Postpartum Psychosis: A Review of Risk Factors, Clinical Picture, Management, Prevention, and Psychosocial Determinants

Background

The birth of a child can be associated with a number of mental disorders [1–5]. It is estimated that up to 85% of women suffer from postpartum mood disorders [6]. These disorders usually resolve on their own and do not require treatment. Problems can take the form of postpartum depression (“baby blues”) or the rarer postpartum psychosis. It affects, according to various sources, between 0.89 and 2.6 women for every 1000 births in the first 6 weeks after delivery [3,4,6–18]. Postpartum or puerperal psychosis is the most serious mental disorder associated with childbirth [4]. It can affect women without a pre-established mental illness. Studies indicate that isolated postpartum psychosis is diagnosed in 40% of women with PP [16,17,19]. The condition is caused by a complex combination of biological environmental and cultural factors. The pathophysiological mechanisms of postpartum psychosis remain very poorly understood. It usually requires hospitalization [20]. Research published in 2018 showed that in the United States, about 700 out of 100 000 women are hospitalized for psychotic illness after giving birth [21]. It was confirmed that women, both at-risk and healthy, were about 22 times more likely to be admitted to a psychiatric hospital 1 month after delivery than they were before pregnancy [22]. In contrast, 20% of women with pre-existing bipolar disorder experienced severe postnatal mental illness, and one-third of women in the risk group experienced relapse [23]. Postpartum psychosis (or puerperal psychosis) is a psychiatric emergency with potentially serious consequences for mothers and children [10,14,24]. Pregnant women with psychosis have an increased risk of obstetric and neonatal complications, and in extreme cases that disease can lead to suicide and/or infanticide [16,21,25]. This article aims to review the current status of risk factors, prevention, and management of postpartum psychosis.

Determinants of Postpartum Psychosis

The etiology of postpartum psychosis has not yet been clearly established [4]. About 50% of people with PP have a previous history of psychiatric problems, and family predisposition is a risk factor [26–29].

The most common risk factor associated with postpartum psychosis is bipolar affective disorder, with an estimated risk of 20% [4,13,20,24,27,29–35]. In women with bipolar affective disorder (BPAD), additional catalysts for the onset of postpartum psychosis may include abuse, traumatic events in childhood, higher daily cortisol levels during the third trimester of pregnancy, psychosocial stress, and biological stress [31,36]. However, previous findings about the association of PP with personality traits, cognitive styles, or affective temperaments in people with BPAD are limited [20]. Studies suggest that dysregulation of the immune-HPA (pituitary-hypothalamic-adrenal) axis, accompanied by stress, may contribute to PP in patients in this risk group [37,38]. Postpartum psychosis can also be triggered by the use of psychoactive drugs, including amphetamines [39].

An analysis of the medical records registry conducted in Denmark found no association of the onset of postpartum psychosis in previously healthy patients with pregnancy and obstetric complications [40], and postpartum complications did not affect the onset of mental illness in at-risk women [41]. This is supported by data from Canada, where mothers of preterm infants under 37 weeks’ gestation showed similar severity of psychiatric disorders during the first 5 years after birth as mothers of babies born at full term. However, it has been shown that extreme prematurity may have influenced the onset of various postpartum psychiatric disorders [42]. On the contrary, other studies have shown that complicated and prolonged labor or stillbirth can contribute to postpartum psychosis [43]. Data are available on the association of preeclampsia and postpartum psychosis [44–46].

A link between PP and depression is being sought. The presence of depression (without psychosis, mania, or hypomania), especially in first-born women, increases the risk of increased perinatal psychosis symptoms [28,47].

Studies show that risk factors for postpartum mental illness may include the mother giving birth for the first time and lower social status, and that the risk of hospital admission for psychosis is highest in the second week after onset [48].

Genetic, Hormonal, and Immunological Determinants as Risk Factors

Genetic, hormonal, and immunological factors affecting the occurrence of PP are being studied and are unclear [30,40]. An immunophenotypic study conducted in India showed that increased CD8 T-cell activation in postpartum psychosis reflects an impaired lymphocyte compartment. Women with PP may have an altered innate immune system, with a decrease in myeloid dendritic cells and non-classical monocytes. There are also decreased numbers of cytotoxic NK cells and increased numbers of regulatory NK cells, indicating immune dysfunction in postpartum psychosis [49]. One finding highlights the importance of immune changes and their impact on the manifestation of postpartum psychosis of first onset. Indications are that the first onset of PP may be related to changes in the cytokine interleukin (IL)-8 [50].

Genetic determinants of the occurrence of PP with the estrogen pathway are also being searched for [51]. One study did not confirm the presence of genetic biomarkers, but indicated a link between postpartum psychosis and psychiatric disorders in the family, particularly BPAD, as mentioned above [52].

Interest in the etiology of PP is also directed at molecular pathways. Tryptophan metabolism is physiologically altered during the postpartum period, which may contribute to the onset of psychiatric disorders during this period [53]. Studies in mice suggest that steroid sulfatase deficiency in these animals causes abnormal maternal behavior, and a similar disorder can also occur in women with PP [54].

Neurobiological and Psychosocial Problems as Risk Factors

PP is known to occur in conjunction with neurobiological changes during childbirth. Brain sensitivity and inflammation may be involved in the occurrence of PP [55]. A study of brain structures carried out on a group of women at risk for PP suggests that they have a smaller anterior cingulate, superior temporal, and medial hippocampal cingulate compared to women in the control group. This could be potential risk markers for susceptibility to PP episodes [35]. In rare cases, anti-NMDAR postpartum encephalitis may contribute to postpartum psychosis [56]. A study on the role of demyelination and inflammatory markers in the occurrence of PP indicated that women at risk had higher serum IL-10 levels compared to controls, indicating hyperactivation of the immune system in women at risk for PP. Patients in the at-risk group had lower myelin content in the temporal lobes and sub-lobar areas than the control group [55].

It is also indicated that sleep disorders are associated with an increased likelihood of depression, generalized anxiety, post-traumatic stress disorder, and high risk of psychosis [4,27,38,57,58]. It has been shown that women with BPAD who suffered from mania-induced sleep disturbance/reactivity were more likely to experience PP [59,60].

A patient’s sensitivity to postpartum hormonal changes, immune thyroiditis [4,27,57,61,62], and other disorders such as isolated FT4 increase and enlargement of thyroid lobe volume can also contribute to postpartum psychosis [63,64]. Other rare catalysts such as steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT), also known as Hashimoto’s encephalopathy, can contribute to PP [14,65].

Psychosocial factors can influence the occurrence of PP [66]. Studies in the area of adverse traumatic experiences and the occurrence of postpartum psychosis are inconclusive. There are studies that point to stress as an additional trigger for PP, which may be related to dysfunction of the immune-hypothalamic-pituitary-adrenal axis [37].

Based on analyses from the UK, it was shown that women with BPAD type I who had been exposed to adverse events in childhood (including sexual abuse) were more likely to develop PP than were women with BPAD but without such experiences [67].

Not all publications support the hypothesis that highly stressful life events are associated with PP. A Swedish study indicates that the death of a loved 1 year before or during pregnancy was not associated with the incidence of psychotic illness during the first 90 days after delivery among women without or with a history of psychiatric disorders [68]. According to Danish data, psychiatric postpartum episodes may be contributed to by difficult life circumstances during childhood, including: placement in foster care, parental psychopathology excluding substance abuse (psychoactive), or parental exclusion from the labor market [69]. Women with lower incomes and less education were more likely to develop a mental illness. The presence of mental illness in a partner or family member should also be cited as demographic factors [40]. Data collected in South Africa indicate socio-demographic problems and psychoactive substance use as risk factors [70].

Infertility is a stressful situation for women, as is the in vitro fertilization procedure. One study conducted in Sweden found no association between the occurrence of PP and in vitro fertilization [71]. Canadian researchers, on the other hand, indicate that reduced fertility or infertility treatment is associated with a slightly higher risk of postpartum mental illness, including PP [72].

Additional Medical Conditions as Risk Factors

The association of pathogens with the occurrence of psychosis is also of interest to psychiatry. A study in the Netherlands indicates that increased exposure to neurotrophic pathogens such as HSV-1, HSV-2, EBV, CMV, and Toxoplasma gondii are not associated with postpartum psychosis [73]. Asthma, which is linked to mental illness in the general population, was identified in a Canadian study as a risk factor for perinatal mental illness [74,75]. Attempts are also being made to discover the effect of environmental exposure on neurodevelopmental disorders, including psychosis due to exposure to elements such as copper, magnesium, manganese, zinc, lead, arsenic, lithium, and tin [76]. A United States analysis found that severe maternal illness during delivery, such as acute myocardial infarction, aneurysm, acute renal failure, amniotic fluid embolism, sepsis, and severe complications from anesthesia, were associated with an increased risk of acute mental illness within 1 year of hospital discharge [77].

Symptomatology of Postpartum Psychosis

PP symptoms are varied and can evolve rapidly. They often include insomnia, elevated mood, depression, disorientation, auditory, visual and olfactory hallucinations, mood swings, delusions (persecutory, relating), loss of inhibitions, racing thoughts, irritability, thought content disturbances, restlessness, affective instability, confusion, and bizarre behavior [7,10,11,60,78,79]. In addition, patients may experience psychomotor agitation and lack of appetite [4]. Less commonly, Capgras delusions or catatonia are observed in patients with PP [80,81]; the prevalence of catatonia is 20%. Higher rates are found in low- and middle-income countries [78].

Postpartum psychosis has an atypical picture compared to affective or psychotic episodes unrelated to pregnancy [14]. The condition appears suddenly, usually within the first 2 weeks after birth, and progresses rapidly [7,27]. The risk of self-harm and suicide, especially for women at risk, also increases in the postpartum period [3,82]. Mothers suffering from PP can cause serious harm to the child, in rare cases, even infanticide [10,25,83]. It is necessary to search for environmental and cultural causes of PP-related infanticide [84]. There are no reliable data on the prevalence of PP in Africa, where it is a serious problem [70].

Suicide has been ranked as the 14th leading cause of mortality and morbidity worldwide, and is expected to increase by 50% to become the 12th leading cause of mortality by 2030 [85]. Maternal suicide is a serious social problem, being the third leading cause of maternal deaths during pregnancy or within 42 days after pregnancy termination, accounting for 13% of all maternal deaths. In the UK, suicide is the leading cause of maternal deaths [86–89]. An estimated 1 in 500 women with postpartum psychosis dies by suicide [70]. Studies indicate that suicide or infanticide occurring in postpartum psychosis is rare. It has been observed that a higher risk exists during subsequent psychotic episodes, rather than in acute manic episodes of PP [60,83]. One study indicated that 70% of women with a history of PP take their own lives during the postpartum period [90].

Women experiencing postpartum psychosis have been observed to have various prodromal symptoms of the disease. The most common is the presence of sleep disturbances such as inability or unwillingness to sleep, and unusual, disturbing thoughts, changes in mood, presence of mental stress, or a sense of having a different mental state may also be involved [91].

Due to the multiplicity of manifestations of PP, this disease entity was divided into 3 profiles: manic profile, depressive profile, and atypical symptoms [80].

For most women with a first episode of PP, the risk of the disease is limited to the postpartum period, but in some cases, relapses occur. A study conducted in the Netherlands found that two-thirds of patients did not have a relapse in the 4 years after giving birth, with BPAD predominating. Other data indicate that women with PP are also at risk for depression [15,32,47].

A study based on a database registry in Taiwan found that women without serious mental illness who experienced an episode of depression and PP were at risk for later onset of schizophrenia and major affective disorder. The same study found that offspring of mothers with depression and psychosis were more likely to develop attention deficit hyperactivity disorder (ADHD), along with attention deficit and autism spectrum disorders [92].

Postpartum psychosis can be accompanied by autoimmune thyroid diseases (AITD), Hashimoto thyroiditis, Graves’ disease, or thyroid dysfunction in previously healthy patients. Patients with PP are at higher risk for AITD and for clinical signs of thyroid failure [57,62]. Perinatal mental illnesses also increase the risk of developing further autoimmune diseases [93].

Diagnostics of Postpartum Psychosis

Diagnosis of PP is difficult due to the lack of specific tools and objective tests to diagnose it. Screening for postpartum psychiatric disorders uses the Edinburgh Postpartum Depression Scale (EPDS) and the Mood Disorders Questionnaire (MDQ), but these tools do not directly address PP, they only allow early detection of bipolar disorder or postpartum depression [94,95]. There are also no guidelines, indicating the need for a specific panel of laboratory tests [95].

Postpartum psychosis itself is not included in DSM5 or ICD-10 as a disease entity, and the current diagnostic criteria equate PP with other psychoses [13,27,96,97]. DSM-5 allows the use of the term “with perinatal onset” to characterize mood disorders with psychotic features during pregnancy or within 4 weeks after delivery [98–100]. This specifier cannot be used in patients with schizophrenia and other psychotic disorders, with the exclusion of short-term disorders occurring after childbirth [98]. ICD-10 allows a separate diagnosis only if the patient cannot be diagnosed with another disorder and only within the first 6 weeks after delivery (F.53.0–53.9, Mental and behavioral disorders associated with puerperium, not elsewhere classified) [100,101]. For women suffering from PP, this poses a serious legal problem, as it hampers the ability of women who have committed the crime of infanticide and have been charged with murder to defend themselves in court [27,96,97,102]. The lack of a definition of the disease, cultural differences in the perception of the disease, and lack of a common timeframe and specific criteria for diagnosis pose a problem in estimating the scale of the problem and determining the prevalence of the disease [16]. There is a need to better address this problem in the ICD and DSM classification systems, which currently do little to ensure that PP episodes are recorded [103]. As of 2016, PP is on the list of rare diseases compiled by Orphanet, which can contribute to raising awareness and encouraging research in this area [104].

The diagnosis of PP consists of a history, physical examination, neurological examination, and laboratory tests, including blood count, tox screen, electrolyte levels, glucose, thyroid hormones, blood urea nitrogen (BUN), liver function tests, creatinine, urinalysis, and testing levels of the vitamins B12, folic acid, and thiamin. In the case of febrile patients, urine and blood cultures can be considered [18,105].

These tests identify diseases that may manifest psychosis such as hypo- and hypernatremia, hypo- and hyperglycemia, hepatic encephalopathy, uremia, hypothyroidism or hyperthyroidism, or hypercalcemia in the course of hyperparathyroidism [18]. Thyroid hormone levels and thyroid peroxidase antibodies are also determined [62].

In hyperthyroidism, we may observe neuropsychiatric symptoms such as restlessness, agitation, irritability, hallucinations, delirium, depression, and catatonia [106,107]. If, after balancing thyroid hormone levels, psychotic symptoms persist, diagnosticians should look for another cause of symptoms present [106].

Differential Diagnosis

Postpartum psychosis should also be differentiated from anti-NMDAR encephalitis. Patients with symptoms of psychosis need to be evaluated for neurological disorders, including extrapyramidal adverse effects of antipsychotic treatment and cognitive deficits, and imaging studies (eg, brain MRI and EEG) should be performed. A lumbar puncture and cerebrospinal fluid (CSF) testing for anti-NMDAR antibodies is necessary, but in 15% of patients, these antibodies are not present in the serum, only in the CSF [56,108–111].

In rare cases, psychosis accompanies Sheehan syndrome. It is assumed that low levels of cortisol, estrogen, and thyroid hormones contribute to the development of psychosis in this syndrome [112–117], which can occur immediately in the postpartum period or several years after the baby is born [118,119]. The most common symptoms include lack of lactation and menstruation and a history of postpartum hemorrhage. Patients may experience anemia, hyponatremia, hypoglycemia, behavioral disorders, and decreased bone mineral density [114,117,118]. MRI shows pituitary involution of varying severity [118,120].

Among behavioral disorders in patients with Sheehan syndrome, delusions and hallucinations, depression, aggressive behavior, and insomnia can be observed. These are due to the hormonal disorders present, which may subside after properly selected treatment [112,113,117,120].

The differential diagnosis of PP should include demyelinating diseases. In multiple sclerosis, in addition to classic symptoms such as visual disturbances, paresthesia, limb weakness, sensory deficits, or bowel and bladder dysfunction, about 1% of patients develop psychosis. Despite the alleviation of symptoms during pregnancy, about 30% of patients experience relapses within the first 3 months after delivery [121,122].

Psychotic symptoms may occur in various diseases such as stroke, central venous thrombosis, pulmonary embolism, postpartum thyroiditis, acute porphyria, vitamin deficiency, electrolyte disorders, sepsis, primary hypoparathyroidism, Sturge-Weber syndrome, late-onset urea cycle disorders, type I citrullinemia, or as a result of psychoactive substance withdrawal [33,123–126]. Before the diagnosis is made, all organic causes should be ruled out, which will result in the resolution of symptoms. Differential diagnosis includes other mental illnesses. Each patient should be diagnosed for postpartum depression, bipolar affective disorder, schizophrenia, compulsive-obsessive disorder, and anxiety disorder [127,128].

Therapeutic Options of Postpartum Psychosis

According to the guidelines of the World Health Organization (WHO), there is an urgent need for medical services for maternal mental disorders [129]. Multidisciplinary treatment with early hospitalization and psychiatric consultation is crucial for successful and rapid recovery [130]. Treatment may be initiated in the perinatal period or only in the postnatal period [24]. There are currently no guidelines for treatment of PP, and its treatment depends on the cause of psychosis onset [18].

Pharmacotherapy

Lithium is the criterion standard in the treatment and prevention of bipolar disorder. In the case of lithium toxicity, lamotrigine therapy is effective in preventing relapses in bipolar affective disorder, but its effectiveness in isolated postpartum psychosis is less known [24]. Treatment of postpartum psychosis is usually based on a combination of several drugs from the groups of antipsychotics, benzodiazepines, mood stabilizers, or antidepressants [33,131,132].

In the Netherlands (2015), researchers proposed a 4-step treatment regimen [123]. In the first stage, it is recommended to use benzodiazepines for 3 days before going to sleep and to observe for remission of symptoms as a result of return to a normal sleep rhythm. If treatment is ineffective from day 4, antipsychotic treatment should be started together with continued use of benzodiazepines for 2 weeks. If further therapy is needed, lithium should additionally be included in stage 3. If it is not effective, in stage 4, electroconvulsive therapy is used. Maintenance treatment consists of gradual withdrawal of benzodiazepines [123]. Patients treated with antipsychotics and lithium were advised to gradually discontinue neuroleptics and continue taking lithium for 9 months. Patients treated with antipsychotics in monotherapy were continued on therapy for 9 months. Use of these drugs was then restricted until they were discontinued. The largest group of patients (73.4%) achieved remission at stage 3, and permanent remission was observed after 9 months in 79.7% of patients [123].

In patients with schizophrenia, oxytocin therapy may be an effective treatment option [133]. Therapy can be effective in treating positive symptoms, negative symptoms, and social cognitive deficits, but more research is needed to confirm the positive impact of therapy [134]. Research has shown that oxytocin levels increase when a parent is caring for a baby. It suggests the need to maintain a direct relationship between mother and baby [135]. For treatment of psychosis, use of estrogens with progesterone is being attempted to supplement estrogen deficiency in this group of patients. The use of antipsychotic drugs creates difficulties in evaluating the effectiveness of these hormones, but such therapy can play a supportive role, and there is a need for further research in this area [61,136].

Remaining Therapeutic Options

PP treatment should take into account coexisting mental illnesses, personality disorders, past trauma, and post-traumatic stress disorder (PTSD). A multidisciplinary approach is necessary. Cognitive-behavioral therapy, psychoeducation, positive psychosis psychotherapy, acceptance and commitment therapy, or therapeutic yoga are used as an adjunct to pharmacotherapy [131,137,138].

Another available treatment option for PP is electroconvulsive therapy. This treatment has a high response rate, significantly higher in the postpartum period. Improvement in the condition was observed in 87% of patients with psychosis or postpartum depression within 6 months after delivery and in 73.5% of patients beyond that period [139].

The greater effectiveness of therapy is influenced by the severity of symptoms – more severe symptoms are associated with a greater chance of response to electroconvulsive therapy. This justifies the use of this method in severe cases resistant to drug treatment, catatonia, life-threatening conditions, or when the patient refuses to take medication [128,139–141].

Adverse effects of electroconvulsive therapy include confusion, cognitive impairment, subsequent amnesia, and prolonged epileptic seizures, the occurrence of which is relatively rare [140,141]. The effect of therapy on breastfed infants is minimal and is related to the use of short-acting anesthetics and muscle relaxants [140].

Breastfeeding during drug treatment for PP may pose a risk to the newborn due to drug penetration into breast milk. Patients who discontinue breastfeeding require non-pharmacological or pharmacological methods of inhibiting lactation to improve comfort and to reduce breast pain and swelling [142].

Pharmacological methods of inhibiting lactation include the use of bromocriptine and cabergoline. The routine use of bromocriptine is not recommended because of a number of concerns about their adverse effects (eg, ischemic disorders, epileptic seizures, and psychiatric disorders including the development of PP) [143]. Cabergoline is better tolerated than bromocriptine, and its adverse effects are less frequent and milder, but there are also reported cases of psychosis during its use [144,145].

However, as a result of the limitations that exist and the low to moderate quality of available studies, algorithms and recommendations for the using of D2 receptor agonists are lacking. It is recommended to limit their use except when other treatments are not possible. Special care should be taken in patients at risk of developing a psychotic illness [142–144].

Prevention of Postpartum Psychosis

Data on identifying women at risk for PP are limited [13,146]. Although the interest and knowledge of medical personnel in psychosis is increasing and training is being organized, it is still insufficient [147].

Patients and people close to them seek information about the disease [148]. There is an urgent need to improve awareness of PP and to provide access to appropriate services and partner support [149]. Women with PP expect support from professionally trained medical personnel [148], but patients and their families believe that support from medical personnel is insufficient. An online survey of fathers in the UK showed a lack of expected partner support from medical staff and wanted to be referred to a person who could provide information and teach strategies for dealing with the situation [150,151]. There is a need to educate midwives, introduce intervention programs in the midwifery environment, and to screen and identify psychosocial psychogenic factors [10,24,152–154].

U.S. studies have shown that PP-related screening is cost-effective for the health care financial balance sheet [155]. PP treatment can also help alleviate the global burden of disease and improve maternal and newborn health [16]. International cooperation is needed on this issue. Building large cohorts of women who have experienced PP would make it possible to identify the background of the disease in various medical aspects [103].

There is a need to create tools to identify the risk of postpartum psychosis [15,29,60,103,156–158]. Attention should be directed to differentiating between isolated PP vs psychosis associated with bipolar disorder [24]. Women with a history of PP should receive preventive services. Different types of prevention are recommended for women with acute PP: those with a history of bipolar disorder and PP may benefit from early detection and prompt treatment to ensure the safety of mother and child [146]. Women with bipolar disorder should be under the care of mental health professionals, a midwife, and a gynecologist. Psychological and psychosocial perspectives on perinatal prevention should be taken into account, and risks should be assessed individually. A key role is played by support from the family and immediate environment, which plays a controlling and supportive role [2,24,33,60,159].

Psychosocial Aspects of Postpartum Psychosis

The COVID-19 pandemic has had a negative impact on mental health. It has been suggested that in women with COVID-19, the mental and biological factors associated with it may induce PP [17,48,160–162]. Cases of psychosis associated with SARS-CoV-2 infection have been reported [163]. Somatization, anxiety, obsessions, depression, phobias, and psychoticism have been observed among patients giving birth during the COVID-19 pandemic [161]. A study in Ghana found that women who feared the effects of COVID-19 had an increased risk of PP, as manifested by suicidal thoughts, depressive symptoms, or sleep difficulties, among other things [15]. An elevated risk of psychosis was positively associated with lower levels of education and experiencing abuse from partners [15]. Communication barriers affects patients’ perceptions of disease [164]. In Australia, women were found to be afraid to report their mental disorders to health services [10]. In the UK, seeking medical help for PP resulted in uncertainty about diagnosis and treatment in some cases, due to health professionals’ limited knowledge of PP [149].

The patients themselves pointed out what promoted the occurrence of perinatal mental illness. They most often mentioned a previous history of psychiatric episodes and traumatic experiences before or during pregnancy, with insomnia and changes in thinking and behavior [10]. Especially in the early stages of the disease, some women had a feeling of being overwhelmed, and some were unable to care for their baby [148]. They felt stigmatized by their illness through the reactions of their family and surroundings and had dilemmas about deciding to disclose their mental state after giving birth for fear of losing custody of their newborn child [10,165]. They mostly preferred to make contact with other PP patients rather than, for example, their mothers or peers [148]. An analysis of Welsh women found that during the initial acute phase, women experienced extreme suffering and feared for their safety. They also feared for those close to them, especially the child. Women with PP may fear another episode or relapse and sometimes display excessive vigilance [148]. BPAD patients’ concerns about relapse included the impact of episodes on the child and on their partner [159].

Family Involvement in Postpartum Psychosis

Patients and their families experience tremendous stress, especially during the initial acute phase of PP [90,148,165,166]. It is believed that the psychological, social, and environmental stressors that accompany childbirth cause brief reactive psychosis in both sexes [29,167].

Cases of PP in men have been reported. An 18-year-old man addicted to marijuana developed symptoms of PP [168]. Similarly, a 34-year-old man experienced a brief psychotic episode after the birth of his child [167]. Partners of mothers who had been admitted to a maternal and child psychiatric unit in the UK showed increased susceptibility to mental illnesses [151].

Women’s partners experienced shock and confusion during the onset of PP. Loss was a common experience that had a potentially permanent impact on relationships. Men indicated that they were disappointed by unfulfilled expectations of parenthood and the delay in becoming a family [149], and their suffering affected their relationship with the mother and child [169]. Such fathers face many emotional and practical challenges [151].

Hospitalization and professional care can give a sense of security to both the patient and their family members [148]. The fathers of the children indicated that admission to the hospital was regarded favorably, although there were barriers to accessing support and involvement in their partner’s care [149].

The family and immediate environment are of great importance for recovery, providing practical and emotional support for the woman and child [148]. It is estimated that 65% of women with bipolar disorder expect family support when they are ill. and 15% of women with PP said that family support conditioned them to plan their first child [159]. PP can also play a role in reinforcing existing relationship patterns. Most partners note the positive changes that have occurred due to PP, including an increase in their own empathy and understanding in partners regarding mental health issues [166,170]. Some of the mothers reported improved interpersonal relationships and an increased sense of personal power as a result of the disease [148].

Although PP is a treatable mental disorder, it prevents people from functioning properly socially and in their immediate environment, and disrupts the relationship between mother and child. Despite the disease, some of the patients remain sensitive to the needs of the newborn and have a good relationship with the baby [10,78,148,171,172]. In women at risk of PP, perinatal stress should be alleviated, which can have a positive effect on forming a better connection with the child [86,173,174].

Most women in the world suffering from postpartum mental disorders can receive help in non-specialized psychiatric facilities [1]; therefore, special mother–child wards are being created in UK, Australian, and French hospitals, which are becoming the expected standard of hospital care worldwide [175–178]. To allow the mother to recover quickly and the child to continue to develop, special attention should be paid to ensuring the health and mutual relationship of mother and child, including allowing them to stay with each other during treatment [133,171,179–181]. Studies confirm that interaction with the child definitely motivated women to recover, but in rare cases, they considered the baby an obstacle to recovery [182]. Despite the undeniable benefits of keeping mothers and babies together in special wards, there are very few such wards in low- and middle-income countries, and a telephone helpline can be a form of support [175,183].

The Role of Culture and Religion in Understanding Postpartum Psychosis

Cultural factors influence the understanding of PP. Psychiatric patients expect sensitivity and customization of mental health services. The research highlights the role of religion and beliefs in the way people with mental illnesses are viewed and treated. This is especially observed among populations where religion shapes behavior and thinking [184].

PPs are not considered disorders in all cultures. This is related to the low standard of living and the unequal status of women in society. In the Philippines, PP is referred to as “burghat” and is considered a natural occurrence after childbirth [185].

A study in India found that patients with PP and their families interpret their condition differently, seeing it not only as a mental illness, but as the work of supernatural forces, such as possession or the work of spirits [186]. Other data indicated a delay in seeking psychiatric care, with the most common reason being a lack of resources, transportation, and time. A secondary role was played by the severity of symptoms and unwillingness to cooperate, as well as the lack of awareness about the disease and the availability of psychiatric help [187]. One study indicated that in India, 6% of women with PP sought help from faith healers, while 21.1% reported seeing a general practitioner [187].

Ethical and Legal Challenges of Medical Professionals

Doctors face ethical dilemmas when treating psychosis, related to risk management regarding the use of drugs during pregnancy and lactation. The patient may refuse treatment and involuntary treatment should be considered. Depending on the laws of different countries, court approval may be required [188,189].

Because PP is not included in the DSM-5 in the U.S., a woman who kills her child while suffering from PP can be sentenced to death for a crime committed during a psychotic episode, with no defense of insanity [97,190]. In the U.S., infanticide by mothers with PP is estimated to account for less than 10% of all infant homicides. Recognition of postnatal illness in the courts can be recorded in 2 primary ways: use of the insanity defense during the trial phase, and through mitigation by judges during the sentencing phase. Under U.S. law, defendants must prove they were incapable of assessing their actions. In addition, various state laws on insanity defense may apply [191].

Future Directions

The etiology of PP is still unknown [4]. Risk factors for its occurrence include bipolar disorder, previous mental problems, use of psychoactive drugs, and psychosocial factors [31,36,39]. However, further research is needed to identify genetic, hormonal, and immunological factors that influence development of PP [30,40].

In addition, there is a need to develop specific diagnostic tools and to include PP as a separate disease entity in DSM-5 and ICD-10, which would allow earlier detection of the disease [13,27,96,97]. A unified system of diagnostic criteria and nomenclature would facilitate future research [16,103].

A high level of knowledge and competence of medical personnel plays an important role in the process of diagnosing and treating PP. Patients are often afraid to report the symptoms they experience for fear of being stigmatized with a mental illness, and emerging communication barriers, and various cultural and religious factors further hinder the process [10,166,184]. In some cultures, postpartum psychosis is not seen as a disorder or is interpreted as the result of supernatural forces. This results in a delay or even abandonment of seeking psychiatric help and the need to tailor care individually to the patient [185,186]. Therefore, there is a need to develop education and continuously improve the competence of medical personnel, to quickly identify patients at risk of postpartum psychosis, and to detect the disease early and achieve better treatment results [10,24,147,152–154].

Conclusions

The main medications used to treat postpartum psychosis are antipsychotics, benzodiazepines, mood stabilizers, and antidepressants. In cases refractory to drug treatment, electroconvulsive therapy may be effective.

Isolating mothers suffering from PP should be avoided and efforts should be made to maintain ties among child, partner, and family. Maintaining relationships and receiving support from loved ones speeds the recovery process.

Care and support should be extended to the partners and families of women suffering from PP, for whom the illness is also a stressful event. There is a need for emotional support and provision of information and practical tips for dealing with the situation.