Postpartum OCD vs Postpartum Psychosis: Intrusive Thoughts of Infant Harm, How to Screen, and Lithium Prevention with Dr. Katie Unverferth

In this episode of the Podcast, Dr. David Puder sits down with reproductive psychiatrist Dr. Katie Unverferth, Director of the UCLA Women's Life Center and Medical Director of the UCLA Maternal Mental Health Program, to clarify the critical differences between common postpartum intrusive thoughts of infant harm, postpartum OCD, and true postpartum psychosis. They discuss how nearly all new mothers experience ego-dystonic thoughts of accidental or intentional harm, how to screen without triggering concealment, when severity and compulsions cross into OCD, the role of high-dose SSRIs plus exposure and response prevention (ERP), red-flag signs of ego-syntonic content, agitation, insomnia, and delirium-like states that signal psychosis, and the strong evidence for lithium prophylaxis and acute treatment in high-risk patients. Link to blog https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-278-postpartum-ocd-vs-postpartum-psychosis-intrusive-thoughts-of-infant-harm-how-to-screen-and-lithium-prevention-with-dr-katie-unverferth Link to YouTube video https://youtu.be/Kb0hnerkiug

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 Katie Unverferth. She is the Director of the UCLA Women's Life Center and Medical Director of the UCLA Maternal Mental Health Program. She was Chief Resident in Reproductive Psychiatry, UCLA with Vivian Burt, who many of you might know as one of the leaders in the field, and then did a Mood Disorder Fellowship. She maintains a reproductive psychiatry practice in Santa Monica. Some of you may have heard the last episode we did on postpartum psychosis with Katrina Fury. We talked about postpartum psychosis onset, safety,

• 0:54David Puder?

  lithium, emergency frame. Today, we want to talk about, more about ruminative depression, postpartum OCD, and the line that separates ordinary ego dystonic intrusive thoughts from psychosis. So, welcome to the podcast.

• 1:11Speaker 01

  Thanks for having me. Glad to be here.

• 1:13David Puder?

  And I want to just maybe start about how common unwanted thoughts are in pregnancy for, for the majority of women. Maybe you can go through kind of what are some of the common unwanted thoughts? What is normal?

• 1:30Speaker 01

  Yeah, yeah. I mean, so, we know that intrusive thoughts are kind of these unwanted thoughts or images that pop into someone's mind sort of unbitten, right? They're influenced a lot by like emotional factors, environmental factors. They often attach to things that you value and care about, right? So I think in pregnancy, that can take the form of like intrusive thoughts of something happening to the pregnancy, right? Accidentally losing the pregnancy, right? We see a lot of fears of contamination in pregnancy, like, oh, what if I ate that and I shouldn't, I shouldn't have, right? Or with the, with the recent like foodborne illness outbreak, right? I'm sure that there have been intrusive thoughts

• 2:09Speaker 01

  around lettuce, right? Taco belliss. I think, you know, what we see in the postpartum is that the partum is a really high stress time. Intrusive thoughts get louder, they're more present during really high stress times. And because you have an infant, an infant is what a lot of times the intrusive thoughts attach to. So we see, some studies really show that 100% of new moms will have intrusive thoughts of accidental harm coming to their infant, right? Like, what if I, what if I accidentally dropped my baby? And then about 50% have intrusive thoughts of intentionally harming their infant, right? One common example of that would be like, what if I smother my baby with a pillow, right? It can be really

• 2:50Speaker 01

  violent. There are these kind of harming intrusive thoughts. What we know is that for the, for the majority of women, right, these thoughts are against their values, ego dystonic, and it makes them unlikely to harm their baby, right? A lot of times, they sort of avoid being around their baby if they think they're going to harm their baby, right? So I think that we have to separate this from psychotic thoughts, right? Where psychotic thoughts are more ego stentonic, where they sort of, it doesn't distress you in the same way that it might when someone has an intrusive thought, right? Or, and it's associated with other psychotic symptoms, like ideas of reference, delusions, hearing voices, seeing things that aren't there.

• 3:31David Puder?

  Yeah. So, okay, so when the mother is horrified by the thought, what does the horror actually tell you clinically?

• 3:40Speaker 01

  Yeah, the horror tells you that it's ego dystonic. It tells you that it is against their values. They are less likely to do it, right? It is much more likely to be part of either OCD, postpartum depression, postpartum anxiety, or sometimes intrusive thoughts just sort of occur on their own, right? What really separates intrusive thoughts from OCD, right, is the severity, the frequency, sort of the stickiness of the thought, the distress, and then obviously the compulsions, right? So someone who's engaging in compulsions, like checking regularly to make sure their baby is breathing because they're having intrusive thoughts that their baby stopped breathing, right? That would be someone who would be more likely to fit the criteria for OCD. What makes this complicated, though,

• 4:23Speaker 01

  is we know that intrusive thoughts can also occur in postpartum psychosis, right? Someone who has postpartum psychosis could still have ego dystonic intrusive thoughts. It's just that they also have symptoms consistent with postpartum psychosis. So you do always want to do like a full evaluation to make sure that they're not hearing voices, seeing things that aren't there. Check, you want to check how they're sleeping. You know, you want to check to make sure that there aren't associated symptoms with that.

• 4:46David Puder?

  Okay. So how do you ask about these thoughts? Like, let's say the, the mother is very nervous that, you know, a mental health professional physician is going to be calling CPS because they're having these horrible thoughts. So what would you tell them to sort of keep them from hiding these thoughts from you?

• 5:10Speaker 01

  Yeah. Well, first, I start with psychoeducation on intrusive thoughts. Like, I will explain what an intrusive thought is before I ask someone about it, right? So I won't just be like, are you having thoughts of harming your baby? I'll say, intrusive thoughts are sort of these unwanted images or thoughts that really, that pop into your mind randomly, right? We know everybody has these at different points in time, right? For example, if people stand on like a high building, sometimes they'll have a thought like, what if I jumped off? Doesn't mean they want to, they're distressed by it. What we see is that in the postpartum, sometimes those thoughts can attach to an infant, right? Like, some, so sometimes people will have thoughts of accidentally harming their infant or intentionally harming their infant. But we know that it is not aligned with their values. They're not likely to harm their baby. Are you having anything like that? Right? I won't always

• 5:54Speaker 01

  go into that level of detail, but what you want to do is you really want to normalize it. In my practice, I've seen people who come to me with really belief that they're losing their mind, right? This belief that they're becoming psychotic because they're so horrified by the intrusive thoughts. They think that it means something new or true about them. And that's sort of this line I'll use. It's like intrusive thoughts don't mean anything new or true about you. And so it's really important to not change your behaviors in response to these intrusive thoughts.

• 6:25David Puder?

  That's great. Yeah. So I'm imagining in the midst of all that's going on in the news, the Lindsay Klansky case, like, some women who are postpartum, who are having intrusive thoughts, maybe they don't want the intrusive thoughts. They're like, this isn't, this is a nightmare. You know, this is horrible. So I imagine that some people are having this sort of extra intrusive thought, like, could I do that?

• 6:54Speaker 01

  Right. I think the Klansky case has brought up a lot of intrusive thoughts for people. I would be shocked if it hadn't. I think, right, I think especially this like fear of loss of control, like, what if I, what if I lose control and actually harm my children, right? I think the truth is, is that is extremely rare, right? Harming your children in that way is not common. I think seeking help from a medical professional is very important to have like a full evaluation to see if the intrusive thoughts are kind of standalone, if they cluster with other things. Most intrusive thoughts resolve. We know that intrusive thoughts really peak within the first few weeks postpartum. It's the same time when we see that postpartum OCD incidence really peaks. They do tend to get better with time. What I've told people, and what I also think is true, is

• 7:39Speaker 01

  that, right, they're, you know, pregnancy is a time of huge brain changes. It's a time of huge hormonal changes. And what we know is that the brain is really primed to sort of protect your infant. And so in some ways, you can think of the intrusive thought as really trying to protect your infant, right? It's trying to protect you from, it's trying to protect the infant from harm, right? We know that for some people, these kind of, these go too far, goes awry, right? That it's, it's, the volume is too loud, it's scary, it can make it really hard to be present with your baby. But in some ways, your brain is just really trying to protect itself and protect the baby, right? And so we know that it will get better, right? For, if it is more OCD, then exposure and response prevention with CBT in combination with an SSRI has been very helpful. If it's part of a postpartum depression or postpartum anxiety, right? Getting evidence-based treatments

• 8:24Speaker 01

  for that, I think is really important, can be helpful as well. But, but it is very scary. But the truth is that the majority of people with postpartum, postpartum intrusive thoughts are almost a universal experience, right? Again, like nearly 100% of people will have intrusive thoughts of accidental harm, about 50% intentional harm, but it doesn't increase the likelihood in that context of harming your baby.

• 8:48David Puder?

  Okay. So where's the line between common postpartum intrusive thoughts and actual postpartum, like obsessive compulsive disorder?

• 8:58Speaker 01

  Yeah. The line is really in the severity and sort of the appraisal of the thought, right? Right? Like, when I was postpartum, I had postpartum intrusive thoughts, right? It would be like, what if I dropped my baby? I'd be like, oh, yuck. And then I would go about my day, right? The difference is that someone with OCD would be like, oh my God, why did I think that? Why did I have that thought of dropping my baby? Does that mean that I don't love my baby? Maybe I shouldn't even be a mom. This means I should never hold my baby. And so what we see is there's this sort of this belief system that connects the compulsion. And what that does is we know in the brain that when you engage in compulsive behaviors, you're sort of teaching the brain that that thought was really important. You need to value it. You need to pay attention to it. And you need more of those thoughts to sort of protect yourself. And so then what we see is the volume of the intrusive

• 9:43Speaker 01

  thoughts really ramps up. So in that context, we would have the obsession with the compulsion. So that would be what would then become OCD. OCD obviously has very specific diagnostic criteria. There are different, you know, rating scales that you can do to really assess the severity and functional impairment. But that would, that would make, that would be the difference, right? Whereas someone else would have the intrusive thought and then they would just kind of let it go. With OCD, it's much stickier. It's associated with much more distress. There are belief systems that are attached to it, and then there are compulsions that are engaged in.

• 10:13David Puder?

  Nice. And what rituals do you most often see? Like, we've talked about some of them, but just to reiterate, checking the baby's breathing, avoiding knives, refusing to be alone with the infant, reassurance seeking is a compulsion as well, Googling, ChatGPT.

• 10:30Speaker 01

  ChatGPT. Definitely ChatGPT. Yeah. Those are, I mean, I think those are the main ones, right? I think you've gotten them. We see a lot of avoidance, right? So avoiding being alone with the baby. I've seen sometimes when family systems sort of, kind of comply with the avoidance, where the whole family is taking care of the baby because they're worried about the mom being alone, even though this is more pure OC, this is pure OCD in this person. And so that's the opposite of what we recommend. So a lot of the work is like, in the Perinatal Intensive outpatient program, where I'm the medical director, right? We will, you know, sort of have the mom do more and more of the care for their infant, sort of in a supervised setting to sort of build up their confidence, right? A lot of reassurance seeking, especially with like partners, friends, family members, therapists,

• 11:15Speaker 01

  sometimes who aren't trained in behavioral therapy, can really sort of engage in this compulsive reassurance seeking as well.

• 11:23Speaker 01

  Also can be like difficulty delegating care of the infant. So there can be avoidance, but there can also be sort of a refusal to let anybody else help. The belief that you're sort of the only person who can take care of the infant, which can also be a compulsion, right? Because you're really, you know, to your own detriment, maybe not allowing other people to help.

• 11:42David Puder?

  Yeah. In your clinic, do you often see women coming in who seem to have postpartum OCD have a prior history of OCD or is it first onset usually?

• 11:51Speaker 01

  Yeah, that's a great question. Often it's, I can see both, right? I see a lot of people who do develop OCD in the postpartum. But what we see is if we look at their history, you know, maybe when they were kids, they were really concerned about getting sick or they always had to like check on their parents to make sure that they were safe, right? Or they've even had more like clear OCD illness in the past, but they haven't really sought treatment. They might not have taken medications. And then what we see is that in the postpartum, when intrusive thoughts attach to the infant, they're often much more distressing. And so they drive people to sort of treatment for the first time. It is also possible that someone develops OCD for the first time in the perinatal period. We know there's a higher incidence of OCD in pregnancy and postpartum.

• 12:34Speaker 01

  Right again, that's probably related to the stress of the time, right? We know that OCD is worse than stress. The hormonal changes that are happening, there's some thought that like oxytocin might be involved, right? So there definitely are certain triggers for new onset OCD. And then we know that kind of these intrusive thoughts are a near universal experience. So if you have a brain that's sort of sensitive to that, those factors, you could develop OCD for the first time in the postpartum. A lot of times when I'm screening for intrusive thoughts, and if someone tells me they have intrusive thoughts, I really encourage them to try to not change any of their behaviors, right? I'm not a CBT therapist, but I'll be like, okay, well, I hear that you're having the intrusive thoughts. The most important thing to do is to try to just move forward in the way you would have

• 13:19Speaker 01

  without the intrusive thoughts. I don't want you engaging in avoidance or checking behaviors. And I don't know if that necessarily prevents the development of OCD in someone who would have developed it, but it, it at least makes me, it gives them like a really quick and dirty understanding of what exposure and response prevention is, which is just don't do the compulsions, right?

• 13:35David Puder?

  Right. Yeah.

• 13:37Speaker 01

  Yeah.

• 13:37David Puder?

  So how do you, as the provider, let's say that you notice them coming to you a lot seeking reassurance? How do you not give them reassurance?

• 13:46Speaker 01

  Yeah, that's a great, that's a great question. I think, you know, I'll answer, it's kind of reminds me of the same thing I recommend for someone with like illness, anxiety, right? It's like you can, you could go to the, you should get everything checked out once, but you can't go over and over again, right? So the same thing with a patient, I'll answer any question once. But if we're going over the same thing over and over again, I might be starting to notice this pattern of reassurance seeking. I'm also very lucky in my practice that I have a lot of really great cognitive behavioral therapists that I collaborate with and work really closely with. And so they're probably more adept than I am at really identifying reassurance seeking really quickly and putting bounds around it with patients. And I find that to be really effective, too.

• 14:27David Puder?

  Great.

• 14:30David Puder?

  Well, okay. So what are the treatments you recommend for postpartum OCD?

• 14:35Speaker 01

  So for postpartum OCD, the treatment is really not very different from OCD at other times in your life, right? You want serotonergic antidepressants, typically higher than you would expect for depression or anxiety, right? You sort of push it to the upper limits in combination with cognitive behavioral therapy. So cognitive behavioral therapy, right? We do the exposure and response prevention where you sort of expose someone to the feared intrusive thoughts and then prevent them from doing the compulsions. And you do it in sort of the stepwise approach, sort of building up to what they can tolerate. That combination is the most effective for OCD in the postpartum. Right? Some programs, and I think we've done this before, is you, you actually sometimes even have moms like hold knives, right?

• 15:18Speaker 01

  Like they're scared of, they're scared of chopping vegetables, they're scared of holding knives. And you have to sort of work them up to increasing their comfort with it. I think OCD is very treatable, but we know that without treatment, OCD really can have a quite a chronic course, right? It doesn't just remit, whereas, you know, depression is more episodic. We expect that eventually it would get better with OCD and especially postpartum OCD, because the intrusive thoughts lead to these compulsions, that makes the intrusive thought stronger, right? It's this, it's this cycle. You really do have to intervene pretty directly with antidepressants and cognitive behavioral therapy.

• 15:54David Puder?

  Okay. Let's look at, I, I wanted to pull up the DOCs. Do you use this ever or to kind of get an idea of how severe postpartum OCD is?

• 16:06Speaker 01

  Yeah, I'm familiar with it. A lot of times we will do assessments with the Y box.

• 16:11David Puder?

  Okay. I, I think it's helpful because like, you know, as, so think about it, like all the people that listen to this podcast, there's probably a lot of people who are not going to be able to refer to a specialist, right? So then have a tool in their tool belt where they can, the Y box is great, but this is another one that we're seeing in the literature for this.

• 16:32David Puder?

  One of the things I noticed, first of all, was that, you know, the first, one of the questions here is like, about how much time do you, have you spent each day thinking about contamination or engaging in washing or cleaning because of contamination? And it's like, you know, less than one hour a day, one to three, three to eight, eight hours per day. And I was thinking about how common it would be for someone with severe OCD, they could be doing this six to eight hours a day. We may not know that unless we ask them.

• 17:06David Puder?

  So that was one of my thoughts on that one. I don't know if you have any thoughts on like just time?

• 17:11Speaker 01

  Yeah, I think it's also interesting to the, the level, you know, what someone sometimes will consider like sort of tolerable. And I think it, it varies so much depending on sort of life stage and life circumstance, right? I see this a lot in the postpartum, really. Postpartum, a lot of times is when someone really gets treatment for their psychiatric condition that might've sort of been like under the surface for a long time, right? So with OCD, maybe it was okay in their life to engage in an hour or two of compulsions a day before they had an infant, right? But then when there's an infant in the picture, your time is so precious and, you know, so you're so busy with all of these different tasks that an hour or two really becomes intolerable. And so we see that a lot of times this is the first time people get treatment. You know, you see the same thing with postpartum depression, right?

• 17:56Speaker 01

  If, if someone engaged in a lot of behavioral strategies to treat their postpartum depression, like exercising, yoga, therapy, seeing friends, going on walks, you know, hobbies, right? In the postpartum, you just don't have that time in the same way. So it really drives people sometimes to try medications for the first time to, you know, seek out evidence-based therapies because they're not able to cope in the same way they used to.

• 18:20David Puder?

  Yeah. So a lot of these questions are like going through the different types of symptoms we've talked about, looking at the amount of time people are spending on it. And you want to talk about the Y box at all because you're more familiar with that one? Maybe I'll just pull that up and show people what that looks like.

• 18:36Speaker 01

  Yeah. Yeah. The, the Y box we use a lot in the perinatal intensive outpatient program. So it's a, it is, it's a clinician given screener, but it does a really good job of looking at severity of OCD symptoms. It really runs through this large checklist of different OCD symptoms. So a lot of times when I've used this with patients in my private practice, you sort of find things that weren't obvious at the beginning, you know, like the religious obsessions that come up in the Y box. Like I am, you know, excessively concerned with morality. You know, that's not always something that comes up right away when you're thinking about OCD. Or I fear losing things, a different miscellaneous subject obsession. So I like this.

• 19:19Speaker 01

  I have found this very helpful when someone thinks that they might have OCD but isn't sure. Sometimes running through the checklist with them can be really helpful. They'll be like, oh, I didn't know that all of these things were OCD. In the perinatal period, I do think that the intrusive thoughts tend to be more typical, right? It could be anything, but it does tend to be related to the infant or around like health of infant or contamination, those types of things. But yeah, that's how we, that's how we use it. We use it in, for diagnosis of OCD. And I think it can also help patients sort of understand what things might be consistent with OCD that they might not have realized before, too.

• 19:58David Puder?

  Cool. Okay. So now let's shift to like the line between ego dystonic versus ego syn tonic infant harm content. Like where's that line for you? And what are the things that when you hear it, you're like, oh, kind of like raises your red flags, like?

• 20:16Speaker 01

  Yeah, I think so what you're looking for a lot of times is distress, right? So if someone is very distressed, they're anxious by the thoughts, they're popping into their mind, unbidden, they're doing these behaviors to sort of like safeguard the infant, right? We know worse than the OCD, but in the short term, these are the things you're looking for, right? Are they, are they worried that they're going to hurt the infant, right? You're looking at what symptoms this is that these intrusive thoughts are associated with, right? So if it's associated with postpartum depression, if it is associated with compulsions, if it's associated with postpartum anxiety, I think that is typically more reassuring. But I do think it is very important to also assess for psychotic symptoms.

• 20:58Speaker 01

  So again, people can have these classic intrusive thoughts with postpartum psychosis. But in that case, you are also assessing for these, you know, visual hallucinations, auditory hallucinations, kind of this like waxing and waning perplexity, confusion, like these kind of classic symptoms that go with postpartum psychosis. And that would really differentiate it. With regard to egosentonic versus egodystonic, I think it can get complicated if someone is so scared of their OCD that they sort of believe their OCD, if that makes sense. Someone who's having such a vivid intrusive thoughts are like, well, what if I did? What if I want to? Maybe I want to. What does it mean? Right? Someone who's really like overwhelmed by it. I think sometimes it can get blurrier than

• 21:42Speaker 01

  you would expect with someone with really, really, really severe OCD. But often, when you're looking at someone in the postpartum, it's the constellation of symptoms that helps you kind of differentiate as well, like postpartum psychosis versus postpartum OCD.

• 21:59David Puder?

  Okay. And then one thing I read in the literature is that it's more frequent to have irritability with the kind of the bipolar psychosis, it's more frequent to have irritability than kind of the manic grandiosity.

• 22:13Speaker 01

  Yeah, right. More, almost more of like this mixed presentation.

• 22:17David Puder?

  Right. So like, how do you see the irritability? Like, any kind of stories jump to your mind? Like in that postpartum psychosis with the irritability?

• 22:27Speaker 01

  Yeah, with the irritability, often I've seen it, I think, I think irritability by itself is not always the best differentiator. I do think it's less common to see sort of the euphoric grandiosity. Most of the time, people I've seen with postpartum psychosis, you know, seem sort of haunted, like more scared, anxious, can't sleep, overwhelmed, loss of touch with reality, sometimes this loss of orientation. The irritability, I think, is more, can sometimes be a driver for them not to seek treatment. Like, I don't need treatment. I'm fine. Leave me alone. Right? Or we can see it with the partner. I've seen before where there are delusions

• 23:08Speaker 01

  related to the partner, either cheating on them, or taping them, or out to get them. And so I've sometimes also seen like violence towards the partner as part of a postpartum psychosis diathesis. And so sometimes I'll see irritability in that way. But I think, I think it is more helpful as a differentiator from a grandiosity than sort of a symptom to look for in and of itself. Because I wouldn't use irritability necessarily alone as a symptom of postpartum psychosis, because then we get into this continuum of like, well, what about postpartum rage, right? Which we know is something a lot of women feel in the postpartum, can have a lot of different diagnostic underpinnings.

• 23:46David Puder?

  Okay. Yeah. So what about the sleep? Okay. Because it seems that a lot of women postpartum are having issues with sleep. So how do you differentiate like postpartum psychosis, not sleeping versus normal postpartum, I can't sleep?

• 24:02Speaker 01

  Yeah, postpartum psychosis, I'm not sleeping, is the classic way that it happens is someone, you know, doesn't sleep during delivery, right? They have a really long labor, right? So sometimes labor can be days, and then they don't sleep moving forward. So with postpartum psychosis, someone isn't sleeping, but they might not identify as tired. It would also be associated with these increased, perhaps like goal-directed activities, this sort of like agitation, which maybe is more what we're looking for. Maybe, maybe agitation would be a better word for irritability in my clinical experience. Kind of like restless, agitated, but irritable, I guess, is sort of nonspecific to me.

• 24:40David Puder?

  I appreciate that. I agree with you. Irritable is too common.

• 24:44Speaker 01

  Yeah, like I'm irritable, right? I guess perhaps that was why I was like, I don't know what to do with the irritable. Agitated. I would say agitation is more common with what I see. So perhaps like pacing, overwhelmed, not sleeping. The insomnia that we see with postpartum psychosis is different in that, again, it's not associated with just simple feelings of overwhelm. It's associated with this kind of triad of symptoms that we often associate with postpartum psychosis, which is worsening insomnia, worsening agitation, which leads to this sort of loss of touch with reality, right? The psychotic symptoms, which can be more prominent, visual hallucinations, which is what we see with postpartum psychosis. So I think, I think, again, it's, it's the

• 25:29Speaker 01

  constellation of symptoms that really matters, rather than, like, I don't think we could be like, well, you know, it could be that someone with postpartum psychosis has more severe insomnia, right? Maybe they're only sleeping one or two hours a night, whereas someone with anxiety might be sleeping four or five. But I don't, I don't think that there's literature to really separate that out. It's more that, you know, what else is happening? Is there a change in behavior from baseline? What does that change in behavior from baseline look like? Is there disorganized behavior? Is there confused behavior in addition to the insomnia? But I do think that people hear sort of that the prodrome of postpartum psychosis is like worsening insomnia, agitation, you know, irritability maybe. And they're like, well, is that me? What does that mean?

• 26:12Speaker 01

  But with a lot of the postpartum psychosis, that kind of classic postpartum psychosis, there's obviously a pretty distinct change in behavior with these kind of confusional episodes, the psychotic episodes, the delusions, with kind of this like agitated, mixed manic state, right?

• 26:30David Puder?

  Okay. And then what are they doing when they're not sleeping? Maybe that's the important question, right? It's like, what, usually when you ask these, the patients you've interviewed, what are they doing when they're not sleeping? Are they trying, are they just laying peacefully in bed, trying to sleep? Are they frustrated they can't sleep? Or what?

• 26:46Speaker 01

  Yeah, more, more agitated, right? So again, this like, this pacing, this overwhelm, most of the time, they're not coming in to need, seeking help. Most of the time, the partner is bringing them in, right? A lot of times with postpartum psychosis, there's also like, there can be a lack of insight, right? So the partner is bringing them to the ER. The partner is calling around, saying like, something is wrong with, with this new mom, right? She's thinks people are out to get her. She's hearing voices, right? She's seeing things that aren't there. She seems confused. She thinks, you know, that is what's driving someone to get care. It's rare that I have someone who's, I don't think I've ever had someone reach out to me and be like, I think I have postpartum psychosis. It's almost always like partner, psychiatrist, therapist, who's like, this is a distinct change in behavior. I'm really worried

• 27:31Speaker 01

  about them. And so I think, I think it can be a lot of different things. I think that I would say, I guess the image in my mind is like, is pacing, right? Just unsettled, overwhelmed, anxious, not sleeping. I guess it's hard to paint like a, it's, it can be kind of different for everybody. But no, I don't think, I don't think they're resting peacefully in bed typically. Yeah.

• 27:57David Puder?

  They're, they're Googling you and asking, if you are listening to this podcast, that may be a good sign. Okay.

• 28:05Speaker 01

  Yeah, right. Right. That's good.

• 28:06David Puder?

  That's your, that's anxiety driving curiosity. Okay. Yeah. What about disorganization? Like, the confusion, the disorganization, almost like a hypoactive delirium, like coming in and out of different states? Describe that to me.

• 28:22Speaker 01

  Yeah. Well, so, so they will be confused about sort of where they are, what's going on. Sometimes they don't know where their baby is. They're worried about their baby's safety, right? It doesn't seem, they're not there with you in the room. They can start doing something and then sort of lose their train of thought in a very severe way, different than how every new mom loses their train of thought, right? It's kind of, it's just like confusion, this profound confusion, where people are sort of watching them and their behavior seems not typical or disorganized, right? So, so one example that I've seen is, you know, a patient who was on the unit, was having a visitation with her baby and was holding her baby and was going, where's my baby? Is my baby okay? Those people on the TV are coming after me and they're gonna get my baby. But she was holding her baby. So really,

• 29:06Speaker 01

  this like profound kind of sense of like, they're not in reality, right? Another one of my patients was in the ER, was like going to, her husband had brought her to the hospital because her husband was worried about this change in behavior. And she didn't know why she was there, or what was happening, was confused, and then also thought that everybody was experimenting on her in the hospital. They were coming to get her. She was hospitalized for postpartum psychosis. So it is this more like disorientation, as well as this disorganization, like, like not doing things in the correct way, not making sense. There can be kind of this like difficulty communicating what's happening, difficulty explaining why they're

• 29:49Speaker 01

  doing something can be part of it. Yeah.

• 29:53David Puder?

  Yeah. I, one of the things I've been looking at lately is like just the research on memory in a manic episode, and how poorly people remember things afterwards. They may not remember a big chunk of time even, because in that sort of delirious state, or delirium is the same thing, right? Like if someone's delirious in the hospital, post-surgery, they're seeing like gremlins on the wall, they may be completely unable to remember that two weeks later, but the family does remember, you know, the family's like, no, this was like really hard.

• 30:30Speaker 01

  Right.

• 30:31David Puder?

  And, and they're like, no, I don't think it was that bad. I don't want to take my meds anymore.

• 30:37Speaker 01

  Yeah. Right. We can see that the partner is, right? Obviously, this is incredibly traumatic for the woman, and I'm not diminishing that at all. But we can also see that it's very scary for the partners, right? The partner, right, can feel like they sort of have lost, like the non-breathing parent can feel like they've lost their partner, right? And it can make it, I've seen it be very difficult if, if people do choose to have more children, for that partner to sort of get over the fear and understand that, you know, there are things we can do to prevent postpartum psychosis too.

• 31:09David Puder?

  Okay, well, maybe you could mention that. What do we do to prevent postpartum psychosis?

• 31:14Speaker 01

  Yeah, it's a great question. So postpartum psychosis is fairly preventable. We have some studies that really show that lithium is one of the best medications we have to prevent postpartum psychosis. So this is a conversation I'll have with women. You know, sometimes I see people in the third trimester. They perhaps have a history of bipolar type one. They're not on medications. That happens not uncommonly, right? Someone's like, I'm pregnant. I don't want to be on my medications. I'm not going to do my medications. They sort of show up to psychiatric care in the third trimester. So in that patient, what I'm talking about is the increased risk of postpartum psychosis. I'm educating on postpartum psychosis signs and symptoms. I'm bringing in a partner, if they're partnered, if not, closest family member or friend to

• 31:58Speaker 01

  educate them on the signs and symptoms. I love the action on postpartum psychosis handouts. They have handouts both for the patient, sort of like, you know, preventing or like learning about postpartum psychosis, but also for friends and family members, which I think is so helpful to sort of have it from these two different perspectives. So I send those. And then in that patient, I'm strongly recommending lithium. I think there are two ways of doing it. You can either start lithium in the third trimester, so sort of before they deliver, try to get it to a therapeutic dose, or you started immediately postpartum, meaning the night after they deliver. Because it's interesting how many logistics are around it when you're like, yeah, I'm going to start lithium in the postpartum, but you're like, when? And at what dose? And how?

• 32:41Speaker 01

  And so the night they deliver, they take sort of the dose you would expect to be therapeutic. It's great if you have data points, right? So if you have data points that maybe on lithium 900, their level was 0.8, that's ideal. We would start 900 milligrams of lithium the night they deliver with a goal level of 0.8 to 1.0. And I think that's important is because you really want it in this anti manic range. You don't want it in this maintenance range because if we're going to use lithium, we want it to work and the best data is keeping it within that range. For patients who have a history of postpartum psychosis, so this is, you know, a subsequent pregnancy after they've had postpartum psychosis. We know they're at a very high rate of relapse, you know, with or without bipolar disorder diagnosis.

• 33:24Speaker 01

  You would either start lithium immediately postpartum, or you could use what worked before. So if, if someone did really well on antipsychotic monotherapy, you could theoretically start antipsychotic monotherapy. It's just that the best data for relapse prevention and for prophylaxis is with lithium. Interestingly, in one study, it showed that Depakote was ineffective. I've seen some sort of creative psychiatrists being like, well, Depakote has low levels in breast milk, so what if I use Depakote? But there's not very good evidence for Depakote, and we don't recommend that as, you know, treatment or prophylaxis of postpartum psychosis. Yeah.

• 34:02David Puder?

  Yeah, great. And then it, so we talked about prophylaxis if they're high risk. And if, if they come in and they are postpartum psychosis, like what's the next day look like for you in treating them?

• 34:17Speaker 01

  Are they on medications or not on?

• 34:19David Puder?

  Not on medications.

• 34:20Speaker 01

  Not on medications have postpartum psychosis. So for me, I am getting them to the hospital as soon as possible. I both want them to go to have a medical evaluation because I want to make sure that there's no other like neurological or immunological condition that's causing these symptoms. And also for safety and containment, right? So it's an inpatient psychiatric hospitalization. If you have a mother baby unit, that's incredible. I think that's a much better, you know.

• 34:49David Puder?

  Where, where do, where are those?

• 34:51Speaker 01

  There's one in California, in Northern California. I think there are a few scattered across the country. We, we obviously need more, right? That's a much more therapeutic healing environment than being separated from your baby in a psychotic state, right?

• 35:08David Puder?

  Yeah.

• 35:09Speaker 01

  Yeah.

• 35:10David Puder?

  It's, it's interesting because like, um, there's like such a dearth of good inpatient experiences in my current location that like, it's like, uh, I get nervous.

• 35:24Speaker 01

  Yeah.

• 35:24David Puder?

  But okay, so you send them to the hospital, get a, get a good workout, get a good workup.

• 35:29Speaker 01

  Yep. Usually we're starting at least lithium plus or minus an antipsychotic. And you would use an antipsychotic, you know, if there's agitation, you know, really prominent psychotic symptoms. Usually you would do the combination, right? Plus or minus a benzodiazepine if they need help with sleeping. Usually we're continuing, once they sort of are close to their baseline or close enough to their baseline, they're discharged from the hospital, usually I'm stepping them down to a PHP or an IOP for additional monitoring and support. I would say roughly after a few months, I would say like three-ish months is usually when I'm trying to taper the antipsychotic if they were on the antipsychotic plus the lithium.

• 36:10Speaker 01

  I really want them to have no psychotic episodes for at least a few weeks, maybe a month or two before we would kind of really cautiously taper the antipsychotic. And then you continue lithium out to, you know, around a year. People will say different timelines, but around a year. If this person does not have a history of bipolar disorder, like you have done the most thorough H and P of your life, right? And there's no evidence of bipolar disorder. At that point, you can really cautiously taper the lithium. This is another one of those times where you really have to bring in the partner. You really have to do psychoeducation, right? There's a lot of sitting down and being like, okay, looking back, what were the first signs for you, right? What, what, what was like the very first thing?

• 36:53Speaker 01

  And sometimes it is this like irritability, right? Is it, is it this, is it this irritability? Was that the first thing? What did that look like? How was it a different flavor than your run of the mill irritability? Was it sleeping less? Was it, we had one patient recently where it was these sort of like perceptual kind of changes where it was like the leaves look a little bit different or like the paintings look a little bit different. And that was her first sign. And so you want everybody to be on the same page about this. And then you slowly and cautiously taper the lithium. And then I think this can be the hardest part for people is because we know it's about 50 50 between, you know, who ends up having a bipolar spectrum illness and who really will only have postpartum psychotic episodes in the postpartum period is it's a bit of

• 37:38Speaker 01

  a waiting game to see how someone does, right? And I think that can be so hard for people where they're like, well, what is my diagnosis? And we're like, well, right now we know you have postpartum psychosis, but only time is really going to tell if this is a bipolar illness or if you are one of those people who's just only going to have episodes in the postpartum.

• 37:59David Puder?

  I see a lot of bipolar in my clinic and I get a lot of patients who have tried everything but lithium.

• 38:06Speaker 01

  Oh, interesting.

• 38:07David Puder?

  And they, they will have had true bipolar, true manic episodes, psychiatric hospitalization, sometimes even like, like life threatening suicide attempts. And the only thing that they've tried is antipsychotics, Depakote, Lamotrigine, everything, everything but lithium.

• 38:28Speaker 01

  Interesting. You think it's the lab testing? What do you think it is?

• 38:31David Puder?

  I think providers are still nervous about doing lithium. I, I think that there's no drug reps pushing lithium.

• 38:40Speaker 01

  I guess that's true.

• 38:43David Puder?

  And I don't know, like if you're, if you, maybe if you went to a residency that wasn't doing a lot of lithium, maybe you didn't get used to it. So any, any more thoughts on lithium?

• 38:52Speaker 01

  I feel, I feel like in reproductive psychiatry, it's really like pounded into your head, right? Lithium is the gold standard of care for bipolar disorder. It's still the gold standard of treatment for, you know, bipolar disorder in pregnancy, even with like, you know, the small increased risks of cardiac malformations. And then with, I think with postpartum psychosis, right? It's, it's kind of the same thing where it's like lithium is the best evidence for, you know, both like acute treatment and then prevention. And so I feel like, I feel like reproductive psychiatrists use lithium all the time, but I guess, I guess that makes sense. It does make sense.

• 39:24David Puder?

  What do you say to someone who's like, comes to you first trimester or maybe before they get pregnant, they're like, look, I'm on lithium, I'm stable bipolar. I'm, I'm afraid of the, you know, side effects during pregnancy. What, what's the conversation look like for you?

• 39:42Speaker 01

  Yeah, that's a great question. I think, you know, when you're seeing someone for the first time, you really want to get a sense of their history, right? So, you know, what were their manic if we're assuming bipolar type one, like, what were their manic episodes like? Were there psychotic features? How severe was it? Were they, had they been hospitalized multiple times, only a few times? What's their course been like since they're on lithium? Because you want to, you still want to find the medication that works the best for them, right? We can't just assume that it's the medication they're on. So if, you know, they say lithium has been amazing for me, I've been totally stable for the last few years since I've been on it. I had a really rocky course before. Then, in my mind, I'm, I'm thinking, okay, we probably need to keep the lithium on

• 40:25Speaker 01

  board with this patient. Then, we're really talking through what we know about lithium in pregnancy and postpartum. And I think, you know, in med school, all of us were taught, like, lithium and Epstein's anomaly, you know, you have to be really cautious, right? What we know is that the absolute increased risk of cardiac malformations is present, but is smaller than was previously thought. So it's about one in 100 increased risk of cardiac malformations with lithium. That risk does seem to go up with higher doses. So, you know, if someone is on 1,200 milligrams, there's a higher risk than someone who's at 600 milligrams. So I'm also, when that person is coming to me, I'm curious, you know, what dose they're on. You know, if someone's on 600 milligrams and rocky and rolling, some studies show that there's really not a statistically

• 41:08Speaker 01

  significant increased risk of cardiac malformations at that dose. If they're on higher doses, it doesn't mean that we need to stop it. It just is, you know, there's just psychoeducation. What we recommend is, you know, we recommend they be seen by an OB regularly for routine screening. We will sometimes recommend that they have a fetal echocardiogram when they're on lithium in pregnancy. However, you know, I think also, when they're seen by an OB, when they get the sort of anatomy scan, if there's anything that's abnormal, they will be referred for a fetal echocardiogram. So I don't necessarily make that recommendation sort of across the board. When lithium is taken in pregnancy, we know that lithium levels change throughout the pregnancy. And so, you know, you can check levels regularly and dose adjust, especially if someone has more

• 41:50Speaker 01

  brittle bipolar disorder, you would want to check levels really regularly. Other, you know, institutions will sort of recommend dosing the lithium clinically, meaning if someone starts to have breakthrough symptoms, you can adjust the dose, but you don't need to adjust it just based on one lithium level. You continue the lithium through delivery and into the postpartum. So there used to be this idea that you might hold the lithium for a few days before delivery. We don't recommend that, because you'd sort of be withdrawing the smooth stabilizer right at the time we know they're vulnerable for postpartum psychosis. I think something that people sometimes forget and is important to counsel on is the interaction of lithium with NSAIDs. So like Ibuprofen,

• 42:30Speaker 01

  we know is really commonly given for pain control after delivery. And so if someone is on lithium, you need to sort of educate them, but also make sure that they're reminding their OB about that interaction. We also know that sometimes, you know, if someone has some kind of renal impairment, maybe as part of like a preeclampsia, that their lithium level could get toxic. And so really important, again, to sort of just make sure that you're on board, communicating with this patient who's communicating with their OB, and remembering all of these like medical interactions, or these medical conditions that can really change lithium levels. But for the most part, you know, feel very comfortable using lithium in pregnancy. I think when you use it in pregnancy, you can use it with breastfeeding. The majority of my patients who

• 43:15Speaker 01

  have bipolar type one, who are on lithium during pregnancy, I think we can kind of think about it as a marker for symptom severity and for illness severity. The majority of those patients with me are not exclusively breastfeeding. A lot of my patients in that situation are either combo feeding, or choosing not to breastfeed, really from a sleep protection standpoint. We know that when someone's exclusively breastfeeding, you know, it really requires pretty extreme sleep deprivation, right? You have to be up, you know, usually every two hours overnight for weeks, if not longer. And for someone with a bipolar disorder, that's really not feasible. It's kind of a counseling I do.

• 43:53David Puder?

  Nice. So what if said person who's struggling that maybe you got stable is going back to work, and they have to work night shifts as a, you know, person?

• 44:03Speaker 01

  Yeah. That's a great question. I would probably write them for a medical accommodation that says that they cannot work night shifts. I would really not recommend it. I've written medical accommodation letters, you know, even for patients with just major depression. I see a lot of people who have worsening of their mental health conditions with night shift because of the circadian rhythm disruption. So I would strongly recommend against that. If there's no option, I would say proceed very cautiously and might add something on to the lithium, like a second mood stabilizer, to really help give them a little bit of extra stability. Mostly, I would just not recommend it.

• 44:43David Puder?

  Yeah, I wouldn't recommend it. Okay. Any, any final thoughts? Any, like, as we kind of wrap up our time together, any things that are still on your mind, like you want every clinician to know? Or maybe just summarize, like, the big takeaways you would want them to walk away with?

• 44:58Speaker 01

  Yeah, the big takeaway. So I think postpartum psychosis is infinitely treatable, right? The truth is, is that most people recover, and recover usually within weeks to months, right? I think that treatment with lithium plus or minus an anticoptic, plus or minus a benzo, is very effective, right? We know that in studies, the majority of people have really remission of their symptoms on that combination. I think, don't be afraid of lithium, I think is a really important thing to highlight here. And then I think it's just really important, you have to bring in the partner if you are concerned about postpartum psychosis, if you're worried about postpartum psychosis, because we know that there can be insight, you know, lack of insight and confusion with this disorder. And so you have to ask the partner how they're

• 45:39Speaker 01

  doing, you know, like, are there any changes in behavior? Are you noticing any disorganization, right? Like, I had a patient one time who really had a delusion that her partner was cheating on her, and she would become aggressive and violent with him. But when I would interview her, I'd be like, have you had any thoughts, you know, any changes in behavior, any thoughts of thinking that your partner was, you know, cheating on you? She'd be like, absolutely not. And then I would call her partner, and be like, yes, on Monday, she ran out of the house because she thought that she had seen me, you know. And so I think really keeping them extremely involved in the care is so important.

• 46:13David Puder?

  So important.

• 46:14Speaker 01

  So important. With paraneuric OCD, I think you can, and intrusive thoughts, I think you can change lives by psychoeducation on what intrusive thoughts are, by letting people know that it's almost a universal experience of the postpartum to have intrusive thoughts. Of course, you have to evaluate for risk factors that might suggest it's not just an intrusive thought, like psychotic symptoms, but for the majority of patients, really educating and normalizing that experience.

• 46:43David Puder?

  Great. Well, this was a great pleasure in connecting with you and, and learning from you. And I'm sure they, I'm sure everyone's grateful at this point, hearing this. So, yeah, it's wonderful.

• 46:54Speaker 01

  Thanks so much for having me.

• 46:56David Puder?

  So if you want Catherine Unverferth to come back, you will let me know. And she's also on Instagram. She's active there. I would go check her out. She has very nice short videos. I'll, I'll put your website on my podcast. Yeah.

• 47:11Speaker 01

  No, you can find me at UCLA or in my private practice.

• 47:15David Puder?

  Great. All right. Okay. We'll leave it there for today.