1
2
Research Proposal Literature Review
July 23, 2023
Postpartum Psychosis
Postpartum psychosis is the occurrence of a combination of manic episodes and psychotic depression that is manifested as insomnia, disorganized behavior, obsession, delusions, severe mood fluctuations, and hallucinations during the first four weeks after childbirth (Rommel et al., 2021). As a condition with an acute onset, it is different from postpartum depression, which Holland (2018) defined as the occurrence of persistent depressed mood for 2 weeks within one month of postpartum and characterized by social withdrawal, feelings of guilt and worthlessness, irrational thoughts, fatigue, and loss of concentration. While the symptoms of postpartum psychosis and postpartum depression appear during the same postpartum period, women who suffer from psychotic depression, hallucinations, delusions, and manic episodes present significant dangers to themselves and their newborns (Xue et al., 2023). Also, the rarity of postpartum psychosis (3 per 1,000 births) makes it challenging for nurses and midwives to detect the conditions when patients are brought to the emergency room for medical care (Holland, 2018). In this regard, a large number of postpartum psychosis cases are misdiagnosed and undertreated, thereby increasing the risks of suicide and filicide among these patients. Therefore, the purpose of this literature review is to compare the effectiveness of standardized prenatal screening for postpartum psychosis with patient education with postnatal screening for postpartum depression to reduce the risks of suicidal and filicidal ideation over six months.
Postpartum Psychosis and Risks of Suicide and Filicide
Suicide and filicide thoughts are part of the clinical manifestations of postpartum psychosis that inform the immediate hospitalization of mother and child after its diagnosis. A narrative review of how postpartum psychosis might be a good indicator of the etiology of mental illness by Jones (2020) found there is an increased risk of patients to support prolonged episodes of psychotic depression after the initial severe symptoms due to the disorder’s strong association with bipolar disorder before and after childbirth. Regarding the risks of suicide and filicide from postpartum psychosis, Jones (2020) claimed that the dramatic levels of reproductive hormones, the role of immunological mechanisms in its occurrence, and genetics are factors that might increase the risk for these adverse outcomes. While this source did not collect any data or utilized any analysis method, its findings are good evidence to support the perspectives on the mechanisms for increased risks of suicide and filicide in nursing mothers who suffer from postpartum psychosis.
Postpartum psychosis hinders the patient’s mothering capacity and triggers any of the psychological processes for suicide, including a belief that the person is a burden to others and society, a low sense of belonging, or a lack of fear and pain suddenly. Although only 5% of postpartum psychosis patients commit suicide, Rommel et al. (2021) found from their “prospective clinical cohort study of 106 women found their risks of suicidal and filicidal ideation in these patients remain high until they receive appropriate interventions and nursing care” (p.37). Also, the study’s use of logistic regression to determine the disorder’s course in these women found that the “recurrence of psychotic episodes and mood disorder in 32% of these women after treatment and transition of more than 60% of the participants into bipolar disorder” confirmed the association between postpartum psychosis and suicide and filicide in patients (Rommel et al., 2021, p.38). While the study’s findings are limited by the small sample size and study design, it utilized appropriate data collection and analysis methods that make the result valid and relevant to the goal of using the research outcomes to demonstrate the importance of early diagnosis and treatment of postpartum psychosis. Hence, postpartum psychosis patients have high risks for suicide and filicide that should inform the screening of women during pregnancy and after childbirth.
The focus of psychological interventions for postpartum psychosis on the safety of both mother and child during the psychotic episode is another indicator of the risks of suicide and filicide from this psychiatric disorder. A qualitative analysis of women’s experience of these interventions by Fordes et al. (2019) thematically analyzed the data from the semi-structured interviews of 13 women and 8 family members to generate evidence that the risks of relapse or recurrence of the condition are high despite the effectiveness of psychological interventions (p.11). Despite the study’s limitations from the homogeneity of the sample, the results by Fordes et al. (2019) have valid clinical implications, including the identification and administration of the right psychological interventions to reduce women’s risk of suicide and filicide from postpartum psychosis and prevent relapse recurrence (p.16). However, a potential examination of the perspectives of women and their families on the importance of screening during pregnancy before undergoing treatment would have added to the strengths of this study.
Screening for Postpartum Psychosis
Screening for postpartum psychosis during pregnancy and after childbirth is necessary for informing treatment and achieving positive long-term outcomes (El-Den et al., 2022). Also, most screening programs for pregnant women only assessed basic depression and anxiety risk factors using the Patient Health Questionnaire (PHQ) and Generalized Anxiety Disorder (GAD) which only had a total of 2 questions to assess their risks for depression and anxiety. The other psychiatric screening instrument is the Edinburgh Pregnancy/Postnatal Depression Scale (EPDS) and used to assess perinatal and postnatal depression and anxiety (Xue et al., 2023). It implies that there is no standardized instrument for detecting psychotic depression or psychosis and assessing the risks for postpartum psychosis during the perinatal period.
Furthermore, the critical review of the literature on the screening for psychiatric disorders among childbearing women showed that most providers focus on screening for the risks of postpartum depression than postpartum psychosis. A systematic review of the recommendations for prenatal screening for depression by El-Den et al. (2022) of 21 publications from 5 OECD countries found that EPDS is the approved tool in these countries, including the United States. Also, the review found that timing and frequency ranged from early as possible or the first antenatal visit to the third trimester and 4-6 postnatally, while physicians in mental health, primary care, and obstetrics settings are required to perform this screening (El-Den et al., 2022). As a systematic review, the data and results from this study by El-Den et al. (2022) are valid and helped identified the limitations in screening pregnant women for risk factors for postpartum psychosis that could guide their education and prevent the occurrence of the disease after childbirth. Although El-Den et al. (2022) did not conduct quality assessments of their selected studies, the findings and data provided the highest level of evidence for answering the clinical question for the proposed research paper.
Waqas et al. (2022) also performed a systematic review of screening programs for common mental health disorders among pregnant women and found evidence of limited screening of these women for perinatal depression and anxiety from the 19 meta-analyses that were reviewed. Waqas et al. (2022) followed PRISMA guidelines for their review, used standardized search methods of electronic databases and two independent reviewers to extract data, and assessed the risk of bias with Cochrane tools to ensure the validity of their data and findings. In this regard, this umbrella review found strong evidence that perinatal screening reduces the risks of depression and anxiety in pregnant women, including those done with EPDS and PHQ9 tools (Waqas et al., 2022). While this study described the benefits of perinatal screening to maternal outcomes and quality of life, the study did not discuss the association between perinatal screening and postpartum psychosis, thereby limiting its relevance to the research paper. Therefore, this study illustrated some of the gaps in the literature on the use of perinatal screening to detect the risk factors of postpartum psychosis that could guide early interventions for women after childbirth.
A literature review by Holland (2018) found that the attitudes and perceptions of midwives toward effective screening for postpartum psychosis are due to the absence of specific assessment tools for the psychiatric disorder and the sudden onset of the disorder. As a review study that focused on suicide prevention, Holland’s (2018) failure to analyze the various studies on postpartum psychosis is the limitation of its relevance to the researcher, especially, when the delayed detection and treatment of the disorder increases the risks of suicide and filicide in women. In a nutshell, the detailed review of the evidence on screening for postpartum psychosis during both perinatal and postpartum periods showed that pregnant women do not have access to this important pre-diagnostic assessment for delivery early treatment and reducing their risks of suicide and filicide in vulnerable ones.
Conclusion
In summary, postpartum psychosis is a severe but rare maternal psychiatric disorder that would remain misdiagnosed and undertreated by primary care providers, including behavioral health nurses. Similarly, postpartum psychosis is characterized by a loss of reality and other psychotic symptoms that increase the nursing mother’s risk of suicide and filicide. As the evidence from various research studies showed, the acute onset of postpartum psychosis makes it challenging for prenatal screening of women. Also, there are no current standardized screening and diagnostic tools for postpartum psychosis during pregnancy and after childbirth in the United States. Although there is evidence that postnatal screening for postpartum depression can inform the clinical decisions that inform additional psychiatric tests, the peak incidence of postpartum psychosis within the same period when these assessments are performed indicates a limitation of this approach. However, there is evidence that early detection of the risk factors for postpartum psychosis outside the postpartum period ensures the provision of treatment and care that prevent the onset of the condition.
References
El-Den, S., Pham, L., Anderson, I., Yang, S., Moles, R. J., O’Reilly, C. L., … & Raynes-Greenow, C. (2022). Perinatal depression screening: A systematic review of recommendations from member countries of the Organisation for Economic Co-operation and Development (OECD). Archives of Women’s Mental Health, 25(5), 871-893. DOI: 10.1007/s00737-022-01249-1
Forde, R., Peters, S., & Wittkowski, A. (2019). Psychological interventions for managing postpartum psychosis: A qualitative analysis of women’s and family members’ experiences and preferences. BMC psychiatry, 19, 1-17. DOI: 10.1186/s12888-019-2378-y
Holland, C. (2018). The midwife’s role in suicide prevention. British Journal of Midwifery, 26(1), 44-50. https://www.britishjournalofmidwifery.com/content/literature-review/the-midwifes-role-in-suicide-prevention/
Jones, I. (2020). Postpartum psychosis: An important clue to the etiology of mental illness. World Psychiatry, 19(3), 334-336. DOI: 10.1002/wps.20780
Rommel, S., Molenaar, N. M., Gilden, J., Kushner, S. A., Westerbeek, N. J., Kamperman, A. M., & Bergink, V. (2021). Long-term outcome of postpartum psychosis: A prospective clinical cohort study in 106 women. International Journal of Bipolar Disorders, 9. DOI:10.1186/s40345-021-00236-2
Xue, W., Cheng, K. K., Liu, L., Li, Q., Jin, X., Yi, J., & Gong, W. (2023). Barriers and facilitators for referring women with positive perinatal depression screening results in China: a qualitative study. BMC Pregnancy and Childbirth, 23(1), 230. DOI: 10.1186/s12884-023-05532-6
Waqas, A., Koukab, A., Meraj, H., Dua, T., Chowdhary, N., Fatima, B., & Rahman, A. (2022). Screening programs for common maternal mental health disorders among perinatal women: Report of the systematic review of evidence. BMC psychiatry, 22(1), 54. DOI:10.1186/s12888-022-03694-9
