Postpartum Psychosis: Symptoms, Diagnosis, Treatment, and Prevention with Dr. Margaret Spinelli

In this essential episode of the podcast, Dr. David Puder and reproductive psychiatrist Dr. Katrina Furey interview pioneering expert Dr. Margaret Spinelli on postpartum psychosis, covering its symptoms, diagnosis, treatment, and prevention. They explore the history of perinatal psychiatry, neonaticide and dissociation, the critical need for mother-baby units, rapid symptom progression, why timely hospitalization and treatment lead to full recovery for most women and much more. Link to blog https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-281-postpartum-psychosis-symptoms-diagnosis-treatment-and-prevention-with-dr-margaret-spinelli Link to YouTube video https://youtu.be/N5KgN47KF2o By listening to this episode, you can earn 1.25 Psychiatry CME Credits. https://www.psychiatrypodcast.com/cme-program

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

• 0:13David Puder?

  All right, welcome back to the podcast. I am joined today with Katrina Fury and Margaret Spinelli. Dr. Margaret Spinelli, Dr. Katrina Fury are both psychiatrists. Dr. Fury and I did a prior episode on postpartum psychosis, and we were talking afterwards about who we could invite back on, and we decided one of the leaders in the field, someone who's been fighting for women's rights for decades, Margaret Spinelli would be the perfect person to have on. And so, Dr. Fury and myself will be interviewing Dr. Spinelli and trying

• 0:52David Puder?

  to draw out her expertise as someone who has treated and advocated for women in the midst of postpartum psychosis for decades. So, welcome to the show. Thank you for coming.

• 1:04Speaker 01

  Thank you.

• 1:05David Puder?

  I think maybe we should start by hearing a little bit about how you got into this, kind of your background and how you got kind of thrust into this space.

• 1:14Speaker 01

  Yeah. Well, I actually didn't get thrust in. I really had to search for it. I was a nurse in OB for like 12 years, and then I went to med school. And my idea was always to go into psychiatry and treat mothers. I have never actually determined the reason for that. With lots of therapy, I have never determined the reason. But I wanted to do so fiercely. And so, in my last year, I was at Cornell Medical School, and I say that

• 1:55Speaker 01

  because this wasn't like unknown, where people wouldn't know. And I went to one of my faculty members as I was leaving medical school, and looking for, let's say, any component of a residency, or any kind of training for maternal mental health, or anything for postpartum illnesses. And he said to me, there is no such thing. And the fact was, for psychiatry, there was no such thing back then. Let me just tell you, it's very quick,

• 2:39Speaker 01

  but I think it's important. There were two psychiatrists back in 1926, who basically said they had a study, quote. And what they had done was, they looked at 50 charts. Half of them were postpartum psychosis, and half of them were another diagnosis of a psychotic episode. And what they determined was that there was no difference between postpartum psychoses and other psychoses. They never met these women. They never evaluated these

• 3:21Speaker 01

  women. And that was their determination from that quote unquote "study." And they suggested that postpartum should be excluded from psychiatry, the words "postpartum," "perinatal." So that was in 1926. Their names were Strecker and Ebow. Strecker then, in 1952, was on the committee, the DSM committee, and he had a very strong movement against postpartum

• 4:02Speaker 01

  illness. And so, it was never put into the DSM. It was put in another way, in first two, like childbearing and something. But there was nothing further about postpartum for all the years we know of it. And most psychiatrists would say, there's no such thing. And at Columbia, I would ask people who I knew were on the DSM committee, they would say, well, there's research on that. And the fact is, the idea that that was researched

• 4:41Speaker 01

  carried over, okay, and followed all of us into our psychiatric training. But I knew, actually, that there was such a thing. And when I was working in a lab in med school, a very nice attending put a book next to my, on my lab, my lab table. And it said, "Motherhood and Mental Illness by Chani Kumar and Ian Brockington."

• 5:13Speaker 02

  I recognize that name.

• 5:15Speaker 01

  Yeah. So, after a brief time, I decided I have to go to England and learn. And I did. I had a clerkship in which I worked on Chani Kumar's mother baby unit in London at the Maudsley and Bethlehem Hospitals. It was one of the best experiences I had in my career. It was just wonderful. Chani continued to be my mentor when I came back

• 5:52Speaker 01

  here. And I suppose a first movement in my fellowship, I designed IPT, interpersonal psychotherapy, for pregnant depressed women. But soon after, we were prescribing medications. And that was, that was pretty wonderful. And I did the IPT study during the fellowship. And after that, I continued with my research and private practice. And it was completely perinatal psychiatry. And that's been, it's been wonderful.

• 6:36David Puder?

  So, okay, so then, I know you've also, you did like an early study where you looked at women after, specifically the very early portion of pregnancy, like the first day when they, when they took their child's life, right? You did like a study where-

• 6:56Speaker 01

  Oh, yes.

• 6:57David Puder?

  It was called, it was 2001 article called "A Systemic Investigation of 16 Cases of Neonatal Side."

• 7:03Speaker 01

  Yes.

• 7:05David Puder?

  And I'm curious, and I don't know how much of this episode will spend on this specific topic, but this seemed very different to me. And I think that you found some very interesting things. Can you tell me about what you found in regard to the pattern of childlike demeanor, and la belle indifference, depersonalization, denial of pregnancy, dissociation, and that ego disorganization?

• 7:30Speaker 01

  Yeah. Well, I must say, there are many people who have disagreed with me. Although I think now, this characterization has, is having some impact today on neonatal side. What I found, just for the public, neonatal side is due to denial of pregnancy. And these women will often deliver in a bathroom, in a bedroom. And some will kill, and some will

• 8:09Speaker 01

  just leave a baby in such a way that the baby dies. And they are, they are then charged with murder. And just like we see in women with postpartum psychosis today. And the thing that struck me was that they all seemed to have the same personality characteristics. And even their families were similar. Their personalities were some, something like

• 8:47Speaker 01

  a little childish. For example, when I interviewed the woman they called back then, the prom mom, who had her baby at the prom, and put her, him, her in a trash bag. When I asked her about delivering, she said, "I thought I was delivering. I thought I was having number two." Now, this was a pretty grown young woman. She was at her senior prom.

• 9:27Speaker 01

  So, many of them seemed very naive, naive about their pregnancies. The first one I saw actually was from England. And it was Chani Kumar who called me and said, "Would I go to Rikers Island and evaluate this woman?" I wasn't too thrilled about going to Rikers Island. A lot of guys from my old neighborhood went there. So, I knew, I knew what it was like. But of course, I would never say no to Chani. He was such a special

• 10:07Speaker 01

  man. He was devoted, and so empathic, and a wonderful teacher. So, anyway, I went to Rikers Island, and I met Carolyn. I could feel from the story, this, there was a lot of innocence around it. And so, as I saw each one, I heard the same story. And, you know, they didn't realize they were pregnant. Some just thought they gained some weight,

• 10:46Speaker 01

  and the delivery was a surprise. So, the bottom line was, I started to look into more serious-

• 10:59Speaker 01

  Dissociation and realized that that was how they got through their pregnancy. But what was interesting is family never knew their fiancés that they were still with, never knew. So, you know, I think, I mean, I know that there's been a lot more, you know, clinical, I wouldn't say clinical study, but reports that support this picture of dissociation.

• 11:33David Puder?

  Yeah. Yeah. And you looked at the dissociation experience scale. I think the mean was 28.89, which suggests a very high level of dissociation. 10 of the 16 scored above 15. One of the quotes from the paper was, "All women described watching themselves during birth."

• 11:54Speaker 01

  Yes.

• 11:55David Puder?

  11 denied pain, which is very common with dissociation.

• 12:01Speaker 01

  Yeah.

• 12:02David Puder?

  Five described pain as not bad. 12 experienced dissociative hallucinations as internal commentary of critical and argumentative voices. Nine reported childhood sexual trauma histories. Seven independently collaborated. Six, physical abuse. Yeah. So I think, I think that sort of dissociative piece is, is important to think about as clinicians when we're thinking about that, specifically the first 24 hour. And I think postpartum psychosis, it seems, is a very different picture, right?

• 12:39Speaker 01

  Yes, very different picture. I suspect one might think of the neonatal sides as somewhat more characterological, you know, the symptoms. The only reason I hate to say that is it was once advertised as being, you know, in some, in some sort of accusing way, saying they were just borderline. And they were doing this and there wasn't. But I didn't find that there was anything. I didn't test for borderline personality disorder.

• 13:24Speaker 01

  I was just looking at the dissociation. And that's what I wanted to report, basically.

• 13:30David Puder?

  Yeah.

• 13:31Speaker 02

  So it would be used in more of a pejorative way?

• 13:34Speaker 01

  Yes, definitely. And I found that was so offensive. And I, and I didn't think, it, it seemed too similar.

• 13:47Speaker 02

  Hmm.

• 13:48Speaker 01

  You know, the stories were so similar. The families were kind of too enmeshed, you know? Especially the fathers with the girls, I found.

• 14:05Speaker 02

  How do you mean?

• 14:07Speaker 01

  Well, they kind of had special relationships. Now, there was a certain amount of sexual abuse in this group, but the fathers were not necessarily identified in that. But I mean, just to give you an example of a certain kind of naive or ignorance in the family. When one father came, because I wanted to interview him, he was probably, my office was probably 20 feet wide, and he was there.

• 14:49Speaker 01

  And when I started to speak with him, he moved his chair up almost so that his knees were touching mine.

• 14:58Speaker 02

  Oh.

• 14:59Speaker 01

  Yeah. So it was just this kind of inappropriate.

• 15:04Speaker 02

  Yeah.

• 15:05Speaker 01

  You know, mechanisms that they use.

• 15:10Speaker 02

  That's interesting that you described the family unit as so enmeshed, and yet there was, it sounds like also so much dissociation.

• 15:17Speaker 01

  Yes.

• 15:18Speaker 02

  You know, in the, in the woman or the girl, but also like in the family with this total denial of the pregnancy. That's just such an interesting dichotomy to me.

• 15:26Speaker 01

  Well, you know, even, I had, I mean, one woman who was raped, actually. She was like a quote unquote champion swimmer. She was in the pool the day before with her, her teacher, her mentor, and they never noticed a pregnancy. So it's something about, you know, even their posture. Now, I know there have been, you know, I haven't kept up with the latest information

• 16:07Speaker 01

  on neonatal side because I've been so invested in postpartum psychosis. But I know they're even looking at the way the baby lies in the womb. Could that be a reason why, you know, they don't tend to look as perfect as they are? But, you know, what's, what is so impressive is that Caroline, for example, the woman from England, eventually she went home. She was in Rikers for quite a, a long time. And then the judge agreed to send her home to England where she would have quote unquote

• 16:52Speaker 01

  probation. And as Chani Kumar said to me, you know, if she had, I mean, she was arrested at the airport, okay, and charged with murder, if she had just made it to Heathrow, there would have been psychiatrists at the airport for her.

• 17:15David Puder?

  Yeah. America seems to be different than a lot of European countries in how we kind of treat this population, infanticide.

• 17:26Speaker 01

  Yeah. Um, yeah, we're so punishing, you know? We really are so punishing. I mean, I, I remember working on the mother baby unit, and there were women who actually had attempted infanticide. And let me just say, the staff was impressive and large. There was a psychiatric nurse for each mother baby and a pediatric nurse for each mother baby. So that was pretty incredible.

• 18:05Speaker 01

  Now, they have universal healthcare, and that's why they could do it. That's why they could afford to have this kind of working process. When I first left residency, before I had decided to do the fellowship, Kathy Wisner, I don't know if you know Kathy Wisner? Kathy Wisner is really a pioneer in this.

• 18:38Speaker 02

  And written a lot of her papers, yeah.

• 18:39Speaker 01

  Yeah, yeah. She's, and she's terrific. So she wanted me to come, and they were going to start a mother baby unit. So we would have started quote unquote, the first mother baby unit. And that was in Pittsburgh. However, they determined that they couldn't do it because of insurance.

• 19:03Speaker 02

  It's so interesting you say that. You know, me being of a different generation, I've literally asked so many of my mentors, like, where, I want to start a mother baby unit. Where do I need to go? Where do I need to move? Who do I need to talk to? Like, where are they? And I'm told the same thing, that they just won't make the hospital money, it's never going to happen, we're trying. And it just drives me nuts.

• 19:29Speaker 01

  Yeah, it's very sad. As I said, even women who attempted infanticide, they were there. They were there with their babies and the staff. And they would learn infant massage and bonding and, that's what I said, it was such a moving experience for me. I could almost cry just, just being it again, you know?

• 19:59Speaker 02

  I have a, I have a friend and colleague who's a reproductive psychiatrist, her name is Jamie Sorenson, out of Florida, and was telling me that there's a whole team who helps moms learn how to read the baby's cues. And this is just part of what, like, everyone learns. And I thought, wow, wow.

• 20:18Speaker 01

  Mm-hmm.

• 20:19Speaker 02

  It's totally different world.

• 20:20Speaker 01

  Oh, boy, is it ever.

• 20:23David Puder?

  It's really sad. It's really sad. I, it hits home really for me. I haven't mentioned this on my, my podcast before, but my, um, my mom's mom had postpartum psychosis.

• 20:35Speaker 01

  Oh, wow.

• 20:36David Puder?

  And she was on Thorazine and lithium.

• 20:39Speaker 01

  Yeah.

• 20:40David Puder?

  And, um, and that, basically, my, my grandpa took over parenting while she was in the hospital for a very long time.

• 20:49Speaker 01

  Yeah.

• 20:50David Puder?

  And, uh, I think it, I think it would have been, it, it's, it would have been a different world, right? If, if there was support.

• 20:59Speaker 01

  Yeah. And that's the other thing about postpartum psychos. Of course, infanticide is the worst.

• 21:09Speaker 01

  It won't say side fact, but outcome.

• 21:12Speaker 02

  Of course, yeah.

• 21:13Speaker 01

  But all of our patients who have postpartum psychosis are really adversely affected. They're not able to take care of their baby, usually for about a month. Other people are caring for the baby and they feel kind of pushed aside. You know, if they, if there's not like a grandparent, then the, the father will often take over, but then can't go to work. I mean, there's a lot of complications with all of this. And then when they finally are starting to mother, they feel very insecure about it.

• 21:58Speaker 01

  They feel like the baby's more attached to that other caregiver.

• 22:03Speaker 02

  Such a ripple effect, I think, you know, in, in doing reproductive psychiatry, that's one thing that really drew me to it in my private practice. I love doing therapy and it's such a rich time for that.

• 22:14Speaker 01

  Yes.

• 22:14Speaker 02

  And you also see that ripple effect now this other way about how much more adversity and struggle and, you know, David, just thinking about your story, I appreciate you sharing that because I can see in your eyes how much it has affected you all these, you know, generations later, that it really does ripple down.

• 22:32Speaker 01

  Yeah, well, I mean, I'm so happy that there are fellowships and there's so much activity around the subject. It's just wonderful compared to, and I should tell you that when I came back here,

• 22:54Speaker 01

  Kathy Wisner and I and Barbara Perry and Kim Yonkers, Mike O'Hara, we were like, I, oh, I hope I'm not leaving someone out, but we were like the early postpartum experts, you know? And, and you know, where we got that from was the English model because it was the Marseille Society and Marseille was very small back there. And we were the Americans who went to the Marseille Society meetings, which were very

• 23:36Speaker 01

  different, as you can imagine, than they are now when they're so large, which is wonderful.

• 23:43Speaker 02

  Yeah.

• 23:44Speaker 01

  And look, you know, I had started, I put in an application and a protocol for postpartum psychosis probably five years ago. Now, Veo Berjing then took it over and she and the group have gotten it through. I mean, it's only an email that I have that we have, but it's an email, you know? And you know, it always comes up in court. The prosecutor would say, Dr. Spinelli, well, postpartum psychosis is not a diagnosis. Isn't that true?

• 24:29Speaker 01

  But, you know, it wouldn't matter because we would use an underlying diagnosis anyway, like bipolar, you know?

• 24:37David Puder?

  When, when did you guys realize that it was kind of more on the bipolar spectrum?

• 24:42Speaker 01

  You know, I think the first paper that came out, although I, I don't know if she's practicing perinatal anymore, was Linda Shodrin, who said, on the other hand, I've looked at some very old studies, which talk about mood fluctuation. Ian Brockington had a very, a very, uh, old story in the 1980s.

• 25:15Speaker 01

  And James Hamilton also, they had recognized that there was this bipolar picture, you know? And it's, it's so interesting because even that fluctuation was recognized when Hippocrates recognized the diagnosis.

• 25:35Speaker 02

  Wow.

• 25:37Speaker 01

  And, yeah, and of course Marseille identified it in his, you know, in his treaties on pregnant and postpartum women.

• 25:49David Puder?

  And, and, and how about the, um, the cognitive fluctuations and kind of the delirium-like picture, confusion? When, when did that really come into like knowledge base of like, this is a little bit different than even a normal manic episode?

• 26:06Speaker 01

  Plus I have this paper, I have the cognitive studies here, just happened to have the cognitive impairment. Marseille, he brought it up in his treaties. And then there were many others who did studies comparing non-postpartum.

• 26:29David Puder?

  Can you describe some of the symptoms that you've seen personally? The confusion, the, the cognitive issues like?

• 26:37Speaker 01

  Confusion, which is one, and perplexity, which I guess is the same thing. I've seen misidentification and, uh, delirium. And that's this identification of cognitive symptoms are important for me because in the courtroom, it can be used in the United States when the verdict is decided by knowing right from wrong. You know, my feeling is, and I usually include that in my report, there's about 13 studies

• 27:20Speaker 01

  that have been, yeah, that have been completed, which describe all of the symptoms. Kathy Wisner actually did a very nice study and it, it was a comparative study. Most of the, most of the studies are comparative, which is really interesting.

• 27:46David Puder?

  One of the things about the waxing and waning is that there can be lucid moments, like moments where the person might look normal, you know? And we, we, we see this often in delirious patients to the hospital. If you see them one moment, they may seem like they have it together. Maybe they're a little bit hypoactive delirium, so they, they look more depressed or lethargic. But then the next moment they're more hyperactive, they're seeing things, they're hearing things. You know, is this kind of the picture that you've seen?

• 28:14Speaker 01

  Absolutely. And, and it's as if she doesn't, doesn't know me or people who are caring for her.

• 28:26Speaker 01

  So it's like, you know, it really is being psychotic at one moment and then lucid in the next. And, you know, it is thought to be part of a delirium in those circumstances.

• 28:43Speaker 01

  And you often wonder, I often wonder, you know, because it all does go back, obviously, to hormone fluctuations. I wonder how much those changes contribute to the delirious aspect of it.

• 29:02David Puder?

  Yeah, I always think about like sensorium, delirium, delirium being the worst portion of a sensorium issue. We all have sensorium issues, you know? 2, 3 PM, we're all a little bit more tired, we're all a little bit yawning, or I don't know, a lot of us are. Whereas like you stretch that and you sleep deprive someone, you put them through a lot of pain, a lot of discomfort, you put them through a lot of stress and all of a sudden now, like you could take a normal person and now shove them into delirium.

• 29:37Speaker 01

  Absolutely.

• 29:39Speaker 02

  Yeah.

• 29:39Speaker 01

  And even when you think of it, the lack of sleep for women, let's say, who have an underlying bipolar diathesis, right? And when they go into labor, they're awake for a long, and then they go right into possibly, well, feeding, if not breastfeeding. And that prolongs that association with light and, um.

• 30:10David Puder?

  Circadian rhythm, yeah.

• 30:13Speaker 01

  Yes.

• 30:13David Puder?

  Dysfunction and, and you talk about wanting to start the treatment sooner than later, like some, you know, like, I think in one of my previous episodes, one of the psychiatrists was mentioning starting a loading dose of lithium on the day of delivery, but it sounds like in one of your lectures, and I'm curious where you're at in this, like where you would start the lithium in the third trimester? What's your sort of protocol?

• 30:39Speaker 01

  Well, you know, there are two groups of women who get postpartum psychosis and it's almost split. Half of them have a history of bipolar disorder in their family or somewhere and others do not. And they're, they're kind of looked at as an isolated postpartum psychosis.

• 31:07Speaker 01

  And those are women who only have episodes with the postpartum period, not in between. So the bipolar women, of course, will have episodes in between. So they are usually on medication during pregnancy, not always, but often. The women who've had isolated postpartum psychosis, they don't need it. So it's, it's not as if if we know about it and expect them to have an episode, you can start them the day after.

• 31:51Speaker 01

  You can start before as kind of preventive measure, but it's, it's reasonable to start them on the day of delivery.

• 32:05David Puder?

  Hmm.

• 32:06Speaker 02

  I'm curious to how you counsel patients who have their first episode of postpartum psychosis, when at that point, you don't know if it's gonna become a bipolar disorder or not. That's one of the most common questions I hear from my patients. And also then the follow up is, will I experience this again when I go through perimenopause?

• 32:27Speaker 01

  Mm hmm. Well, you know, there's no good prediction.

• 32:31Speaker 02

  I know.

• 32:32Speaker 01

  Right? But, but they wanna know, and it's understandable. And it's likely that they'd have another one in the postpartum period. And perimenopause, it's, it's hard to say. I mean, I have, I have patients who have had it. Because again, you're having frustrations.

• 32:53Speaker 02

  Right. Mm hmm.

• 32:54Speaker 01

  So yes, it can, it definitely can happen. But the important thing I would say to them is that, you know, to look out for it.

• 33:05Speaker 02

  Mm hmm.

• 33:06Speaker 01

  And report it to your psychiatrist.

• 33:09Speaker 02

  Mm hmm. Yeah, usually I think the way I've been handling it so far is to, again, expand to look at their family history. Really try to see if there's any family history of bipolar or something that happened postpartum that maybe decades ago, they didn't know what to call it. And then also kind of ask them, have they had any maybe more mild symptoms around their periods, either before or after? Just to try to get, and then that's the conversation I have is we don't really know. But this is what it shows, and we're gonna keep a close eye on you. And, and I'm gonna bring your partner in and tell them about all this stuff too.

• 33:44Speaker 01

  Well, there's often a history, not all the time. There's some history of hypomania, whether it has to do with being a leader at work, or, you know, an overworker, overachiever, those kind of patients. Now, something interesting that was a study done by Adriana Fiori.

• 34:10Speaker 02

  She's one of my, um, my boss in the access program here in Connecticut.

• 34:15Speaker 01

  Really?

• 34:16Speaker 02

  Uh huh.

• 34:17Speaker 01

  That's wonderful. Because do you know about her study on first onset postpartum psychosis? She looked at women who had first onset. She looked at women, and this was done in London, I believe. Uh, she looked at women who had bipolar disorder. And then there was a large control group. And, and this was in the bipolar group, there was like a thousand. And what she found was, I'm, I'm so not great with genetics. Um, she found that there was a variant in those women

• 35:02Speaker 01

  that was similar to the ones with bipolar disorder, suggesting that there was a similar risk factor in those women, even though we don't know whether they actually had one or not.

• 35:18Speaker 02

  Hmm.

• 35:21Speaker 02

  That's so fascinating.

• 35:23Speaker 01

  I know, it really, really is.

• 35:26David Puder?

  I have, um, paraphrased from your 2009 article, the story of the 34-year-old female. I could read that, and then we could discuss it. Would that be a, what do you think?

• 35:39Speaker 01

  Okay.

• 35:40David Puder?

  Okay. So Ms. A is a 34-year-old married female with five-year-old daughter, history of a mother with bipolar and prior postpartum depression. She has a planned pregnancy, some depression at 28 weeks. She has a healthy boy, starts breastfeeding. Day two, she cannot sleep, cannot get out of bed, cannot attend to hygiene. She's suspicious her husband will harm the baby. She has ego dystonic images of throwing him out the window. She believes her milk is hurting him. Even after the pediatrician says no, she will not bathe him.

• 36:21David Puder?

  She thinks something bad is inside him, and he cannot be moved. So if you were hearing this story at this point, what would you be thinking?

• 36:33Speaker 01

  Definitely psychosis. It's a lot of paranoid thinking. And what was interesting about this patient was that her ego dystonic symptoms ultimately became psychotic.

• 36:52David Puder?

  Hmm.

• 36:53Speaker 01

  And then I almost hate to say it, because people might get over-concerned about that. But I think it's worth it, uh, to be aware that these kinds of things do happen. She was actually one of the first patients in whom I identified the delusion of.

• 37:18Speaker 02

  Of influence?

• 37:19Speaker 01

  Thank you, delusion of influence.

• 37:21David Puder?

  I can, I can read your quote if you, if, if.

• 37:24Speaker 01

  Yeah, please do.

• 37:25David Puder?

  Okay, well, let me, let me, um, let me just go through every day, day by day, because I feel like the progression is helpful for us to kind of get a picture of how things progress, right? So, okay, so, so day two, even at that day, you're seeing some paranoia. That's what I appreciate. Um, okay, so day 12, alone in the car with her baby. She thinks, without knowing why, of killing herself and the infant. Day 13, she has an overdose. She sleeps through the night, tells no one, abruptly weans the baby. Then she's disorganized, wrong formula, wrong bottles, calling friends day and night. Day 15, she tries to smother him.

• 38:09David Puder?

  Her words, "I don't believe it was a thought, it was autopilot." Her husband comes upstairs. She says, "His presence shook her out of the state. After that evening, the compulsion is gone. She thinks she is not thinking straight. He knows she is not herself. He does not know why she is psychotic. She is not treated." That was day 15. Day 20, husband and daughter kiss her goodbye and leave for school and work. She, she feels taken over, dazed, trance-like.

• 38:50David Puder?

  Her words are, quote, "Something internal, like a force. It was not a voice, but it did not have control. It was an instant. I don't recall any, I, I don't recall thinking anything. I had no feelings. It was happening, but I wasn't there. At the time, nothing came into my head saying, no, do not do this. My inside was gone, and it was, it was something else." She's not connected with her own hand, the infant dies. She then washes him, changes his diaper, leaves the room, and tries to cut her wrists.

• 39:35Speaker 01

  So, uh, shall I comment? Or did you want?

• 39:39David Puder?

  Yes.

• 39:40Speaker 01

  Okay. So this was one, probably one case where I found that the ego dystonic thoughts became psychotic. She was the first person that I identified the delusions of influence with. And when she was talking about the force, boss, force, I thought, oh, well, this must be an OCD component to it. Because she feel like she's being forced, she's got to do it, she doesn't wanna do it. But there was something different.

• 40:21Speaker 01

  So I asked her to draw a picture of herself before and during, uh, at the time of the killing, and then afterwards. I wish I could show it to you, because I do still have it.

• 40:37Speaker 02

  Well.

• 40:38Speaker 01

  And, you know, she talks about the middle picture being the time when she killed the baby. And that middle picture, you know, she had an arrow with the force going through it.

• 40:52Speaker 02

  Hmm.

• 40:52Speaker 01

  Since that time, each woman that I have evaluated have the same kind of thing. Often, they don't identify it as a symptom because they don't know. And it is, they become a puppet. Okay, they become a puppet, and this delusion is causing them to kill. So as a matter of fact, I was, uh, pleased when Phil Resnick used the term now.

• 41:28Speaker 02

  Mm hmm.

• 41:29Speaker 01

  And what's interesting is one of our colleagues, you'll recognize her. She saw that picture several years ago at a PSI conference. And I used the term, and she identified it. She was having a lot of infanticidal thoughts. And she identified it as what happened to her. Like she had no control over her movements. And she said, she folded the paper and kept it. Because that was, it, it really identified it as a symptom.

• 42:14Speaker 01

  And often, the symptom is not identified.

• 42:19Speaker 02

  Yeah, I think I think this just really points to how important it is. And I feel like Dr. Smalley, you've just done this so remarkably well over your career is really like while you're evaluating your patients, also really learning from them, like what it's really like what they're actually experiencing and helping them even find words to describe it. I think it's it's such a catch 22 like like wanting someone who's so ill to be able to tell you exactly what they're experiencing so we can diagnose them the right way. But that's really expecting a lot of someone who is so ill, you know, so it's we really do have to do a better job at knowing what to ask, how to ask, what to look for and

• 43:04Speaker 02

  and all of that.

• 43:05Speaker 01

  Yeah, and I think what's most important is not to make your diagnosis at that time. You know, when she's feeling depressed or agitated, but to do a mental status exam, sometimes that's really missing, you know, and to ask questions about psychosis and even to do, you know, our, you know, our questions, whether they have abstract thinking and all of that, because it can really determine whether they are psychotic without even asking them. And sometimes they're not asked. I think they're not asked because

• 43:48Speaker 01

  sometimes the physician, the practitioner, doesn't want to know. You know, it's like it's going to create a big problem. I know that sounds weird, but I almost feel because it's neglected so much.

• 44:08David Puder?

  Are you are you talking specifically about cases where you've represented the the victim in a court case, like as you look through records, as you kind of like hear testimony from different physicians, these are questions that are neglected?

• 44:25Speaker 01

  Yeah, and definitely not in the records, you know, we're all very fortunate that we're in institutions that teach us state of the art. You know, we have a state of the art kind of education. And when I've had to look at charts from, you know, smaller smaller institutions or places in the Midwest that they don't maybe don't know that much about it.

• 45:08Speaker 01

  The charting and evaluations have been minimized. And you don't necessarily get a sense of even that visit, you know? And I don't mean to pick on any states in particular. I'm really just talking about, in fact, I'm talking about those of us who are very lucky to be in institutions that will teach us about something like postpartum psychosis.

• 45:46David Puder?

  Yeah, and I think that's why I'm passionate about putting these things out there right now, especially as like people are finally like waking up to like, oh, we should really, you know, there's like all these memes on social media about how physicians are charting nowadays, for example, and how carefully they're charting. It's like, um, you know, memes as in like, it's like, we're all a little bit petrified to like, make sure we're doing the right charting.

• 46:13Speaker 01

  Yeah.

• 46:13David Puder?

  So.

• 46:15Speaker 01

  And there's always the, if you didn't write it, you didn't do it, right?

• 46:22David Puder?

  Yeah, I see, I, I think for me, charting is always like one of these like things when I've, you know, I used to teach residents quite a bit. I found that they spent almost too much time charting and not enough time with the patients. Right? So I always was I always was trying to get them to be like, okay, chart for five minutes, spend 50 minutes with the patient instead of chart for 50 minutes, spend five minutes with the patient.

• 46:46Speaker 01

  Yeah, definitely. But now also with insurance, the, there are such limits on time.

• 46:56David Puder?

  Oh, yeah.

• 46:57Speaker 01

  They're supposed to do a complete evaluation in 15 minutes or that kind of thing.

• 47:04David Puder?

  Yep.

• 47:05Speaker 02

  When I, when I was coming out of residency about eight years ago and interviewing for jobs, I interviewed for one of the big telehealth companies. And I immediately said no, because they wanted me to do initial evals in like 15 or 20 minutes. And then they said, and most of your patients are going to be, you know, in the geriatric age range. And I said, what? Like, what? But I think as a physician, kind of watching everything going on, that part I feel like isn't getting enough attention about just the limitations that are really put on.

• 47:41Speaker 01

  Yeah.

• 47:42Speaker 02

  Care delivery these days and how so much of it is, it feels really out of our control.

• 47:47Speaker 01

  Yes, it really does feel out of control. And for those of us who are in larger cities for whom people pay cash or, you know, straight, not just from their pocket, they get better evaluations.

• 48:07Speaker 02

  Yeah, that's a big reason I went into private practice so I could do, oh, you know, my 90 minute evals and things like that.

• 48:16Speaker 01

  Yeah, of course.

• 48:18David Puder?

  Let me, let me kind of just get your, get your thoughts on this. A lot of women postpartum will have thoughts that are distressing. Some women will have postpartum OCD where they'll have distressing images. And I'm wondering about the shift from distressing images to psychosis. Like, once again, reiterate kind of like what you're looking for, how you're making that assessment.

• 48:47Speaker 01

  Okay, well, you just heard about the patient who did have that switch. I haven't seen many like that, but she definitely did. My advice to a physician who's seeing a patient who's having thoughts and it sounds like it's obsessional OCD. I think first, ask them, is there any voice attached to this? Because obsessional thoughts are thoughts, right? If there's voice, that's concerning.

• 49:28Speaker 01

  And then to do a full mental status exam and ask questions like, you know, not direct questions, but let her just speak. You know, do the things you would normally do to evaluate whether someone is having psychotic symptoms. Look at even serial sevens, you know? We don't tend to do that as much, but with someone like this, like, let's say this woman is disorganized, that would be important.

• 50:11Speaker 01

  And I think the thoughts versus the voice is very important.

• 50:20Speaker 01

  And, you know, if you have questions with a patient like this, you should see her frequently.

• 50:27David Puder?

  Right, yep.

• 50:28Speaker 01

  And collateral, speak to the families. That's so important. If there's a husband or partner, that is very important. I mean, you, then you're kind of covering all your bases. I know what has come down is, well, you ask the patient if she wants to harm the baby. If she doesn't want to harm the baby, then it's OCD. But if she does, it's postpartum psychosis. Well, that's not true because psychotic women don't want to hurt their babies.

• 51:04Speaker 02

  Right, right. And I think in this day and age with social media being what it is, people are very quick to want to put out some things so cut and dry.

• 51:16Speaker 01

  Yeah.

• 51:16Speaker 02

  And so like, I shouldn't I laugh about this sometimes, like in a, you know, dark sense of humor way, that like, well, if only postpartum psychosis was that simple. But it's just, it's just not, you know, like it, you just, you really can't say if it's this way or it's that way. It's really the whole picture, which takes time to elicit.

• 51:36Speaker 01

  It takes time and connection. I mean, one of the things that's very important as we've learned, because when I was doing my depression study in Colombia, I had a lot of immigrant moms from Colombia, from the country of Colombia. And they were very worried about telling me any of their symptoms, even if they were just depression, because they thought their child would be taken away from them. So I would have with moms a discussion about this.

• 52:23Speaker 01

  And tell them first, if they're not psychotic, tell them that's not going to happen. And if they are, you may have to say it's going to happen, but it would be with a loved one.

• 52:40Speaker 02

  Temporary.

• 52:41Speaker 01

  Yeah. Yeah.

• 52:43David Puder?

  Yeah. So, um, Whistler term cognitive disorganization psychosis.

• 52:50Speaker 01

  Right.

• 52:51David Puder?

  So you're, you're checking the mental status because the cognitive impairment, the thought disorganization, the lack of insight,

• 53:01David Puder?

  delirium-like appearance, which, you know, they wouldn't be able to do serial sevens, spell world backwards, draw clock. All of those are impaired in delirium-like pictures.

• 53:11Speaker 01

  I love Kathy Whistler's study.

• 53:14David Puder?

  And then also the, uh, you know, like, uh, delusions of reference, delusions of persecution, homicidal ideation behavior, visual tactile olfactory hallucinations she also mentions.

• 53:28Speaker 01

  That's, um, and, you know, probably has to do with that delirium picture.

• 53:34David Puder?

  Yeah.

• 53:35Speaker 01

  Right? I mean, you don't usually see that, but in postpartum psychosis, you do.

• 53:44Speaker 02

  And I, one way that I've heard a couple, like a handful of my patients with postpartum psychosis, describe the confusion, delirium, um, like pictures. They say it's like this weird deja vu sensation. I've had two independently describe it like that where that's like, they can't remember. Did that really happen? Did it not? Like, what day is it? It's just like this.

• 54:07Speaker 01

  Yeah.

• 54:08Speaker 02

  And I thought that was a really interesting way to describe it.

• 54:11Speaker 01

  It is. Yeah.

• 54:13David Puder?

  You also quote in one of your papers, uh, Chandra et al. saying that the majority of women with postpartum psychosis, 53% have delusional ideas that are related to the infant specifically. So someone would kill the infant or the baby would be harmed by the breast milk, stuff like that.

• 54:33Speaker 01

  Yeah. I mean, I thought that was a very interesting pa- paper of hers because it makes sense that they would have those kinds of psychotic thoughts. And if they do, of course, you want to separate them from the baby. And I would say, just as part of this, it is so important. At least that's how we do it at Columbia. If a woman comes in with a postpartum psychosis, you separate her from the baby.

• 55:09Speaker 01

  Because things can happen very quickly.

• 55:12David Puder?

  Hmm.

• 55:13Speaker 01

  The other thing I wanted to mention, and there has not been a good study and there should be because you see it or hear it in cases, is, uh, weaning. When mothers wean from breastfeeding, that they will have an increase in their symptoms or new symptom onset. And that's especially important in things like postpartum psychosis where they will give you, I mean, the new data will, will give 12 weeks before the beginning of symptoms.

• 55:52Speaker 01

  But even if it's that later, they can also have it. They might have depression first and somebody may not recognize it. They might have hypomania where people will think it's relatively normal, what they're saying, and so they don't have anything florid until later on.

• 56:17David Puder?

  Hmm.

• 56:18Speaker 01

  And often the practitioner will say, well, it's not that because it didn't start within.

• 56:27Speaker 02

  Yes.

• 56:27Speaker 01

  X weeks.

• 56:30Speaker 02

  They haven't traced, they haven't really traced it back.

• 56:32Speaker 01

  Right.

• 56:32Speaker 02

  I find, especially that hypomania picture I think is so risky because a lot of people from the outside might think like, oh, she's doing really great after having a baby. And I always think, you're not supposed to do that great after having a baby. But I, I think that can just fly right under the radar if you're not, you know, talking to the collateral information. And one way I like to ask about it is just asking them to tell me how she's spending her time. What's she doing all day? Just have them tell you, right? Because they might not realize. That's a lot of goal-directed behavior. Like they're not going to use those phrases.

• 57:11Speaker 01

  She feeds the baby and then paints a wall.

• 57:14Speaker 02

  Yeah, exactly. That's where you're like, hmm.

• 57:18David Puder?

  And what's baseline? What's baseline? Because

• 57:20Speaker 02

  Yes.

• 57:21David Puder?

  if, if a person is chronically a little bit hyperthymic, maybe it's not hypomania. But if this is very unusual behavior for them, it's like, um, you also cite this author, um, I'm going to butcher this name, Wu-Fen Zhen.

• 57:37Speaker 01

  Uthuzian.

• 57:38David Puder?

  Uthuzian. Found when comparing 20 women with postpartum psychosis versus bipolar disorder, that postpartum psychosis had more rapid intense mood shifts, more confusion, more delusions of control, such as overpowering force that made them act completely out of their own control.

• 58:01Speaker 01

  Essentially could be just like we're talking about, right? Delusions of influence. There are several studies done, I think hers was in the eighties, but there are several. That's, um, where I was able to collect the 13 who had cognitive impairment. And the picture of postpartum psychosis is very different. Maybe not very different, but it's different. You know, as we spoke of before, oh, well, you know, patient comes in, I know postpartum psychosis is a bipolar disorder.

• 58:44Speaker 01

  So they're looking for mania, history, okay? And that's not always the case. And they do their investigation or evaluation based on that visit. But don't go back, I mean, the previous pregnancy is so important to look at.

• 59:07Speaker 02

  Yes.

• 59:08Speaker 01

  The postpartum period because they may have had subtle hypomanic symptoms, right? And the mania is not so much like the mania of non-postpartum women. It's, it's kind of, okay. They're, they may have euphoria, but they're not giddy or happy, you know? At least most of them aren't. And it's also more likely to be hypomania or mixed states, particularly a mixed state. Uh, and people miss those kinds of things.

• 59:54David Puder?

  I, I think, I think as a, just as an outpatient psychiatrist who sees postpartum patients now, I'm very, you know, concerned, like, okay, is it, is an SSRI a good idea? If someone comes in, you know, knowing that post, you know, the postpartum psychosis

• 1:00:14David Puder?

  is more of a bipolar spectrum, I, you know, you don't really want to give an SSRI to someone who's postpartum psychosis. But if they're coming and all you see is that depression picture or that OCD-like picture, you may be thinking SSRI. Any thoughts on that?

• 1:00:30Speaker 01

  Yes. What I would do if I thought an SSRI was, even, even with, without the history or anything. If you give an SSRI, talk to her about the activation.

• 1:00:45Speaker 02

  Mm-hmm.

• 1:00:46Speaker 01

  And tell them to call you either the next day or the one after. Then I would bring them back. Let's say they did have the symptoms. I would bring them back and do one more test with either an SSRI or another antidepressant. And again, speak to them, call them, have them call you and let you know how they're feeling. You know, because if somebody does have depression and anxiety, it's very likely going to make the anxiety worse, right?

• 1:01:25Speaker 01

  But you want to make sure that the anxiety is not a, a component of any kind of psychotic episode. So if they did not have activation, I would leave them on it, but I would check in with them at least twice a week.

• 1:01:45David Puder?

  Hmm.

• 1:01:46Speaker 01

  Couple of weeks. If they did have, then I would put them on a mood stabilizer. I mean, you don't want to label people with something that's not necessary. So that's why I like to do it at least twice.

• 1:02:04Speaker 02

  Mm-hmm.

• 1:02:07David Puder?

  If Katrina, anything else, any other questions come into your mind?

• 1:02:11Speaker 02

  Oh, my gosh, a zillion. I guess, Dr. Spinelli, I'm just curious to hear now, looking back on, you know, the past few decades, working in this forensic space, what has that been like? And how do, you know, how does the next generation of trainees who hopefully still want to go into reproductive psychiatry? How do we like empower the next generation to keep talking about this moving forward? And so there's more experts to draw on as, you know, as a forward.

• 1:02:47Speaker 01

  All those years, nobody would do it at all. Or, you know, maybe somebody in the South, maybe somebody, you know, Midwest. Okay, I would recommend, you know, I didn't have forensic training. I kind of learned on the way, which is not always the best way to do it. But you learn, it's better than them not having anybody sticking up for them.

• 1:03:18Speaker 02

  Yes.

• 1:03:19Speaker 01

  One of the things that I keep in mind, and when people ask me about this, it's really about saving lives. I mean, you talk about, well, there are two dead babies and why are you sticking up for her? That kind of thing. Because while we may not save those children, there are other children that can be saved if people identify this illness. As far as the forensic piece, it's tough because a forensic fellowship is another year or two.

• 1:04:02Speaker 01

  And if you've had good training in perinatal psychiatry, it should be a reasonable time also. You know, for people who say, well, this organization, you know, I had three days of education on perinatal illness or postnatal illness. It's really not enough because if you're doing a fellowship or training, you are also seeing patients.

• 1:04:44Speaker 01

  And you're getting an idea, a good sample of patients that you're going to be medicating. It isn't enough to say, oh, well, she's pregnant. SSRIs are quote unquote, "safe," right? That's not the only thing you learn. It can be such a mixed picture.

• 1:05:08David Puder?

  I think it would be good to kind of give the, the audience an update. Where we are going with the DSM, with the diagnosis, you have some inside kind of information?

• 1:05:19Speaker 01

  It's, it's positive. I mean, the committee wrote an email to Viral version. And, you know, there's Viral and maybe 20 more of us on this committee. And said that they agree that the specifiers are not useful, except in some cases. And they will place it in the DSM. So that will be hopefully the next DSM TR, DSM V TR.

• 1:05:58Speaker 01

  So there was that sentence, which is very, very positive. In addition, which is actually a positive thing, because they didn't know where to put it. They decided that all of us should write a chapter. I mean, this group should submit a chapter on illnesses associated with childbearing. So that's a very positive thing.

• 1:06:31David Puder?

  What do you think it would take for our laws in the US to mirror other European laws that are a little bit more compassionate?

• 1:06:41Speaker 01

  Yeah. We don't have a very compassionate legal system, as you know. It's hard to answer that, but you know, Susan Feingold got one passed in Illinois. That was kind of special. It was essentially written with Susan and her partner by a woman who had served 30 years away. I don't know what the answer is because it's not in our purview, you know?

• 1:07:19David Puder?

  Sure, sure.

• 1:07:20Speaker 01

  Maybe the fact that it goes into the DSM.

• 1:07:24David Puder?

  I think that's a good step.

• 1:07:26Speaker 01

  Do it. Yes, definitely.

• 1:07:28David Puder?

  And I think educational, things like this as well, that, you know, if, if, if more people understand it and more, more people understand, you know, the delirium aspect, the confusion aspect, the delusional, feeling like you're being controlled by a puppet. It really is a loss of, I talk about free will on my podcast, you know? And I see free will as a spectrum. And I see the, the more severely ill you are, you have less choice.

• 1:08:03Speaker 01

  Yeah.

• 1:08:03David Puder?

  And if you are at the fringe of the most severe place, cognitively, emotionally, psychologically, you have almost no, like, no choice.

• 1:08:17Speaker 01

  I would suggest to anybody who's going to be giving lectures or anything else, that they pull up the picture of the HPO axis because it explains it. You know, it explains how the neurotransmitters, right? In the base of the brain, in the hypothalamus, will interact with the thyroid, et cetera, and the ovaries, and that there is a reciprocal relationship. And that keeps the menstrual cycle going.

• 1:08:59Speaker 01

  But that's so important so that when there is a loss of hormone, it has quite an impact on the brain and the neurochemicals in the brain. And so I feel like that gives people a biological foundation. I mean, you know, it's not because your father beat you. Or it's not because her mother yelled at her. But that this is biology and there's no other way to explain it.

• 1:09:39David Puder?

  Yeah, and there's, there's, you know, hormones, there's inflammation, there's genes, there's all these things coming together. And, you know, if you, if you understand delirium, you know, I mean, and there is very little studies on postpartum psychosis compared to things like delirium. But if you understand delirium, there's huge hormone, huge neurotransmitter imbalances in the brain during delirium. There's like, it's not just like a couple neurotransmitters. It's like hundreds, if not thousands of things going wrong all at once.

• 1:10:13Speaker 01

  Yeah.

• 1:10:13David Puder?

  And I, I don't know if there's any studies where they stick postpartum psychosis people actively in the psychotic state in an MRI. But there's some bipolar that I've seen who are just in a manic state and their brain is not a normal brain. Their brain is a very disturbed brain. So, yeah.

• 1:10:36Speaker 01

  And remember, well, there was one study about, I think she was, well, she was psychotic or depressed, where there was a few women. And they went into the MRI or the CT scan. And they put a picture of their baby up next to the scan. And I think, yes, then they took pictures of the brain. They had, and the women with depression, the women without depression, the amygdala and something else lit up.

• 1:11:21Speaker 01

  And for the women with depression, it did not. I was always so impressed with that study, you know? And I agree what you're saying with inflammation. The reason I bring up the hormones, it explains it for people. I mean, they can see it. They're not going to get right now until we have more data. They're not going to get the inflammation so much.

• 1:11:52David Puder?

  Yeah, and I think my point is that there's so many things going on, right? There's so many things. It's not just like,

• 1:12:00Speaker 01

  Yeah.

• 1:12:00David Puder?

  You know, and, and we're, we're, this is like the frontier of psychiatry. We need people, hopefully people listening to this that want to do more research, that want to join research teams, that are looking at more mechanisms of understanding. But yeah, I would point to the other literature that we do have bipolar mania, what's going on, memory issues in the mistomania. I have patients all the times that lose weeks of time. I had a patient just today, manic patient in the psychiatric hospital, doesn't remember three weeks of her life. Completely blank. Does, she has little, little moments where she'll remember just frac, like just a teeny bit here and there.

• 1:12:44David Puder?

  But for the, for the vast majority, she was in a psychiatric hospital. She's like, I, I asked my husband, how long was I in there? And he said, three weeks. And I said, three weeks? I only remember like two things happening in that whole hospitalization. Like she was blown away that it was three weeks. So yeah, there's a lot of things going on. Well, it, it was a pleasure having you on, Dr. Spinelli, Dr. Fury, as always. I know we should probably wrap this up here. Any last sort of advice, last input?

• 1:13:17Speaker 01

  Yes. If you see a woman and you believe she has postpartum psychosis, separate her from the baby, get in touch with the family. And if she does, hospitalize her. That's the best prevention. You know, I think this is such a wonderful thing that you're doing. And I appreciate your invitation.

• 1:13:45David Puder?

  Well, I appreciate you coming on, taking the time with us and Dr. Fury as well. Dr. Fury, any last thoughts, any last things you want to?

• 1:13:53Speaker 02

  Oh, I could just sit and listen to you all day and try to soak it all in. I think just thank you for being such a pioneer in the field and being so warm and open and educating all of us. And, you know, leaves me feeling a lot of hope that, you know, this condition-

• 1:14:11Speaker 01

  There is. You guys have so much to work with now.

• 1:14:15Speaker 02

  Yeah. And I think that's, that's the final thought I'd want to leave people with is that postpartum psychosis is very severe. It's very scary. The potential outcomes are tragic and yet most women get better. If you diagnose it and you treat it, it's, it's very treatable. It's very reversible. And I think that speaks to the underlying biological nature of it. And that is what makes doing this work so rewarding. You really do feel like you're saving lives.

• 1:14:44Speaker 01

  You do. You do, and you are. And again, if you testify, you're not, as some people would say, testifying for a murderer. You're testifying because you're going to save lives in the future. But you're also testifying for a murderer who is ill, of course.

• 1:15:08Speaker 02

  Yeah.

• 1:15:09David Puder?

  You're, you're trying to explain very complex, very nuanced things that it's taken me as a psychiatrist, years to understand. If it's taken me years to understand, we have to be patient with the public, with the jury, that, you know, it's just hearing this for the first time, is trying to understand it for the first time. And we need to continue to speak in such a way that it makes sense. And it's, you know, we can present our case, having research studies showing, showing, by the way, very hopeful that with treatment, the majority of women can recover.

• 1:15:49Speaker 01

  Very well.

• 1:15:51Speaker 02

  Exactly.

• 1:15:52Speaker 01

  There's also something important, just as an addition. When you do your evaluation, remember to increase, to look at thyroid studies with the rest of your urine culture with, but there should be a whole metabolic panel.

• 1:16:11Speaker 02

  Yes.

• 1:16:12Speaker 01

  But people might forget thyroid and thyroid antibodies.

• 1:16:18David Puder?

  Yeah. And if there's other neurological issues, anti-NMDA, which is about two to 4%, but it's a small amount. But if there are other, other glaring symptoms, neurological symptoms, then we should, you know, consider that. Postpartum thyroiditis is a different type-

• 1:16:36Speaker 02

  And that's one way, that's one way in my practice at least, that I've had some success when women don't want to go to the ER. If they don't want to be separated from their baby, or there can be a whole host of reasons why. I will often say, we, you know, you just had a baby. We really need to do a full medical workup to make sure everything checks out. And I, I really believe that. And I think again, it points to how important it is to do that full medical workup. And as a doctor, like we talked about last time, Dr. Peter, call ahead and talk to the ER physician directly so that they don't show up and wait and then get discharged because they quote unquote, "look fine."

• 1:17:13David Puder?

  And my other, my other thought is like, you know, think about what university hospital you send them to. You know, because I, because I think that not everywhere has a Columbia, UCLA, you know, unfortunately, right? So it's, it's like, we have to think about where we're sending the people. Hopefully they have some sort of reproductive psychiatry presence onsite. Like if the university has that, that's probably where you want to send them. And you want to, of course, coordinate care and yeah.

• 1:17:47Speaker 01

  And even if they don't have that, if they know state of the art treatment, you know, that they know how to treat psychosis even. But yes, they have a, if you can get to a reproductive site, that's wonderful. But to end, let's just say this is a tragic illness.

• 1:18:14David Puder?

  Yeah. Yes. Well, thank you so much once again, Dr. Spinelli, Dr. Fury. Thank you so much for coming on. Appreciate you guys. And we'll leave it there for today.

• 1:18:25Speaker 01

  Thank you both.

• 1:18:26Speaker 02

  Thank you.