health Questionnaire-9^[9] 

• PHQ-9 calculator
• Used to assess depression severity and monitor effects of treatment (though not specific for PP depression PP depression Depression in postpartum women, usually within four weeks after giving birth (parturition). The degree of depression ranges from mild transient depression to neurotic or psychotic depressive disorders. Postpartum Psychiatric Disorders)
• Self-reported 9-item questionnaire
• Includes constitutional symptoms Constitutional Symptoms Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis → reduces specificity in PPD
• Screening Screening Preoperative Care tool recommended by ACOG,^[13] NICE,^[5] and the WHO^[4]

Administering the PHQ-9:

• Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship are asked how often they have been bothered by certain things over the past 2 weeks.
• Each item on the questionnaire has the same 4 answer choices, each of which assigned a score between 0 and 3:
  • Not at all = 0 points
  • Several days = 1 point
  • More than half the days = 2 points
  • Nearly every day = 3 points
• Questionnaire items:
  • Little interest or pleasure in doing things?
  • Feeling down, depressed, or hopeless?
  • Trouble falling or staying asleep or sleeping too much?
  • Feeling tired or having little energy?
  • Poor appetite or overeating?
  • Feeling bad about yourself, feeling that you are a failure, or feeling that you have let yourself or your family down?
  • Trouble concentrating on things, such as reading the newspaper or watching television?
  • Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?
  • Thoughts that you would be better off dead or thoughts of hurting yourself in some way?
• The scores from each item are added together to determine the final score.
• Interpretation:
  • Scores ≤ 4 suggest minimal depression that likely does not require treatment.
  • Scores of 5‒9 suggest mild depression that may require only observation and repeating the PHQ-9 at follow-up.
  • Scores ≥ 10 are 88% sensitive and 88% specific for detecting major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder.

Other validated screening Screening Preoperative Care tools

• PP Depression PP depression Depression in postpartum women, usually within four weeks after giving birth (parturition). The degree of depression ranges from mild transient depression to neurotic or psychotic depressive disorders. Postpartum Psychiatric Disorders Screening Screening Preoperative Care Scale Scale Dermatologic Examination ( PDSS PDSS Postpartum Psychiatric Disorders):^[13]
  • Self-reported 35-item questionnaire 
  • High sensitivity (91%‒94%) and specificity (72%‒98%)
• Generalized Anxiety Disorder-7 (GAD-7):
  • A 7-item questionnaire to assess the severity of GAD GAD Generalized anxiety disorder (GAD) is a common mental condition defined by excessive, uncontrollable worrying causing distress and occurring frequently for at least 6 months. Generalized anxiety disorder is more common in women. Clinical presentation includes fatigue, low concentration, restlessness, irritability, and sleep disturbance. Generalized Anxiety Disorder symptoms (and monitor symptom changes over time)
  • Assesses how much patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship have been bothered by certain symptoms over the past 2 weeks.

Postpartum Blues

Clinical presentation and diagnosis^[12,18]

• Symptoms may include:
  • Feeling guilty and/or overwhelmed (especially about being a mother)
  • Crying, sadness
  • Rapid changes in mood and irritability
  • Anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder 
  • Poor concentration
  • Eating too much or too little
  • Insomnia Insomnia Insomnia is a sleep disorder characterized by difficulty in the initiation, maintenance, and consolidation of sleep, leading to impairment of function. Patients may exhibit symptoms such as difficulty falling asleep, disrupted sleep, trouble going back to sleep, early awakenings, and feeling tired upon waking. Insomnia or frequent awakenings at night
• Symptoms are mild and do not interfere with activities of daily living.
• Onset of symptoms: within a couple of days after birth 
• Duration of symptoms: lasting up to and no more than 2 weeks
• Does not meet the criteria for major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder
• Note: Postpartum blues Postpartum blues Mild depressive symptoms that are transient and self-limiting in the perinatal period Postpartum Psychiatric Disorders lacks its own diagnostic codes/descriptors by some major organizations.
  • WHO’s International Classification of Disease 10, 10th revision (ICD-10) classifies postpartum blues Postpartum blues Mild depressive symptoms that are transient and self-limiting in the perinatal period Postpartum Psychiatric Disorders as “ postpartum depression Postpartum depression Depression in postpartum women, usually within four weeks after giving birth (parturition). The degree of depression ranges from mild transient depression to neurotic or psychotic depressive disorders. Postpartum Psychiatric Disorders not otherwise specified.”
  • The Diagnostic and Statistical Manual, 5th edition (DSM-5) of the American Psychiatric Association (APA) does not recognize it as a separate entity (providers can use “unspecified depressive disorder” or “ adjustment disorder Adjustment disorder Adjustment disorder is a psychological response to an identifiable stressor. The condition by emotional or behavioral symptoms that develop within 3 months of exposure, and do not last more than 6 months. Adjustment Disorder with depressed mood”).

Management

• Resolves spontaneously
• Provide reassurance Reassurance Clinician–Patient Relationship. 
• Encourage self-care.

Postpartum Depression

Clinical presentation

• Symptoms may include:
  • Disinterest in self, in child, and in normal activities
  • Feeling isolated, unwanted, or worthless
  • Feeling a sense of shame or guilt about parenting skills
  • ↑ Anger outbursts
  • Suicidal ideation Suicidal ideation A risk factor for suicide attempts and completions, it is the most common of all suicidal behavior, but only a minority of ideators engage in overt self-harm. Suicide or frequent thoughts of death
• Symptoms are more severe and patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship have an inability to cope.
• Onset of symptoms: 
  • Most organizations, including ACOG, the APA, NICE, and the WHO consider perinatal-related depression to be depression that begins during pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care or up to 1 year after delivery.
  • To use specific diagnostic codes:
    • From the APA: Onset of depression must be within 4 weeks of delivery to use a diagnosis of “major depression” with the DSM-5 specifier “with peripartum onset.”
    • From the WHO: Onset of depression must be within 6 weeks of delivery to use the ICD-10 diagnosis “ postpartum depression Postpartum depression Depression in postpartum women, usually within four weeks after giving birth (parturition). The degree of depression ranges from mild transient depression to neurotic or psychotic depressive disorders. Postpartum Psychiatric Disorders not otherwise specified.”
    • Note: The APA and WHO still recognize the increased risk of depression in the perinatal period past the 4‒6-week mark, it is simply coded as “major depression.”
• Duration of symptoms: > 2 weeks

Diagnosis^[11]

Postpartum depression Postpartum depression Depression in postpartum women, usually within four weeks after giving birth (parturition). The degree of depression ranges from mild transient depression to neurotic or psychotic depressive disorders. Postpartum Psychiatric Disorders is a clinical diagnosis, which may be assisted by using screening Screening Preoperative Care questionnaires and the DSM-5 criteria, as well as excluding any contributory medical conditions:

• Screening Screening Preoperative Care questionnaires (e.g., EPDS EPDS Used to assess patients for PP depression specifically (as opposed to major depressive disorder in general) Postpartum Psychiatric Disorders, PDSS PDSS Postpartum Psychiatric Disorders, or Patient Health Questionnaire-9) 
• DSM-5 criteria for major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder with peripartum onset:^[11]
  • Patients must meet at least 5 out of 9 symptoms for > 2 weeks.
  • Depressed mood or anhedonia Anhedonia Inability to experience pleasure due to impairment or dysfunction of normal psychological and neurobiological mechanisms. It is a symptom of many psychotic disorders (e.g., depressive disorder, major; and schizophrenia). Schizophrenia (reduced pleasure from previously enjoyable habits) must be among the patient’s symptoms.
  • Symptoms include:
    • Depressed mood, almost everyday
    • Anhedonia Anhedonia Inability to experience pleasure due to impairment or dysfunction of normal psychological and neurobiological mechanisms. It is a symptom of many psychotic disorders (e.g., depressive disorder, major; and schizophrenia). Schizophrenia
    • Appetite/weight changes (↓ or ↑)
    • Sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep disturbances (↓ or ↑, unrelated to caring for the newborn Newborn An infant during the first 28 days after birth. Physical Examination of the Newborn)
    • Psychomotor agitation Agitation A feeling of restlessness associated with increased motor activity. This may occur as a manifestation of nervous system drug toxicity or other conditions. St. Louis Encephalitis Virus or retardation (patient is anxious and moves a lot, or barely moves)
    • Loss of energy/ fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia
    • Feeling worthless or excessively guilty
    • Trouble concentrating
    • Suicidal ideation Suicidal ideation A risk factor for suicide attempts and completions, it is the most common of all suicidal behavior, but only a minority of ideators engage in overt self-harm. Suicide and/or attempts
  • Symptoms cause a significant decline in function in social and occupational/school settings.
  • The patient does not have a history of:
    • Other psychiatric disorders (especially bipolar Bipolar Nervous System: Histology disorder)
    • Substance use 
    • Medical conditions such as hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto’s disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism, nutritional deficiency, and cerebrovascular disease, which cause depressive mood
  • Limitations Limitations Conflict of Interest of the DSM-5 criteria:
    • Many symptoms, especially weight changes and sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep disturbances, are common and frequently unrelated to depression in the PP period.
    • Restricts the diagnosis to symptoms beginning within 4 weeks of delivery → may lead to underdiagnosis
• DSM-5 criteria for minor depressive episode:^[11]
  • Patient meets 2 of the 9 symptoms used as diagnostic criteria for major depression for ≥ 2 weeks.
  • One symptom must be depressed mood or anhedonia Anhedonia Inability to experience pleasure due to impairment or dysfunction of normal psychological and neurobiological mechanisms. It is a symptom of many psychotic disorders (e.g., depressive disorder, major; and schizophrenia). Schizophrenia.
• Laboratory studies:
  • If patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship do have a history of medical conditions known to cause depressive symptoms, tests should be ordered to assess status.
  • Should be ordered if patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship have other findings consistent with these conditions (e.g., new-onset constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation and goiter Goiter A goiter is a chronic enlargement of the thyroid gland due to nonneoplastic growth occurring in the setting of hypothyroidism, hyperthyroidism, or euthyroidism. Morphologically, thyroid enlargement can be diffuse (smooth consistency) or nodular (uninodular or multinodular). Goiter, which are suggestive of hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto’s disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism)

Management^[6,15,19,20]

• In most cases, the management team should include both the patient’s obstetrician/internist and a psychiatrist.^[15]
• 1st-line treatments:^[6]
  • Mild depression: psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy alone
  • Moderate-to-severe depression: psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy plus an antidepressant Antidepressant Antidepressants encompass several drug classes and are used to treat individuals with depression, anxiety, and psychiatric conditions, as well as those with chronic pain and symptoms of menopause. Antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and many other drugs in a class of their own. Serotonin Reuptake Inhibitors and Similar Antidepressants
• Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy
  • Cognitive behavioral therapy Cognitive behavioral therapy A directive form of psychotherapy based on the interpretation of situations (cognitive structure of experiences) that determine how an individual feels and behaves. It is based on the premise that cognition, the process of acquiring knowledge and forming beliefs, is a primary determinant of mood and behavior. The therapy uses behavioral and verbal techniques to identify and correct negative thinking that is at the root of the aberrant behavior. Psychotherapy 
  • Family-centered therapy
  • Nondirective counseling
• Antidepressants:
  • Weigh risks against benefits for breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding mothers.^[19]
    • Most are relatively safe when clinically warranted.
    • There are risks associated both with taking medication and with untreated major depression.
    • Amount of drug in breast milk is typically low.
    • Amount of drug detected in infant serum is typically very low or undetectable, without clinically significant serotonin Serotonin A biochemical messenger and regulator, synthesized from the essential amino acid l-tryptophan. In humans it is found primarily in the central nervous system, gastrointestinal tract, and blood platelets. Serotonin mediates several important physiological functions including neurotransmission, gastrointestinal motility, hemostasis, and cardiovascular integrity. Receptors and Neurotransmitters of the CNS reuptake blockade in infants.
  • Consider prior treatments:
    • Try to use medications that have worked well for the patient in the past.
    • Avoid medications that have not worked well.
  • Monotherapy is preferred over polytherapy.^[19]
  • Monitoring serum levels:^[19]
    • Generally not needed
    • May be helpful in assessing significant changes in an infant’s behavior (e.g., new irritability or feeding problems) or if the mother is on a particularly high dose
  • Selective serotonin reuptake inhibitors Selective Serotonin Reuptake Inhibitors Serotonin Reuptake Inhibitors and Similar Antidepressants ( SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants):^[19,20]
    • 1st-line treatment; best studied
    • Best options: paroxetine Paroxetine A serotonin uptake inhibitor that is effective in the treatment of depression. Serotonin Reuptake Inhibitors and Similar Antidepressants 10–50 mg/day, sertraline Sertraline A selective serotonin uptake inhibitor that is used in the treatment of depression. Serotonin Reuptake Inhibitors and Similar Antidepressants 50–200 mg/day (unlikely to have ↑ drug levels in breastfed infants)
    • Associated with potentially high risks: fluoxetine Fluoxetine The first highly specific serotonin uptake inhibitor. It is used as an antidepressant and often has a more acceptable side-effects profile than traditional antidepressants. Serotonin Reuptake Inhibitors and Similar Antidepressants 20–60 mg/day (higher risk of ↑ levels in infants exposed to fluoxetine Fluoxetine The first highly specific serotonin uptake inhibitor. It is used as an antidepressant and often has a more acceptable side-effects profile than traditional antidepressants. Serotonin Reuptake Inhibitors and Similar Antidepressants) 
    • Target doses are similar to those used in the general adult population.
  • Other relatively safe options:
    • Tricyclic antidepressants Tricyclic antidepressants Tricyclic antidepressants (TCAs) are a class of medications used in the management of mood disorders, primarily depression. These agents, named after their 3-ring chemical structure, act via reuptake inhibition of neurotransmitters (particularly norepinephrine and serotonin) in the brain. Tricyclic Antidepressants ( TCAs TCAs Tricyclic antidepressants (TCAs) are a class of medications used in the management of mood disorders, primarily depression. These agents, named after their 3-ring chemical structure, act via reuptake inhibition of neurotransmitters (particularly norepinephrine and serotonin) in the brain. Tricyclic Antidepressants): nortriptyline Nortriptyline A metabolite of amitriptyline that is also used as an antidepressant agent. Nortriptyline is used in major depression, dysthymia, and atypical depressions. Tricyclic Antidepressants 25–150 mg/day^[19,20]
    • Serotonin Serotonin A biochemical messenger and regulator, synthesized from the essential amino acid l-tryptophan. In humans it is found primarily in the central nervous system, gastrointestinal tract, and blood platelets. Serotonin mediates several important physiological functions including neurotransmission, gastrointestinal motility, hemostasis, and cardiovascular integrity. Receptors and Neurotransmitters of the CNS– norepinephrine Norepinephrine Precursor of epinephrine that is secreted by the adrenal medulla and is a widespread central and autonomic neurotransmitter. Norepinephrine is the principal transmitter of most postganglionic sympathetic fibers, and of the diffuse projection system in the brain that arises from the locus ceruleus. Receptors and Neurotransmitters of the CNS reuptake inhibitors ( SNRIs SNRIs Serotonin Reuptake Inhibitors and Similar Antidepressants)
• Electroconvulsive therapy Electroconvulsive therapy Electrically induced convulsions primarily used in the treatment of severe affective disorders and schizophrenia. Major Depressive Disorder (ECT) can also be considered (no risk to infant).
• Continue to monitor symptoms using the EPDS EPDS Used to assess patients for PP depression specifically (as opposed to major depressive disorder in general) Postpartum Psychiatric Disorders or PHQ-9.
• Indications for referral to a psychiatrist:
  • Severe depression and/or a poor response to initial treatment
  • Bipolar Bipolar Nervous System: Histology disorder or other psychiatric comorbidities Comorbidities The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. St. Louis Encephalitis Virus
  • Suicidal ideations or behaviors
  • Any psychotic features
• Most women recover within 6–12 months.

Complications of postpartum depression Postpartum depression Depression in postpartum women, usually within four weeks after giving birth (parturition). The degree of depression ranges from mild transient depression to neurotic or psychotic depressive disorders. Postpartum Psychiatric Disorders

• Risk of impaired maternal-child bonding → risk of behavioral problems and/or developmental delay in the infant
• ↑ Risk of developing major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder later in life
• Suicide Suicide Suicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death. Suicide (preventable with adequate treatment)
• Infanticide

Postpartum Psychosis (PPP)

Clinical presentation^[16]

• Symptoms are similar to those of non-obstetric psychosis, which is a disturbance in an individual’s perception Perception The process by which the nature and meaning of sensory stimuli are recognized and interpreted. Psychiatric Assessment of reality.
  • The presenting symptoms are often:
    • Severe
    • Interfere with daily activities
    • Require emergent hospitalization Hospitalization The confinement of a patient in a hospital. Delirium. 
  • ~ 50% of women with PPP have a prior psychiatric history, such as:
    • Major depression with psychosis
    • Schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia
    • Schizoaffective disorder Schizoaffective disorder Schizoaffective disorder is a mental disorder that is marked by 2 components: a psychotic component (hallucinations or delusions) and a mood component (mania or depression). Patients must therefore meet the diagnostic criteria for both major mood disorder and schizophrenia. Schizoaffective Disorder
  • PPP often predicts a subsequent diagnosis of bipolar Bipolar Nervous System: Histology disorder.
• Symptoms may include:
  • Hallucinations Hallucinations Subjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders. Schizophrenia ( sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology experiences which have no physical sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology stimulation), which may involve any one of the 5 senses:
    • Tactile
    • Visual
    • Auditory
    • Gustatory
    • Olfactory 
  • Delusions: fixed, false, idiosyncratic beliefs that are not culturally based (especially those regarding issues of parenthood) 
  • Thought disorganization: disorganized way of thinking that leads to abnormal ways of expressing language when speaking and writing
  • Disorganized behavior (odd, bizarre behavior) such as:
    • Smiling
    • Laughing
    • Talking to oneself 
    • Being preoccupied/responding to internal stimuli
    • Can also include purposeless, ambivalent behavior or movements, or catatonic behavior
  • Paranoia, confusion 
  • Mood symptoms (e.g., mania Mania A state of elevated excitement with over-activity sometimes accompanied with psychotic symptoms (e.g., psychomotor agitation, inflated self esteem and flight of ideas). It is often associated with mental disorders (e.g., cyclothymic disorder; and bipolar diseases). Bipolar Disorder, depression, or both)
  • Obsession with caring for the infant 
  • Severe insomnia Insomnia Insomnia is a sleep disorder characterized by difficulty in the initiation, maintenance, and consolidation of sleep, leading to impairment of function. Patients may exhibit symptoms such as difficulty falling asleep, disrupted sleep, trouble going back to sleep, early awakenings, and feeling tired upon waking. Insomnia or frequent awakenings at night
  • Irritability, anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder, hyperactivity Hyperactivity Attention Deficit Hyperactivity Disorder, and psychomotor agitation Agitation A feeling of restlessness associated with increased motor activity. This may occur as a manifestation of nervous system drug toxicity or other conditions. St. Louis Encephalitis Virus 
  • Homicidal or violent thoughts related to the infant
  • Suicidal ideation Suicidal ideation A risk factor for suicide attempts and completions, it is the most common of all suicidal behavior, but only a minority of ideators engage in overt self-harm. Suicide or attempts
• Onset: few days to 1 year after delivery (most commonly 2 weeks after delivery)
• More common in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with bipolar Bipolar Nervous System: Histology disorder or other psychiatric disorders characterized by psychosis (e.g., schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia)

Etiology and diagnosis^[16,22]

According to the DSM-5, postpartum psychosis Postpartum psychosis A psychiatric manifestation with abrupt onset after delivery that is characterized by psychotic symptoms.Symptoms are similar to those of non-obstetric psychosis. The presenting symptoms are often severe, interfere with daily activities, and require hospitalization. Postpartum Psychiatric Disorders is not recognized as a distinct disorder. Instead, classification is based on the primary psychiatric disorder (e.g., bipolar Bipolar Nervous System: Histology disorder) and given the modifier “with peripartum onset” if symptoms begin within 4 weeks of delivery.

Most common associated psychiatric disorders:

• Bipolar Bipolar Nervous System: Histology disorder: Patient has had episodes of both mania Mania A state of elevated excitement with over-activity sometimes accompanied with psychotic symptoms (e.g., psychomotor agitation, inflated self esteem and flight of ideas). It is often associated with mental disorders (e.g., cyclothymic disorder; and bipolar diseases). Bipolar Disorder and depression.
• Schizoaffective disorder Schizoaffective disorder Schizoaffective disorder is a mental disorder that is marked by 2 components: a psychotic component (hallucinations or delusions) and a mood component (mania or depression). Patients must therefore meet the diagnostic criteria for both major mood disorder and schizophrenia. Schizoaffective Disorder: development of chronic psychosis without mood symptoms
• Schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia: functional decline for at least 6 months with ≥ 2 psychotic symptoms Psychotic symptoms Brief Psychotic Disorder present for at least 1 month
• Major depression with psychotic features: depression symptoms and psychosis without mania Mania A state of elevated excitement with over-activity sometimes accompanied with psychotic symptoms (e.g., psychomotor agitation, inflated self esteem and flight of ideas). It is often associated with mental disorders (e.g., cyclothymic disorder; and bipolar diseases). Bipolar Disorder for at least 2 weeks
• Substance abuse disorder
• Psychosis due to general medical conditions
• Brief psychotic disorder Brief psychotic disorder Brief psychotic disorder is the presence of 1 or more psychotic symptoms lasting more than 1 day and less than 1 month. An episode is often stress-related with a sudden onset, and the patient fully returns to baseline functioning after an episode. Brief Psychotic Disorder: symptoms are present for < 1 month

Other potential causes of psychosis:

• Illicit drug use
• Infectious diseases (e.g., mastitis Mastitis Mastitis is inflammation of the breast tissue with or without infection. The most common form of mastitis is associated with lactation in the first few weeks after birth. Non-lactational mastitis includes periductal mastitis and idiopathic granulomatous mastitis (IGM). Mastitis, endometritis Endometritis Endometritis is an inflammation of the endometrium, the inner layer of the uterus. The most common subtype is postpartum endometritis, resulting from the ascension of normal vaginal flora to the previously aseptic uterus. Postpartum Endometritis)
• Metabolic encephalopathy Encephalopathy Hyper-IgM Syndrome
• Endocrine dysfunction
• CNS events

Workup:

• The same as psychosis workups in non-postpartum patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship
• Interviews with:
  • The patient
  • Family members or caregivers
  • Other medical or mental health providers
• Physical exam:
  • Mental status exam:
    • Affect
    • Mood
    • Thought processes and content
    • Hallucinations Hallucinations Subjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders. Schizophrenia
    • Concentration
    • Memory Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment
    • Attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment
  • Neurologic exam
  • Heart and lung exam
  • Abdominal exam
• Laboratory studies to evaluate other potential causes:
  • Urine drug screen
  • CBC: Leukocytosis Leukocytosis A transient increase in the number of leukocytes in a body fluid. West Nile Virus may indicate infectious diseases.
  • CMP: Abnormal electrolytes Electrolytes Electrolytes are mineral salts that dissolve in water and dissociate into charged particles called ions, which can be either be positively (cations) or negatively (anions) charged. Electrolytes are distributed in the extracellular and intracellular compartments in different concentrations. Electrolytes are essential for various basic life-sustaining functions. Electrolytes may suggest metabolic encephalopathy Encephalopathy Hyper-IgM Syndrome.
  • Thyroid Thyroid The thyroid gland is one of the largest endocrine glands in the human body. The thyroid gland is a highly vascular, brownish-red gland located in the visceral compartment of the anterior region of the neck. Thyroid Gland: Anatomy studies: may suggest hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto’s disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism
  • Vitamin B₁₂ level
  • Test for syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis (e.g., rapid plasma reagin test Rapid plasma reagin test Treponema)—likely done during antenatal care
• Neuroimaging Neuroimaging Non-invasive methods of visualizing the central nervous system, especially the brain, by various imaging modalities. Febrile Infant:
  • Indicated if the physical exam suggests an underlying structural cause (such as a focal neurologic deficit Focal Neurologic Deficit Intracerebral Hemorrhage)
  • Typically with MRI or CT

Factors suggesting a primary psychiatric (as opposed to a medical) diagnosis:

• Insidious (as opposed to acute) onset 
• Auditory (as opposed to olfactory or tactile) hallucinations Hallucinations Subjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders. Schizophrenia 
• Family history Family History Adult Health Maintenance of psychiatric illness

Management^[17,19,22]

Postpartum psychosis Postpartum psychosis A psychiatric manifestation with abrupt onset after delivery that is characterized by psychotic symptoms.Symptoms are similar to those of non-obstetric psychosis. The presenting symptoms are often severe, interfere with daily activities, and require hospitalization. Postpartum Psychiatric Disorders is considered a psychiatric emergency.

Hospitalization Hospitalization The confinement of a patient in a hospital. Delirium:

• Especially if there is homicidal or suicidal ideation Suicidal ideation A risk factor for suicide attempts and completions, it is the most common of all suicidal behavior, but only a minority of ideators engage in overt self-harm. Suicide
• The patient should be under the care of a psychiatrist (not an obstetrician).
• Ensure safety of the patient and infant:
  • Mother should remain hospitalized until stable.
  • Mother should not be left alone with the infant.
  • Supervised visits with the infant may be possible.

Medical therapy:

• Antipsychotics:
  • Typically considered 1st-line therapy
  • Consider risks of medication for breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding infants:
    • Medications do enter the breast milk, though levels tend to be low.
    • During lactation Lactation The processes of milk secretion by the maternal mammary glands after parturition. The proliferation of the mammary glandular tissue, milk synthesis, and milk expulsion or let down are regulated by the interactions of several hormones including estradiol; progesterone; prolactin; and oxytocin. Breastfeeding, choose options with more safety data.
  • Consider effects (response vs. nonresponse) of prior medications.
  • Best options (expert opinion): older 2nd-generation antipsychotics (start with the following initial doses, with a higher dose given for severe symptoms):^[21]
    • Quetiapine Quetiapine A dibenzothiazepine and antipsychotic agent that targets the serotonin 5-HT2 receptor; histamine h1 receptor, adrenergic alpha1 and alpha2 receptors, as well as the dopamine d1 receptor and dopamine D2 receptor. It is used in the treatment of schizophrenia; bipolar disorder and depressive disorder. Second-Generation Antipsychotics 50 mg once daily, up to 50 mg twice daily
    • Risperidone Risperidone A selective blocker of dopamine D2 receptors and serotonin 5-HT2 receptors that acts as an atypical antipsychotic agent. It has been shown to improve both positive and negative symptoms in the treatment of schizophrenia. Second-Generation Antipsychotics 0.5–1 mg/day
    • Olanzapine Olanzapine A benzodiazepine derivative that binds serotonin receptors; muscarinic receptors; histamine h1 receptors; adrenergic alpha-1 receptors; and dopamine receptors. It is an antipsychotic agent used in the treatment of schizophrenia; bipolar disorder; and major depressive disorder; it may also reduce nausea and vomiting in patients undergoing chemotherapy. Second-Generation Antipsychotics 2.5–5 mg/day
  • 2nd-Line treatment:
    • 1st-generation antipsychotics (more side effects; e.g., extrapyramidal effects): haloperidol Haloperidol A phenyl-piperidinyl-butyrophenone that is used primarily to treat schizophrenia and other psychoses. It is also used in schizoaffective disorder, delusional disorders, ballism, and tourette syndrome (a drug of choice) and occasionally as adjunctive therapy in intellectual disability and the chorea of huntington disease. It is a potent antiemetic and is used in the treatment of intractable hiccups. First-Generation Antipsychotics, perphenazine Perphenazine An antipsychotic phenothiazine derivative with actions and uses similar to those of chlorpromazine. First-Generation Antipsychotics, trifluoperazine Trifluoperazine A phenothiazine with actions similar to chlorpromazine. It is used as an antipsychotic and an antiemetic. First-Generation Antipsychotics
    • Newer 2nd-generation antipsychotics (minimal safety data): aripiprazole Aripiprazole A piperazine and quinolone derivative that is used primarily as an antipsychotic agent. It is a partial agonist of serotonin receptor, 5-HT1a and dopamine D2 receptors, where it also functions as a postsynaptic antagonist, and an antagonist of serotonin receptor, 5-HT2a. It is used for the treatment of schizophrenia and bipolar disorder, and as an adjunct therapy for the treatment of depression. Second-Generation Antipsychotics, ziprasidone Ziprasidone Second-Generation Antipsychotics
  • If IM administration is required:
    • Haloperidol Haloperidol A phenyl-piperidinyl-butyrophenone that is used primarily to treat schizophrenia and other psychoses. It is also used in schizoaffective disorder, delusional disorders, ballism, and tourette syndrome (a drug of choice) and occasionally as adjunctive therapy in intellectual disability and the chorea of huntington disease. It is a potent antiemetic and is used in the treatment of intractable hiccups. First-Generation Antipsychotics 0.5‒10 mg, based on severity of symptoms
    • Olanzapine Olanzapine A benzodiazepine derivative that binds serotonin receptors; muscarinic receptors; histamine h1 receptors; adrenergic alpha-1 receptors; and dopamine receptors. It is an antipsychotic agent used in the treatment of schizophrenia; bipolar disorder; and major depressive disorder; it may also reduce nausea and vomiting in patients undergoing chemotherapy. Second-Generation Antipsychotics 10 mg (maximum, 30 mg/day)
• May be combined with antidepressants or mood stabilizers depending on the symptoms:
  • Mood stabilizers (used in bipolar Bipolar Nervous System: Histology disorder):
    • Lithium Lithium An element in the alkali metals family. It has the atomic symbol li, atomic number 3, and atomic weight [6. 938; 6. 997]. Salts of lithium are used in treating bipolar disorder. Ebstein’s Anomaly (if not breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding) 300 mg twice a day (requires serum monitoring)
    • Valproate Valproate A fatty acid with anticonvulsant and anti-manic properties that is used in the treatment of epilepsy and bipolar disorder. The mechanisms of its therapeutic actions are not well understood. It may act by increasing gamma-aminobutyric acid levels in the brain or by altering the properties of voltage-gated sodium channels. First-Generation Anticonvulsant Drugs (if breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding) 500 mg once or twice daily, titrated until blood levels are 50‒125 µg/mL
  • Antidepressants are added to antipsychotics in women with:
    • Major depression with psychotic features 
    • Schizoaffective disorder Schizoaffective disorder Schizoaffective disorder is a mental disorder that is marked by 2 components: a psychotic component (hallucinations or delusions) and a mood component (mania or depression). Patients must therefore meet the diagnostic criteria for both major mood disorder and schizophrenia. Schizoaffective Disorder with affective symptoms
• Consider benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines for insomnia Insomnia Insomnia is a sleep disorder characterized by difficulty in the initiation, maintenance, and consolidation of sleep, leading to impairment of function. Patients may exhibit symptoms such as difficulty falling asleep, disrupted sleep, trouble going back to sleep, early awakenings, and feeling tired upon waking. Insomnia.

Other treatment options:

• Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy:
  • Generally only useful after the initial crisis 
  • May help prevent recurrence (no clinical trials)
  • Family-centered therapy can provide support for recovery.
• ECT can be used to reduce depressive symptoms.

Complications

• Temporary disruption to the maternal-infant bond → risk of behavioral problems and/or developmental delay in the infant
• Suicide Suicide Suicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death. Suicide and/or homicide (usually preventable with adequate treatment)

Differential Diagnosis

• Acute stress disorder Acute stress disorder Acute stress disorder describes stress reactions displayed after an individual has experienced a traumatic event. Symptoms last more than 3 days but less than 1 month and include re-experiencing the event as flashbacks or nightmares, avoidance of reminders of the event, irritability, hyperarousal, and poor memory and concentration. Acute Stress Disorder: presents after an individual has experienced a life-threatening event. Symptoms last > 3 days and < 1 month and involve re-experiencing the event as flashbacks or nightmares, avoidance of reminders of the event, irritability, hyperarousal, and poor memory Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment and concentration. Management uses cognitive behavioral therapy Cognitive behavioral therapy A directive form of psychotherapy based on the interpretation of situations (cognitive structure of experiences) that determine how an individual feels and behaves. It is based on the premise that cognition, the process of acquiring knowledge and forming beliefs, is a primary determinant of mood and behavior. The therapy uses behavioral and verbal techniques to identify and correct negative thinking that is at the root of the aberrant behavior. Psychotherapy and medications including anxiolytics. 
• Major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder: a unipolar Unipolar Nervous System: Histology mood disorder characterized by persistent low mood and loss of interest, in association with somatic symptoms Somatic symptoms Major Depressive Disorder for at least a 2-week duration. Major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder has the highest lifetime prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency among all psychiatric disorders. Biological, psychosocial, and genetic factors contribute to depression. Treatment modalities include pharmacotherapy, psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy, and neuromodulation, such as ECT. Suicide Suicide Suicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death. Suicide is the leading cause of mortality Mortality All deaths reported in a given population. Measures of Health Status in major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder.
• Bipolar Bipolar Nervous System: Histology disorder: a recurrent psychiatric illness characterized by periods of manic and hypomanic features. Manic features include distractibility, impulsivity Impulsivity Attention Deficit Hyperactivity Disorder, increased activity, decreased sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep, talkativeness, grandiosity, and flight of ideas. These features may present with or without depressive symptoms. Management of bipolar Bipolar Nervous System: Histology disorder varies based on the presenting features but usually involves pharmacotherapy with mood stabilizers. 
• Schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia: a chronic psychiatric disorder characterized by the presence of psychotic symptoms Psychotic symptoms Brief Psychotic Disorder such as delusions and hallucinations Hallucinations Subjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders. Schizophrenia. The signs and symptoms of schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia include both positive symptoms (delusions, hallucinations Hallucinations Subjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders. Schizophrenia, disorganized speech, and behavior) and negative symptoms (flat affect, avolition Avolition Lack of initiative. Schizophrenia, anhedonia Anhedonia Inability to experience pleasure due to impairment or dysfunction of normal psychological and neurobiological mechanisms. It is a symptom of many psychotic disorders (e.g., depressive disorder, major; and schizophrenia). Schizophrenia, poor attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment, and alogia Alogia Poverty of speech. Schizophrenia). Management includes antipsychotics in conjunction with behavioral therapy.
• Brief psychotic disorder Brief psychotic disorder Brief psychotic disorder is the presence of 1 or more psychotic symptoms lasting more than 1 day and less than 1 month. An episode is often stress-related with a sudden onset, and the patient fully returns to baseline functioning after an episode. Brief Psychotic Disorder: defined as the presence of 1 or more psychotic symptoms Psychotic symptoms Brief Psychotic Disorder lasting more than a day and less than a month. Brief psychotic disorder Brief psychotic disorder Brief psychotic disorder is the presence of 1 or more psychotic symptoms lasting more than 1 day and less than 1 month. An episode is often stress-related with a sudden onset, and the patient fully returns to baseline functioning after an episode. Brief Psychotic Disorder usually has a sudden onset and is often stress related. The diagnosis is clinical and management includes a brief course of 2nd-generation antipsychotics for 1–3 months along with education on the condition and reassurance Reassurance Clinician–Patient Relationship, and potentially, psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy. 
• Delusional disorder Delusional disorder In delusional disorder, the patient suffers from 1 or more delusions for a duration of 1 month or more, without any other psychotic symptoms or behavioral changes and no decline in functioning abilities. Delusional Disorder: a condition in which the patient suffers from 1 or more delusions for a duration of 1 month or longer, without any other psychotic symptoms Psychotic symptoms Brief Psychotic Disorder or behavioral changes and without a decline in the ability to function. Diagnosis is clinical, and the 1st-line treatment is with antipsychotic Antipsychotic Antipsychotics, also called neuroleptics, are used to treat psychotic disorders and alleviate agitation, mania, and aggression. Antipsychotics are notable for their use in treating schizophrenia and bipolar disorder and are divided into 1st-generation antipsychotics (FGAs) and atypical or 2nd-generation antipsychotics. First-Generation Antipsychotics medications provided within the context of a trusting therapeutic relationship. Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy based on support and education may be helpful.
• Schizoaffective disorder Schizoaffective disorder Schizoaffective disorder is a mental disorder that is marked by 2 components: a psychotic component (hallucinations or delusions) and a mood component (mania or depression). Patients must therefore meet the diagnostic criteria for both major mood disorder and schizophrenia. Schizoaffective Disorder: a psychiatric disorder that includes both a psychotic component and a mood component. The diagnosis is clinical and management consists of both pharmacotherapy and psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy similar to that used for schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia and mood disorders.