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A Mnemonic for Identification and Management of Postpartum Psychosis
LETTERS TO THE EDITOR LETTERS TO THE EDITOR
A Mnemonic for Identification and Management of Postpartum Psychosis To the Editor Postpartum psychosis is a rare but serious psychiatric disorder that accompanies 1–2 in 1000 childbirths, and the rate is 100 times higher in women with a previous history of bipolar disorder.1 As many as 0.2% of women with postpartum psychosis die by suicide, and 4% of women commit infanticide.2 Known risk factors for postpartum psychosis include primiparity, personal or family history of bipolar disorder or postpartum psychosis, sleep loss, and the use of antidepressants in the context of a bipolar diathesis.1–4 Given the onset of symptoms immediately following childbirth, early identification of “at risk” women is crucial for prevention and management of postpartum psychosis. Mnemonics are often used to help clinicians learn and recollect criteria for various diagnoses. Specifically, mnemonics have been developed for various DSM-IV disorders.5 We suggest the following mnemonic to provide obstetricians with a broad approach to the prevention, initial identification, and management of women who are at high risk of developing postpartum psychosis. The literature on the risk factors, clinical features, screening, and treatment of postpartum psychosis was reviewed and the key elements incorporated in the mnemonic. H History (personal or family) of bipolar disorder or postpartum psychosis P Parity I Involvement of psychiatrist and patient’s family P Promote sleep A Avoid antidepressants R Reduce stimulation O Observe for early symptoms U Use mood stabilizers/neuroleptics S address Safety issues The two major risk factors for the development of this condition are primiparity and a personal or family history of postpartum psychosis or bipolar disorder. One study reported that the incidence dropped from 2.6 per 1000 for first-time mothers to 1.4 per 1000 after subsequent deliveries.4 The risk of postpartum psychosis is 20% to 30% in women with bipolar disorder, and it rises to 74% among women with bipolar disorder who have a first-degree relative with postpartum psychosis.1 1028 l NOVEMBER JOGC NOVEMBRE 2010
Once women “at risk” have been identified, preferably antenatally, it is imperative for clinicians to closely monitor their mood and sleep patterns. Effort should be made to minimize sleep disruption and to promote sleep. Further, it is important to elicit the help of the patient’s family in monitoring the patient’s condition, especially in regard to the emergence of mood symptoms before birth. Patients considered at risk of developing postpartum psychosis should be referred for psychiatric consultation and follow-up. Prophylactic and acute treatment should include the use of mood stabilizers and antipsychotics, and antidepressants should not be used. Finally, effort should also be made to minimize sleep disruption and to promote sleep. Sapna Sharma, MD Department of Obstetrics and Gynaecology University of Western Ontario, London, ON Mustaq Khan, PhD Verinder Sharma, MB, BS Department of Psychiatry, University of Western Ontario London, ON
REFERENCES 1. Jones I, Craddock N. Familiality of the puerperal trigger in bipolar disorder: results of a family study. Am J Psychiatry 2001;158:913–7. 2. Spinelli MG. Postpartum psychosis: detection of risks and management. Am J Psychiatry 2008;166:405–8. 3. Sharma V. Treatment of postpartum psychosis: challenges and opportunities. Current Drug Safety 2008;3:76–81. 4. Kendall RE, Chalmers JC, Platz C. Epidemiology of puerperal psychoses. Br J Psychiatry 1987;150:662–73. 5. Pinkofsky HB, Reeves RR. Mnemonics for DSM-IV substance-related disorders. Gen Hosp Psychiatry 1998;20:368–70.
A Retrospective Review of Patients Seen in a Multidisciplinary Pelvic Floor Clinic To the Editor We read with interest the paper by Chan et al.1 in the January issue of the Journal of Obstetrics and Gynaecology Canada. The authors describe their cohort of 207 women, 52% of whom presented with two or more morbidities. However, they do not elaborate on which symptom clusters were common and what surgery these 52% of patients required. In 2008, we published our data2 from a cohort of 113 new cases seen in our pelvic floor clinics by a gynaecologist, colorectal surgeon, and nurse specialist. Our main symptom clusters were obstructed defecation with rectoceles and
A Mnemonic for Identification and Management of Postpartum Psychosis To the Editor Postpartum psychosis is a rare but serious psychiatric disorder that accompanies 1–2 in 1000 childbirths, and the rate is 100 times higher in women with a previous history of bipolar disorder.1 As many as 0.2% of women with postpartum psychosis die by suicide, and 4% of women commit infanticide.2 Known risk factors for postpartum psychosis include primiparity, personal or family history of bipolar disorder or postpartum psychosis, sleep loss, and the use of antidepressants in the context of a bipolar diathesis.1–4 Given the onset of symptoms immediately following childbirth, early identification of “at risk” women is crucial for prevention and management of postpartum psychosis. Mnemonics are often used to help clinicians learn and recollect criteria for various diagnoses. Specifically, mnemonics have been developed for various DSM-IV disorders.5 We suggest the following mnemonic to provide obstetricians with a broad approach to the prevention, initial identification, and management of women who are at high risk of developing postpartum psychosis. The literature on the risk factors, clinical features, screening, and treatment of postpartum psychosis was reviewed and the key elements incorporated in the mnemonic. H History (personal or family) of bipolar disorder or postpartum psychosis P Parity I Involvement of psychiatrist and patient’s family P Promote sleep A Avoid antidepressants R Reduce stimulation O Observe for early symptoms U Use mood stabilizers/neuroleptics S address Safety issues The two major risk factors for the development of this condition are primiparity and a personal or family history of postpartum psychosis or bipolar disorder. One study reported that the incidence dropped from 2.6 per 1000 for first-time mothers to 1.4 per 1000 after subsequent deliveries.4 The risk of postpartum psychosis is 20% to 30% in women with bipolar disorder, and it rises to 74% among women with bipolar disorder who have a first-degree relative with postpartum psychosis.1 1028 l NOVEMBER JOGC NOVEMBRE 2010
Once women “at risk” have been identified, preferably antenatally, it is imperative for clinicians to closely monitor their mood and sleep patterns. Effort should be made to minimize sleep disruption and to promote sleep. Further, it is important to elicit the help of the patient’s family in monitoring the patient’s condition, especially in regard to the emergence of mood symptoms before birth. Patients considered at risk of developing postpartum psychosis should be referred for psychiatric consultation and follow-up. Prophylactic and acute treatment should include the use of mood stabilizers and antipsychotics, and antidepressants should not be used. Finally, effort should also be made to minimize sleep disruption and to promote sleep. Sapna Sharma, MD Department of Obstetrics and Gynaecology University of Western Ontario, London, ON Mustaq Khan, PhD Verinder Sharma, MB, BS Department of Psychiatry, University of Western Ontario London, ON
REFERENCES 1. Jones I, Craddock N. Familiality of the puerperal trigger in bipolar disorder: results of a family study. Am J Psychiatry 2001;158:913–7. 2. Spinelli MG. Postpartum psychosis: detection of risks and management. Am J Psychiatry 2008;166:405–8. 3. Sharma V. Treatment of postpartum psychosis: challenges and opportunities. Current Drug Safety 2008;3:76–81. 4. Kendall RE, Chalmers JC, Platz C. Epidemiology of puerperal psychoses. Br J Psychiatry 1987;150:662–73. 5. Pinkofsky HB, Reeves RR. Mnemonics for DSM-IV substance-related disorders. Gen Hosp Psychiatry 1998;20:368–70.
A Retrospective Review of Patients Seen in a Multidisciplinary Pelvic Floor Clinic To the Editor We read with interest the paper by Chan et al.1 in the January issue of the Journal of Obstetrics and Gynaecology Canada. The authors describe their cohort of 207 women, 52% of whom presented with two or more morbidities. However, they do not elaborate on which symptom clusters were common and what surgery these 52% of patients required. In 2008, we published our data2 from a cohort of 113 new cases seen in our pelvic floor clinics by a gynaecologist, colorectal surgeon, and nurse specialist. Our main symptom clusters were obstructed defecation with rectoceles and