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ABSTRACT FROM: Bergink V, Burgerhout KM, Koorengevel KM, et al. Treatment of psychosis and mania in the postpartum period. Am J Psychiatry 2015;172:115–23.
What is already known on this topic
Postpartum psychosis (PPP) is a severe psychiatric illness that occurs in the first weeks following delivery and may have devastating consequences (eg, suicide, infanticide).1 Hospitalisation and medication are required to stabilise and protect the mother and ensure the baby’s safety. Current treatments include one or a combination of antipsychotics, mood stabilisers and electroconvulsive therapy (ECT);2 however, there is limited evidence for specific treatments of PPP.
Methods of the study
Bergink and colleagues designed a four-step algorithm and examined outcomes of 64 mothers (mean age: 31.9) diagnosed with PPP via the Structured Clinical Interview for DSM Disorders (SCID-I), Patient Edition. Participants were recruited between 2005 and 2011 from a psychiatric inpatient unit in the Netherlands specifically for postpartum patients with severe psychopathology. A psychiatrist (1 of 2 study authors) evaluated participants weekly during admission and 9 months post partum. Clinical remission was defined as the absence of psychotic, manic and depressive symptoms for at least 1 week with a Clinical Global Impressions-Bipolar Disorder (CGI-BP) score ≤3, a Young Mania Rating Scale score ≤8, and an Edinburgh Postnatal Depression Scale score ≤10. Each algorithm step is described below.
Step 1: All patients were to be treated initially with lorazepam at bedtime for 3 days; however only 53 received solely lorazepam, as a subset of 11 patients who had already been treated with an antipsychotic for more than 2 days before admission (eg, by acute services) skipped step 1 and continued treatment with the same antipsychotic.
Step 2: For patients with persistent manic or psychotic symptoms, antipsychotic medication was recommended beginning on day 4 (haloperidol 2–6 mg/day, but patients could switch to a second-generation antipsychotic, if side effects occurred). After step 1, two participants (3.8%) experienced remission of manic/psychotic symptoms. Of the remaining 62 participants, 2 declined any further treatment and 1 declined treatment with an antipsychotic. Therefore, 59 were included in step 2.
Step 3: After 2 weeks of combination treatment with a benzodiazepine and an antipsychotic, adjunctive lithium was recommended for those patients who did not have a significant clinical response. After step 2, 10 participants (16.9%) experienced remission of manic/psychotic symptoms. Of the 49 remaining participants, 2 could not initiate or declined lithium therapy. Adjunctive lithium (plasma levels: 0.8–1.2 mmol/L) was initiated in the remaining 47 participants.
Step 4: For non-remitters after 12 weeks, ECT was planned (all psychotropic medications would have been tapered off before initiation of ECT). However, after step 3, 46 participants (97.9%) achieved remission and 1 participant was discharged against medical advice, so nobody received ECT.
After complete remission of symptoms, all women were advised to discontinue benzodiazepines. Women receiving antipsychotic monotherapy were advised to continue this treatment for 9 months and those who achieved clinical remission using antipsychotics and lithium were advised to taper off antipsychotic treatment, with lithium monotherapy as maintenance treatment until 9 months post partum (lithium levels: 0.6–0.8 mmol/L). Sustained remission (defined as the absence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) mood/psychotic episodes and maintenance of a CGI-BP score of ≤3) was observed in 51 (79.7%) participants at 9 months post partum.
What this paper adds
This is the first attempt to provide evidence for a precise treatment algorithm for this severe illness using a prospective research design in a field dominated by case reports and retrospective studies.
The majority of patients achieved remission at step 3 and maintained it over 9 months.
The percentage of participants who responded to benzodiazepines alone was 3.7%. Being able to offer monotherapy and tailor treatments is potentially helpful in this population where women are reluctant to take pharmacotherapy (eg, breast feeding concerns).
The authors’ conclusion that maintenance with lithium monotherapy, in comparison to maintenance with antipsychotics, is highly protective against relapse may not be accurate. Participants maintained on lithium monotherapy received benzodiazepines, lithium and antipsychotics during the acute phase, whereas participants maintained on antipsychotic therapy received only benzodiazepines and antipsychotics. Thus, it is unclear whether the lower rates of relapse in the lithium group are due to the protective effects of lithium or due to the continuing benefits of acute treatment with a combination of an antipsychotic and lithium.
Only eight participants were continuously maintained on antipsychotics during the follow-up period; this sample is too small to get an accurate picture of the relapse rate in this group.
Symptom severity at admission is not reported, leaving open the question of non-equivalence at baseline. Thus, differences in outcome could be due to differences in symptom severity at baseline.
What next in research
Inclusion of a lithium–benzodiazepine study group would provide greater confidence that postremission lithium monotherapy is superior to antipsychotics in preventing relapse. A larger sample size would enhance the generalisability of these results.
Do these results change your practices and why?
Yes. Women with PPP may benefit from taking benzodiazepine monotherapy, in addition to strict sleep hygiene methods. This may be sufficient treatment for a small subset of women and preclude requiring multiple psychotropic medications. Given that the combination of benzodiazepines, antipsychotics and lithium produced the highest remission rates, adding lithium earlier in the postpartum phase may induce remission more quickly and effectively.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
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