Postpartum Psychosis: Symptoms, Warning Signs, Risk Assessment, and Treatment with Dr. Furey and Dr. Puder

In this essential episode, Dr. David Puder sits down with board-certified reproductive psychiatrist Dr. Katrina Furey to unpack postpartum psychosis. They cover its early warning signs, symptoms, diagnostic challenges, risk assessment, and evidence-based treatment. They discuss classic onset within days to weeks after delivery, common delusions centered on the infant, fluctuating mental status, the critical distinction from postpartum OCD, elevated risks of filicide and suicide, strong links to bipolar spectrum disorders, and the vital roles of lithium, antipsychotics, sleep protection, ECT, medical workup, and family support. Learn why this psychiatric emergency demands rapid intervention, how most women fully recover, and practical guidance for clinicians and families navigating this rare but treatable condition. Link to blog https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-276-postpartum-psychosis-symptoms-warning-signs-risk-assessment-and-treatment-with-dr-furey-and-dr-puder Link to YouTube video https://youtu.be/IrZ6WAnA9r8 By listening to this episode, you can earn 0.5 Psychiatry CME Credits. https://www.psychiatrypodcast.com/cme-program

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:14David Puder?

  Welcome back to the podcast. I am joined today with Dr. Katrina Fury. She is a board certified reproductive psychiatrist, Yale trained, in private practice, has an online training, Repro Psych Academy for training on reproductive psychiatry. She also practices mostly reproductive psychiatry. She is someone who is a colleague of Brandon Kattay, who was on my podcast in the past. Shout out to him. He did some great episodes on ketamine. And you work as well, kind of like a hotline for like when an OB-GYN psychiatrist,

• 0:54David Puder?

  pediatrician needs a reproductive psychiatrist specialist. And so it's great to have you on the podcast. Obviously, if you're paying attention to the news, there are some stuff about this going on. So why don't we just start out talking a little bit about what is postpartum psychosis?

• 1:14Speaker 01

  That's a great question. So thank you so much for having me. So what is postpartum psychosis is, actually, I wish there was a straight answer, but since there is not definitive diagnostic criteria in the DSM V, there, I think, therein lies the first problem when it comes to identifying and treating postpartum psychosis, right? It's hard to treat a condition if people aren't told exactly what to look for to diagnose it in our medical model. So sometimes it gets missed. When we think about classic postpartum psychosis, it is psychotic symptoms that develop soon after delivery. Classically, it's within 24 hours to three weeks. I believe the average onset is right around eight days,

• 1:59Speaker 01

  usually within the first two weeks. But if you talk to women who have experienced this, or you talk to experts like Dr. Margaret Spinelli and some other experts in the field, they will, and they have been advocating to expand that timeframe up to 12 weeks. There was a 2025 consensus statement really urging the DSM to expand that timeline. So most cases develop very early. We believe it's due to that swift drop in the hormones. However, up to like three months is still that high risk time. And even beyond that, women can develop psychotic symptoms in the postpartum period. And the jury's out. I think the field

• 2:44Speaker 01

  is still unsettled as to whether that would be qualified as classic postpartum psychosis, or if it is, you know, other psychotic symptoms developing within the postpartum period that would have developed around then anyway, since most women, right? Like if you're going to develop a bipolar disorder or a schizophrenia spectrum disorder, tends to happen a little later for women than men in your late 20s, early 30s, which is around when a lot of women are having children. So that's what makes all of this very complicated. But again, it's psychotic symptoms of delusions, hallucinations, paranoia, as well as you can have mood symptoms, anxiety, irritability, restlessness, and decreased need for sleep.

• 3:26David Puder?

  Okay, yeah, you see, you rattled off some symptoms. I think we should go through some of those, just to kind of

• 3:30Speaker 01

  Sure.

• 3:30David Puder?

  enliven this. But I think one thing that you said that was so interesting, because I'm watching this Lindsey Clancy court case and the cross examination. And he's like, you know, he is aware that postpartum psychosis is not in the DSM.

• 3:47Speaker 01

  Yes, very aware.

• 3:48David Puder?

  It's like

• 3:49Speaker 01

  Do you know, it used to be, it used to be in DSM two and three, and then it got removed.

• 3:54David Puder?

  And there is, you know, in the DSM with peripartum onset, but then it always happens like in the first four weeks, or most of it, right? Most of it, most of the time, psychotic symptoms in the first four weeks. So this is an emergency. This is like drop everything. This is the one patient to take care of. I've had a couple of these just this year. And maybe I can de-identify it and talk about it a little bit like, thank God, it went well. But delusions, what are some of the delusions that you've seen? And maybe we'll start with that one. And then we'll talk about some of the other symptoms.

• 4:32Speaker 01

  Sure, sure. So oftentimes in postpartum psychosis, the delusions are centered around the infant, or kind of the family unit as a whole. Not all the time, though. So I think that's the other thing about postpartum psychosis that can be so tricky, is most of the psychotic symptoms, most of the time will be centered around the baby, but not all the time. And so a lot of the delusions might be, is the baby possessed? Is the baby cursed? Is the baby not really a baby, but an adult masquerading as a baby, like things like that? I've also seen cases where it gets really tricky to decide where is that

• 5:15Speaker 01

  line between a very anxious preoccupied mother with, is something wrong with my baby? And when does it cross over into being delusional? So there can be a lot of preoccupations with the baby's health, with them thinking something's wrong with the baby that other people aren't seeing. Oftentimes, there may also be some paranoia that goes along with the delusions about how much can I trust my partner, or my family, or their doctor, the people around me, or can I not really trust those people? And then, of course, you can also just have other random delusions, like, you know, paranoia that someone's following you, someone's listening to you, someone's talking to you through the radio. A very important delusion

• 5:58Speaker 01

  that we see in postpartum psychosis that has been connected to the high safety risk is this idea of delusions of control. Are you familiar with that?

• 6:08David Puder?

  Yep, but good to find it. Yeah.

• 6:11Speaker 01

  Yeah. So when you believe that something outside of you is controlling you. So the woman really believes that, whether it's God, the devil, aliens, the universe, or some unknown entity, it's like they've lost control of their own body, their own autonomy, their own like decision making, and something else is controlling them. And so, you know, forensic psychiatrists who really look at this stuff have found a correlation between delusions of control and that risk of violence being pretty high. So that's one of the biggest red flag symptoms, especially if it gets paired with, you know, paranoia, or command

• 6:52Speaker 01

  auditory hallucinations telling you, you have to do X, otherwise Y is going to happen. And so, again, I think we can also imagine how scary it must be for women to experience this, and to be able to openly talk about it, or put words to their experience when they're in such a vulnerable timeframe as well.

• 7:10David Puder?

  Oh, yeah. But I mean, they do not want to talk about these things out loud, right? So this is where it gets complicated, because they're not always telling the psychiatrist, they're not always telling their husband. Sometimes they're keeping these thoughts very internal, right? But they're distressed, they're anxious. And so sometimes it could be hard to pull out, you know, what are the delusions? You have to create a connection, you have to decrease the fear that, you know, these things are going to be seen as bad. Sometimes people have obsessive thoughts, OCD, postpartum obsessionality. How do you differentiate that? Like, let's say, a woman has a thought, I am going to hurt my child. It's ego dystonic, meaning they don't want that thought. But they keep having this obsessive

• 7:54David Puder?

  fear that they're going to hurt their child. How do you differentiate that from like more of a psychotic thought?

• 8:02Speaker 01

  That is a great question. And I'm glad you asked it, because I think that there's a lot of miseducation about this. You may have learned, like I did, that there's this real cut and dry way to figure this out, right? If the intrusive thought is ego dystonic, and you're frightened by it, and it's not in alignment with your values, and you probably have anxiety or OCD, and you're probably not going to act on it. But if you're having these intrusive thoughts, and they're not distressing, and you do want to act on them, they're ego syntonic, then you probably have psychosis. That's when we should worry. It sounds great to make it that simplistic. But I will tell you, in real practice, it's

• 8:40Speaker 01

  not always that simplistic. In patients I've worked with, and in women I've spoken to through organizations like Postpartum Support International, they have a wonderful postpartum psychosis task force. And every year at the conference, they have a lot of panels where women with lived experience share their experience. They're doing wonderful work. But it's through all of that experience, I've learned that a lot of patients have some slivers of insight. It's not like insight is either on or off. And so a lot of women will describe having these intrusive thoughts and being terrified by them. And they don't want to act on it, but they're still having them. And so I think this is where it gets tricky. And you have to take the whole clinical picture in mind, and really try to drill

• 9:25Speaker 01

  down on, is this more aligned with anxiety? You're not seeing those other symptoms that often go along with postpartum psychosis, like decreased need for sleep. If a woman isn't sleeping as much because she's anxious, she's probably tired during the day. And the reason she's not sleeping is probably because she's up worrying about the baby. Whereas with postpartum psychosis, a lot of the time, we just see this delirium like picture, which often goes along with a decreased need for sleep. And so there's a little bit of like a qualitative difference, but it is, it's tricky to discern.

• 10:00David Puder?

  Really good. Yeah, I want to like pull out some of these threads that I think are especially.

• 10:04Speaker 01

  I feel like I'm.

• 10:05David Puder?

  You're doing great.

• 10:06Speaker 01

  It's so tricky.

• 10:07David Puder?

  You're doing great.

• 10:08Speaker 01

  It's very tricky.

• 10:09David Puder?

  You're doing great. I think one very clear example of postpartum OCD kind of new onset that I had was, you know, the, the mother's fearful that her child is going to be contaminated, that she's going to hurt her child. The, the compulsion was to stay away from the child, to not touch the child, to want to clean the house. She was cleaning the house like four to six hours a day. So the compulsions are often like hours and hours a day. And OCD, I think is a doubting disease. I'm curious how you kind of think about this differently in terms of like postpartum onset. But when I think of OCD, I treat a lot of OCD as doubtings. They have a constant doubt of something.

• 10:52Speaker 01

  What if, what if, what if?

• 10:53David Puder?

  Yeah. And they're doing the compulsion to, to gain certainty. So the cleaning allows them a moment of certainty. But yeah, the, the sleep and the irritability are another big factor of this postpartum psychosis picture, right? Irritability is very common. I think, I'd like to hear your thoughts on that specifically. And then the sleep, I'm glad you brought that up as well.

• 11:15Speaker 01

  Yes. So irritability is very common in the postpartum period across the board. And I would say that I think you can see it with, with any of the postpartum conditions, depression, anxiety, psychosis. I don't, I'm not aware of it being more common in psychosis compared to other conditions. I think with psychosis, you can have mood symptoms, whether hypomania, mania, or depression or not. Sometimes you just have the psychotic symptoms. But most of the time, you have some kind of anxiety or restlessness. And so for me, as a reproductive psychiatrist, when I hear my newly postpartum patients, or also my patients with bipolar disorder who are getting into their third trimester,

• 12:00Speaker 01

  when I hear them start to talk about things like, I'm so anxious, I'm having trouble sleeping, like almost this inner restlessness, that makes me very worried. And I try to really ask them to drill down on, what are you anxious about? And do you actually feel worried? Like, are you worrying? Or do you feel physiologically anxious? Or are you actually getting restless and kind of revved up? Because I think a lot of people will use that word anxiety to mean all sorts of different things.

• 12:29David Puder?

  Really, really helpful. Yeah. Okay. So diagnosis, sometimes can you just have it more of a depressed picture with the psychosis? And any, any thoughts on that specifically?

• 12:45Speaker 01

  You definitely can. You definitely can. I think the thing with postpartum psychosis is the cases that are quote unquote, easy to spot would be the woman who is acting very bizarre, very euphoric, very manic, not sleeping, running around, maybe having hyper religiosity, delusional beliefs like that, like that kind of case, I think we're all going to be like, okay, there's something up here, right? Especially if it's presenting in that first month postpartum. I think the cases that get trickier are the ones that have this early prodrome. And I don't mean, sometimes it can be weeks or months long, but I, it can even be like a couple hours or days where it looks more like that irritable anxiety picture. And then they're not sleeping, right? And then it kind of

• 13:29Speaker 01

  starts to snowball. Those cases can also be evidence of postpartum psychosis. And it's really about teasing apart or picking up on the psychotic symptoms, the delusions, the hallucinations, the paranoia. And again, as psychiatrists, we all know this is very tricky. And these are very hard symptoms to ask about. And so I think we also have to be really careful in our own observations of our patient in case they are withholding some of these symptoms. I've, I've worked with countless women who, you know, they don't, they don't have postpartum psychosis, they have postpartum OCD, but they're terrified to bring up the intrusive images and thoughts that they're having because they're so graphic and violent, which it turns out intrusive thoughts are more graphic and violent in

• 14:13Speaker 01

  the postpartum period. Who, who knew? But that's what the evidence shows. And so it's important also to be a very astute observer of their behavior. And then to also talk to the other people in their life to really get at, are they different? What are you observing? And depression can certainly go along with this. And I think that's where it gets tricky is because some of these cases will very much look like postpartum depression and anxiety at first, until some of those more psychotic symptoms develop.

• 14:44David Puder?

  Very good. Yeah. One of the things I was looking at was with specifically, phyllicide, there, there's been some cohorts where they've looked at phyllicide versus severe postpartum mental illness versus healthy population. One study in particular I looked at was Bram Mente et al., let's see, 2025, looked at 30 in the, the phyllicide group. And they were looking at like, well, what are the differences, you know, in terms of like these populations? And I, I think maybe the, the first thing to say is that phyllicide is actually very rare. I don't know if you want to mention that. It's like 1% of postpartum psychosis, which is.

• 15:27Speaker 01

  Of untreated cases.

• 15:28David Puder?

  Of untreated. Yeah. So it's pretty rare.

• 15:31Speaker 01

  Pretty rare.

• 15:31David Puder?

  And, and I, I did it. I started doing like this data, trying to find every case of it in the US. And I, it was like, it's not a lot. Okay. So this is like, this is like, the cohorts where you look at like, this is the biggest cohort study. 30 is actually a pretty big cohort.

• 15:51Speaker 01

  And it might be like 30 people. Yeah.

• 15:52David Puder?

  Yeah. This is a big cohort.

• 15:53Speaker 01

  Right. But it's, so it's, the safety risk is high, right? Like when you compare the rate of phyllicide in this condition compared to other conditions, but overall, it's still low? Is that the point you're trying to make?

• 16:06David Puder?

  That, I think that's the first point. Yeah. As, as providers, because I've heard some providers say like, after the, this Lindsay Kletz case, I don't want to treat anyone postpartum.

• 16:15Speaker 01

  I know. I've heard that too.

• 16:16David Puder?

  And that breaks my heart because it's like, no, we can do this.

• 16:18Speaker 01

  We, we need people.

• 16:20David Puder?

  We, we need to do this? Like, we, we don't want hurdles in the way of women seeking care postpartum. Like, you know, they need to be seen quickly, right? They need to be seen. Like, this is, this is a medical emergency.

• 16:35Speaker 01

  Right. And to reassure the patients too, that you're not doomed to have this awful, terrible, tragic outcome. Like, our interventions work and the treatment works. And when you are treated, it is reversible and temporary.

• 16:51David Puder?

  Okay. So one of the things I noticed was that none of the people with OCD actually went on to do the phyllicide in this one group, which is kind of interesting. It's like, so if, if you were more of the obsessive type of rumen, you know, the pure OCD, OCD like obsessive distressing thoughts, that doesn't mean you're actually going to harm the child.

• 17:13Speaker 01

  Right. Right.

• 17:14David Puder?

  So that was one thing I want to say. The, the group that ended up being different from the severe postpartum had worse psychotic symptoms. The odds ratio was like 3.8, worse insomnia, odds ratio 9.8. And they had more of the schizophrenia, bipolar diathesis, odds ratio of 4.8, and family history of violent death was also elevated.

• 17:40Speaker 01

  Oh, that's interesting.

• 17:41David Puder?

  27% in the phyllicide group versus 3% in the severe postpartum psychosis. But one, one thing I would say is that as I'm looking into these studies more and more, and I don't know if you kind of agree with this, but there's no predictive model on how to predict. The, the data is so sparse. And I'm hoping I can come back maybe a couple weeks from now with some larger sense of predictive power. But right now, what I'm seeing, and I don't know if you agree with this or not agree with this, but it's like, there's no predictive power to like, okay, this person's especially at risk for hurting their child.

• 18:23Speaker 01

  I think unfortunately, you're, you're correct because, and I think this sort of is indicative of the bigger problem when it comes to perinatal mental health disorders, and particularly postpartum psychosis, is because I just think it's so hard to study when we don't have a clear diagnostic code or way of us all agreeing on a diagnosis to then study it, right? And then randomize and like all the things we usually do. Let's say if we were going to look at STEMI's versus NSTEMI's, right? It's like, well, once you, we all kind of have to agree on that difference to then look at two different groups. But if we're, you know, diagnosing postpartum psychosis in different ways, how do we really

• 19:07Speaker 01

  study it in a more evidence-based, larger kind of way? So I think we end up relying on case reports, cohort studies, or the very, like a handful of forensic reproductive psychiatry experts who have, you know, interviewed the women who have committed phyllicide to try to piece together, like, what are the similarities? What are the differences? So I think you're, I think you're exactly right. It's, it's very hard to figure that out and to predict.

• 19:39David Puder?

  In the forensic literature, they differentiate the timing of like how soon after these events occur. So within like the first 24 hours, they call that neo-naticide, right? And what I was seeing was that in this group, in this study, out of the five of them, four had personality disorders, three had dissociation, all had low socioeconomic status, four of the five had less than eight years of education total. They had no acute postpartum psychiatric affective diagnosis at the time, none had any psychiatric care at the time. So that group was a little bit different than the 11 women in the infanticide group. The infanticide

• 20:23David Puder?

  is within the first year, the median was about five months. And it seems like the bipolar spectrum was larger in this group. So of the 11 group, of these two in the context of a lifetime psychotic disorder, five had bipolar 2 disorder, four had unipolar depression. Positive psychotic symptoms were present in every case. Three women also met criteria for dissociative disorders, two women hypomanic symptoms, and then eight out of 11 women had experienced a psychiatric episode during pregnancy, six major depressive disorder, two psychosis. Only one woman had a history of psychosis prior to pregnancy. Only one

• 21:08David Puder?

  woman had a previous concern regarding child safeguarding. At the time of the infanticide, no women had been, were taking antipsychotics or mood stabilizers. Four women were on SSR I monotherapy, three on sertraline, one combined with zolpidem, one esitalipram. This included one woman that had a previous history of bipolar disorder, and two who later developed hypomanic episode after the infanticide. So, and then finally, five women were not receiving any psychiatric care and had no contact with services despite previous history of severe psychiatric disorders. So this was in this one cohort with 30 women, so.

• 21:52Speaker 01

  And I think that, that is aligned with what I have been taught and learned from other reproductive psychiatrists, that again, it's, it's, it's kind of like catatonia, where like excited catatonia, you can easily spot, but the depressive, slowed down catatonia can kind of get missed when you're thinking about like a big inpatient unit, right? That quiet little old lady in the corner could fly under the radar. Sadly, I feel like it's a similar thing with postpartum psychosis, where the floridly manic, bizarre, delusional, revved up patient, you're, you're going to spot easier. But the quieter, sort of like

• 22:32Speaker 01

  preoccupied, depressed patient is also very risky. And that mixed picture, when you have a little hypomania, but also some depressive symptoms, those are also risky. And so that was one thing that I learned in my training is that the cases that have very severe depression plus psychotic features, plus those delusions of control, that's your highest risk patient. Like that's the one you really got to worry about.

• 22:55David Puder?

  Yeah, it's like Philip Resnick, I remember talking about this at a, at a conference. I don't know if you've heard him speak. He's actually an infanticide expert. This is what he did his early research in, interviewed a lot of women. And, you know, when I first heard him talk about it, he had a lot of compassion for these women who kind of got swept into this, you know? So he talked about how the dangerous thing is when you have the delusion, and then on top of that, you have the command auditory hallucination. And you feel like this more obligation. You're not going to, you're not going to cover up the scene of the crime. You're not going to put gloves on to commit the atrocity. You're

• 23:37David Puder?

  not going to hide from the police after, because you're not in your own mind doing something that's, that's horrible. So, you know, concealing crimes was, was more of like an antisocial, psychopathic, confabulating of, of psychosis type of thing. So.

• 23:57Speaker 01

  And that is directly aligned with what I have, you know, heard as well from women who have survived postpartum psychosis, who maybe did act violently or something happened, is that in the moment, they, they don't feel in control. They, I've had it described to me as like they're a puppet being controlled, and that the command auditory hallucinations are, are telling them something even worse will happen if you don't do this.

• 24:24David Puder?

  Yep.

• 24:25Speaker 01

  And I just, I think that's, that's the part for these cases that really just gets me, because I just can't imagine how utterly terrifying that must feel like, and how confusing, and how like, so many of the women who have survived have said things like, you know, I, I knew this was bizarre, and yet I really believed it. And I, I didn't want to tell anyone, because like, what would you think if I told you this? Like, you're going to think I'm crazy. And, and it's just, it's so complicated, right? Because it's like you, you want the woman to feel safe enough to tell you these things. And yet, have we really built a system where that's the reality?

• 25:05David Puder?

  Hmm. But I mean, this is where, I think as, as like clinicians, the more we learn about it, the more we know about it, the more comfortable we feel having these types of conversations with patients. People, patients will feel that comfort. They'll know we're advocating for them. They'll know that we're trying to help them. I've had a lot of patients, when they're manic, they don't remember much of what happened in the mania. And they, like, I've had this one patient in particular years ago, she was in a inpatient CD unit, and she goes floridly manic.

• 25:37Speaker 01

  What's a CD unit?

• 25:38David Puder?

  A chemical dependency unit. So you don't, you're not expecting this person to be, to all of a sudden become floridly manic. But she went from like having a normal conversation to six hours later being floridly manic. And we, I, I spent like an hour switching her units, talked to her, you know? And then one week later, she comes back and she doesn't remember me at all. And she, she had no recollection of ever having a conversation with me. And I, I, I spent hours with this person.

• 26:10Speaker 01

  Right.

• 26:11David Puder?

  And so it's like.

• 26:12Speaker 01

  I've had, yeah. It's so true.

• 26:14David Puder?

  Not every patient will remember what happens in the midst of their mania, whether they did something good, or if they didn't do something good. I mean, what if they did something bad, or they didn't do something bad? They're not going to remember it either way.

• 26:28Speaker 01

  And I think that sort of speaks to another hallmark sign for postpartum psychosis, which is that delirium-like fluctuating mental status. I know we, we can see this with other types of psychosis too. Like I'm thinking about in training, like prednisone-induced psychosis, or something else like that. But we see this as well with postpartum psychosis, and I think it can really trip people up, is that over the course of hours, like over the course of a day, a woman might be a little confused in the morning, or not seem like herself, not really understand what's going on, maybe not floridly psychotic in terms of like talking to someone in the corner, or, you know, having very obvious paranoia,

• 27:10Speaker 01

  but just being off. And then by the end of the day, they might be kind of back to themselves. They seem kind of back to it. And I think some people will think like, oh, oh, she, she needs a nap, she just had a baby, like, you know, she's, she'll get better. But those of us who work with postpartum psychosis know that's actually a very telling sign, and something that you want to intervene on very quickly. And I think that goes against some other conditions where there might be more of a like, let's wait and see kind of model approach. So that fluctuating mental status is, is really important to keep an eye on. And sometimes also, we have to keep in mind that you also got to rule out any potential medical causes. And that can be sometimes the, the way to get a patient into

• 27:52Speaker 01

  the ER for a good assessment, is to just remind them, you've just had a baby, you know, you're not acting quite right. I know you feel okay, if they do, but let's, let's just get you checked out. Let's just make sure everything's okay. And there is a lot of truth in that, because you want to make sure there's not a medical cause as well.

• 28:10David Puder?

  So many, so many good points. The confusion seems to be unique and kind of like an added thing to look for in postpartum psychosis, the confusion from what I'm reading in the literature, from what I've seen. The medical workup is a great, is great points. Infection, you're thinking of mastitis, endometritis, you're thinking of autoimmune thyroid issues are more common. You're thinking of anti-NMDA receptor encephalitis potentially?

• 28:38Speaker 01

  Yeah.

• 28:39David Puder?

  You know, if they're, especially if they have other symptoms as well, neurological symptoms, metabolic, neurologic disturbances as well. So, you know, it may make sense. And I would say this, if you're a therapist and you have a patient and this is like day eight and they seem to be having these symptoms, you know, and there's no one to take them to the ER, take them to the ER, you know?

• 29:03Speaker 01

  Yeah.

• 29:03David Puder?

  Exit out of the frame to get them to the ER, to talk to the, talk to the ER doctor, explain what they think's going on, demand an expert consult, right?

• 29:14Speaker 01

  Demand that they're watched for two to, like ideally two to three days. And I know that's very hard in our healthcare system these days, but what's so tricky with postpartum psychosis is if they show up to the ER and they look good and no one does a workup, that can be a missed opportunity to intervene.

• 29:31David Puder?

  Yeah. I'm thinking like, you really have to do a warm handoff. Like if you've heard some things that are concerning and the psychotic symptoms, like I can almost assume that a busy ER is not going to see it. You know, they may not see the psychotic symptoms. They may not understand it. So you really have to like do a warm handoff in this case.

• 29:50Speaker 01

  I totally agree.

• 29:52David Puder?

  Yeah. Okay. There was another thing that I was thinking about was there is a risk of bipolar disorder developing in about 50% of people who have first onset postpartum psychosis. So they later go on to develop bipolar disorder. This isn't the case for schizophrenia. Do you see this as more of a bipolar issue or more schizophrenia issue personally?

• 30:18Speaker 01

  This is a, yes. So this is a really good question. So that, so far, the evidence that we have, which is limited, is that women are 23% more likely to experience psychosis in the first month after childbirth compared to any other point in their life. However, what we have come to find is about one to two women will experience postpartum psychosis out of every 1,000 live births. So about one to two per thousand live births is the running statistic for postpartum psychosis. I think we also have to keep in mind though, that there have been case reports of postpartum psychosis following miscarriage that don't get captured in that data as well as following stillbirth. So again, when we think about

• 31:00Speaker 01

  it, clinically speaking, we would call it rare. Like if you look up, what is the definition of a rare disorder? This would qualify. However, it's about as common as other disorders like Down syndrome, for example, is also about one to two in a thousand. When you think of last year, there was about 3.5 million live born children. If you do the math, which I'm not smart enough to do in my head right now, but that's around three to 4,000 women who probably experienced postpartum psychosis. So that's a good chunk of people. So again, it's much less common than baby blues, postpartum depression, postpartum anxiety, postpartum OCD. All of those conditions are more common. However, it can still happen and it's not

• 31:42Speaker 01

  so, it's not such a zebra that we're never going to see it. Does that make sense?

• 31:46David Puder?

  Makes sense. Yeah. And I, I think it's worth the, the emphasis that if you have a prior history of bipolar, that, that the risk for having postpartum psychosis is 17%. So it's pretty high. Also, if you have had previous postpartum psychosis, the risk of a future one is 23%. Interestingly, so, okay. So the way that I understand this actually came from, there's a, there's a consensus paper that came out by Dr. Berg, Inc. et al. It's called Postpartum Psychosis and Bipolar Disorder: Review of Neurobiology and Expert Consensus Statement on Classification. And one of the things that he's arguing for is

• 32:30David Puder?

  that this get added into the DSM under like a bipolar spectrum phenotype. So it's postpartum psychosis in the bipolar spectrum phenotype, right? So because, and his, his argument for this is that lithium is the best medication to prevent relapse, better than an antipsychotic. A lot of these patients will go on to later have bipolar disorder. The risk of having bipolar disorder makes the risk of postpartum psychosis much higher. And there is also, you know, is this a unique thing or is this bipolar? What he would say is a lot of women

• 33:15David Puder?

  will go on to be completely normal. So they won't have future issues. Like once they come out of this.

• 33:22Speaker 01

  Right.

• 33:23David Puder?

  So in one prospective cohort, 68% of women had episodes confined only to the postpartum period. So we're really-

• 33:32Speaker 01

  Isn't that fascinating?

• 33:33David Puder?

  It's, it's amazing. It's amazing. Yeah.

• 33:36Speaker 01

  And they, I don't know the exact data or where it stands right now, but as of two years ago, at the Postpartum Support International Conference, the task force was talking about how they are doing some research about different genetic polymorphisms. And they are seeing that when they look at the genes, and this is where it's like way over my head, the genes are more like bipolar disorder than the schizophrenia spectrum disorders. And yet not every case, there are, and it's a good chunk of patients that don't have a future mood episode. So that's where I think we just, we don't fully know. We don't fully understand.

• 34:15David Puder?

  I, I think one of the things that they came out of this paper is be very careful to put them on an SSRI. And I think that that is, is good wisdom, right? So-

• 34:27Speaker 01

  Yeah. Yes.

• 34:28David Puder?

  Because, you know, if, if we're talking about the first four weeks after birth, you know, lithium, in one, in one really good paper that I saw, it showed that it reduced risk of relapse more than the antipsychotic. And lithium is antidepressant. Now, there's a question of like, well, what about for breastfeeding? Do you have any thoughts on that?

• 34:52Speaker 01

  I do. I have a lot of thoughts. So my thoughts would be that mom's mental health is paramount. If we're thinking lithium, we're thinking we really need to keep mom well. It's not contraindicated in breastfeeding. You can certainly breastfeed if you're taking lithium. You just need to have a really nuanced discussion of the potentials, things to watch out for, for the baby. And you also would want to make sure that the baby is full term, doesn't have any like neurological or respiratory issues. And you'd want to just talk about it with the pediatrician. Usually if you're a patient that I'm seeing who's on lithium and you're pregnant, we have all those conversations upfront. But in the postpartum period, if you've never been on a medication and we're suspecting postpartum psychosis, I agree with you. I want to start lithium and I also want to make sure mom is sleeping.

• 35:36Speaker 01

  So sleep is another like prescription.

• 35:38David Puder?

  Right.

• 35:39Speaker 01

  And in the postpartum period, at least a five to six hour chunk every night. And sometimes that will affect your ability to breastfeed, just depending on the other factors in terms of if you're able to maintain a milk supply, if you're sleeping during that chunk or not. And those can be tough conversations to have with, with mom. And yet we have to think about overall, what's going to be best for the baby and the mom is a well mom and a mom who is not becoming more and more psychotic.

• 36:08David Puder?

  Hmm. Yeah.

• 36:09Speaker 01

  So it's, it's, it's complicated. I don't think if you have to take lithium, I don't think that means there's no hope to breastfeed. Maybe we think about, can you combo feed? Can we do a little bit of both? Or if it's better for mom overall to just switch to formula, let's do it.

• 36:25David Puder?

  Right. So the patient, one of my patients this, this year that had postpartum psychosis, manic, not sleeping, psychotic. I don't want to describe it too in detail because it's a patient.

• 36:39Speaker 01

  Sure. Sure.

• 36:40David Puder?

  But lithium was started right away, 900, pushed it up after a lab test to 1,200, and then I think maybe even 1,500. And this was all done like in a week and then that wasn't working. So we added a little lanzapine, five, and then 10. I think we might've gone up to 15 or 20. I forget. Still not sleeping. Ativan, one, and boom. Okay. Once we had 15 of lanzapine, 1,500 of lithium, one milligram of Ativan, sleeping well. Okay. And really good parental support from the father.

• 37:20Speaker 01

  Great.

• 37:20David Puder?

  Really good family support. Amazing family support. So this was all handled outpatient. I don't know if I would do that again, but that's, that's what this was done. After reading about the medical issues, I, I think I'd be hesitant to, to do that. But this person did have a history of bipolar. And after three or four weeks, talking lucidly, not psychotically, not having psychotic thoughts. So, yeah. If, if-

• 37:46Speaker 01

  They get, they can't get better.

• 37:48David Puder?

  If, if, in this one study, when they looked at lithium, antipsychotic, and Ativan, they found that the combination of those three, about 90, 99% or so went into remission.

• 38:03Speaker 01

  Yes.

• 38:04David Puder?

  And then they, they weren't doing the Ativan forever. You know, they were doing it for like five to 10 days, you know, like whatever's needed.

• 38:11Speaker 01

  Gets you to sleep. Yeah.

• 38:12David Puder?

  Gets you to sleep.

• 38:13Speaker 01

  Right. Right.

• 38:13David Puder?

  Yep. So any nuance?

• 38:15Speaker 01

  That's exactly right.

• 38:16David Puder?

  I, I want to learn from you though, like push against like how I'm doing things. Like would, how, how do you normally start to try to think about treating a patient who comes to you?

• 38:26Speaker 01

  I think, again, I am hesitant to treat this in the outpatient setting on my own unless it's a patient who I know really well, I know exactly what has worked before in the past, and I'm following her really closely. If this was a newer patient to me, or someone was calling me for the first time, I would send them to the ER, just because the safety risk. And again, just to reiterate, you are more likely to have postpartum psychosis and not kill someone than you are to have postpartum psychosis and kill someone. However, the safety risk is so high that we just take it very seriously, right? And to do the medical workup and to have monitoring and to make sure you're getting better quickly, so you

• 39:10Speaker 01

  can titrate those meds up very fast. I think that's another good reason to get evaluated in the ER and probably admitted, is so we can get those meds on board and titrate them up fast. And because they are so sedating, a lot of the times, you want to make sure you're being monitored. Also, ECT is a great treatment option for postpartum psychosis, and it works quickly. So that's another thing that I think, just to remind people, is always on the table, and is not contraindicated in breastfeeding. And so, again, that's another tool to kind of keep in mind. But usually, I think, I think the biggest thing that I hope people listening will take away from this is, you know, if you start to get that like prickly feeling on the back of your neck, those red flags, those pink flags, as

• 39:54Speaker 01

  we call them, those softer early signs are coming, like that confusion. Like, I had one patient who once, that was the first sign, was just this, this feeling of like, I feel like I'm losing track of time. And, and this was a patient with a known history in the past. And so I said, no, let's go up on your Seriquil, and let's talk to your OB about delivering the baby because you're full term. And like, that was enough for me to say, okay, that's a situation where we don't want to wait. But for anyone who's evaluating someone in your office, and they have no prior mental health history, they still could have postpartum psychosis. However, you want to make sure it's not one of the other more common postpartum mental health conditions. So I think we're getting more

• 40:36Speaker 01

  used to screening with things like the Edinburgh, which can look for symptoms of depression and anxiety. But then, if they score positive, please do more assessment to rule out any personal, prior or family history of bipolar disorder, whether mania, hypomania, or depression, because that's going to be the real, the real clincher as to do you start an antidepressant, or do you move to something like lithium? And if this were my patient, they were depressed, they didn't have active psychotic signs yet, but they had a pretty strong family history of bipolar disorder, I would be more conservative and hedge my bets and talk to them about starting lithium. And again, that's a harder conversation to have, to start someone on lithium for the first time. But I think when you really lay out the facts,

• 41:20David Puder?

  Yep.

• 41:21Speaker 01

  You know, you can...

• 41:22David Puder?

  Yeah, it's, you know, lithium is a great med. I've done multiple episodes on it. And it's, I think it's way underutilized in psychiatry.

• 41:30Speaker 01

  I agree. I agree. And it's also like, natural.

• 41:35David Puder?

  The, um, I, this particular patient had a good pediatrician, and they, they checked the infant's blood level, and it was undetectable on lithium. Sometimes it can be higher, especially like, early on, if, if the, I guess, you know, later on, if lithium is added, I think it's safer for the infant. But, you know, work with the pediatrician, you know, read the data, consider breastfeeding or not breastfeeding, what the risks are.

• 42:05Speaker 01

  And it's not a reason to not breastfeed, right? Like, I think that's an important thing to, to come across, is that just because you're taking lithium, that doesn't mean there's absolutely no way you can breastfeed, much like any other medication. And we just watch the baby for signs of toxicity, which would be similar to what we'd see in an adult. It's just, again, like you're saying, early on, when that baby's metabolism is so new and things like that, you just keep a closer eye on the baby. And there's ways to try to time it around feeding and stuff like that, too.

• 42:34David Puder?

  The other, the other thing that I think is a key statistic is suicide risk is higher.

• 42:40Speaker 01

  It's heavy.

• 42:43David Puder?

  It's heavy, yeah. So I'm, I'm looking at this suicide statistic, and in these long-term follow-ups of postpartum psychosis, like, in patients who are actively ill, the rate of suicide in different studies was four to 11%, right? So there is, this is a high-risk period of time. And even some of these suicides were after discharge from psychiatric hospitals, which I think it just goes to show that we really need to have a good follow-up, explain why these, you know, if they're on medications, make sure they're not having side effects of medication, make sure that they're actually helping. And then, in this one consensus paper, they talked about, yeah, the benzodiazepines antipsychotics lithium being kind of the

• 43:23David Puder?

  mainstay of this bipolar type of issue. So...

• 43:30Speaker 01

  And I think at this point, we, we would all agree to treat it as bipolar, like, until proven otherwise. If, you know, so if your patient doesn't have a history of bipolar, that's still how we treat it, is you get better outcomes if you include a mood stabilizer like lithium with the antipsychotic, rather than just the antipsychotic.

• 43:49David Puder?

  Yeah, I'll show you, there's one, this is one article that this consensus guy prior wrote, and he was looking at a group that was either maintained on antipsychotic with the lithium, or

• 44:06Speaker 01

  Or lithium.

• 44:07David Puder?

  Or with the, maintained on the antipsychotic. And the people that were maintained on the lithium had a lot less relapse.

• 44:15Speaker 01

  Mm-hmm.

• 44:17David Puder?

  So that makes me, the, I, I agree with you, like, treat, treat as bipolar until proven otherwise. And then, um, yeah, this is a heavy topic. I hope that if you're listening to this, um, you know, you can tell Dr. Ferry's heart in treating these patients, definitely see it, your passion, passion at educating other psychiatrists. Definitely want to have you back, back on, maybe as I like, we could, we could kind of pull some more studies together and kind of dig into it.

• 44:48Speaker 01

  Yeah, that would be great. That would be great.

• 44:50David Puder?

  There's so much, so much to learn here and grow. And I think the more that we can feel comfortable, like, knowing this stuff, kind of being ready for it, the more, when it happens, we'll, um, you know, be able to help people.

• 45:03Speaker 01

  We'll feel so helpless.

• 45:04David Puder?

  We'll feel helpless.

• 45:05Speaker 01

  Right, exactly. Exactly. And these cases do get better. I think that's one of the things that's so remarkable about postpartum psychosis, and why a lot of us who are in reproductive psychiatry, it's those kinds of cases that first get you going, huh, look at that. Because it's, it can be so dramatic, just the onset of the symptoms, the way they can fluctuate. It can seem like patients are kind of coming in and out of the psychotic symptoms, but then that they do get better, and they can come back to lucidity, and you can keep the family whole. I mean, there's, there's like, nothing more powerful than that.

• 45:39David Puder?

  Beautiful, yeah. And, um, and I would say also, we really haven't talked about this, but I, I usually speak strongly to the husbands, or the partner, you know, and I'm like, hey, this is not a time to work, this is not a time to, this is a time to be at home to take FMLA. I told a dad just this last week, it's time to take FMLA. And, um, you know, be up in the middle of the night, and take care of the kid when the kid is waking up, so that your wife can sleep eight hours. You know, if, if we're going to put them on medications to make them sleep, like, they should not be expected to wake up.

• 46:17Speaker 01

  They have to sleep.

• 46:18David Puder?

  They have to sleep. This is a time to call mom and dad. This is a time to, you know, pull in all the resources possible.

• 46:24Speaker 01

  All the troops.

• 46:25David Puder?

  All the troops.

• 46:26Speaker 01

  As many troops as possible, right?

• 46:27David Puder?

  All the troops. Yep.

• 46:29Speaker 01

  And sometimes you do have to think creatively, like you're saying. And I think, including the partner and the family and the support system, both when you're getting that collateral information, when you're trying to make a diagnosis, but also when you're educating everyone about what's going on. I'd say especially in the acute phase, when like, you're saying, the patient might not remember what you're telling her or talking about, it's critically important.

• 46:51David Puder?

  Yep. And, and the other thing I would say to providers, this is kind of a practical point. So I used to run an IOP for people with medical and psychiatric issues. So we'd work with the OB department, they would send all the postpartum cases to my IOP, and I would keep putting them on disability and FMLA. I would extend it for the, for the full year. You know, like, I would be like, you are not going back to work, like, we are putting you, you know, so sometimes we'd keep them in the program so that we could just let them have all of that baby bonding time and heal, right? Heal process, because it's, they could have like, like, like what you said, they could have a sense of loss of like, they had this idyllic version of what would happen, and then this nightmare happens,

• 47:33David Puder?

  and then they need to process what that felt like, because it felt awful. And

• 47:38Speaker 01

  Right.

• 47:39David Puder?

  And it's not...

• 47:40Speaker 01

  Let alone going back to work and all the stress of that.

• 47:42David Puder?

  Yeah. So this is, this is one of those conditions, I do some, I don't know what kind of justice you call this, but put them on long-term, put them on like, disability for 12 months, and, you know, let them, let them improve.

• 47:57Speaker 01

  Hey, you gotta, you gotta work in the system you're in.

• 48:01David Puder?

  Yep. So yeah, okay. Any closing thoughts, or any things that you feel like we haven't quite discussed yet?

• 48:07Speaker 01

  I think that, you know, like we're saying, this, this is a severe psychiatric emergency that does warrant emergent evaluation by a specialist, and yet, it is treatable. And any one of us, any provider can learn how to pick up these signs. And so don't feel like you have to avoid treating this patient population. We need good, quality providers now more than ever. There's so many trainings out there, and there's a lot of help available to providers, too, which I know we'll include in the show notes, but things like Postpartum Support International has a free psychiatric consultation lines, 30 states have it, have access mental health hotlines where you can call to get real-time consultation. There's

• 48:51Speaker 01

  a lot of organizations doing a lot of advocacy work. So there's a lot of, of positive movement going on. So even though we talked about a lot of heaviness, and it is very serious and very scary, I hope that people also leave feeling like there is hope, and you can intervene, and people can get better.

• 49:08David Puder?

  Yeah, that's great. And I'm going to put on the website, usually I'll do like a transcription of the podcast, we'll put some of these articles that we talked about, we'll talk, I'll put all those resources you just mentioned, maybe you can help me put those down. Also, the resource on your own teaching and training, which

• 49:25Speaker 01

  Sure.

• 49:26David Puder?

  I think would be very helpful for providers to do. Check it out. I'll put a link to you, to it in the, on the website, psychiatrypodcast.com. And yeah, I'm hoping to have you back. This was great. This is really helpful.

• 49:39Speaker 01

  I'd love to, yeah, anytime. Great. Thank you. Thank you for getting it together so quickly.

• 49:44David Puder?

  Yeah, very important. Okay, so we'll leave it there for today, and then we'll just chat after. Okay, okay, bye.

• 49:49Speaker 01

  Okay, sounds good.