Mental or behavioural disorders associated with pregnancy, childbirth or the puerperium, with psychotic symptoms

ICD-10F53.1	Severe mental and behavioral disorders associated with the puerperium, not elsewhere classified
DSM-5-TRF23	Brief Psychotic Disorder, With Postpartum Onset

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 the risk of maternal suicide is 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; with a history of previous PPP the recurrence risk is 30–40% (up to 44% without prophylaxis).
• Comorbidity: mostly bipolar in nature.
• Mortality: infanticide 4%, suicide up to 5% (untreated).

4. Etiology 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 “chosen”; 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 — medical emergency.
• 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 hospitalization 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 unless 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, as a case-by-case decision.

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 Mental or behavioural disorders associated with pregnancy, childbirth or the puerperium, with psychotic symptoms. 2024.
2. APA. DSM-5-TR. 2022.
3. NICE CG192. 2014, 2020 update.
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., Bouvy P.F., Vervoort J.S., Koorengevel K.M., Steegers E.A., Kushner S.A. Prevention of postpartum psychosis and mania in women at high risk. Am J Psychiatry 2012;169(6):609–615.
6. Graus F., Titulaer M.C., Balu R., Benseler S., Bien C.G. et al., Dalmau J. Lancet Neurol 2016 (autoimmune encephalitis).