Antidepressants won’t work here, but adding lithium to an antipsychotic brought nearly every woman into remission.
STUDY: Jairaj C et al, Journal of Psychopharmacology 2023;37(10):960–970
STUDY TYPE: Expert review
FUNDING: None; one author reports speaker fees from Lundbeck and Janssen.
Background
Postpartum psychosis affects 1 to 2 of every 1,000 new mothers, usually starting between days 3 and 10 after delivery, and carries a high risk of suicide and infanticide. Genetic and clinical evidence places it on the bipolar spectrum.
I posted this study in 2023, and am reviving it in the wake of the Clancy trial. Only one of the 13 medications she was prescribed are endorsed in the guidelines.
Method
- A narrative review of English-language PubMed articles on postpartum psychosis treatment, along with studies of antipsychotics and lithium in breastfeeding.
- Perinatal psychiatrists from the UK, Ireland, the Netherlands, and the USA combined the evidence into an algorithm covering prevention, acute care, and maintenance.
Summary
Before treating, rule out medical causes, including labs:
- CBC, metabolic panel, thyroid profile with anti-thyroid peroxidase antibodies, calcium, B12, folate, thiamine, and a urine drug screen.
About 19% of women with first-onset postpartum psychosis have autoimmune thyroid disease, and 4% have autoimmune encephalitis, so check anti-NMDA antibodies if neurological signs appear.
Lithium and antipsychotics are first-line, with benzodiazepines for acute management of anxiety and agitation. In a stepwise study of 64 women:
- 6% remitted on a benzodiazepine alone
- 19% remitted after adding an antipsychotic
- 73% remitted after adding lithium, bringing total remission to 98%
At 9 months, 80% of women on lithium alone stayed well, versus 50% on antipsychotics alone in a separate analysis.
For women with a prior episode, start lithium or an antipsychotic immediately after delivery (aim for 0.8 to 1.0 mmol/L during the first month. Begin tapering after 3 months but continue for a full year). Women with isolated postpartum psychosis don’t need medication during pregnancy, though they should be monitored.
Consider ECT if rapid treatment is needed or lithium/antipsychotics fail. In one cohort of 78 women, 44% received ECT with good response. The authors advise using it early for catatonia, suicidal or infanticidal thoughts, severe agitation, or poor oral intake.
On breastfeeding, the authors advise women on lithium to formula-feed, partly because night feeds disrupt sleep and sleep loss can trigger relapse. Olanzapine, quetiapine, and lorazepam are the preferred choices if a mother breastfeeds. Valproate has no place in women of reproductive age.
Postpartum psychosis is an emergency, and hospitalization is often necessary, ideally to a mother and baby unit.
Limitations
Much of the evidence comes from a single Dutch cohort, and there are no randomized trials. Olanzapine lactation safety data come largely from Eli Lilly’s surveillance reports.
Practice Implications
- It makes sense that lithium has robust efficacy in this disorder, which is being re-conceptualized as a bipolar spectrum illness.
- Involve the family, and guide them to peer support (Action on Postpartum Psychosis).
- Learn more in 35 Minutes, where six psychiatrists discuss the implications of the Clancy case (I was one of them).
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
