Mothers at risk for infanticide often sought help, but the psychosis was not recognized
STUDY: Alford AY et al, Archives of Women’s Mental Health 2024
STUDY TYPE: Systematic review (narrative synthesis of case reports and case series)
FUNDING: Independent
Background
Postpartum psychosis affects 1-2 in 1,000 women after childbirth. Untreated, it carries a high risk of infantacide (up to 4%) and suicide (4-11%). This review looks at why this psychiatric emergency is often missed.
The Study
- Systematic review following PRISMA guidelines, looking at articles of mothers with postpartum psychosis who committed infanticide; 12 studies, mostly case reports and small case series, met criteria.
Results
Three patterns emerged from the cases:
- No standardized tool was used to screen for psychotic symptoms in the perinatal period, so delusions about the infant or command hallucinations went undetected even when the mother had recent contact with a clinician.
- Families in several cases turned first to traditional or cultural healing practices or explained the symptoms away as stress or a difficult adjustment, which delayed psychiatric evaluation.
- Limited access to urgent psychiatric care, including a shortage of inpatient mother-baby units, left acute psychosis unmanaged during the window when risk runs highest.
Dr. Aiken’s Take
Postpartum psychosis resembles affective psychosis (the type in mood disorders) more than schizophrenia. In affective psychosis, the person can usually relate well to others; well enough to cover up the psychosis, which they understand is socially unacceptable and fear could lead to removal of their children. Postpartum psychosis also waxes and wanes, so they may appear well one day but floridly psychotic another.
Screening
There is no standard screening instrument for postpartum psychosis, but a few have shown promise in research:
- Prodromal Questionnaire (16-item)
- Postpartum Psychotic Experiences Scale (PPES)
- The Mood Disorder Questionnaire can pick up on the associated manic symptoms.
UNC has a useful tool kit with screening information, including how to distinguish OCD from psychosis.
Limitations
This is a qualitative synthesis of 12 mostly case reports and case series published over a decade.
Practice Implications
- Treat any new psychiatric symptom in the two weeks after birth, including confusion, intrusive thoughts, or anything resembling hallucinations or delusions about the baby, as an emergency
- The Edinburgh Postnatal Depression Scale won’t catch psychosis. Better to screen women with a few items from this scale and a few more to identify delusions, hallucinations, and confusion. Get input from family as well.
- Learn how to treat it.
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
