Current Psychiatry Reports

, Volume 4, Issue 3, pp 185–190

Postpartum psychoses: Prognosis, risk factors, and treatment

  • Bruno Pfuhlmann
  • Gerald Stoeber
  • Helmut Beckmann


Puerperal psychoses do not represent a nosological entity, but rather a selection of puerperally triggered "ordinary" functional psychoses with cycloid psychoses predominating and schizophrenias occurring very rarely. The prognosis is basically favorable concerning symptom remission and social and occupational functioning. However, there is a considerable frequency of relapses and an increased suicide rate. The most important risk factors for an episode of a puerperal psychosis are being primiparous and having suffered a previous episode of a psychosis, particularly a cycloid psychosis. Controlled treatment studies up to now are absent. Case studies suggest in acute episodes the efficacy of a symptom-oriented pharmacologic treatment where ablactation is recommended. With respect to prophylactic treatment some authors propose to apply lithium in late pregnancy or immediately after delivery. Because of its possible teratogenic effects and the altogether rather sparse data, the authors however cannot recommend the use of lithium during pregnancy. Applying estradiol after delivery may be beneficial and safe, but further studies are necessary to clarify these issues.


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References and Recommended Reading

  1. 1.
    Terp IM, Mortensen PB: Post-partum psychoses. Clinical diagnoses and relative risk of admission after parturition. Br J Psychiatry 1998, 172:521–526.PubMedGoogle Scholar
  2. 2.
    Kendell RE, Chalmers JC, Platz C: Epidemiology of puerperal psychoses. Br J Psychiatry 1987, 150:662–673.PubMedGoogle Scholar
  3. 3.
    Brockington IF, Cernik KF, Schofield EM, et al.: Puerperal psychosis. Phenomena and diagnosis. Arch Gen Psychiatry 1981, 38:829–833.PubMedGoogle Scholar
  4. 4.
    Klompenhouwer JL, van Hulst AM, Tulen JHM, et al.: The clinical features of postpartum psychoses. Eur Psychiatry 1995, 10:355–367.CrossRefPubMedGoogle Scholar
  5. 5.
    McNeil TF: A prospective study of postpartum psychoses in a high risk group. 1. Clinical characteristics of the current postpartum episodes. Acta Psychiatr Scand 1986, 74:205–216.PubMedGoogle Scholar
  6. 6.
    Lanczik M, Fritze J, Beckmann H: Puerperal and cycloid psychoses. Results of a retrospective study. Psychopathology 1990, 23:220–227.PubMedGoogle Scholar
  7. 7.
    Schöpf J, Rust B: Follow-up and family study of postpartum psychoses. Part I: overview. Eur Arch Psychiatry Clin Neurosci 1994, 244:101–111.PubMedCrossRefGoogle Scholar
  8. 8.
    Pfuhlmann B, Stöber G, Franzek E, Beckmann H: Cycloid psychoses predominate in severe postpartum psychiatric disorders. J Affect Disord 1998, 50:125–134.PubMedCrossRefGoogle Scholar
  9. 9.
    Leonhard K: Classification of Endogenous Psychoses and Their Differentiated Etiology, edn 2 revised. Edited by Helmut Beckmann. Wien: Springer; 1999.Google Scholar
  10. 10.
    Jabs BE, Pfuhlmann B, Bartsch AJ, Stöber G: Cycloid psychoses: from clinical conceptions to biological foundations. J Neur Transm 2002, In press.Google Scholar
  11. 11.
    Kadrmas A, Winokur G, Crowe R: Postpartum mania. Br J Psychiatry 1979, 135:551–554.PubMedGoogle Scholar
  12. 12.
    Platz C, Kendell RE: A matched-control follow-up and family study of puerperal psychoses. Br J Psychiatry 1988, 153:90–94.PubMedGoogle Scholar
  13. 13.
    Dean C, Williams RJ, Brockington IF: Is puerperal psychosis the same as bipolar manic-depressive disorder? A family study. Psychol Med 1989, 19:637–647.PubMedGoogle Scholar
  14. 14.
    Pfuhlmann B, Stöber G, Franzek E, Beckmann H: Long-term course and outcome of severe postpartum psychiatric disorder. Psychopathology 1999, 32:192–202. A study that aimed to maximize the validity of follow-up data about postpartal psychoses by three methodic peculiarities—a restriction to women with first manifestation of a psychosis post partum, a personal catamnestic investigation by an experienced psychiatrist, and a standardized evaluation of outcome with the Stauss-Carpenter Scale.PubMedCrossRefGoogle Scholar
  15. 15.
    Rohde A, Marneros A: Postpartum psychoses: onset and longterm course. Psychopathology 1993, 26:203–209.Google Scholar
  16. 16.
    Videbech P, Gouliaev G: First admission with puerperal psychosis: 7–14 years of follow-up. Acta Psychiatr Scand 1995, 91:167–173.PubMedGoogle Scholar
  17. 17.
    Arentsen K: Postpartum psychoses with particular reference to the prognosis. Dan Med Bull 1968, 15:97–100.PubMedGoogle Scholar
  18. 18.
    Protheroe C: Puerperal psychoses: a long term study 1927–1961. Br J Psychiatry 1969, 115:9–30.PubMedGoogle Scholar
  19. 19.
    Müller C: On the nosology of postpartum psychoses. Psychopathology 1985, 18:181–184.PubMedCrossRefGoogle Scholar
  20. 20.
    Davidson J, Robertson E: A follow-up study of post-partum illness, 1946–1978. Acta Psychiatr Scand 1985, 71:451–457.PubMedGoogle Scholar
  21. 21.
    Hunt N, Silverstone T: Does puerperal illness distinguish a subgroup of bipolar patients? J Affect Disord 1995, 34:101–107.PubMedCrossRefGoogle Scholar
  22. 22.
    Appleby L, Mortensen PB, Faragher EB: Suicide and other causes of mortality after post-partum psychiatric admission. Br J Psychiatry 1998, 173:209–211. The first study that specifically investigates the risk of suicide in postpartum psychiatric disorder by linking nationwide registers of birth, causes of death, and psychiatric admissions.PubMedGoogle Scholar
  23. 23.
    Da Silva L, Johnstone EC: A follow-up study of severe puerperal psychiatric illness. Br J Psychiatry 1981, 139:346–354.PubMedGoogle Scholar
  24. 24.
    Kendell RE, Rennie D, Clarke JA, Dean C: The social and obstetric correlates of psychiatric admission in the puerperium. Psychol Med 1981, 11:341–350.PubMedCrossRefGoogle Scholar
  25. 25.
    Brockington IF, Martin C, Brown GW, et al.: Stress and puerperal psychosis. Br J Psychiatry 1990, 157:331–334.PubMedGoogle Scholar
  26. 26.
    Dowlatshahi D, Paykel ES: Life events and social stress in puerperal psychoses: absence of effect. Psychol Med 1990, 20:655–662.PubMedCrossRefGoogle Scholar
  27. 27.
    Marks MN, Wieck A, Checkley SA, Kumar R: Life stress and postpartum psychosis: a preliminary report. Br J Psychiatry 1991, 158:45–49.Google Scholar
  28. 28.
    Terp IM, Engholm G, Moller H, Mortensen PB: A follow-up study of postpartum psychoses: prognosis and risk factors for readmission. Acta Psychiatr Scand 1999, 100:40–46. The only study that examines risk factors for readmission and quantifies the respective relative risk in a case register based sample by linking a nationwide birth register and psychiatric central register.PubMedGoogle Scholar
  29. 29.
    Kendell RE: Emotional and physical factors in the genesis of puerperal mental disorders. J Psychosom Res 1985, 29:3–11.PubMedCrossRefGoogle Scholar
  30. 30.
    McGorry P, Connell S: The nosology and prognosis of puerperal psychosis: a review. Compr Psychiatry 1990, 31:519–534.PubMedCrossRefGoogle Scholar
  31. 31.
    Coyle N, Jones I, Robertson E, et al.: Variation at the serotonin transporter gene influences susceptibility to bipolar affective puerperal psychosis. Lancet 2000, 356:1490–1491. This article is the first one reporting a molecular genetic finding relevant for the etiology of puerperal psychoses, namely a polymorphism that may exert substantial and important influence on susceptibility to such psychoses.PubMedCrossRefGoogle Scholar
  32. 32.
    Jones I, Middle F, McCandless F, et al.: Molecular genetic studies of bipolar disorder and puerperal psychosis at two polymorphisms in the estrogen receptor alpha gene (ESR 1). Am J Med Genet 2000, 96:850–853.PubMedCrossRefGoogle Scholar
  33. 33.
    Middle F, Jones I, Robertson E, et al.: Tumor necrosis factor alpha and bipolar affective puerperal psychosis. Psychiatr Genet 2000, 10:195–198.PubMedGoogle Scholar
  34. 34.
    Feng J, Zheng J, Bennett WP, et al.: Five missense variants in the amino-terminal domain of the glucocorticoid receptor: no association with puerperal psychosis or schizophrenia. Am J Med Genet 2000, 96:412–417.PubMedCrossRefGoogle Scholar
  35. 35.
    Kornhuber J, Weller M: Postpartum psychosis and mastitis: a new indication for clozapine? Am J Psychiatry 1991, 148:1751–1752.PubMedGoogle Scholar
  36. 36.
    Hamilton JA: Postpartum psychosis and ECT. Am J Social Psychiatry 1984, 4:2829.Google Scholar
  37. 37.
    Sneddon J, Kerry RJ: Puerperal psychosis: a suggested treatment model. Am J Social Psychiatry 1984, 4:30–34.Google Scholar
  38. 38.
    Cox JL: Psychiatric disorders of childbirth. In Companion To Psychiatric Studies, edn 5. Edited by Kendell RE, Zealley AK. Edinburgh: Churchill Livingstone; 1993.Google Scholar
  39. 39.
    Reed P, Sermin N, Appleby L, Faragher B: A comparison of clinical response to electroconvulsive therapy in puerperal and non-puerperal psychoses. J Affect Disord 1999, 54:255–260.PubMedCrossRefGoogle Scholar
  40. 40.
    Cohen LS, Sichel DA, Robertson LM, et al.: Postpartum prophylaxis for women with bipolar disorder. Am J Psychiatry 1995, 152:1641–1645.PubMedGoogle Scholar
  41. 41.
    Stewart DE, Klompenhouwer JL, Kendell RE, van Hulst AM: Prophylactic lithium in puerperal psychosis: the experience of three centres. Br J Psychiatry 1991, 158:393–397.PubMedCrossRefGoogle Scholar
  42. 42.
    Austin MP: Puerperal affective psychosis: is there a case for lithium prophylaxis? Br J Psychiatry 1992, 161:692–694.PubMedGoogle Scholar
  43. 43.
    Willcox DL, Yovich JL, McColm SC, Philips JM: Progesterone, cortisol and oestradiol-17 beta in the initiation of human parturition: partitioning between free and bound hormone in plasma. Br J Obstet Gynaecol 1985, 92:65–71.PubMedGoogle Scholar
  44. 44.
    Ahokas A, Aito M: Role of estradiol in puerperal psychosis. Psychopharmacology 1999, 147:108–110.PubMedCrossRefGoogle Scholar
  45. 45.
    Galen-Buckwalter J, Buckwalter DK, Bluestein BW, Stanczyk FZ: Pregnancy and post partum: changes in cognition and mood. Prog Brain Res 2001, 133:303–319.CrossRefGoogle Scholar
  46. 46.
    Sichel DA, Cohen LS, Robertson LM: Prophylactic estrogen in recurrent postpartum affective disorder. Biol Psychiatry 1995, 38:814–818.PubMedCrossRefGoogle Scholar
  47. 47.
    Gregoire AJP, Kumar R, Everitt B: Transdermal estrogen treatment of severe postnatal depression. Lancet 1996, 347:930–933.PubMedCrossRefGoogle Scholar
  48. 48.
    Ahokas AJ, Turtiainen S, Aito M: Sublingual oestrogen treatment of postnatal depression. Lancet 1998, 351:109.PubMedCrossRefGoogle Scholar
  49. 49.
    Ahokas A, Aito M, Rimon R: 0Positive treatment effect of estradiol in postpartum psychosis: a pilot study. J Clin Psychiatry 2000, 61:166–169. Despite the small number of patients, this report of a positive therapeutic effect of estradiol in patients with puerperal psychoses could open up new vistas for treatment and stimulate etiologic research.PubMedCrossRefGoogle Scholar
  50. 50.
    World Health Organization: Chapter V: mental and behavioral disorders (including disorders of psychological development): Clinical descriptions and diagnostical guidelines. In The International Classification of Diseases, edn 10. Geneva: World Health Organization; 1991.Google Scholar

Copyright information

© Current Science Inc 2002

Authors and Affiliations

  • Bruno Pfuhlmann
    • 1
  • Gerald Stoeber
    • 1
  • Helmut Beckmann
    • 1
  1. 1.Department of PsychiatryUniversity of WürzburgWürzburgGermany

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