Ten Ways to Improve Post Partum Psychosis Care in the United States

I have two recent posts on the issue and thought I would add this as a better summary.  The media refrains at this point are tiresome and not helpful.  Just yesterday I heard arguments about how the current Clancy case is or is not an indictment of the mental health system.  That was followed by a poll that said most men consider filicide cold blooded murder and most woman are more sympathetic.  There are of course social media influencers amplifying those extremes to get likes and improve their revenue streams and politicians doing the same. All of this occurs in the context of highly publicized incidents of violence perpetrated by persons with obvious severe mental illness on the streets in New York and other large cities. Those incidents have resulted in loss of life of both victims and perpetrators. 

Any consistent reader of this blog over the years should get the strong message that there is no system of care for mental illnesses in the US and that the system of care for physical illnesses is rapidly going down the same tube. Disproportionate rationing of care for mental illnesses started out as a profit maker for the managed care industry and that has expanded to all medical care.  As a result, there has been an explosion in the number of administrators compared with people doing the work and a transfer of a trillion dollars a year to management.  It is more than profit making at this point. It leads to a current lack of quality care for those who can access it and it is unsustainable.

Here are a few thoughts on getting an actual system in place that might be able to address the real problems rather than focusing on all of the non-functional political rhetoric.    There is some overlap between points.  That is intentional to place more of a focus on postpartum care. 

1:  Improve mental health and the care of mental illnesses in general – The first time the federal government took a direct role in the provision of mental health services was the Community Mental Health Act of 1963 signed by President Kennedy.  The goal was to move mental health care out of asylums and back to communities.  It led to the creation of many Community Mental Health Centers.  Even as late as 1988, I was providing care at a rural hospital so they would not default on a grant they obtained though that original Act.  Since then many CMHCs have been closed.  Some have been assimilated by other non-public systems of care.  New certified community behavioral health clinics (CCBHCs), were established under the Protecting Access to Medicare Act of 2014 rather than continuing the CMHC category.  This changing landscape has made facilities a poor proxy for access to mental health care. 

 Better metrics and the current statistics are included in the table below:

Metric	What it measures	Key statistics	References
1. Treatment rate / minimally adequate treatment	Whether care reached the person and met a guideline-based quality threshold	Of 24.9% of US adults with a past-year disorder, 60.7% received any treatment but only 34.0% received minimally adequate treatment (MDPS, SCID-5). Historically ~47.7% of adults with serious conditions received no treatment; only ~44.8% of adults with any mental illness treated in 2019	[1-3]
2. Workforce supply per population (HPSA)	Provider capacity relative to population; shortage-area designation	>1/3 of Americans live in a behavioral health workforce shortage area; majority of counties lack any practicing psychiatrist, psychologist, or social worker; psychiatrists per 100,000 fell ~10% (2003–2013) while PCP/neurology supply grew	[4-5]
3. Timely access (availability & wait times)	Whether providers accept new patients and how long the wait is	Only 18.5% of sampled psychiatrists available to new patients; median wait 67 days (in-person) vs 43 days (telepsychiatry); worse for Medicaid than private insurance	[6]
4. Two-dimensional geographic access (availability + affordability)	County provider supply per 100,000 AND cost of a treatment course vs disposable income, mapped simultaneously	Reveals counties where providers are physically present but financially inaccessible; income was the strongest predictor of both dimensions; rural and Southern counties carry dual burdens	[7-8]
5. Medicaid acceptance & out-of-pocket burden	Whether existing providers accept Medicaid/new patients and cost-sharing faced by patients	~Nearly half of psychiatrists do not accept insurance due to poor reimbursement eliminates SMI patients who hit benefit limits; SMI care is disproportionately publicly financed	[5]
1:  Edlund M, Guyer H, Ringeisen H, Stambaugh L, Dever J, Carpenter L, Olfson M, First M, Geiger P, Liao D, Peytchev A, Carr C, Zangeneh S, Chwastiak L, Dixon L, Monroe-Devita M, Stroup TS, Swanson J, Swartz M, Gibbons R, Bareis N, Kessler RC. Treatment of Mental Disorders Among U.S. Adults: Findings From the Mental and Substance Use Disorders Prevalence Study. Psychiatr Serv. 2026 Jul 22:appips20250398. doi: 10.1176/appi.ps.20250398. Epub ahead of print. PMID: 42482274. 2:  Olfson M, Wang S, Wall M, Marcus SC, Blanco C. Trends in Serious Psychological Distress and Outpatient Mental Health Care of US Adults. JAMA Psychiatry. 2019;76(2):152–161. doi:10.1001/jamapsychiatry.2018.3550 3: Askari, M.S., Mauro, P.M., Kaur, N. et al. Age, Period, and Cohort Trends in Perceived Mental Health Treatment Need and Differences by Mental Health Severity in the United States, 2008–2019. Community Ment Health J 59, 631–640 (2023). https://doi.org/10.1007/s10597-022-01044-3 4:  Substance Abuse and Mental Health Services Administration. Expanding Behavioral Health Teams in Care Deserts With Community Health Workers and Peer Support Specialists. Publication No. PEP26-07-001. Substance Abuse and Mental Health Services Administration. 2026. 5:   Huskamp HA, Iglehart JK. Mental Health and Substance-Use Reforms--Milestones Reached, Challenges Ahead. N Engl J Med. 2016 Aug 18;375(7):688-95. doi: 10.1056/NEJMhpr1601861. PMID: 27532837. 6:  Sun CF, Correll CU, Trestman RL, Lin Y, Xie H, Hankey MS, Uymatiao RP, Patel RT, Metsutnan VL, McDaid EC, Saha A, Kuo C, Lewis P, Bhatt SH, Lipphard LE, Kablinger AS. Low availability, long wait times, and high geographic disparity of psychiatric outpatient care in the US. Gen Hosp Psychiatry. 2023 Sep-Oct;84:12-17. doi: 10.1016/j.genhosppsych.2023.05.012. Epub 2023 May 25. PMID: 37290263. 7:  Park J, Kim HR, Duffy RD, Vogel D, Keum BT, Lee S, Tomé NL. Two dimensions of access: Availability and affordability of mental health care across the United States. Am Psychol. 2026 Jun 4. doi: 10.1037/amp0001735. Epub ahead of print. PMID: 42241094. 8:  Cummings JR, Allen L, Clennon J, Ji X, Druss BG. Geographic Access to Specialty Mental Health Care Across High- and Low-Income US Communities. JAMA Psychiatry. 2017;74(5):476–484. doi:10.1001/jamapsychiatry.2017.0303

 

The data for postpartum depression in various clinical settings is that only 6.3% of women with the disorder receive adequate treatment and only 3.2% of that cohort achieve remission (1).  Similar rates are not available in those populations for postpartum psychosis, but there is no reason to expect the numbers would be better.  In a study of postpartum psychosis where all of the cases were identified as a cohort treated by the same research group the remission rate was 82-94% (2) illustrating the rates of treatment response with a comprehensive program.

The first metric is the clearest indicator of a non-system.  Less than half of anyone with a serious mental disorder or any mental disorder receives minimally adequate care in this country. For some conditions like depression that number goes as low as 10% when considering effective treatment for depression. With those numbers it should not be surprising that people with acute symptoms are obvious at times. Metrics 2 – 5 explain why the gap exists (capacity, timeliness, geography, and financing).  There are concrete ways to address every one of those problems.

2:  Develop state of the art guidelines for treatment - the existing system has evolved to ration access and shift costs to non-mental health care settings like jails, shelters, and county detox units.  This impedes access to medical providers with the most resources and access to referrals.  The standard crisis approach at most hospitals creates a boarding situation in emergency departments (ED), excessive congestion, and slows access to mental health care.  Many people end up leaving without treatment.

3:  Develop adequate inpatient units for care – bed requirements to produce the same wait time and access to care that medical and surgical patients get have been determined.  States and health care systems have been reluctant to build and staff those adequate numbers and there is some indication that medical and surgical beds are also in short supply.  Granted there is more ambulatory care than in the past – but it clearly has been inadequate at alleviating pressure on both the ED and hospital admissions.  Many outpatient mental health providers use the ED for after hours crisis referral and in many cases it is the only way to access more intensive services like electroconvulsive therapy.  The ED services that I am familiar with do not provide crisis care.  They provide a decision about whether a person should be admitted to the hospital or not and the bias is on the not side.

4: Adequately fund treatment maternal care including replacing the Medicaid funding that has been cut - Medicaid is the largest single payer of maternal care, mental health and substance use treatment – even before additional funding is considered.  The current administration cut this funding source by $1trillion over the next decade.  Even before those cuts directly impact all of those millions of individuals – hundreds of rural and safety net hospitals and other facilities will be closed.  In the process all health care premiums will increase fueling the ongoing cycle rationing and cost-shifting to increase corporate profits.  Safety net hospitals are generally critical components of the treatment of severe mental illnesses and psychiatric emergencies.  Every hospital with a large obstetric component needs mental health consultants that know about perinatal care.   

5:  Educate medical professionals about the disorder – most of the physicians I have discussed this disorder with have encountered some form of maternal mental disorder that compromised the safety of the mother or child at some point in their training and career.  In my experience it first happened during my clinical rotation though obstetrics and gynecology (OBGYN) in medical school.  At that time there was no discussion of the mental disorder or what care was necessary. Even as a psychiatric resident, I saw patients with the disorder but there was no discussion of specific evaluation or treatment.   I did not start to see that information until about a decade into clinical practice.  My next post will have the top groups worldwide studying this disorder as well as some of the top references.   

6:  Promote maternal mental health as a necessary subject in primary care and psychiatric specialties – the full array of psychiatric disorders associated with the peripartum state has become a lot clearer with research. It is a frequent topic at psychiatric research and continuing education conferences.  All primary care specialists need to have a good idea about necessary care and available resources.  The psychopharmacology of these disorders is also a necessary topic and the experts in that area do not necessarily overlap with postpartum psychosis experts (3).

7:   Prioritize prophylactic treatment of severe mental disorders before and during pregnancy – in woman with known preexisting psychiatric disorders there is a lot known about effective prophylaxis that is safe at all stages of pregnancy.  Pregnancy is a known cause of rapidly worsening pre-existing mental disorders and there should be a plan in place to prevent that disruption.  

8:  Educate the general public about the disorder – in one of the studies I referenced in a previous post the partner involved was unaware of pregnancy related mental health disorders and was often concerned about the loss of the relationship or future with the woman involved.  All of that can be addressed in education about peripartum and postpartum care and the appropriate educational materials made available.

Social media is a very poor format for these discussions because of the level of misinformation out there about psychiatric disorders as well as the political posturing involved.  That has resulted in moralistic positions being taken that have no basis in reality.  And yes – I am saying as a psychiatrist that mental conditions can affect consciousness, insight, judgment, and agency to the point that a person will make a decision that they would not otherwise make in the commission of a crime.  And further I am saying that is a qualitative change and not a quantitative one.  In other words it is not getting excessively angry or emotional in the heat of the moment, it is an entirely different state of mind.   

9:  Adequately fund research on the disorder – like most people reading this I do not have a scorecard on what research programs or scientists were cut doing research on this disorder.  I think there is a general bias with the new political movement against women up to an including the criminalization of pregnancy complications in some states.  Those laws place the lives of women at risk and the careers of professionals trying to treat them at risk. With that level of overt bias against women, I would not be shocked to see research grants in this area defunded.  After reading some of the research from groups with organized research efforts – I do not want to see that happen.  

10:  Add postpartum psychosis and depression to the DSM – this was an ongoing debate in the research I reviewed for my posts on the topics.  As noted in the graphic at the top of this post – ICD has discrete diagnoses for both postpartum depression and postpartum psychosis. The DSM uses a “peripartum” specifier for 11 pre-existing categories most of which are mood disorders.  There is always debate about what codes to include in a DSM – but my reading of the literature suggests that there are clearcut cases that only occur postpartum and that is a critical distinction in terms of whether maintenance medication is required.  The only non-mood disorder diagnosis in the DSM with a peri-partum specifier is brief psychotic disorder. Based on the cases I have seen and treated my speculation is that the group of women in that category who are postpartum is extremely small.

A section on women’s mental health in the DSM listing these disorders and other considerations would be a welcome addition.  It fulfills the goal of mapping onto the ICD codes and could be a valuable source of education about these disorders.

These are a few of the thoughts I have about what is needed to improve mental health care in the US. I am painfully aware of the The Mental Health Parity and Addiction Equity Act (MHPAEA) and its unfulfilled promise. It also illustrates that as long as governments allow for profit businesses to run the healthcare system – the only expectation should be continued deterioration in care and higher expenses.  The current stance of most companies denying care is they will ignore you until you either get a national news organization to look into their care denial or you sue them.

That is not a way to run an ethical healthcare company or have an actual system of care.

 

George Dawson, MD, DFAPA

 

Supplementary 1:  I have posted my experience in his area many times on this blog and therefore did not include it in the above post.  When I started working at a major medical center in 1989, the department heads were all physicians who were doing clinical work, teaching, and research.  The only business people present were business managers who answered to the head of the department. Over the next 20 years – department heads were physicians in name only who mostly did administration.  There was still a business manager.  And now there was an entire tower of executives managing all of us by basically giving us the message that we were not working hard enough.  We were routinely called up to implement bad ideas from management.  When I tried to contact the tower directly I was told: “You should think of a firewall between the clinicians and us”.   Translation: don’t ever call us – just listen to us through your physician/manager and business manager.

Supplementary 2:  I will have a major post out in the next few weeks looking at all of the top research groups in the world on postpartum psychosis and a few of their references.  I will have a separate post on peripartum psychopharmacology since I have attended several of these meetings and have first hand knowledge of many of these researchers.

 

References:

1:  Cox EQ, Sowa NA, Meltzer-Brody SE, Gaynes BN. The Perinatal Depression Treatment Cascade: Baby Steps Toward Improving Outcomes. J Clin Psychiatry. 2016 Sep;77(9):1189-1200. doi: 10.4088/JCP.15r10174. PMID: 27780317.

2: Kamperman AM, Veldman-Hoek MJ, Wesseloo R, Robertson Blackmore E, Bergink V. Phenotypical characteristics of postpartum psychosis: A clinical cohort study. Bipolar Disord. 2017 Sep;19(6):450-457. doi: 10.1111/bdi.12523. Epub 2017 Jul 12. PMID: 28699248.

3:  Bourke CH, Stowe ZN, Owens MJ. Prenatal antidepressant exposure: clinical and preclinical findings. Pharmacol Rev. 2014 Feb 24;66(2):435-65. doi: 10.1124/pr.111.005207. PMID: 24567054; PMCID: PMC3973612.

Photo Credit:  Rick Ziegler - sunset over Lake Superior March 2024

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Peripartum Depression and Psychosis - Nosology, Phenomenology, and Research

 Peripartum Depression and Psychosis – A Major Change Is Ignored

 

In my previous post, I covered some of the legal, social, and cultural shortcomings affecting peripartum and postpartum depression and psychosis.  In this post I am going to cover a very basic concept that I have discussed before and that is consciousness. It is a major shortcoming of criteria-based diagnoses like the DSM.  It is conspicuous by its absence. The DSM makes it seem like all you need is a set of criteria, an adequate time frame, and the ability to rule out other causes and you can make any psychiatric diagnosis.  The only time human consciousness enters the picture is when the discussion is of altered states of consciousness like delirium or dementia.  Even then older neurological terms like stupor and coma seem to do a better job of capturing what is happening (1).

The additional limitation of criteria-based diagnoses is that they do not get to a more complete description of behavior. A delusion is not the total experience – the individual’s subjective experience is of secondary importance.  It is assumed that behavior is either predicated on the delusion or other aspects of the person’s life or personality. In psychiatric practice there is an entire other constellation of factors that are typically included in a formulation, but even then, the current subjective experience is not a focus. 

We all have a baseline conscious state that we are familiar with. Most discussions of consciousness begin with a disclaimer about no universally accepted definitions.  A good general definition addresses 2 components – level of consciousness (wakefulness/arousal) and contents of consciousness (specific objects and events that one is aware of).  The content can be encyclopedic but there are also ongoing neurobiological processes to consolidate, cue, and reinforce that content in varying ways. It is a dynamic rather than static process. It has to be in order to give you an integrated experience of life.  The most important product is the integrated first-person experience of oneself and the world.  But it is important to note that consciousness is more than just that since there are additional processes (access, intentionality, self-awareness).

Let me back up a bit and start out with the concept of phenomenal experience. This is the subjective or “what it is like” to have an experience.  A common example in the literature is the color red as in: “My experience of the color red is not your experience.”  That happens at a number of levels but most people consider there is a consensus about the color and leave it at that. Core features include qualia or the pure sensory experience without associated information processing, first-person experience, and distinct from other capacities like reasoning or controlling one’s behavior.

Phenomenal experience is one aspect of human consciousness.  Additional aspects include:

Cognitive access: content can be reported upon, accessed, and manipulated (reasoned about and used to guide action).

Self-awareness:  awareness as oneself with a capacity for generating thought and action.  Ability to distinguish oneself from the world including other people.

Intentionality: directed perception of objects and processes in the environment.

Reflective capacity:  knowing that the sensory experience is more than just sensation e.g. knowing that you see is more than just seeing it leads to an integrated experience at several levels.

Flexible cognitive control:  flexible modulation of attention, processing novel situations, decision-making, and integrating information. That includes daydreaming, fantasizing, mental work, and directing yourself to and away from those processes

There are numerous studies that map these functions onto neuroanatomical structures and neurophysiological events. There is also the interesting mapping of these functions onto ego functions that have been extensively elaborated on since Freud.  An example of a common ego-function that most people have heard of is reality testing.  It is defined just as it sounds: “The components are (a) the distinction between inner and outer stimuli; (b) accuracy of perception (including orientation to time and place and interpretation of external events), and (c) accuracy of inner reality testing (psychological mindedness and awareness of inner states).”  (13).  I have consolidated these mappings into the following table to illustrate what happens in psychosis.

Feature of Human Consciousness	Corresponding Ego Function(s)	How Altered in Psychosis (with Examples)	References
Cognitive access / reportability (content broadcast for report, reasoning, action — access consciousness)	Thought processes; judgment; regulation/control	Elevated threshold for conscious access with intact subliminal processing, attributed to disrupted top-down attentional amplification; correlates with reduced long-distance white-matter connectivity in the global-workspace network. Example: Schizophrenia patients require longer stimulus durations to consciously perceive a masked word, while unconscious priming is preserved.	[1]–[3]
Self-awareness and a unified self (awareness of oneself as a persisting agent)	Synthetic/integrative function; relation to reality (self/world demarcation)	Self-disorders with permeable ego-boundaries and disturbed agency; altered cortical-midline (mPFC, PCC/precuneus) and temporoparietal-junction activity during self-reflection and source monitoring. Examples: Thought insertion, thought broadcasting, passivity/made experiences, misattributing self-generated actions to others.	[4]–[6]
Intentionality (aboutness) + distinguishing internal from external	Reality testing (relation to reality)	Breakdown in differentiating internally generated from externally sourced experience across "reality distortion," "uncertainty of perception," and "hallucinations/delusions" domains; reduced parahippocampal/inferior-parietal activity during reality evaluation. Examples: Hallucinating a voice with no external stimulus; fixed delusional beliefs; confident memory errors misattributed to real events.	[8]–[10]
Reflective / metacognitive capacities (knowing that one experiences)	Judgment; synthetic function; observing-ego capacity	Metacognitive deficit with impaired insight and overconfidence in errors; disrupted anticorrelated balance between frontoparietal control and default-mode networks scaling with symptom severity. Examples: Poor illness insight (anosognosia for psychosis), high confidence in incorrect judgments, impaired self-monitoring.	[10]–[12]
Flexible cognitive control (attention modulation, novel contexts, decision-making, cross-modal integration)	Regulation and control of drives; autonomous functions; synthetic function	Imprecise hierarchical predictive coding — low precision of priors relative to sensory data — yielding aberrant salience and maladaptive belief updating via hippocampal-prefrontal-striatal dysfunction. Examples: Aberrant salience attributed to irrelevant stimuli seeding delusions; disorganized thought; failure to integrate prior task outputs into a working schema.	[1], [13]–[15]

The table is an indication of what is not in the DSM but what has been described by psychiatrists who were focused on phenomenology in the mid-20^th century. Kurt Schneider suggested that a group of what he called first rank symptoms were a more definite sign of schizophrenia and represented a “radical qualitative change in the thought-processes themselves” rather than a quantitative change.  Norgaard and Parnas (15) expanded on this as “Kurt Schneider explicitly emphasized that the formative matrix out of which the “first rank symptoms” emerge, was a “radical qualitative change” in the field of consciousness, comprising a disturbed first personal perspective(“Ichheit”) and a disturbed sense of “mineness”of experience (“Meinhaftigkeit”).  Schneider argues that the psychosis in schizophrenia is not merely eccentric beliefs or quantitative changes in symptoms but that it is a qualitative change in state.”  In the case of schizophrenia insight and judgment are affected by changes in experience related to these changes in consciousness while baseline sensorium and personality are preserved. 

DSM criteria do not tell you that the person affected by psychosis is operating from an entirely different conscious state. These observations about how a conscious state affect consciousness have been made for centuries. The changes in processing, reality testing, and phenomenal experience also affect moral and ethical decision making.  Baseline moral frameworks are often maintained but the decisions are affected by the changes in experiential reality.  This has been studied in postpartum psychosis and filicide.  Several types of patterns of thought have been noted in studies of filicide and psychosis.  Before I reference those studies, I want to add the following diagram.  It illustrates differences in usage of the term phenomenology in clinical psychiatry.

 

 

The diagram (click to enlarge) shows that some research defines phenomenology as descriptive psychopathology – basically defined signs and symptoms, syndromes of disorders, or phenotypes. All of these phenomena can be described in terms of clinical course and associations.  They can be studied with validated structured interviews and produce consistent results at the syndrome and severity level.  Apart from the symptoms they have little to say about subjective experience. It is phenomenology at the population level.

The first-person account of psychosis is a much different type of phenomenology.  It is focused on how that person is experiencing the psychosis. Do they feel different?  Does their world seem changed? Do familiar people seem like strangers? Has their day-to-day experience changed?  To borrow a question from the old Present State Exam –“Are you thinking clearly or is there is something interfering with your thinking?”  Even though these are unique experiences some researchers have developed semi-structured interviews to capture experiences in certain conditions.  The Examination of Anomalous World Experience (EAWE) is one example designed to capture subjective experience of people experiencing schizophrenia spectrum disorders. It has 75 items across 6 domains of subjective experience. 

The clinical interview in psychiatry combines elements of both forms of phenomenology – basically because physicians are all taught how to interview people around a central subjective theme called a chief compliant.  After doing many of these interviews of people with the same or similar diagnoses – it becomes apparent that no two people with the same diagnosis experience it the same way.  In psychiatry and neurology it is more complex because the substrate that has the problem is the same one that produces the conscious state and the patient’s subjective experience of it.  By clinical or semi structured interview – the focus is on psychopathology at the individual level and the effect on consciousness.   

How does all that apply to postpartum psychosis? There are good studies of postpartum psychosis and research groups with ongoing projects.  The Massachusetts General Hospital Postpartum Psychosis Project (MGHP3) is one research group that has published on a large cohort of women (N=248) with postpartum psychosis (PP) (17).  Data was collected by administration of the Mini International Interview for Psychotic Disorder Studies (MINI-PDS).  61.7% of the sample met criteria for a psychiatric disorder prior to an at the index episode of PP.  12.5% had a prior episode of psychosis.  Substance use disorders were not excluded from the sample to improve generalizability and 22.6% had a diagnosis of alcohol use disorder (AUD) or substance use disorder (SUD).  Most patients were hospitalized (74.4%), received medications (93%), and psychotherapy (65.89%).  Median time to return to psychiatric baseline was 25 weeks. This is the first time I have seen psychiatric baseline used in the literature as an outcome criteria, even though clinical psychiatrists have used this as a treatment standard for decades.  

Psychotic symptoms were well documented and there was significant variability in the duration of symptoms.  For 60.9% of subjects the symptoms lasted between 1 day and 1 month, 24% lasted from 1 month to 6 months, and 10.47% lasting greater than 6 months.  Half of the subjects said that their symptoms wax and wane.  The authors point out that periods of lucidity as possible and this may lead to a false impression that the patient is doing better than they really are. Since most of the subjects received atypical antipsychotics, the authors discuss the importance of determining subgroups that may need maintenance medication and others where the medication can be discontinued.    

The issue of whether PP develops into bipolar disorder was discussed.  Not all women go on to develop subsequent episodes, suggesting there may be a form that only occurs in the postpartum period.  The issue of prevention of these episodes in woman with a pre existing diagnosis of bipolar disorder was discussed and how that can be prevented with appropriate prophylactic treatment.   I would look to this group in the future for more state-of-the-art research on PP.  They appear to also have a genomics component.    

The question of child related delusions and their specificity for PP was discussed.  The authors conclude that paranoia directed at partners and infants safety and wellbeing were common and consistent with the idea that this may be a period of enhanced vulnerability.  I would see this paper as a critical resource for psychiatrists interested in this disorder both at a clinical and theoretical level.

A second paper is interesting in that it looks at women hospitalized on a Mother-Baby Inpatient unit in the Netherlands.  This group goes by the title Onderzoeksprogramma Postpartum Psychose Erasmus MC Rotterdam (OPPER) and they have previously published (18).  The sample size was 130 women.  I wrote a post on this setting a decade ago as an ideal resource for postpartum conditions.  Since then I am not aware of any similar treatment setting in the US.  One of the interesting aspects of this sample is that 48% of the subjects were admitted on an involuntary basis.  The standards described parallel most US standards for involuntary treatment of risk to self or others or inability to care for oneself.  17% of the sample had either obsessive concerns about harming the child or more or infanticidal thoughts.

This group used standardized questionnaires and rating scales to characterize psychopathology including the Structured Clinical Interview for DSM-IV Disorders (SCID), Young Mania Rating Scale (YMRS), Edinburgh Postpartum Depression Scale (EPDS), and Hamilton Rating Scale for Depression (HAM-D). That resulted in a total of 58 symptoms that were used to determine symptom prevalence and generate profiles by statistical modeling (latent class analysis).  Anxiety, depression and delusions were the most common symptoms across all profiles.  A total of 11 symptoms were used to develop profiles: anxiety, depression , melancholia, agitation, mania, atypical , disorganization, delusions, hallucinations, child-related, and catatonia.  From these symptoms a manic profile (34%), a depressive profile (41%), and an atypical profile (25%) were developed.  Dysphoric mania was more likely and the authors point out it is more prevalent in woman at baseline.  Patients in the manic and atypical categories were more likely to be treated on an involuntary basis. Like the MGH study remission rates were high (82-94%) with fastest remission in the manic group and slowest in the depressive group. The authors identified 2 cases of NMDA autoimmune encephalitis in the group with disorientation, disturbance of consciousness, and disorganization suggesting it is important in the differential diagnosis of this disorder.

The authors of this paper make the compelling argument that PP is one of the few psychiatric disorders where the etiology (childbirth) is known. They point out that it is a severe disorder that frequently requires involuntary treatment, needs careful medical assessment, and although it seems like it is on the bipolar spectrum – it should not be included there too quickly.  Like the MGH group they point out that even with the profiles they developed they are not able to predict disease course and this would be a major advance in treatment.  

There are other papers that apply to the current case and similar cases in the past.  Resnick (21) described cases of altruistic psychotic filicide associated with altruistic delusions.  The decisions are associated with thoughts that the child will be protected from harm from evil, criminal activity, or in some cases a specific family member that the mother has delusional concerns about.  In some cases, the child is seen as already affected by evil that is irreversible.  Death is the only way to protect the child but it makes sense only in the context of an alteration in consciousness.

To summarize, a category-based diagnosis is not a comprehensive explanation of behavior. That is the main reason psychiatrists are taught additional approaches to formulation of the current problem.  There is a general tendency of non-experts to lump all people with a similar diagnosis into the same category.  That is an error that most second year medical students recognize when they see the vast variations in diagnostic presentations, outcomes, and treatments.  In psychiatry, that variation is amplified greatly by all of the factors contributing to unique conscious states.

In forensic settings psychiatrists are called upon to present a diagnosis, a formulation, and comment on how both inform any statutory requirements for a defense or prosecution.  As a psychiatrist who has testified in hundreds of these hearings – the adversarial process is far from ideal.  A few examples include, a judge telling me what I can and cannot talk about, attorneys asking me questions they said they were not going to ask, rhetorical techniques by attorneys that they thought would shake me up, and questions that were clearly framed to distort the reality of the situation. All of those factors suggested to me that the only way real clinical psychiatry is expressed in court is if you have an expert witness who is familiar with all of that rhetoric and can ignore it.

The other critical piece is what can be done to educate the public as well as the jury.  Formal psychiatric training develops large categories that we need to cover in order to do a good job.  These categories exist diagnostically but also in the mental status exam (MSE) or direct examination of the patient.  For most forensic purposes the relevant categories are insight and judgment.  Both are critical in any postpartum case of filicide. That generally involves conclusory remarks based on connections with other MSE categories.  There is typically no description of a conscious state, but there might be discussion of other mitigating factors.  It is probably time to consider detailed discussion of how to include that component – not only in court but in the DSM in general.  Some of the other proposed inclusions are probably less important.

 

George Dawson, MD, DFAPA

 

References:

1:  Posner JB, Saper CB, Schiff ND, Plum F.  Plum and Posner’s Diagnosis of Stupor and Coma.  Oxford University Press, New York, 2007; 401 pp. 

2:  Zeman A, Coebergh JA. The nature of consciousness. Handb Clin Neurol. 2013;118:373-407. doi: 10.1016/B978-0-444-53501-6.00031-7. PMID: 24182393.

3:  Seth AK, Bayne T. Theories of consciousness. Nat Rev Neurosci. 2022 Jul;23(7):439-452. doi: 10.1038/s41583-022-00587-4. Epub 2022 May 3. PMID: 35505255.

 4: Feyaerts J, Henriksen MG, Vanheule S, Myin-Germeys I, Sass LA. Delusions beyond beliefs: a critical overview of diagnostic, aetiological, and therapeutic schizophrenia research from a clinical-phenomenological perspective. Lancet Psychiatry. 2021 Mar;8(3):237-249. doi: 10.1016/S2215-0366(20)30460-0. Epub 2021 Jan 21. PMID: 33485408.  (see figure 1)

5:  Martino M, Magioncalda P. A working model of neural activity and phenomenal experience in psychosis. Mol Psychiatry. 2024 Dec;29(12):3814-3825. doi: 10.1038/s41380-024-02607-4. Epub 2024 Jun 6. PMID: 38844531.

6:  Naccache L. Why and how access consciousness can account for phenomenal consciousness. Philos Trans R Soc Lond B Biol Sci. 2018 Sep 19;373(1755):20170357. doi: 10.1098/rstb.2017.0357. PMID: 30061470; PMCID: PMC6074081.

7:  Overgaard M. Phenomenal consciousness and cognitive access. Philos Trans R Soc Lond B Biol Sci. 2018 Sep 19;373(1755):20170353. doi: 10.1098/rstb.2017.0353. PMID: 30061466; PMCID: PMC6074085.

8:  Halligan PW, Oakley DA. Giving Up on Consciousness as the Ghost in the Machine. Front Psychol. 2021 Apr 30;12:571460. doi: 10.3389/fpsyg.2021.571460. PMID: 33995166; PMCID: PMC8121175.

9:  Cooke JE. What Is Consciousness? Integrated Information vs. Inference. Entropy (Basel). 2021 Aug 11;23(8):1032. doi: 10.3390/e23081032. PMID: 34441172; PMCID: PMC8391140.

10:  Mudrik L, Faivre N, Pitts M, Schurger A. On a confusion about there being two types of consciousness. Trends Cogn Sci. 2026 Aug;30(8):687-699. doi: 10.1016/j.tics.2025.11.012. Epub 2025 Dec 17. PMID: 41412917.

11:  Mogi K. Artificial intelligence, human cognition, and conscious supremacy. Front Psychol. 2024 May 13;15:1364714. doi: 10.3389/fpsyg.2024.1364714. PMID: 38807956; PMCID: PMC11130558.

12:  Carhart-Harris RL, Friston KJ. The default-mode, ego-functions and free-energy: a neurobiological account of Freudian ideas. Brain. 2010 Apr;133(Pt 4):1265-83. doi: 10.1093/brain/awq010. Epub 2010 Feb 28. PMID: 20194141; PMCID: PMC2850580. (Neuropsychoanalysis)

13:  Bellak L.  Basic aspects of ego function assessment. In: The Broad Scope of Ego Function Assessment.  Bellak L, Goldstein LA (eds).  John Wiley and Sons, New York, 1984: 6-30.

14:  Schneider, K. (1959), Clinical Psychopathology, pp. 100, 132–134

15:  Nordgaard J, Parnas J. Self-disorders and the schizophrenia spectrum: a study of 100 first hospital admissions. Schizophr Bull. 2014 Nov;40(6):1300-7. doi: 10.1093/schbul/sbt239. Epub 2014 Jan 29. PMID: 24476579; PMCID: PMC4193705.

16:  Parnas J, Henriksen MG. Disordered self in the schizophrenia spectrum: a clinical and research perspective. Harv Rev Psychiatry. 2014 Sep-Oct;22(5):251-65. doi: 10.1097/HRP.0000000000000040. PMID: 25126763; PMCID: PMC4219858.

17:  Cohen LS, Arakelian M, Church TR, Dunk MM, Gaw ML, Yoon HE, Kobylski LA, Vanderkruik R, Freeman MP. The phenomenology of postpartum psychosis: preliminary findings from the Massachusetts General Hospital Postpartum Psychosis Project. Mol Psychiatry. 2025 Jun;30(6):2537-2544. doi: 10.1038/s41380-024-02856-3. Epub 2024 Dec 6. PMID: 39643690.

18:  Kamperman AM, Veldman-Hoek MJ, Wesseloo R, Robertson Blackmore E, Bergink V. Phenotypical characteristics of postpartum psychosis: A clinical cohort study. Bipolar Disord. 2017 Sep;19(6):450-457. doi: 10.1111/bdi.12523. Epub 2017 Jul 12. PMID: 28699248.

19:  Robertson E, Lyons A. Living with puerperal psychosis: a qualitative analysis. Psychol Psychother. 2003 Dec;76(Pt 4):411-31. doi: 10.1348/147608303770584755. PMID: 14670189.

20:  Holt L, Sellwood W, Slade P. Birth experiences, trauma responses and self-concept in postpartum psychotic-like experiences. Schizophr Res. 2018 Jul;197:531-538. doi: 10.1016/j.schres.2017.12.015. Epub 2018 May 7. PMID: 29402582.

21:  Resnick PJ. Child murder by parents: a psychiatric review of filicide. Am J Psychiatry. 1969 Sep;126(3):325-34. doi: 10.1176/ajp.126.3.325. PMID: 5801251.

Table References

1. Patniyot NS. Deficits in access consciousness, integrative function, and consequent autonoetic thinking in schizophrenia. Med Hypotheses. 2021 Oct;155:110664.
2. Berkovitch L, Charles L, Del Cul A, et al. Disruption of Conscious Access in Psychosis Is Associated with Altered Structural Brain Connectivity. J Neurosci. 2021 Jan 20;41(3):513-523.
3. Berkovitch L, Dehaene S, Gaillard R. Disruption of Conscious Access in Schizophrenia. Trends Cogn Sci. 2017 Nov;21(11):878-892.
4. Potvin S, Gamache L, Lungu O. A Functional Neuroimaging Meta-Analysis of Self-Related Processing in Schizophrenia. Front Neurol. 2019 Sep 11;10:990.
5. Jimenez AM, Green MF. Disturbance at the self-other boundary in schizophrenia: Linking phenomenology to clinical neuroscience. Schizophr Res. 2024 Oct;272:51-60.
6. Henriksen MG, Raballo A, Nordgaard J. Self-disorders and psychopathology: a systematic review. Lancet Psychiatry. 2021 Nov;8(11):1001-1012.
7. 7. Feyaerts J, Sass L. Self-Disorder in Schizophrenia: A Revised View (1. Comprehensive Review-Dualities of Self- and World-Experience). Schizophr Bull. 2024 Mar 7;50(2):460-471. doi: 10.1093/schbul/sbad169. PMID: 38069912; PMCID: PMC10919772.
8. Helyel ES, El-Sayed MM. Beyond the symptoms: Exploring attachment styles and reality-testing among schizophrenia clients from a nursing perspective. J Psychiatr Ment Health Nurs. 2025 Feb;32(1):1-12. doi: 10.1111/jpm.13081. Epub 2024 Jul 3. PMID: 38958525.

9.  Lee JS, Chun JW, Lee SH, Kim E, Lee SK, Kim JJ. Altered neural basis of the reality processing and its relation to cognitive insight in schizophrenia. PLoS One. 2015 Mar 20;10(3):e0120478. doi: 10.1371/journal.pone.0120478. PMID: 25793291; PMCID: PMC4368728.  

10. Seabury RD, Bearden CE, Ventura J, Subotnik KL, Nuechterlein KH, Cannon TD. Confident memory errors and disrupted reality testing in early psychosis. Schizophr Res. 2021 Dec;238:170-177. doi: 10.1016/j.schres.2021.10.007. Epub 2021 Oct 25. PMID: 34710715.

11. Jia W, Zhu H, Ni Y, Su J, Xu R, Jia H, Wan X. Disruptions of frontoparietal control network and default mode network linking the metacognitive deficits with clinical symptoms in schizophrenia. Hum Brain Mapp. 2020 Apr 15;41(6):1445-1458. doi: 10.1002/hbm.24887. Epub 2019 Dec 2. PMID: 31789478; PMCID: PMC7267896.   

12. David AS, Bedford N, Wiffen B, Gilleen J. Failures of metacognition and lack of insight in neuropsychiatric disorders. Philos Trans R Soc Lond B Biol Sci. 2012 May 19;367(1594):1379-90. doi: 10.1098/rstb.2012.0002. PMID: 22492754; PMCID: PMC3318769.  

13. Heinz A, Murray GK, Schlagenhauf F, Sterzer P, Grace AA, Waltz JA. Towards a Unifying Cognitive, Neurophysiological, and Computational Neuroscience Account of Schizophrenia. Schizophr Bull. 2019 Sep 11;45(5):1092-1100. doi: 10.1093/schbul/sby154. PMID: 30388260; PMCID: PMC6737474.  

14.  Sterzer P, Adams RA, Fletcher P, Frith C, Lawrie SM, Muckli L, Petrovic P, Uhlhaas P, Voss M, Corlett PR. The Predictive Coding Account of Psychosis. Biol Psychiatry. 2018 Nov 1;84(9):634-643. doi: 10.1016/j.biopsych.2018.05.015. Epub 2018 May 25. PMID: 30007575; PMCID: PMC6169400.   15.  

15. Liddle PF, Sami MB. The Mechanisms of Persisting Disability in Schizophrenia: Imprecise Predictive Coding via Corticostriatothalamic-Cortical Loop Dysfunction. Biol Psychiatry. 2025 Jan 15;97(2):109-116. doi: 10.1016/j.biopsych.2024.08.007. Epub 2024 Aug 22. PMID: 3918138 

Peripartum Depression and Psychosis - The Ignored Basics

 

This is just a sampling of headlines about a current case of postpartum depression and psychosis and an ongoing trial for homicide.  A woman killed her three children and her defense is decreased criminal responsibility due to a mental disorder.  I do not know any of the actual details of the case, but I do know this clinical situation very well for a number of reasons.

I was an acute care psychiatrist of 22 years and in that capacity treated many cases of this disorder, including cases associated with homicide where I was called to testify in both criminal court and civil court.  In doing evaluations of women with recurrent psychotic disorders, it was apparent to me that many had the onset of that disorder during or immediately after a pregnancy and it was never adequately treated. Practically all of those women had bipolar disorder, but given the inadequate treatment and chronicity – the diagnosis was typically modified to schizoaffective disorder.

During my career, I quickly learned that a detailed history of all of the pregnancies in a woman’s life was extremely important.  In many cases it was associated with a new onset of a psychiatric disorder.  Those disorders were often not treated even when it was clear they resulted in permanent changes. My clinical experience is reflected in the literature where 50-75% of women with depression and anxiety are undiagnosed (1).  In those populations there is a significant prevalence of suicidal ideation and variability in available screening.  Only a fraction of woman diagnosed with postpartum depression get adequate care at about the same rate of adequate care for depression in the general population (10% vs 17%) (2).     

In the 1980s and 1990s psychiatric care for women during pregnancy was often lacking due to concerns about medication toxicity to the fetus. During that era, psychiatrists specializing in women’s health became more visible and started to address major issues like the timing and type of treatment recommended for perinatal and postpartum psychiatric disorders.  That included decisions about not stopping medications during pregnancy, breastfeeding, and reviewing the results of these strategies. 

As it became known that I was interested in the problem, I started to get self referrals. They were usually women who were told they could not take their psychiatric medication during pregnancy or in the immediate post-partum state.  These women were concerned about their mental state without maintenance medication especially the ability to function as well as suicidal ideation.  Several psychiatric colleagues practiced in a woman’s health clinic at that time and were treating the same population.

Without going too far into detail, all of these conditions that women experience in the postpartum state are very serious conditions.  They tend to be minimized by saying it is something that most women go through and must endure.  A universal experience almost always invites group comparisons that rarely apply at the individual level.  There should be no conclusions that one experience is the experience that everyone has. 

The women I treated had very serious disorders at all stages of pregnancy whether they were outpatients or hospitalized on an inpatient unit.  In some cases, I had to reconstruct what happened during a pregnancy they experienced 10 or 20 years earlier and how that applied to their current experience.  Some were disabled, not able to work, and had disruptions with significant relationships in their lives. 

I have posted about this in the past and a remarkable approach to treating perinatal disorders in the Netherlands.  At the time I wrote this post nearly a decade ago, there were specialty units called maternal-baby units (MBUs).  In the study woman with psychosis or mania within 6 weeks of childbirth were admitted and stabilized. Most were treated with lithium or antipsychotic monotherapy and followed for 9 months.  The discharge goal was remission of symptoms for one week prior to discharge and the average length of stay was 55 days.  Functional outcomes were very good.  In the original post, I made the observation that none of this care would have been possible in the US.  At the time there were no MBUs.  All inpatient psychiatric units where I have worked were suboptimal settings basically due to business management tactics. 

An ideal inpatient setting for mothers who are either pregnant with a perinatal disorder or a postpartum state would be a supportive environment that is environmentally pleasing, calm, clean, and has access to obstetric services.  I will be the first to say that as an acute care psychiatrist – I have never seen such a place.  I have talked with many patients who refused inpatient care based on what the environment was like.

The environment is probably the most critical factor in treating a person with a severe psychiatric disorder.  They should feel safe and cared for.  They should encounter staff dedicated to optimizing the inpatient experience.  The concept of asylum comes to mind as an environment that is a stress free and safe.  Lamb (3) defines it as “sanctuary, a place that lowers levels of stress and provides protection, safety, security, and social support, as well as an array of treatment services.”  I would add that there needs to be frequent contact with the treating professionals – especially in the cases where there is unpredictability, symptoms of psychosis, and impaired judgment. That frequent contact should involve ongoing assessment as well as psychotherapy. 

The reason for optimizing the environment is to encourage the necessary level of communication for diagnosis and treatment.  It should be obvious but anyone who feels trapped on an inpatient unit – is not going to communicate freely.  They will say what they think they need to get discharged.  That may include covering up significant symptoms.  I have had people tell me this - weeks after discharge. At some point the patient must be engaged in a process that not only addresses their acute symptoms but also longer-term risks.  In the case of severe peripartum disorders that includes both suicidal and aggressive ideation. The therapeutic process is interwoven with the assessment of safety in the home environment.

I am very confident that psychiatrists can diagnose and treat these problems.  I am also very confident that there are serious legal, cultural, and political obstacles to care.  There is the problem of a low standard of care on inpatient units that is the product of business and political rationing of care.  There is a prominent problem with cultural processing of peripartum psychosis with filicide.  There is currently only one state (Illinois) – that explicitly recognizes the effect of the postpartum mental illness on culpability (4).  It does not replace the not guilty be reason of insanity (NGRI) defense but allows for mitigation during sentencing to reduce lengthy incarcerations.

The need to use a general NGRI defense for infanticide or filicide associated with peripartum states is highly problematic.  Only about 1-6% of general felony cases use the NGRI defense and in those cases, it is successful about 12-17% of the time.  The defense became more restrictive after the Hinckley verdict in 1982 when 36 states modified their statutes and that included 4 states eliminating the defense.  Successful defense generally depends on the diagnosis of a psychotic disorder or a mood disorder with psychotic features. States of intoxication and personality disorders are generally not successful with this defense, but there is likely some overlap between both sets of conditions.     

An NGRI diminished capacity defense rests on the reality that the behavior is driven by symptoms of psychosis and not malice. Enduring these experiences results in intense grief, guilt, and regret (5).  Future harm to the mother is significant with up to 30% dying by suicide and high risk of both future severe mental illness and poor maternal infant attachment.  Partners experience the loss of relationship and planned future of the relationship in addition to a lack of knowledge about the condition (6). 

One of the useful conceptualizations of these disorders and their impact comes from family systems theory.  A perinatal mental disorder compromises the entire family’s ability to function (7).  Reviews invariably consider the problem of peripartum mental illness associated with infanticide/filicide as one of missed opportunities for screening, intervention, and access to care. 

What is not useful is a binary framing of the perpetrator and victim.  At the level of media and culture there is the killer mother trope that splits people who want to help from people who want to blame. That adversarial framing impacts the entire family going forward and obscures potential points of intervention and prevention.  Like most polarizing situations – the amplification is evident today with monetization and political gain from the divisiveness a primary consideration.  I consider the elimination of Medicaid - the single largest source of maternal care in the US to be both an end result of this split as well as a potential cause of more of these cases.

In the final analysis it is easy to blame one person for the catastrophic outcomes associated with perinatal mental illness and infanticide/filicide. You can pretend that modern society is not a cooperative effort with division of labor and resources. You can pretend that you don't have to care about anyone else other than you and your immediate family.  You can pretend that people who really need help are freeloaders, criminals, malingerers, or just too weak to survive on their own. But that is an poor analysis of the problem.  Families, parents, and children need to be supported in ways that foster growth and security way before there are catastrophic outcomes.

  

George Dawson, MD, DFAPA

 

1: Solomonov N, Kerchner D, Dai Y, et al. Prevalence and Trajectories of Perinatal Anxiety and Depression in a Large Urban Medical Center. JAMA Netw Open. 2025;8(9):e2533111. doi:10.1001/jamanetworkopen.2025.33111

2:  Vigo D, Haro JM, Hwang I, et al. Toward measuring effective treatment coverage: critical bottlenecks in quality- and user-adjusted coverage for major depressive disorder. Psychol Med. 2022 Jul;52(10):1948-1958. doi: 10.1017/S0033291720003797. Epub 2020 Oct 20. PMID: 33077023; PMCID: PMC9341444.

3:  Lamb HR, Weinberger LE. Rediscovering the Concept of Asylum for Persons with Serious Mental Illness. J Am Acad Psychiatry Law. 2016 Mar;44(1):106-10. PMID: 26944750.

4:  Tabb KM, Hsieh WJ, Ramirez XR, Kopels S. State legislation and policies to improve perinatal mental health: a policy review and analysis of the state of Illinois. Front Psychiatry. 2024 Apr 18;15:1347382. doi: 10.3389/fpsyt.2024.1347382. PMID: 38699448; PMCID: PMC11064060.

5:  Milia G, Noonan M. Experiences and perspectives of women who have committed neonaticide, infanticide and filicide: A systematic review and qualitative evidence synthesis. J Psychiatr Ment Health Nurs. 2022 Dec;29(6):813-828. doi: 10.1111/jpm.12828. Epub 2022 Mar 24. PMID: 35255182; PMCID: PMC9790608.

6:  Lyons T, Hennesey T, Noonan M. A systematic review of qualitative evidence: Perspectives of fathers whose partner experienced postpartum psychosis. J Adv Nurs. 2024 Feb;80(2):413-429. doi: 10.1111/jan.15832. Epub 2023 Sep 1. PMID: 37658618.

7:  Wisner KL, Murphy C, Thomas MM. Prioritizing Maternal Mental Health in Addressing Morbidity and Mortality. JAMA Psychiatry. 2024;81(5):521–526. doi:10.1001/jamapsychiatry.2023.5648

8:  Alford AY, Riggins AD, Chopak-Foss J, Cowan LT, Nwaonumah EC, Oloyede TF, Sejoro ST, Kutten WS. A systematic review of postpartum psychosis resulting in infanticide: missed opportunities in screening, diagnosis, and treatment. Arch Womens Ment Health. 2025 Apr;28(2):297-308. doi: 10.1007/s00737-024-01508-3. Epub 2024 Sep 2. PMID: 39222077.

 

Remission Before Discharge? An Un-American Concept

I encountered a paper this week that had me nostalgic for the old days in American psychiatry.  The days when people were treated in hospitals to the point that their symptoms remitted before they were discharged.  That of course depends on a couple of assumptions.  The first is that their symptoms can be treated to that point.  There are a number of people with a disease process that cannot be treated to that point.  Neurodegenerative disorders like Alzheimer's disease or vascular dementia are good examples, but there are also a number of people who have no known brain insult and yet have treatment resistant depression or psychosis.  Their symptoms do not respond or poorly respond to treatment.  The second assumption is that the person with the illness recognizes why they need to be in a hospital or some form of intensive treatment and they agree to stay long enough.  That is one of the more complicated assumptions because psychiatry is almost exclusively the only medical specialty where the treating physician can disagree with the patient's preference for discharge and put them on a hold pending a judge's decision to order them to stay in a hospital longer.  That court decision in most states depends on three standards - danger to self, danger to others, and general ability to care for oneself.  Those three standards have been condensed over the years to a single word dangerousness.  Practically all inpatient treatment units in the United States are impacted by managed care companies who would generally like people discharged in about 3-5 days irrespective of their diagnosis or treatment plan.  Their de facto discharge criteria is dangerousness.

If you are reading this for the first time, it may sound absurd to base a medical decision on an oversimplified legal standard that is designed to not unduly impact the civil liberty of citizens.  It is definitely absurd for any number of reasons.  If you work in inpatient settings you can have the most carefully crafted treatment plan to restore a person to their previous level of functioning and have to tolerate a managed care case manager or physician ask you "Where is the dangerousness?"  If there is no dangerousness the expectation is that the patient will be discharged and if you (as the treating physician) disagree - the insurance company via their own review can just stop paying for the hospitalization.  The practical result of all of that politics is that a partially stabilized patient is discharged.  That would be bad news if that person was dangerous, but what nobody talks about is that it is probably worse if they are not.  First, the vast majority of people that psychiatrists treat in inpatient units are not dangerous but they are having a very difficult time functioning both in terms of symptom management and what they need to manage in life every day.  If they are partially treated, it is very likely that they will not be able to follow up with a detailed treatment plan.  Managed care companies and the usual critics of psychiatry frequently rationalize this process with global statements like "the outcomes are no different" or inpatient treatment especially involuntary inpatients treatment is not necessary.  The problem is that there are very few studies that look at the process.  After all, who has an interest in continuing to discharge partially stabilized patients?  It is certainly not psychiatrists, patients or their families.

The study I encountered was in the Journal of Clinical Psychiatry this month (1).  The investigators are from the Netherlands.  They looked at 78 cases of postpartum psychosis admitted to the Mother-Baby Inpatient Unit (MBU) at the Erasmus Medical Center between August 2005 and June 2011.  The MBU is a specialized unit to treat cases of severe psychopathology during the postpartum period.  Patients with an onset of psychosis or mania within 6 weeks of the delivery were included.  They included the typical DSM functional psychosis categories and mood disorders with psychotic features.  Substance induced psychosis was excluded.  Of the final group 64 patients had only postpartum psychosis and 14 had either a prior episode of psychosis or mania/hypomania.  The authors had previously developed a standardized approach to treating postpartum psychosis that involved using typical medications indicated for acute inpatient stabilization.  The goal was remission of their symptoms for one week prior to discharge with standard recommendations for pharmacotherapy to maintain symptomatic remission.  They were followed for 9 months and by that time 16 patients had discontinued medication with the remainder taking lithium (n=40) or antipsychotic monotherapy (n=8).

The main outcome measure used was the Longitudinal Interval Follow-up Evaluation-Range of Impaired Functioning Tool (LIFE-RIFT).  That research instrument looked at a number of domains including work, interpersonal relationships, global satisfaction, and recreation.  All of these areas have been shown to be adversely impacted in other studies of the problem of postpartum psychosis.  As an example the authors quote a study that noted a divorce rate of 18% in a similar cohort of patients.  In a previous post on this blog, I made the observation that many women seen in inpatient practice who have a chronic psychotic disorders can be traced back to an initial episode of postpartum psychosis.  The authors here note that although they may have had a sample with low premorbid complications their outcomes were generally very good compared to previous retrospective studies and a matched sample of postpartum women.  As an example, 88.5% of the women had resumed full work and household responsibilities.  In comparison to a general postpartum population, the experimental group showed slightly more anxiety and depressive symptoms due to the the portion of the sample that relapsed.  In comparison to a group of patients with first episode bipolar disorder occurring outside of the postpartum period the comparison favored the experimental group.  Despite the usual limitations of these studies like sampling bias and missing data, the authors conclude that there is plenty of optimism in the treatment of postpartum psychosis using their methodology.  In what I consider to be an understatement of the past three decades in American psychiatry the authors write about how a specialized unit may have biased their results: "Unfortunately, many regions of the world do not have MBU care within a reasonable travel distance for the patient."  To my knowledge there are no MBUs at all in the United States.  They are inconsistent with the prevailing managed care rationing model for psychiatric care in this country.

This is a very important article for a number of reasons.  It highlights the importance of specialized care for women with postpartum psychosis through reduced chronicity and better functional outcomes.  The psychopharmacology result with lithium or antipsychotic monotherapy and discontinuing all benzodiazepines prior to discharge is far superior to any result that could be expected in the US.  Short stays result in polypharmacy.  I would be shocked to see any case of postpartum psychosis not discharged on antidepressants, antipsychotics, benzodiazepines, sleep medications and possibly valproate from American inpatient units.  These medications are difficult to manage and the follow up appointments are typically brief and focused primarily on symptoms and medications.

In the trade off between short lengths of stay and unmanageable polypharmacy - it seems like this research group has developed a quality approach.  It is time for American psychiatrists to acknowledge that the way inpatient units are run by businesses is not working because they never adequately stabilize patients.  That leads to a large population of people who are unnecessarily symptomatic and never recover their baseline level of functioning.  That same population may be taking a lot of medication  that they don't really need.


George Dawson, MD, DFAPA                        
 


Supplementary:

I confirmed that there are no MBUs in the USA and that the median length of stay on the unit described in this study was 55 days.


References:

1: Burgerhout KM, Kamperman AM, Roza SJ, Lambregtse-Van den Berg MP, Koorengevel KM, Hoogendijk WJ, Kushner SA, Bergink V. Functional Recovery After Postpartum Psychosis: A Prospective Longitudinal Study. J Clin Psychiatry. 2017 Jan;78(1):122-128. doi: 10.4088/JCP.15m10204. PubMed PMID: 27631144.

2: Bergink V, Burgerhout KM, Koorengevel KM, Kamperman AM, Hoogendijk WJ, Lambregtse-van den Berg MP, Kushner SA. Treatment of psychosis and mania in the postpartum period. Am J Psychiatry. 2015 Feb 1;172(2):115-23. doi: 10.1176/appi.ajp.2014.13121652. PubMed PMID: 25640930.


Attribution:

Photo at the top is Erasmus Medical Centre - the affiliation of the lead author in this article and location of the study.  It was downloaded from Shutterstock on February 8, 2017 per their agreement specifying editorial and noncommercial use.

Editorial credit: Jaroslav Moravcik / Shutterstock, Inc.
ROTTERDAM, NETHERLANDS - APRIL 1: Erasmus medical centre in Rotterdam on April 1, 2014 in Rotterdam