Postpartum psychosis: Strategies to protect infant and mother from harm

Susan Hatters Friedman, MD
Senior instructor, Departments of psychiatry and pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH

Phillip J. Resnick, MD
Professor, Department of psychiatry, Case Western Reserve University School of Medicine, Cleveland, OH

Miriam B. Rosenthal, MD
Associate professor emeriti, Departments of psychiatry and obstetrics and gynecology, Case Western Reserve University School of Medicine, Cleveland, OH

Postpartum psychosis (PPP) presents dramatically days to weeks after delivery, with wide-ranging symptoms that can include dysphoric mania and delirium. Because untreated PPP has an estimated 4% risk of infanticide (murder of the infant in the first year of life), and a 5% risk of suicide, psychiatric hospitalization usually is required to protect the mother and her baby.

The diagnosis may be missed, however, because postpartum psychotic symptoms wax and wane and suspiciousness or poor insight cause some women—such as Andrea Yates—to hide their delusional thinking from their families. This article discusses the risk factors, prevention, and treatment of PPP, including a review of:

• infanticide and suicide risks in the postpartum period

• increased susceptibility to PPP in women with bipolar disorder and other psychiatric disorders

• hospitalization for support and safety of the mother and her infant.

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Psychiatry's future is here

Henry A. Nasrallah, MD, Editor-in-Chief

Do you sometimes wonder what psychiatry’s future holds? Wonder no more: abundant clues point to exciting innovations in our field. Let me highlight 6 trends that will shape how we practice psychiatry.

1. Earlier diagnosis and early intervention.
2. A tsunami of genetic discoveries.
3. Neuroplasticity as treatment target.
4. Neurostimulation for brain repair.
5. Pharmacogenomics in clinical practice.
6. Intertwining of physical and mental disorders.

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When clozapine is not enough: Augment with lamotrigine?

Stabilizing glutamate transmission may benefit some patients with treatment-resistant schizophrenia.

John A. Gray, MD, PhD
Resident, department of psychiatry, postdoctoral fellow, department of cellular and molecular pharmacology, University of California, San Francisco

Samuel C. Risch, MD
Professor, department of psychiatry, University of California, San Francisco

Current antipsychotics are reasonably effective in treating positive symptoms, but they do less to improve the negative and cognitive symptoms that contribute to patients’ long-term poor functional capacity and quality of life. So what do psychiatrists do in clinical practice to mitigate antipsychotics’ limitations? We augment.

Schizophrenia patients routinely are treated with polypharmacy—often with antidepressants or anticonvulsants—in attempts to improve negative symptoms, aggression, and impulsivity. Most adjuncts, however—including divalproex, antidepressants, and lithium—have shown very small, inconsistent, or no effects. The only agent with a recent meta-analysis supporting its use as augmentation in treatment-resistant schizophrenia is lamotrigine, an anticonvulsant approved for use in epilepsy.

This article examines the evidence supporting off-label use of lamotrigine as an augmenting agent in schizophrenia and explains the rationale, based on lamotrigine’s probable mechanism of action as a stabilizer of glutamate neurotransmission.

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