Postpartum Psychosis- More than the baby blues

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It’s almost been a year since Karen* gave birth to her beautiful baby boy. Devin* is now cutting teeth and is a little fussy as he sits in his father’s lap. Karen turns to her son and gives him a smile and a pat on the back as her husband takes him out of the room to play. “This hasn’t been easy,” Karen says. “I cry a lot.” As a matter of fact she says, “There are times when I can’t stop crying; I can’t get out of bed and I just feel horrible.” It’s not Devin that makes Karen cry-he’s perfectly healthy. As she sits in the chair, Karen talks about her career as an elementary school teacher-a job she loves. She smiles when she describes how her husband dotes on her and Devin and “takes really good care of us.” But for Karen, her episode of psychosis that occurred after her delivery is what caused her to feel like she lost control of her life. She now continues to have rapid mood fluctuations and occasional psychotic symptoms. Karen doesn’t want to be identified. Like many women who develop this illness, the stigma makes her not want to admit to anyone that she has it.

While postpartum psychosis has received a lot of media attention recently given high profile cases in both the U.S. and Canada of mothers killing their children, those are a rare occurrence. But what those cases have done for the illness is to raise greater public awareness about it. Between 1-2 women per 1,000 births experience a postpartum psychosis. If the psychosis occurs it is most likely to happen during the postpartum period rather than during pregnancy.

Psychosis is a condition occurring in the context of an underlying psychiatric disorder like bipolar affective disorder, major depression or schizophrenia. For some women, a postpartum psychosis may be the only psychotic episode they will experience. For others, a psychosis may be the first episode of a psychiatric disorder or an acute exacerbation of an underlying disorder.

In Karen’s case, she has bipolar disorder and was on medication prior to her pregnancy to help stabilize her moods. When she discussed the possibility of going off the medication with her psychiatrist in order that she and her husband could start a family, Dr. Verinder Sharma fully outlined the risks to her for developing postpartum psychosis. “He was definitely concerned,” Karen says, “and so was the rest of my family.” Dr. Sharma, a psychiatrist at Regional Mental Health Care London explains, postpartum psychosis happens more in first time mothers, but the concern lies in the fact that you don’t know who will develop it because it happens so quickly. Karen remembers vividly how fast it happened to her. “Twenty four hours after giving birth I crashed; it felt like I was being stepped on,” she says.

Symptoms of postpartum psychosis include hyperactivity, delusions, paranoia, confusion, hallucinations and mood lability. Dr. Sharma says the pathophysiological basis of postpartum psychosis remains poorly understood, but factors such as difficult labour, first delivery, genetic predisposition and hormonal changes have been implicated.

But there was something else that Dr. Sharma thought could factor into the equation. Based on a review of the literature and on clinical experience, Dr. Sharma along with Dr. Mustaq Khan and researcher Angela Smith hypothesized that sleep loss is a common and early symptom of impending psychosis in the postpartum period.

Karen was one of many London and area women who had lost a night’s sleep during labour and were asked to participate in a study examining the course of bipolar disorder during pregnancy and after delivery. The team reviewed charts of women delivering at Woodstock General Hospital, St. Joseph’s Hospital and London Health Sciences Centre who developed psychosis within four weeks of delivery. Twenty-six were found to have suffered from postpartum psychosis. These women were age and parity matched with a control group of 26 women who delivered at the same hospitals. Psychosis and control groups were compared to determine whether postpartum psychosis is associated with longer duration of labour and with nighttime labour (hence sleep loss).

The results indicated these factors definitely play a role as insomnia is a prominent symptom of postpartum psychosis. It was also confirmed that the condition belongs to the bipolar spectrum. Clinical implications include the importance of careful history taking as well as close monitoring of the patient while ensuring sleep and reducing stimulus. If possible, daytime delivery is preferred as well as a shortened duration of labour. The avoidance of antidepressants is also essential.

While researches still don’t know exactly why and how postpartum psychosis happens, it is known there are certain risk factors that can be identified in women even prior to childbirth. A woman like Karen with a history of bipolar disorder who has had at least one episode of postpartum psychosis is at a 100 per cent risk for another psychotic episode.

For Karen, breastfeeding has been the only thing that has made her feel as if she has some control over her constant crying and overwhelming feelings of helplessness. “It’s the only thing I feel I can do right,” she explains. While her husband took a parental leave from work to care for their son, that time is nearly up. Karen is feeling a little apprehensive about his returning to work but is trying to remain optimistic that things will be all right. She’s anxious to get pregnant again because she felt so good during her first pregnancy. Dr. Sharma explains that preliminary results of the study show that pregnancy has a protective effect on the course of bipolar disorder, but there is an extremely high risk of relapse including psychosis. And that’s why Karen fears delivery time. “I know I’ll have a hard time again,” she admits, “but knowing I have a good support system in my husband, my family and my care team, allows me to know everything will be okay.”