Advances in Women's Health

Postpartum psychosis occurs in approximately one per 1,000 births and is one of the most serious postpartum mental health illnesses. Symptoms of postpartum psychosis typically present within two weeks of childbirth and can manifest in a myriad of ways, including delusions or hallucinations that sometimes command the mother to hurt herself or her infant. Women who experience postpartum psychosis are at risk for significant morbidity, including hospitalization, suicide, chronic psychiatric disability, and infanticide.

Saundra Albers

Saundra Albers, a fourth-year medical student at Columbia Vagelos College of Physicians and Surgeons, wanted to better understand the risk of postpartum psychosis. “I find the overlap between mental health and pregnancy to be very interesting and not fully understood,” she says. “While [postpartum psychosis] is relatively rare, it can have devastating consequences on patients and merits further research and understanding.”

Albers worked with several NewYork-Presbyterian/Columbia maternal-fetal medicine specialists, including Alexander Friedman, MD, MPH, Whitney Booker, MD, and Mary D’Alton, MD, chair of obstetrics & gynecology, as well as Catherine Monk, PhD, a women’s health psychologist at NewYork-Presbyterian/Columbia, and colleagues from the University of California-San Francisco to conduct an analysis to determine trends in and risk factors for postpartum psychosis during delivery hospitalizations and postpartum readmissions.

The researchers turned to the Nationwide Readmission Database (NRD), a robust repository that supports analyses of readmissions throughout the country for all patients of all ages. “This database, which is widely used in epidemiology and health services research, enables you to follow patients through time within a given state, within a given year,” says Dr. Friedman. “If a patient has multiple hospitalizations, you can follow the timeline of readmission as each patient has a unique identifier.”

Dr. Alexander Friedman

Data was analyzed for demographic, medical, obstetric, and hospital factors available in the NRD that were associated with readmission for postpartum psychosis and present during the delivery hospitalization between 2016 to 2019. The database included 12,334,506 deliveries of which 13,894 carried a diagnosis of postpartum psychosis during the delivery hospitalization, and 7,128 patients who had a 60-day readmission for postpartum psychosis. The study’s findings, published in the American Journal of Obstetrics & Gynecology MFM, showed:

• Postpartum psychosis was associated with a wide range of medical conditions and obstetrical complications, with the largest effects seen for comorbid psychiatric diagnoses
• Readmissions for postpartum psychosis increased significantly over the study period
• Majority of readmissions with the diagnosis occurred 0 to 10 days (43 percent of readmissions) or 11 to 20 days after discharge (18 percent of readmissions)
• In models analyzing postpartum psychosis diagnoses at delivery, risk factors associated with the highest odds included anxiety disorder, schizophrenia spectrum disorder, bipolar disorder, stillbirth, and substance use disorder
• Clinical factors associated with the highest probability for readmission included delivery postpartum psychosis, depression, bipolar spectrum disorder, and schizophrenia spectrum disorder
• Pregestational diabetes, obesity, asthma, substance use, postpartum hemorrhage, and cesarean delivery were also associated with delivery and readmission postpartum psychosis

“Our findings enabled us to identify a number of important risk factors [for postpartum psychosis],” says Dr. Friedman. “The most important predictors were the presence of an underlying comorbid psychiatric diagnosis. This was one of our key findings in analyzing the national dataset and supports what has previously been reported in the literature. A traumatic delivery, such as a pre-term delivery or stillbirth, was also associated with risk for postpartum psychosis. Additionally, we found that patients on the younger side, 15 to 19 years old, and those 40 and older, had a slightly higher risk as did patients on Medicaid or Medicare. While a diagnosis of postpartum psychosis is relatively rare, it is important that clinicians remain vigilant for concerning symptoms, particularly for patients who have other underlying psychiatric conditions or those with delivery complications.”

While a diagnosis of postpartum psychosis is relatively rare, it is important that clinicians remain vigilant for concerning symptoms, particularly for patients who have other underlying psychiatric conditions or those with delivery complications.” – Dr. Friedman

Albers, Dr. Friedman, and their colleagues presented the findings from the study during a poster session at the Society for Maternal-Fetal Medicine’s 2023 Annual Pregnancy Meeting. “We plan to do a follow-up study that looks at maternal mental health from a different perspective,” Albers says. “We are interested in whether patients with pre-existing mental health conditions such as depression or bipolar disorder are more likely to need hospital readmission after delivery. We hypothesize that patients with mental health concerns may need increased postpartum care even for non-psychiatric reasons.”

The most important thing that providers can do is to screen postpartum patients for signs of mental health concerns, such as postpartum depression. “For patients with one or more of the risk factors we identified in this work, there may be a role for closer monitoring to ensure that patients get the care they need should psychosis arise,” Albers says.