With Psychosis — MENTAL OR BEHAVIOURAL DISORDERS ASSOCIATED WITH PREGNANCY, CHILDBIRTH OR THE PUERPERIUM, WITH PSYCHOTIC SYMPTOMS

1. Definition and nosology

Mental or behavioural disorders associated with pregnancy, childbirth or the puerperium, with psychotic symptoms (commonly termed Postpartum Psychosis, PPP; ICD-11: 6E21; DSM-5-TR: Brief Psychotic Disorder or Bipolar I with peripartum onset specifier) — an acute-onset psychotic episode after childbirth (typically within the first 2 weeks); hallucinations, delusions, cognitive disorganization, mood lability. This is a medical emergency — infanticide (~4%) and maternal suicide risk high.

2. History

• Marcé L.V. (1858) — classic description of postpartum psychosis.
• Bergink V. et al. (2015) — 4-step treatment algorithm.
• NICE CG192 — peripartum psychiatric conditions.

3. Epidemiology

• Incidence: 1–2/1000 births.
• 25–50% in women with a history of bipolar disorder; 30% with a history of previous PPP.
• Comorbidity: mostly bipolar in nature.
• Mortality: infanticide 4%, suicide up to 5% (untreated).

4. Aetiology and pathogenesis

• Hormonal — sharp postpartum drop in estrogen and progesterone.
• Sleep deprivation.
• Bipolar disorder predisposition (most PPP — manifestation of a bipolar episode).
• Family history.

5. Clinical features

• Rapid onset (24–72 hours, typically within first 2 weeks).
• Polymorphic psychotic symptoms — delusions (particularly regarding baby — baby being “evil” or “demanded”; mother “must escape”), hallucinations.
• Mood lability — manic or depressive components.
• Cognitive disorganization, confusion.
• Sleep disturbance severe.
• Behavior — bizarre, extreme, impaired infant care.
• High risk: Suicidal mother, harm to infant (infanticide).

6. Diagnosis

6.1 Unified diagnostic criteria

Clinical diagnosis: acute-onset psychotic episode postpartum; coded under bipolar manic or acute psychotic category + peripartum onset specifier.

6.2 Differences between sources

• NICE CG192 — emergency medical condition.
• Royal College of Psychiatrists perinatal psychiatric service standards.

6.3 Diagnostic algorithm

1. Clinical interview — rapid onset, nature of symptoms.
2. Medical assessment — postpartum medical conditions (thyroiditis, infection, encephalopathy, eclampsia, B12 deficiency) to be ruled out.
3. Laboratory — TSH, complete blood count, electrolytes, liver, kidney, ammonia, glucose, infection markers.
4. Brain MRI and EEG — if atypical presentation or neurological signs (autoimmune encephalitis — anti-NMDA-R especially!).
5. Toxicology.
6. Assessment of suicide and infanticide risk (C-SSRS, infant safety).

6.4 Differential diagnosis

7. Examination and assessment

• Clinical psychiatric and neurological.
• The above medical panel.
• Anti-NMDA-R antibodies (CSF) — in atypical cases.
• C-SSRS, infant safety.

8. Treatment

8.1 General principles (NICE CG192 · Bergink 2015)

1. Urgent hospitalisation is mandatory — for mother and baby; if possible, Mother-Baby Unit (joint inpatient service for mother and baby).
2. Bergink 4-step algorithm (Am J Psychiatry 2015):
   • Step 1: Benzodiazepine (lorazepam) acute stabilization;
   • Step 2: atypical antipsychotic (olanzapine, quetiapine, risperidone);
   • Step 3: Addition of lithium;
   • Step 4: ECT in refractory or catatonic features.
3. Bipolar primarily — lithium first line. Valproate is contraindicated in women of childbearing potential and permissible only where the conditions of the Pregnancy Prevention Programme are met (EMA/MHRA 2018); in bipolar disorder it is absolutely contraindicated during pregnancy.
4. Breastfeeding decision — lithium is a relative contraindication in breastfeeding (passes into breast milk); olanzapine and quetiapine relatively safe; discuss this with the patient and the family.
5. Risk of recurrence in subsequent pregnancies is high (~30–40%) — prophylactic lithium is considered in the peri-postpartum period.
6. ECT — safe in pregnancy and postpartum period; rapid effect.
7. Multidisciplinary coordination — psychiatrist, obstetrician-gynecologist, pediatrician, social worker.

8.2 Treatment methods

1. Bergink 4-Step Algorithm (Bergink) — Benzodiazepine → antipsychotic → lithium → ECT.
2. Mother-Baby Unit (MBU) — Shared hospitalization of mother and infant; preserving bonding and safety.
3. ECT Postpartum — Safe in pregnancy and lactation; rapid effect; first-line for catatonic features.
4. Prophylactic Lithium in Subsequent Pregnancies — Bergink V. et al. Am J Psychiatry 2012 — relapse prophylaxis during the peripartum period.

8.3 Differences between sources

• NICE CG192 — Mother-Baby Unit recommendation.
• Bergink V. et al. Am J Psychiatry 2015 — evidence base for the 4-step algorithm.

9. Prognosis

• Full recovery in most patients with adequate treatment.
• Risk of recurrence in subsequent pregnancies is high (~30–40%).
• Long-term management of bipolar disorder is crucial.

10. Myths and misconceptions

Myth 1: “PPP is a strong expression of ‘maternal feelings’”

Evidence: Clinical psychotic state; risk of infanticide and suicide high; emergency intervention.

Myth 2: “Monitoring at home is sufficient”

Evidence: NICE CG192 — hospital admission mandatory; MBU preferred.

Myth 3: “Antipsychotics and lithium are contraindicated during breastfeeding”

Evidence: Olanzapine and quetiapine relatively safe in breastfeeding; lithium passes into milk, but may be recommended with infant monitoring; individual balance.

Myth 4: “It will not recur in a subsequent pregnancy”

Evidence: Previous PPP history shows relapse of ~30–40% (up to 44% without prophylaxis); a prophylactic plan is crucial.

Myth 5: “Anti-NMDA-R encephalitis is rare, no need to search for it”

Evidence: In a young woman atypical psychosis + movement symptoms + seizures is the classic presentation of Anti-NMDA-R encephalitis; antibody test saves lives.

11. Sources

1. WHO. ICD-11. 6E21 Puerperal psychosis. 2024.
2. APA. DSM-5-TR. 2022.
3. NICE CG192. 2014/2018.
4. Bergink V. et al. Treatment of psychosis and mania in the postpartum period. Am J Psychiatry 2015;172(2):115–123.
5. Bergink V. et al. Prevention of postpartum psychosis and mania in women at high risk. Am J Psychiatry 2012;169(6):609–615.
6. Graus F. et al. Lancet Neurol 2016 (autoimmune encephalitis).