Postpartum Psychosis: Diagnosis, Treatment, Lithium, and Relapse Prevention with Dr. Veerle Bergink

In this essential episode of the Psychiatry & Psychotherapy Podcast, Dr. David Puder sits down with internationally renowned expert Dr. Veerle Bergink, Director of Mount Sinai's Women's Mental Health Center, for an in-depth discussion of postpartum psychosis. Covering early warning signs and symptoms, differential diagnosis including anti-NMDA receptor encephalitis and thyroid issues, a highly effective acute treatment algorithm using benzodiazepines, antipsychotics, and lithium, the remarkable 98% remission rates with proper care, lithium's superior role in preventing relapse during the first postpartum year, the simple but powerful prophylaxis strategy of "baby out, lithium in" for high-risk women with bipolar disorder or prior episodes, the urgent need for mother-baby psychiatric units in the U. S., and the ongoing push to formally classify postpartum psychosis in the DSM. Link to blog https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-280-postpartum-psychosis-diagnosis-treatment-lithium-and-relapse-prevention-with-dr-veerle-bergink Link to YouTube video https://youtu.be/fW9xmccggV4 By listening to this episode, you can earn 0.75 Psychiatry CME Credits. https://gecko-ladybug-pa2l.squarespace.com/cme-program

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

• 0:13David Puder?

  All right, welcome back to the podcast. I am joined today with Dr. Veerle Bergink. She is the Director of Mount Sinai's Women's Mental Health Center and internationally renowned as an expert in psychiatric disorders in women. Her research started in 2008, where she established a prospective postpartum psychosis study, currently the largest first onset postpartum psychosis and mania cohort in the world. She has a highly effective clinical treatment algorithm, we're going to discuss today, for acute phase and also prevention of postpartum relapse. And she has written tons of articles.

• 0:57David Puder?

  She's someone who I've been excited to have on here, and so welcome to the podcast.

• 1:02Speaker 01

  Yeah, very happy to be here.

• 1:05David Puder?

  Yeah, so I was thinking I would start with kind of a case, and then we would kind of add to the case or change the case slightly, and then see how that might change, how you might handle it, okay?

• 1:18Speaker 01

  Yeah, sure.

• 1:19David Puder?

  Okay. So, this is someone who has had no previous pregnancies, no mania, no depression, no psychosis. Day zero to two, she feels tired, happy, sleeping two to three hour stretches because of cluster feeds. Partner is not worried. On day three, she cannot fall back asleep after 3:00 AM. Mind will not turn off. Mild irritability when her mother suggests that she stops nursing so she can sleep. Day four, she's checking obsessively the baby's breathing. She tells her husband, something is wrong with her. I can feel it.

• 2:05David Puder?

  She's still organized, breastfeeding every two to three hours. On day five, there's some mood swings within hours. Tearful, then elated. She says she feels like she's been chosen, sleeps 90 minutes in 24 hours.

• 2:25David Puder?

  Day six, mood incongruent, delusions appear. She says, my husband wants to take the baby. He's not who he says he is. Brief visual misconceptions of a shadow over the crib.

• 2:41David Puder?

  And then, day seven, she's brought in after she kicks her mother in the abdomen, where the mother tries to take the baby so that she can sleep. On interview, she's pressured, grandiose.

• 2:56David Puder?

  She's admiring of her ability to potentially nurse her baby for 24 hours straight. She's slightly disorganized, lacks insight, misrecognizes a nurse as a childhood friend, oriented to name but not date. Okay, so walk me through the case, what your thoughts are, how you're approaching this.

• 3:17Speaker 01

  Yes, when I would see her, I would keep it very short, because women are usually, you know, very irritable, and she sounds manic, and it's a very clear story that she has manic and psychotic features right after delivery. So, the most important thing, I would like to know if she has ever had hypomania or mania before, and whether she has a family history of bipolar disorder. And after that, I would spend the time to establish a relationship with her, to motivate her to be admitted as an inpatient, so that we can do some diagnostics.

• 3:59Speaker 01

  And I would reassure her and her husband that we're thinking about postpartum psychosis, but that this is a very treatable condition, and that I expect her admission not to be too long, but that in my view, it is very important that she will get admitted, so that we can check her blood, rule out some somatic causes for psychosis and mania, and that we can treat her so that she can be reunited with her baby as soon as possible. Yeah, so that would be my first step.

• 4:41Speaker 01

  So only very shortly speak to her, and mostly spend time with her and her husband to explain that she has postpartum psychosis and what we should rule out. And then, one of the first things we should rule out is whether she has an infection, and check her thyroid, whether she has a postpartum thyroiditis, which can be a major trigger as well, and then, you know, do some broad standard metabolic lab work. And that is diagnostically the first step. And then I would explain to them that, you know, sleep loss has also contributed, so that it's very important that we treat her for sleep.

• 5:23Speaker 01

  And in Europe, we start with a few days only sleep medication, but there we have mother baby unit, so we have a bit more time to treat moms, because occasionally someone gets better with only two nights of good sleep. But given that, you know, she had these symptoms now for many days in a row, I probably would start, if she could not be admitted with her baby, sleep medication together with antipsychotic medication, to, you know, to get her out of her mania and psychosis as soon as possible.

• 5:57David Puder?

  Okay, perfect. Okay, so you start her with some, let's say, some Haldol, and then...

• 6:04Speaker 01

  Yeah, or first generation or second generation. I would either start her on Haldol. We have seen many women getting better on Haldol, but yeah, also, olentipin is a good treatment option before the night. There is not much research to guide us here, what works. We basically know that all antipsychotics work if we dose them high enough in postpartum psychosis, as far as we know. But again, there is hardly any research supporting it, but that's my clinical experience.

• 6:37David Puder?

  Okay, so let's say you started the Haldol, or antipsychotic, it doesn't matter. And soon after, she develops rigidity, tremor, bradycinesia. What are you thinking at this point?

• 6:51Speaker 01

  Well, yeah, that obviously is a reason to not treat with first generative antipsychotics, but that gives me also another reason to also look for NMDA antibodies, because we know that these neurological soft signs, we see those more often with women with postpartum psychosis, who have an underlying autoimmune encephalitis. And that is not that common, that's only a few percent of the cases with postpartum psychosis, but it needs to be ruled out. You can measure it in blood, but ideally, you do a spinal tap, if you can motivate the patient to actually do that. So in this scenario, then I would switch her to olentipin.

• 7:33David Puder?

  Okay. And so, so I was using one of your papers where you studied anti-NMDA receptor encephalitis, and kind of the tell is that rigidity, tremor, bradycinesia after starting the antipsychotic, okay? So that's what I was thinking about.

• 7:51Speaker 01

  Yeah, absolutely. And those patients who had autoimmune encephalitis all had that. But the other way around, I know that, you know, 30% of our patients of first generation antipsychotics actually have some neurological subsigns, so it's not, you know, it's not always, but it should be tested, and I think it should be tested in all women with postpartum psychosis, because we know of NMDA encephalitis, but I think it could very well be, given that postpartum period is such a strong immune trigger, that there are way more women with an autoimmune encephalitis with unidentified antigen, if that makes sense. And, you know, one of our research proposals is also to test this better, because that

• 8:36Speaker 01

  actually has treatment consequences, right? That's just a different disease. If someone has a postpartum autoimmune encephalitis, it's different than someone having a postpartum psychosis, for which the cause is unknown.

• 8:50David Puder?

  Okay, so during pregnancy, there's a huge immune system dampening, and then

• 8:56Speaker 01

  Yes.

• 8:57David Puder?

  after delivery, it just comes back, the immune system starts revving up again? Is that why you think there's like an over-revving of the immune system, and there's a lot of these kind of autoimmune issues that come?

• 9:12Speaker 01

  Yeah, absolutely. I think that's very clear, right? But I mean, we know this from all immunities, that almost all the women do feel better after pregnancy, have a high risk of relapse. And that is because, yeah, as you say, your pregnancy, the immune system is somehow suppressed, otherwise a mother would reject her own child. It's of course not completely down, because otherwise pregnant women would die of infection, and that is not happening at all. So it's just that the immune system is differently organized, with more prominent role for the innate, a very basic line for defense, and not so much a specific adaptive immune response.

• 9:53Speaker 01

  So, the professor in immunology I work with say, you know, pregnant women have the basic immune system of a snail or so, very simple, basic immune defense. So what happens after delivery is that the innate immunity is still high, and the adaptive T-cell mediated immunity comes back to where it was before. So we see it's an immune stimulation, and that is why people with rheumatoid arthritis feel worse after delivery, with multiple sclerosis, with autoimmune thyroiditis, or they have their first onset after delivery, whereas pregnancy is protective. Well, in our first, very recent research, also in bipolar women showed, we looked at

• 10:37Speaker 01

  register, that pregnancy really seemed to be protective for first onset mania. There are quite a few papers out now, and ours was this year. And also for severe depression, we see that that is lower than at other times. So, in particular, within psychiatry, bipolar disorder seems to have this same pattern as autoimmuneities of pregnancy being protective, and postpartum being a high risk period. And why that is specifically for bipolar disorder, and not for other diseases in psychiatry, such as, you know, schizophrenia, OCD, or whatever disease, ADHD, I don't know.

• 11:18Speaker 01

  I think it gives us an important clue about the underlying nature of the disorder.

• 11:25David Puder?

  Very interesting. Okay, so let's say there was some sort of autoimmune thyroid disease. Are you more hesitant to use lithium?

• 11:37Speaker 01

  No, I would still treat her the same because we do not know how to treat otherwise. Yeah, of course lithium works on the thyroid, but via different mechanism. I think the most important thing is also monitoring the thyroid and referring to internal medicine doctors and especially, you know, after autoimmune thyroiditis is typically characterized by first hypertiridism and then hypothyroidism, right? And, and all of these contribute to the psychiatric symptomatology and, and we need to monitor it. And of course, if it really leads to clinical hypothyroidism, then the patient should get treated with thyroid

• 12:22Speaker 01

  supletion. And that is very relevant. Also, for many women with postpartum depression, I've seen so many women in which physicians do not think about the thyroid and then it has such a major impact. And, and sometimes it helps also in the treatment of the women still have the depression in addition to the postpartum thyroiditis, but it kind of helps them to understand that this contributes. And I think that helps as well, because then I explain like, yeah, but this, this is, I mean, often we do not know what causes it, right? But in this scenario, we know something that really likely contributed to, to not feeling mentally well. And that helps if I explain to women that, that most of

• 13:04Speaker 01

  these cases are transient and the thyroid get back to normal and, and they will feel better. And that, that we can also be very optimistic about their treatment of their postpartum mood disorder. So I think that's something most people do not know that actually postpartum depression is more easily treatable than depression at other times. So don't tell anyone, but our, our field is not that difficult. A lot of women actually do get better.

• 13:34David Puder?

  Yeah, that was, that was some really interesting things from reading your papers is there's a, this if treated, it's very treatable. It's very

• 13:44Speaker 01

  Yeah. And both postpartum psychosis and postpartum depression. So postpartum psychosis is like amazing, like 98% gets fully better as in really our criteria for getting better were strict. We published a paper this year, a, a letter in American Journal and, you know, really no medic symptoms, no psychotic symptoms, but also I don't know if you know the EPDS, that's a very simple postpartum depression rating scale, 10 items. And they had to be really low on that scale as well. You and I on a bad day score higher than these women. So they were not only not manic and psychotic, but also not depressed after

• 14:25Speaker 01

  the acute phase. And I think that is a very optimistic message to give, especially of course in this time where there's so much attention for the, you know, the potential tragic consequences of postpartum psychosis. And it's really discussed as, yeah, a very difficult condition and, you know, very high risk of, of suicide and in fantasize. So there are so many myths out there. And I'm, I'm happy, you know, to, to be on this podcast because I think it's important to know that, yeah, in, in many cases, women get diagnosed

• 15:10Speaker 01

  in time and then it's a very treatable condition with a better prognosis than women would have if they had that at other times in their life, if that makes sense. So.

• 15:21David Puder?

  Yes. So from your research, what have you found in terms of like women who do not have a history of bipolar, who have their first episode postpartum, so their first episode of postpartum psychosis occurs, what percentage of those women will not have recurrence?

• 15:41Speaker 01

  Yeah, in, in our own cohort, more than half.

• 15:45David Puder?

  Okay.

• 15:45Speaker 01

  So, and, and they, those women are treated in academic center, excellent care, they're treated with lithium, closely monitored. So, but yeah, if we look at all studies done ever, then ours was quite recent, but all other studies are like, yeah, I know, ever is 30 years ago, like really old psychiatric literature. Then we see everywhere the same pattern that roughly half of women get better and remain well until they get pregnant again, have another delivery, and then they're at sky high risk again. So those women really

• 16:23Speaker 01

  have a postpartum only illness. Whereas for other women, they have these episodes and then they're treated with antipsychotics and lithium, and they try to taper lithium, but you know, that doesn't work that well. They get depressed and then in retro, and they have more mood episodes in their lives. And then in retrospect, this, this very severe postpartum episode was the first onset of a lifelong bipolar disorder. Yeah. And of course, we would like to answer that question for those women being acutely ill, not only like what causes it and how do we get her better as soon as we can, but also how can

• 17:05Speaker 01

  we prevent that disease course, right? So, or how at least can we know which women are at high risk for a lifelong bipolar vulnerability or mood disorder and which women, yeah, have this postpartum only disorder, which makes a bit difference for them as well, right? So, and unfortunately, the only way we can tell is by, you know, try after one year to start tapering the medication. And in that sense, I, at least in my experience, I don't know what your experience is, but it's not so different, different from, you

• 17:46Speaker 01

  know, mania or affective psychosis at other times. If, if young people have this, they're treated, they're very sick, they get better. At some point after they get better, they start asking themselves like, do I need this medication long term, right?

• 18:00David Puder?

  Absolutely.

• 18:01Speaker 01

  And most people then at some point try to taper. And that's only the very hard way to figure out if you actually need it or not, because that means that you get sick, that means that you needed it. And at this point, we cannot tell like which patients, of course, we know some risk factors, but we, we, we really cannot tell which patients can safely taper or not. And especially for young, you know, people with bipolar disorder, that's, that's a very difficult one. And, and same for the, those, the women I treat, right? I mean, that, these, these patients are a bit older, but not that old. I think women get, you know, their first child often in twenties, beginning thirties, and then

• 18:46Speaker 01

  it's quite something to think about, having to use medication long term.

• 18:53David Puder?

  Okay. So it sounds like you have, we've kind of talked about two categories, people with maybe a history of bipolar and first onset postpartum psychosis. And I think you also differentiated in your research, like postpartum psychosis that comes out of more of a depressed picture. And it's usually a little bit slower to start. Can you talk about that a little bit?

• 19:18Speaker 01

  Yeah. So we try to figure out if women have depression with psychotic features, or if they only have psychotic symptoms, or if they're manic. Does that matter in terms of their treatment response? Does that matter in terms of their prognosis? Well, the short answer is no, as in all women get better, but, but women with depression with psychotic features, they have a longer disease episode than mania. And that's what we know from outside the perinatal period as well, right? That depression with psychotic features is usually not so easy to treat. That those episodes are, are a bit longer. But yeah, we know that also women with depression with psychotic features, yeah, in the long

• 20:02Speaker 01

  term, it doesn't, at least in our research, doesn't make a difference in terms of their prognosis, whether they, you know, they had a mania or a mixed episode, or a depressed episode with psychotic features, or a psychotic episode without, without much mood symptoms. So in a way, the phenomenology.

• 20:24Speaker 01

  Doesn't seem to matter that much. The it's it's more that, yeah, in some women childbirth triggers severe mental health disorder with a with a variety of symptoms, basically.

• 20:37David Puder?

  Hmm.

• 20:38Speaker 01

  If that makes sense.

• 20:39David Puder?

  Does studying this make you hesitant to put on an SSRI on a woman who's just just depression? You know, it's just more of the depressed picture.

• 20:51Speaker 01

  If if it's just depression, I I'm I'm not hesitant to to treat with an SSRI. It it really depends on the course. We know that many women with postpartum depression, well, honestly, already were depressed, either during pregnancy or even before. Uh, but there are also some women who develop new onset depression after delivery. And then it really depends on the pattern. If if a woman has like a, you know, very sudden acute onset.

• 21:23David Puder?

  Hmm.

• 21:23Speaker 01

  Very severe depression in in the early weeks after delivery without clear trigger as her, you know, her baby being severely sick on the NICU or or other disasters. Yeah, that I'm I'm really worried about. Um, yeah, about a bipolar depression, honestly. And and that has been described as well quite extensively that, you know, depressions occurring in the postpartum period are more often bipolar depressions than depressions at other times. That is an an old ratio of two. So let's say, yeah, if you had a depression, then you had a certain risk of that depression being the first onset of a bipolar disorder.

• 22:07Speaker 01

  But, yeah, well, that won't happen to you. But if you had that depression postpartum, then then the the risk of that depression being bipolar depression is two times as high. So I think in general, yeah, we should always be a bit cautious with SSRI in the postpartum period. And of course, we saw in the Lindsay Clancy case how how horrible some people react to to SSRIs, right? That that's, um, I've seen that more often. I I have a case series of patients who really had like, you know, psychosis or mania triggered by SSRIs in the postpartum period. And Verinder Sharma from Canada has published on that as well. And so so so we know this.

• 22:52Speaker 01

  So we should also, you know, we should be a bit cautious. On the other hand, we should not let severe postpartum depression be untreated, of course. But, yeah, sometimes I I see both a lot of undertreatment of postpartum depression and over treatment. And what I mean with over treatment, if that is a woman, you know, this first week postpartum, women have mood swings, they have low moods, sometimes they have sleep loss. They they are told like, oh, if you see your baby, you're gonna feel amazing. And they don't experience that at all. They're low. And I have seen many women in which their healthcare provider immediately

• 23:33Speaker 01

  gave them an SSRI, as in the first week after childbirth or the second week. And I'm always very, you know, not that fast, not so much in a hurry, because you really wanna see how that develops over time. This is such a period of rapid changes. You see what I mean? That you don't not want to there. And there is no need to, you know, acutely treat depressive symptoms with SSRI. I think we we should better carefully see, you know, see someone another time, see how it develops over time, really see if it's a depression before we start.

• 24:14David Puder?

  Okay. And in your algorithm, you know, you were doing the benzo, antipsychotic lithium, holding the lithium for nine months, right? But like, my question is, why not start the lithium right away? Or do how do you, like, in this patient that I told initially, like, why not immediately lithium, immediately?

• 24:37Speaker 01

  Yeah, after we published the papers, we we really tried to change that clinical practice and start it earlier. So we're trying to do this now and have a polish on it yet. But, um, especially in the US, lithium has not a good name. I think that's that's not correct, you know, but people are really hesitant to use lithium. They they have all kinds of associations with lithium. So it's not used enough. So it all also takes time because lithium is something for the longer term, right? You're not gonna use it very short. We know that antipsychotics have a more rapid antemonic effect, honestly. So lithium is really, you know, for the long term, for this first year of postpartum.

• 25:21Speaker 01

  So you want someone to be well informed and also motivated to actually take the lithium and to to also understand why they need it. Yeah, because it's important in the treatment of postpartum psychosis, because the women without lithium, we saw unfortunately that half of them relapsed within a year after delivery.

• 25:44David Puder?

  Hmm.

• 25:45Speaker 01

  Yeah, and that is a problem if you if you treat with electroconvulsion therapy, which some, you know, there's some people saying like, okay, why why shouldn't we treat immediately with like with ECT? You know, it's so severe, isn't that the fastest way? Well, I'm not sure if that is faster than medication. And the problem is, ECT also gets women completely better, but then you still face the discussion like, yeah, and now what? You know, then I still would advise to start lithium for the first year postpartum after the ECP course. You you see what I mean?

• 26:24Speaker 01

  So that's why i- if if it was me or if it was my sister or my child, I I would prefer lithium over ECT treatment.

• 26:36David Puder?

  Yeah, yeah. Okay, I I wanna share this from your study, which you were the first author of, amazing study, showing days of remission until relapse. And the lithium, when I saw this, I was like, oh, my goodness, this is this is incredible. And so what, for those who are listening to audio, maybe you can describe this figure once again and what it says.

• 26:59Speaker 01

  Yeah, so the orange line are women who use lithium and and antipsychotics in the acute phase. And the green line is women who only used antipsychotics. And it's good to understand that this was not a randomized controlled trial. So it's not that we randomized women, no. We offered antipsychotics and lithium during the acute phase. Um, but some women recovered really fast, and those were women who only were on antipsychotics. And we did not get to the point that we discussed lithium with them. And of those women, we also thought, okay, they, you know, their their disease episode was very short, they they recovered fast on antipsychotic only.

• 27:43Speaker 01

  And we thought, well, perhaps we don't need to start lithium. But then we analyzed our data and then we saw that, you know, those women for who were initially better off because they had a short episode and recovered really fast, were actually more often have a relapse one year after delivery, which is, of course, not great because that means that after your depression with psychotic features, you have another depression or after your mania, you you have this typical pattern. Of course, women, we see this in bipolar disorder as well, women or people, patients getting out of their mania and I mean, stable for a while or sometimes even immediately going into a depression.

• 28:27Speaker 01

  And and we really see that lithium can prevent this pattern. So and and we know that, you know, lithium works well at other times as well. But I don't know why lithium works especially well postpartum. Because we know at other times that, you know, lithium is not for everyone, right? There are also many people being non responders to lithium, whereas in a postpartum period, we don't see that that much.

• 28:55David Puder?

  Yeah, it's.

• 28:58David Puder?

  It's incredible to think, I mean, for those of you who can't see the picture, I'll just say like, you can see that lithium, most of the people are not relapsing. Whereas the people who are not on the lithium, 50% relapse. That's a huge difference. And so, yeah, we need to bring, bring back lithium, make lithium cool again. Have some drug reps maybe in America, bringing lithium in a special colored, expensive lithium pills. I'm joking.

• 29:30Speaker 01

  Yeah, I think that's the problem. It's so cheap. There's really no money to make with lithium. So that's why people have not arguing hard for, for treatments lithium in general, right? Because other treatments were, were much more moneymakers. So, but I'm, I'm not, I'm not sure if the ultimate solution is making lithium more expensive, but.

• 29:53David Puder?

  No, I'm joking, I'm joking.

• 29:54Speaker 01

  No, no, I know.

• 29:56David Puder?

  Yeah. So I just, I just had a bipolar patient just yesterday, who I had started on lithium two weeks before. And he had seen many different psychiatrists. And he had never been on lithium. He had been on five or six different antipsychotics. He had been on Depakote. He had been on Lamotrigine. He had never been on lithium and he was completely a different person two weeks later after starting lithium. So.

• 30:27Speaker 01

  Yeah, no, absolutely. And it's so weird because all our guidelines say that, you know, lithium is first choice. So all guidelines say it in different countries. Basically, no one is doing it, especially not in the US. And yeah, it's interesting because if you see,

• 30:45Speaker 01

  if you compare studies in the rest of the world, like Australia or Asia or Europe, bipolar studies to US patients, then in many studies, it has been shown that bipolar disorder in the, in the US, the mortality is higher. People have more episodes. They are more on polypharmacy, as you say, like using so many medications and yet being unstable. And yeah, I always thought, yeah, that's just because, you know, in, in the, in the US, like less than 20% gets lithium, whereas in the rest of the world, more than half of the bipolar patients get lithium. But there are also some alternative theories out there that back in the days,

• 31:30Speaker 01

  only the adventurous people emigrated to the US, right? So in order to emigrate, you had to be either miserable, depressed, or, you know, being in a hypomatic state to think it was a good idea to, to embark on that ship. So that somehow in the US, we end up, yeah, and I'm, I might be one of those persons because I also emigrated from, you know, Europe to the US for whatever reasons. I love it here, but you know, and so that was, that has been even proposed as a reason why we see worse outcomes here. Whereas I sometimes think, well, I think the more likely explanation

• 32:13Speaker 01

  is that we don't follow the guidelines that much and treat with lithium, right? And yeah, for my field, the, the problem that we don't have in patient mother baby units, that makes also a huge difference.

• 32:27David Puder?

  Do you, do you have a mother baby unit that you currently, at your current institution? Or no? Yeah.

• 32:34Speaker 01

  No, we're looking for funding to start one, like the first one in, in the US. We don't have, we have them in, in Western Europe, in Australia. In India is a very good one and, and not in the US. And there, there are quite a few good day treatment centers, but not enough. Not in every area in the country, only in, in California, in North Carolina, here in New York City. But those, in those units, babies cannot stay overnight. And that is a huge difference because, you know, women want to go home. Well, first of all, they don't want, no one wants to be admitted, of course, to a psych ward, right? Most, most people don't want that.

• 33:18Speaker 01

  But especially not if you're separated from your baby. So here we get the weird situation that, that both patients and clinicians are kind of getting in a rush to, to make women better by throwing, you know, so many medications at them as, you know, she needs to be reunited with her baby. And we see that for both severe postpartum depression and postpartum psychosis. And that's just not helpful. And, and also women go home and I can't blame them, nor their clinicians, before they are in full remission. So what happens, and we have those numbers out there as well, that women, you know, they're admitted to a psych ward.

• 34:02Speaker 01

  They go home, well, they're not fully recovered. And then they, they come home and they relapse again. And that leads ultimately, of course, to, to readmissions and worse outcomes. So I'm, I'm a huge advocate of mother baby units. But the, the problem is really the financing of the babies. Because here in the US, insurance companies say we are not gonna pay for healthy babies being in a hospital, basically.

• 34:32David Puder?

  Yeah, I think, I think if someone's listening to this and wants to fund your mother baby unit, I'll put them in contact with you.

• 34:41Speaker 01

  That would be amazing.

• 34:43David Puder?

  Because we need that. We really, really do need that.

• 34:46Speaker 01

  It's gonna have their name, everything. No, I think we, well, I, I think always the first step is more, most difficult because I think if we can show that we can open one such a unit and that it works and that mothers get better. And, and also honestly, that it, that it saves money in the end. Even if you don't care about mothers and you don't think babies are sweet, then still, and you only are interested in money, then still it's the cheaper option to, as society, to have a mother baby unit.

• 35:19David Puder?

  Well, yeah, because it's cheaper because of future, future outcomes, right? And that's the problem.

• 35:26Speaker 01

  Everything. Yeah, the mother doesn't get back to work. You know, if she has more kids, the other kids are miserable as well. Don't forget how miserable the husbands are, right? With having a baby and a severely mentally ill wife. And this group is not mentioned a lot, but I think there, there is a, yeah, a huge pain and, and struggle for partners, men or women. But in most scenarios, it's a man. Yeah, they, they struggle as well. And yeah, so it's, it's really a, a larger problem.

• 36:04David Puder?

  So, okay, we're pushing this idea of a mother baby unit. And somehow we have to figure out how to make it work in our insurance model, which is awful. And to do that, we first probably need someone to, to donate to you or to your team. Maybe three teams across the US ideally, and then do some good research that shows, you know, the cost effectiveness of it.

• 36:30David Puder?

  And then subsequently, you know, there's some justification, maybe. You know, that's how it works in the US. We, we did, we did a money justification study of my IOP program. We had medically complex adults. So people with lots of medical admissions for psychosomatic illness.

• 36:51David Puder?

  And we found that we were able to cut the amount of money that insurance would spend after the program, right? From, compared to the year before and, you know, that we, we use this to argue with insurance companies to let us actually treat the patients, right? Sometimes it worked.

• 37:08Speaker 01

  Oh, wow. So you're the person, we, as one of the first steps, we should hire you as well.

• 37:16David Puder?

  Well, I, I could, I could give you the name of the, the guy that did the majority of the study, at least.

• 37:23Speaker 01

  Yeah, yeah. So any, any help is welcome. Yeah.

• 37:28David Puder?

  But, um, yeah, so we, okay, so we're, we're talking about the mother baby unit, but I also wanted to make sure the DSM. I understand you are, you are like the ringleader of this new push for this to be introduced in the DSM. You're writing the chapter. You sent me an outline of it. Do you want to mention what you're doing with this?

• 37:51David Puder?

  And maybe I'll show, I'll kind of bring it up so you can kind of like.

• 37:55Speaker 01

  Yeah. Yeah. So postpartum psychosis is a disease that exists that has been almost unfortunately for thousands of years among all cultures. So it's simply said, very weird that it doesn't exist or is not acknowledged. It's for us doing research, a clear phenotype mainly that you can define it well, given the onset is so clear. So there is a large push from psychiatrists, but also patients to have this in our classification system. And yeah, we started working on this six years ago, sending in a proposal that it has to have all kinds of criteria. It was like

• 38:39Speaker 01

  thirty pages long. And since then, it just hasn't moved fast enough. It's now six years. There is fully agreement among all health professionals, what the criteria should be like. There's also flexibility, as in, okay, we're, you know, we're, we're not rigid. And all patients organizations bought in on this idea. So it, it just has to happen. We proposed postpartum psychosis to be placed in a bipolar chapter. The DSM steering committee said, we would like to see as an entire chapter dedicated to childbirth. So we made an outline, again,

• 39:23Speaker 01

  with a very large group of people who worked a lot clinically and also research leaders, to, to make a childbirth related chapter in DSM and, and give an outline what that should look like. And I think it's important that, you know, we, what we would like to see as a field is to make sure that people can classify the onset of any disorder, either being during pregnancy, or the first three months after delivery. And that is important because those periods are very different in terms of biology, but also treatment. I mean, that's a bit of

• 40:04Speaker 01

  a no brainer, right? Pregnancy is very different than postpartum, but also the prevalence and incidence is sometimes different. So, well, anyway. And in addition to that, I think, given that depression is so common, and we would like to see depression with onset during pregnancy, and depression with onset within three months after delivery, as a separate possibility to classify. And then the most important thing, and how this all started, and because that is really going to prevent the maternal death, and is having postpartum psychosis in there. Of course, if it's classified, it doesn't, it doesn't immediately solve all the problems,

• 40:48Speaker 01

  but it's kind of the other way around. If this is not solved, then we, we, as a first step, we need to classify to speak the same language, right? So to have the criteria. And, you know, members of the DSM steering committee even said, yeah, they can, they can write research proposals also without criteria. But that's a bit of a nonsense argument, because, you know, we're able to do studies, but also to replicate each other's work, we need to, to do the same thing and speak the same language. So I think it's a problem that there are so few groups working on this, right? That, that I'm telling you all those things. And that,

• 41:32Speaker 01

  that is then taken as the truth, whereas in, in, in real science and in medicine, ideally, studies get replicated and replicated, and clinicians add to evidence. And then you can build solid guidelines, which, which people can follow. So and, and all those steps needs to be taken. So we're, yeah, we're, I, I, I said before, we're in the Middle Ages. And I might regret some things I have said in public, but that's not one of them, because that's really how I feel about it.

• 42:06David Puder?

  Yep. Yep. And I think what we need is we need like an ICU level billing code that comes along with this. You know, there's like inpatient stays, but a mother baby unit should be like an ICU level billing stay, you know, it should be like a level above, right?

• 42:22Speaker 01

  Absolutely.

• 42:23David Puder?

  I think that's what I would go for.

• 42:25Speaker 01

  And, and that's totally justified, because it's, it's, it's complex care, right? I mean, we, we have a severely ill mother. Yeah.

• 42:34David Puder?

  And you have, and you have an infant, so you need, you need the, you know, a nurse for the, the mother, a nurse for the baby, and you need to watch them twenty four seven, so, so that the infant is not hurt.

• 42:46Speaker 01

  I know, but obviously, the infant is of course separated from the mom during the night, the door is closed. So I have to say, in Europe and UK, we also have medical students looking after the babies, but because they're, they're babies, they're healthy babies, they're, they're, but I'm not sure if that is even, you know, I don't know the US healthcare system well enough to see if that would fly. But that makes of course also a difference in terms of funding.

• 43:13David Puder?

  No, they, they would volunteer for it.

• 43:16Speaker 01

  Yeah, I would volunteer for it. Yeah. Yeah. Maybe, maybe not if you just have your young children, but this, as for me, it's a long time ago. Many people volunteer on looking after healthy babies.

• 43:28David Puder?

  Oh, they would, oh, you, it would be a great sublimation of the natural delay that medical school requires for a lot of people, right? Of having their own infants.

• 43:39Speaker 01

  Yeah, yeah. Well, I, I still think it's also helpful if, if doctors get, get, get children at some point in their career, but yeah.

• 43:49David Puder?

  Right, right. Yeah. I mean, absolutely. Yeah. And I'm not saying otherwise. Yeah.

• 43:54Speaker 01

  No, no, no. But, no, I know what you mean. But.

• 43:58David Puder?

  But yeah, okay. So DSM, I'm surprised OCD isn't in this list here. That's like, postpartum OCD, I don't know if that's like.

• 44:09Speaker 01

  Yeah, because it's extremely rare, honestly. So OCD doesn't have a peak postpartum. So everyone gets a bit more obsessed biologically after childbirth. So, you know, mothers check on their babies few times. That's all very physiological. I think nature built that in to, to have the most relaxed, you know, not so spot on persons have taken care of their child well enough. So everyone gets a bit more obsessive during this period. And we see that, you know, women were, yeah, very perfectionistic, always function well at other times, sometimes, yeah, struggle with that, because then they even feel even more the

• 44:51Speaker 01

  need to be in control or to check on things. So that what we see, that women with high perfectionism have sometimes a higher risk of postpartum depression. And our research showed that as well. And we see that women with OCD, already diagnosed with OCD, sometimes have, you know, more symptoms, but not always. But actually, new onset postpartum OCD is very rare. I've only see, seen a few women in my lifetime. So, but yeah, obsessive thoughts

• 45:30Speaker 01

  are very common. But like first onset OCD is quite rare. So, so that is why we did not specify so many other disorder. Also, for example, PTSD, right? Some women have trauma after childbirth. Their delivery was horrible, and they do not only have trauma, they also have nightmares and flashbacks. And, but that is also quite rare. We see that most women who struggle in this period are women who already had trauma. So who have PTSD in history. And in women, that is often related to sexual trauma, unfortunately, right? So,

• 46:15Speaker 01

  and we see, and that makes sense then, because the delivery is, you know, people re experience sometimes that loss of control that they had in their lives before, and that can revoke trauma. And, but that is in many cases, not new onset PTSD. So that is why other disorders such as OCD and PTSD, we saw that was better served by being able to specify the onset for any disorder. You see what I mean? So.

• 46:45David Puder?

  Sure.

• 46:46Speaker 01

  Mental health disorder during pregnancy. PTSD with onset during pregnancy or PTSD with onset postpartum, same for OCD. So we we propose that in our document as well. And yeah, the reason to take depression separately is that there has been so much. There's been done so much research on depression specifically. So there is a much larger evidence base. And another reason is that there is a big, a peak of in in incident depression cases. And especially there is a peak in severe depression. So that is really a thing if you look in epidemiological studies.

• 47:28David Puder?

  Very good. That's very helpful. Wow, this is you're such an expert on this and I can feel, I don't know if you're always this energetic, but I feel like you're hyperthymia, you're like Roosevelt or Kennedy level energy.

• 47:41Speaker 01

  Oh, wow, that is tricky to speak with you as a psychiatrist before I know it. I got a diagnosis on this phone.

• 47:48David Puder?

  No, no, no.

• 47:49Speaker 01

  As a compliment.

• 47:50David Puder?

  Hypertrophy is a compliment. Hypertrophy is a compliment.

• 47:53Speaker 01

  To answer your question, no, I'm I'm not always that energetic. But yeah, if I know that I'm doing a podcast, then then yes, I am. And with regards to this topic, I am very passionate. And that's sometimes also very unfortunate because I can't let it go. Right? So I sometimes feel like, OK, it would be good for me if I now focus on something else and not the classification of postpartum psychiatric disorder. And I've also been working on postpartum psychosis now for 22 years. And sometimes I feel like, OK, it would be good to to not do it. But yeah, I don't know how to do it, David.

• 48:35Speaker 01

  So yeah, any tips there are welcome.

• 48:39David Puder?

  I I would say it's a meaningful, I it hits all the meaning buttons, you know? So like, we talk about like logo therapy sometimes in the podcast, Viktor Frankl, like finding one's purpose, one's sense of meaning. And it's like, if if this is, if you get to the end of your life and you can look back and, you know, realize that there's a lot of, you know, there's a ripple effect of impact that you've had. I think I think, you know, solving one issue is enough for a lifetime, right? And this is an issue worth solving.

• 49:10Speaker 01

  That's it, because that's I I feel that it's really solvable, right? So that's why I'm might, yeah, not be thinking about other important themes such as, you know, saving climate change or all the wars in the world, because those are all very unfeasible for for a human being and that I feel this is so, well, I won't say easily to be done, but it's really doable. Things as changing classification are doable and things as building a mother baby unit, those are not impossible things. And the same for, yeah, I I feel if if women at high risk for postpartum psychosis hear

• 49:52Speaker 01

  that or their doctors that how they can prevent it, that that's also relative easy, right? It's not difficult to prevent postpartum psychosis. And because it's so relatively easy, I feel like, yeah, we we should do it and get the word out.

• 50:08David Puder?

  Well, it's it's maybe the the harder part is the education and the implementation. Right? So I hope I hope in some small part, you know, the four episodes that I put out on this can hopefully.

• 50:24Speaker 01

  Yeah, that that hugely helps. Thanks a lot for doing that.

• 50:27David Puder?

  Activate. And I I think this episode in particular is especially helpful. I'd love to have you back in the future. And yeah, but any final thoughts that you want to get at, anything that you haven't mentioned that you you want to make sure is out there?

• 50:41Speaker 01

  Yeah, I want to make sure that women at high risk with bipolar disorder or with a prior history of postpartum psychosis know that if they have another child, that they really can prevent it by taking medication right after delivery. And so that we really can prevent postpartum psychosis. I think that is the most, you can forget everything, but that's the most important message for.

• 51:06David Puder?

  So so do you start the lithium towards the end of the third trimester? Or do you start it on the day of delivery?

• 51:13Speaker 01

  Yeah, we say baby out, lithium in.

• 51:15David Puder?

  Oh, OK.

• 51:17Speaker 01

  That's easy. You know, talking about education, if you're a high risk, then that works well.

• 51:22David Puder?

  Baby out, lithium in. OK, that's that's a great place to leave you, boy.

• 51:27Speaker 01

  It's not for everyone, but yeah.

• 51:29David Puder?

  Yeah, yeah, awesome. OK, all right. Thank you so much for your time. We'll have you back in the future. I love talking to you.

• 51:35Speaker 01

  Yeah, thank you for having me. Bye.