3 Coping strategies to minimize the impact of Post-Partum Psychosis (Puerperal Psychosis)

Childbirth is a moment of great hope for a family. Rarely do people prepare for the worst. It is devastating to the family when a mother develops complications following childbirth. Postpartum Psychosis (puerperal psychosis) is one of the most serious mental health conditions that affect women after childbirth. Though described as a rare disease, it has dire consequences sometimes resulting in the fatal death of the mother by suicide or infant (infanticide). It carries also a substantial stigma that can mime the reputation of the mother many years after the episode. 

Postpartum psychosis is defined as a severe form of mental illness that starts abruptly without warning a few days or weeks after childbirth. It presents with delirium-like waxing and waning of consciousness characterized by psychotic, delusion, and maniac behaviors. Postpartum psychosis can manifest in women with no prior history of mental illness. About 50% of women diagnosed with postpartum psychosis have a history of mental disorders before pregnancy. Literature has pointed to a strong relationship between bipolar disorders and postpartum psychosis. Women with bipolar disease have a 20% more risk of postpartum mental illness when compared to the general population. As well, it is proven that women who experience puerperal psychosis can go on to develop mental diseases later in life, especially bipolar affective disorders.

Types of postpartum mental illness

Generally, almost every woman (85%) experiences some form of mood change after childbirth. These may range from mild to severe episodes. Two categories of postpartum mental illness have been identified;

Postpartum Depression
Occurs within weeks to three months post-delivery. Early signs of postpartum depression may be evident even before childbirth. Postpartum depression presents the same way depression presents in a woman’s life with prolonged sad mood, tearfulness, loss of interest in activities of daily living, poor concentration, and feeling of worthlessness. In its worst form, suicidal thoughts can manifest, as well as, intrusive thoughts about harming the baby.

Postpartum Psychosis
This is a rare but worst form of psychiatric illness that affect women during the postpartum period that requires immediate medical attention. It starts abruptly within 48 to 72hours after delivery. Global evidence indicates that puerperal psychosis affects 1 to 2 women per 1000 deliveries. Though the rate of puerperal psychosis appears to be below, it has the potential to cause serious and harmful consequences to the new mother and her baby. It has been recognized as a leading cause of maternal death in the first year post-delivery, and negatively affects the development of the infant.  

Risk factors for postpartum psychosis
The origin of postpartum psychosis remains largely unknown but few factors are associated with increased risks. A basic understanding of possible risk factors is a step towards minimizing its consequences;

1. Biological hormonal changes in childbirth 
   Pregnancy and childbirth are under the influence of a large number of hormones (progesterone and estrogen). The sudden withdrawal of the hormones after childbirth is thought to affect the mental state. Women with bipolar disorders are likely to be affected more by this sudden withdrawal of hormones plunging them into postpartum psychosis.
2. Bipolar disorder
   Puerperal psychosis is 100 times more likely to occur in a woman with an already existing bipolar disorder. Incidentally, the bipolar mental disease starts to manifest from the age of 19 to 30 years. These years also coincide with the woman’s age of childbearing increasing the risks of postpartum psychosis. Moreover, when compared to the general public, women with bipolar disorder are 20 to 30 times more likely to die from suicide induced by postpartum psychosis.
3. Positive family history of bipolar disorder
   Family studies have demonstrated a close link between postpartum psychoses among close relatives. You are likely to experience postpartum psychosis if your mother or any other first-degree relative had bipolar disorder. Furthermore, evidence suggests a possible recurrence of postpartum psychosis in mothers with a strong family history of bipolar psychiatric disease in subsequent deliveries.
4. Primiparity
   Studies conducted assessing the risks of postpartum psychosis find that first pregnancy carries a higher risk. The birth of the first child contributes a significant risk factor for postpartum psychosis, especially bipolar disorder.
   
5. Sleep deprivation
   Childbirth and child care disrupts the normal function of a woman characterized by loss of sleep due to child care. In a vulnerable woman, loss of sleep can trigger a more serious mental illness such as postpartum psychosis.

Clinical presentation of Postpartum Psychosis
Normally, a mother who experiences postpartum psychosis presents with multiple abnormal behaviors. Often, the mother may experience heightened mood changes with elation and depression, psychotic features with delusions, and hallucinations related to the infant or herself. The mother experiences forceful powers controlling the thoughts that tell her to kill herself or the newborn.
Signs and symptoms of postpartum psychosis may include some or all of the following;
Sudden onset in an otherwise healthy postnatal woman
• Prolonged history of Sleeplessness
• Low or poor appetite
• Diminishing level of consciousness with disorientation
•Confusion with thoughts disorganization and waxing
• Lack of insight into self and environment
• Bizarre delusions (believing things that are not there) related to the baby
•Hallucinations (can be visual, auditory, tactile)
•Delirium like expression

Coping strategies for mothers at high risk of postpartum psychosis
It is known that women with bipolar disorder, who have suffered other forms of mental illness or experienced postpartum psychosis are at higher risk of postpartum psychiatric illnesses. Though the onset of postpartum psychosis is abrupt with cascading signs and symptoms, some precautions can be implemented aimed at minimizing the impact of the disease on both the mother and the newborn;
1. Preconception measures
Having an understanding of the factors that increase the risk of postpartum psychosis is essential. You can gather the family history of relevant information concerning a close relative or any family member with such a history. Studies have shown that there is a strong link between close relatives and genetics is believed to be culpable. In case of positive family history, you and your partner must talk through it. If a decision to have a baby is made, it is in full knowledge of the possible occurrence of postpartum psychosis, this way your partner can be in a position to walk with you during pregnancy and be vigilant for possible signs or symptoms of postpartum psychosis.  
Even before conception, it is important to establish a good working relationship with your health professionals. This will ensure that during pregnancy and childbirth, you have the best possible support and in case you develop postpartum psychosis after childbirth, your family and health professionals can work together so that you are not overwhelmed by the incidence. Ensuring you have the best possible medical care and your baby is in safe hands.
2. During pregnancy
During pregnancy, in addition to your obstetrician and midwife, you will need to incorporate the care of a perinatal psychiatrist. This is a doctor who specializes in the care of pregnant women with prior history of mental health challenges. In a place where you cannot access a specialist, then a general psychiatrist can suffice. The doctor will conduct an evaluation based on your family history and decide the best form of prophylactic treatment to stabilize your mood during pregnancy, or immediately after childbirth. Postpartum psychosis can be heightened by ordinary stresses, being aware can help you evade some daily stressors so that you do not provoke an episode of postpartum psychosis. Because of the risks of medication to the unborn baby, your 3and engaging your care team gives a better outcome.

3. Post-delivery care
Following safe childbirth, the mother must remain vigilant of the signs and symptoms associated with postpartum psychosis. Having a supportive partner is key. Another family member should be available to give support in taking care of both the mother and the baby. Ensuring that the mother gets adequate sleep and enough rest will help. Any indication that the mother is anxious or stressed should be addressed promptly. In case there is evidence that the mother has early signs of postpartum psychosis, alert the health care team. Inpatient treatment is a better option has it ensures the safety of the mother and the baby. Early health-seeking has better treatment outcomes with full recovery.

Though postpartum psychosis is a rare disease affecting1 to 2 women by 1000 births, it is associated with serious consequences to the mother and the baby. However, with proper education and risk management, most women can delivery safely and continue to have normal deliveries even after an episode of postpartum psychosis. Known people with bipolar disorder carry a significant risk of up to 100 times more compared to the general public. But with proper planning and psychosocial support, a woman can have a successful pregnancy and postpartum. Supportive family and health professionals can significantly minimize postpartum complications such as postpartum psychosis and its undue consequences. Proper pregnancy planning, and adhering to medication during pregnancy and immediately after childbirth can greatly alter the risks of postpartum psychosis.

Picture courtesy of Shutterstock