Mental Health Series for Perinatal Prescribers Severe postpartum syndromes
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Maternal Filicides Acutely psychotic - 24% Depression Altruistic - 56% to relieve suffering associated with suicide 80% due to psychiatric disorders Unwanted child -11% Accidental - 7% Spouse revenge - 2% Resnick American Journal of Psychiatry 1969
Acute Postpartum Psychosis Previously healthy Within 2 wks of delivery (3-10 days) Insomnia Acute confusional state: disorientation, derealization, depersonalization Kaleidoscopic picture (rapid symptom fluctuation over time and can be hidden) Psychomotor disturbances (agitation/stupor) Mood fluctuation: anxiety, irritability, ecstatic happiness,depression Hallucinations, illusions, delusions (related to mothering, labor, child, death, destruction, can be mood incongruent) Occurs in 0.3-0.6/1000 births Klompenhouwer et al 1991 Acta Psychiatr Scand; Bergink et al 2016 AJP
Probes for psychosis ASK PATIENT AND FAMILY MEMBERS ASK DIRECTLY ABOUT SUICIDAL AND INFANTICIDAL THOUGHTS Guilt/Depressive delusions Do you feel your child would be better off without you? Do you feel there is something defective about you or your infant that can t be fixed? Paranoia Have you felt afraid for your safety? Does it seem that anyone is against you? Or trying to harm you in some way? Referential ideation Have you noticed hidden meanings in how people talk to you or act around you? Are there more coincidences happening lately? Hallucinations - Observe for thought blocking Are you hearing or seeing things that you aren t sure are there? Are there command hallucinations?
Differential diagnosis for postpartum psychosis Infection, ie: endometritis Medication side effects, ie: bromocriptine, substances of abuse Autoimmune thyroiditis (up to 20%) Acute porphyria Stroke Central venous thrombosis Meningioma Urea Cycle Disorder with hyperammonemia Cerebral hypertension Headache, nausea/vomiting, ocular paresis Autoimmune encephalitis 4% (ie: NMDA receptor)
High relative risk of psychosis hospitalization in the postpartum period 24.6 Relative risk 0.9/1000 Absolute risk Breakdown by diagnosis (n=120) Major Depression 55% Bipolar Disorder 41% (includes schizoaffective, unspecified) Schizophrenia 4% Kendell et al (1987) British Journal of Psychiatry
Postpartum psychosis is a medical emergency Confused, disorganized, delusional thinking and behavior Safety and treatment planning is urgent Inpatient hospitalization is often necessary Acute treatment **Lithium - associated with 80% sustained remission Antipsychotics ECT Catatonia, agitation, not eating Benzodiazepines as adjunct Prevention if history of bipolar disorder or postpartum psychosis or mania **Lithium Antipsychotics more research needed Bergink et al 2016 AJP
OCD is not Psychosis!! Obsessive compulsive symptoms may affect as many as 25% of postpartum women Common Postpartum OCD symptoms aggressive thoughts to harm infant, aggressive obsessions, contamination obsessions, and cleaning and checking compulsions Obsessions are ego-dystonic, very distressing, and mothers try to resist them or avoid danger Psychotic ideas are ego-syntonic, not resisted and can be associated with increased risk of aggression OCD and true risk to the child are not mutually exclusive Wisner, Hudak et al AJP; Fairbrother and Woody AWMH 2008
Mortality after Postpartum onset psychiatric disorder 8 suicide deaths in 1.5 million women Johannsen et al AJP 2016
Perinatal Suicide: Risk Profile DEMOGRAPHICS Older (~30 s) Married Employed, including as professionals Stable housing Primiparous No ETOH or drug use disorder CLINICAL FEATURES Sudden illness onset with rapid deterioration Onset in the 1 st few weeks postpartum >50% have been in recent psychiatric care, including inpatient Shorter illness duration (less than 1 yr) Violent suicide means (hanging or jumping)
5-Step approach to suicide assessment 1.Assess suicide directly and specifically 2.Identify risk factors 3.Identify protective factors 4.Determine level of risk and appropriate treatment plan 5.Document ASK PATIENT AND FAMILY MEMBERS Download a card that elaborates on each of these 5 steps http://www.sprc.org/resourcesprograms/suicide-assessment-five-step-evaluation-and-triage-safe-t-pocket-card
13 Step 1: Assess suicide directly and specifically Frequency, Intensity, Duration Plans Behaviors Last 48 hours, Last month Homicidality Violent means: Firearms, rope, bridge Worst ever ideation Preparations for dying: timing, location, method, rehearsal behaviors
Step 2: Identify risk factors Psychiatric Depression, especially comorbidity with Substance use Panic symptoms PTSD Mixed symptoms of bipolar disorder Impulsivity Hopelessness Insomnia Psychosocial Loss, financial stress, family discord, IPV, infant/child stressors Has lethal means for committing suicide Medications Psychotherapy Intensive outpatient Respite Hospital Educate family Enlist family and community support Restrict access!!!
15 Step 3. Identify protective factors Successful past stress coping Spirituality Reality testing (not psychotic) Control frustration, distress tolerance Responsibility Optimism Social supports
Suicide risk assessment High Risk Medical emergency Suicidal ideation with a plan, with intent or attempt Have made a serious or nearly lethal suicide attempt Recent onset of major psychiatric syndromes, especially depression Recent discharge from psychiatric inpatient unit History of acts/threats of aggression Command hallucinations Psychotic Emergency room Involuntary commitment Suicide precautions
Suicide risk assessment Moderate/Low Risk Thoughts of death, with or without plan, no intent or behavior No imminent threat to self/others If many risk and few protective factors, hospitalization may be necessary Crisis/Safety plan Begin treatment Set up Behavioral Health appointment Start medications F/U call by the office Give patient resources if symptoms worsen Allegheny County: re: solve Crisis Network 1-888-796-8226 WPIC ER
Thanks for your attention! mosesel@upmc.edu postpartumpgh@gmail.com