Treatment of postpartum psychosis*

SGA: second-generation antipsychotic; SSRI: selective serotonin reuptake inhibitor; ECT: electroconvulsive therapy.

* This algorithm assumes there is no prior history or established diagnosis of depression with or without psychosis, bipolar disorder with or without psychosis, or psychotic disorder such as schizophrenia or schizoaffective disorder. Refer to UpToDate content for treatment of psychosis in the postpartum period for individuals with an established disorder.

¶ For all individuals with postpartum psychosis, our priority is to ensure their safety and the safety of their children. In most cases, we hospitalize individuals with postpartum psychosis. Refer to UpToDate content for further discussion of assessing and ensuring safety of the individual and child in the context of psychosis in the postpartum period.

Δ Refer to UpToDate content for discussion of lithium treatment and contraindications to lithium treatment. In individuals with contraindication to lithium (eg, renal insufficiency, dehydration, significant cardiovascular disease), we begin treatment with antipsychotic monotherapy. This option is the exception and is less preferred.

◊ For individuals with mild levels of disorganization that do not lead to agitation, insomnia, or other psychosocial disruption, we begin lithium monotherapy. Treatment with lithium monotherapy is the exception.

§ We prefer to use an SGA as the initial antipsychotic option. Our choice of antipsychotic is based upon desirable effects of medication (sedation) weighed against adverse effects (weight gain, metabolic dysregulation). Refer to UpToDate content for discussion of choice of antipsychotic, titration, maintenance, and monitoring of antipsychotic medications.

¥ We begin lithium at 300 mg orally on the first day of treatment. If tolerated, we increase to 300 mg orally twice daily on the second day of treatment. We check levels five days later and then five days after each dose change. Further adjustments in dose are based on serum lithium levels. Refer to UpToDate content for discussion of initiation, titration, and monitoring of lithium in pregnant and postpartum adults.

‡ We work with the patient and their supports to determine what constitutes adequate improvement in symptoms. Examples include absence of psychosis and disorganized thinking, absence of suicidal or homicidal thoughts, ability to safely care for self and children.

† Our preference is to avoid using valproate beyond the initial stabilization period due to teratogenicity in future pregnancy. Refer to UpToDate content on initiation, titration, and length of treatment with valproate in females with postpartum psychosis and who are breastfeeding.

** Our choice among antidepressants is an SSRI. We do not add an antidepressant in individuals with symptoms of excessive lability, irritability, or sleep disturbance, or in those in which rapid cycling bipolar disorder or mixed bipolar disorder are diagnostic considerations. These individuals may be at high risk for medication induced precipitation of mania. Refer to UpToDate content for further discussion of choosing an antidepressant in females who are breastfeeding.

¶¶ Our preference among benzodiazepines is treatment with a short half-life and few metabolites, such as lorazepam. Refer to UpToDate content for further discussion of choosing a benzodiazepine in postpartum females who are breastfeeding.

ΔΔ Individuals that respond to treatment are generally maintained on an antipsychotic for six to nine months and the antidepressant and lithium for nine months to one year. Additionally, in these cases we often augment with supportive psychotherapy. Refer to UpToDate content for description of medication maintenance, tapering of medications, and augmentation with supportive psychotherapy.

◊◊ We begin ECT once the individual is appropriately screened for ECT unless the individual has responded to treatment at this point. We are vigilant to the precipitation of delirium in administering ECT to individuals on multiple medications. For individuals on lithium, we skip one dose prior to each ECT session in order to reduce to subtherapeutic range. Refer to UpToDate content for discussion of ECT in adults.