Post-partum or puerperal psychosis (PPP)

Post-partum or puerperal psychosis (PPP) is a serious, but fortunately rare
disorder, occurring after about 0.1–0.2 per cent of deliveries (Kendell, Chalmers
& Platz, 1987). The onset is commonly within the first three weeks after
delivery, but it may sometimes begin with a prodromal mood disturbance
(usually unrecognised) during pregnancy. PPP is usually a diagnosis of affective
or mood disorder, that is, a manic or depressive episode or a mixed picture. The
onset of schizophrenia and recurrence of previously diagnosed psychotic illness also occurs post-partum. Within the DSM-IV system there is the option of
indicating post-partum onset of mood disorders, including manic and depressive
psychosis, but this option is not available within the DSM-IV classificatory
system if schizophrenia is the primary diagnosis (APA, 1994; Castle, McGrath &
Kulkarni, 2000).
The clinical picture includes a combination of mood and thought disorder,
which may manifest as: loss of contact with reality; confusion; disorganised
thinking; strange ideas; delusions; hallucinations; extremes, or rapid swings of
activity and mood, which may be confident, aggressive, talkative, grandiose,
extravagant, elated, withdrawn, anxious, quiet, miserable, numb, agitated or
immobilised; and/or insomnia and anorexia. In comparison with psychotic
disorders occurring at other times there is often greater fluctuation in mood and
mental state and episodes of confusion or disorientation that may resemble a
delirium or disorder secondary to a medical illness. Assessment needs to exclude
an organic or medical explanation for the symptoms and this is discussed further
below.
The predominant risk factors for puerperal psychosis are a family history of
psychosis, and/or a prior history of psychiatric disorder (Jones & Craddock,
2001). Other risk factors include a first baby, having no partner at the time of
delivery, undergoing caesarean section delivery or the baby being very sick or
dying.
Assessment must always include consideration of maternal and infant safety.
In the acute stage of the illness, the mother may not be able to care for the baby
without supervision, and alternative care for the baby may need to be arranged
in the short term. Management usually includes hospital admission (with the
baby as appropriate), medication and sometimes electro-convulsive therapy
(ECT), in addition to counselling and support for all concerned.
Recovery from a particular episode is usually good, although there is a high
risk of recurrence, particularly with later pregnancies, and for some women a
post-partum psychotic episode may herald ongoing episodes of illness
independent of pregnancy. Psychiatric support is helpful in decision making
about the risk of recurrence with subsequent pregnancies, and active
management and intervention to prevent recurrence is advisable.