Perinatal Psychiatry — Viva

Q1: A 32-year-old woman is brought to the emergency department by her husband on day 9 postpartum. She has not slept for 3 nights despite exhaustion, believes the baby is "not hers", and is hearing a voice telling her the baby is evil. Take me through the diagnosis, the immediate risks, and your emergency management. (2 min)

This is postpartum (puerperal) psychosis — a psychiatric emergency. The phenotype fits: onset within the first 2 weeks of delivery, the cardinal prodrome of insomnia for 2 or more nights despite exhaustion, a delusion concerning the infant (that the baby is "not hers") and an auditory hallucination with threat content (the voice telling her the baby is evil). Postpartum psychosis affects 1 to 2 per 1000 deliveries and is most often the postpartum presentation of bipolar disorder — about 25 to 50 percent of women with pre-existing bipolar I disorder develop it. The strongest clue here would be a personal or family history of bipolar disorder.^[3]

The immediate risks are suicide and infanticide. A woman with command hallucinations or delusions concerning her infant is at the highest single risk of harming the baby. I would ask directly about thoughts of harming herself or the infant, intent, plan, access to means, and protective factors.^[3]

Emergency management:

1. Admit urgently, ideally to a mother-and-baby unit (MBU) so mother and infant remain together under supervised care; if no MBU bed, admit to an acute psychiatric ward with arrangements for the infant's safe care. Do NOT manage at home.
2. Remove the infant from immediate unsupervised risk — care by partner, family, or safeguarding team.
3. Constant 1-to-1 observation while risk is active; remove access to means.
4. Exclude an organic cause: septic screen, TSH, U&E, calcium, glucose, LFT (postpartum sepsis, thyroiditis, electrolyte disturbance, eclampsia can mimic psychosis).
5. Rapid tranquillisation if acutely agitated: oral lorazepam 1 to 2 mg or olanzapine 5 to 10 mg first-line; IM lorazepam or IM olanzapine if oral refused (not within 1 hour of each other — risk of respiratory depression).
6. Definitive treatment: antipsychotic (olanzapine, haloperidol) ± mood stabiliser if bipolar ± ECT if severe or life-threatening.^[3]

Q2: Walk me through your use of the Edinburgh Postnatal Depression Scale. When do you use it, how do you score it, and what is the single most important item? (2 min)

The EPDS (Cox, Holden and Sagovsky, 1987) is a 10-item self-report questionnaire completed by the mother for the past 7 days, taking about 5 minutes. It is the global screening standard for postpartum depression but is not diagnostic — a score at or above threshold triggers a structured clinical assessment.^[1]

Timing: I screen at the 6 to 8-week postnatal check and at the booking antenatal visit (NICE CG192). Many services re-screen at 3 to 4 months and 6 months.

Scoring: each item is scored 0 to 3, total 0 to 30. Items 1, 2 and 4 are reverse-scored (the "well" response scores 3, the "unwell" response scores 0); the rest are scored 0 = well, 3 = unwell. The cutoffs I use:

• 13 or more — probable major depression; offer clinical assessment and treatment.
• 10 to 12 — possible depression; re-assess and repeat in 2 weeks.

The single most important item is item 10 — "The thought of harming myself has occurred to me." Any score of 1, 2 or 3 on item 10 mandates direct exploration of suicidal risk, regardless of the total score. I would never interpret an EPDS without reading item 10.^[1]

A common pitfall: the EPDS screens for depression, not psychosis — a woman with postpartum psychosis may have a low EPDS if she does not recognise her symptoms as depression. Clinical judgement always trumps a single score.

Q3: Take me through your stepwise management of postnatal depression, with specific drug doses and the rationale for your first-choice antidepressant in a breastfeeding mother. (3 min)

Management is stratified by severity (NICE CG192):^[1][6]

• Step 1 — Mild PND (EPDS 10 to 12, no harm thoughts, intact bonding): guided self-help, sleep hygiene, exercise, peer support, address psychosocial stressors (housing, finance, relationship, domestic violence). Review in 1 to 2 weeks.
• Step 2 — Moderate PND (EPDS 13 to 19): psychological therapy first-line — CBT or interpersonal therapy (IPT). IPT has particular evidence in PND because it addresses the role transition to motherhood. Add an SSRI if moderate-to-severe or if psychological therapy is delayed.
• Step 3 — Moderate-to-severe PND (EPDS 20 or more, functional impairment): SSRI first-line. Sertraline 50 mg PO once daily, titrate to 100 to 200 mg/day; full effect at 4 to 6 weeks. Sertraline is preferred in breastfeeding because it has the lowest relative infant dose in breast milk — about 1 to 2 percent of the maternal weight-adjusted dose — established by the Pinheiro 2015 meta-analysis.^[6] Alternatives: citalopram, escitalopram.
• Step 4 — Severe, treatment-resistant or psychotic PND: refer to perinatal mental health; consider ECT (safe in pregnancy and postpartum, fast, first-line for psychotic depression, catatonia, or refusal to eat or drink).^[9]
• Step 5 — Relapse prevention: continue SSRI for at least 6 months after remission, then taper over 4 weeks; plan future pregnancies (1 in 3 to 1 in 2 recurrence risk).

The rationale for sertraline in a breastfeeding mother: it is effective for major depression, has the lowest breast-milk transfer among SSRIs, and the substantial benefits of continued breastfeeding (cognition, immunity, maternal bonding) outweigh the small infant-exposure risk. I would continue breastfeeding throughout.^[6]

Q4: A woman with known bipolar I disorder presents at 8 weeks of pregnancy, currently well on lithium. How do you counsel her about medication in pregnancy, and what do you do postpartum? (3 min)

This is a high-risk perinatal situation — bipolar I confers a 25 to 50 percent risk of postpartum psychosis, the highest single risk in psychiatry. The decisions balance teratogenicity against relapse risk, and must be made jointly with the patient, her perinatal psychiatrist and her obstetrician.^[3][4]

Counselling on lithium in pregnancy: lithium is associated with Ebstein anomaly of the tricuspid valve — Patorno et al. 2017 (NEJM) quantified the absolute risk at approximately 1 in 650 first-trimester exposures, versus a baseline of 1 in 20,000 — an order of magnitude lower than older estimates but still elevated above background.^[4] Stopping lithium abruptly in pregnancy carries a high relapse risk; the decision is individualised. If she continues lithium: monitor levels frequently (every 4 weeks to 28 weeks, every 2 weeks to 36 weeks, weekly thereafter, and immediately postpartum as fluid shifts raise levels), target the lower end of the therapeutic range (0.6 to 0.8 mmol/L), maintain hydration in labour, and arrange a fetal echocardiogram at 18 to 20 weeks. If she chooses to discontinue, do so gradually with a clear relapse-prevention plan, ideally keeping an antipsychotic (olanzapine or quetiapine) as cover.

Drugs to avoid: valproate is absolutely contraindicated in pregnancy (and in all women of childbearing potential without a Pregnancy Prevention Programme — the UK MHRA PREVENT programme) due to neural tube defects, cardiac and skeletal anomalies, and a dose-dependent reduction in offspring IQ.^[5] Carbamazepine also carries teratogenicity. Lamotrigine is relatively safer but its clearance rises markedly in pregnancy, requiring dose adjustment.

Postpartum: restart lithium (or the mood stabiliser/antipsychotic) immediately after delivery to prevent postpartum psychosis — this is the single most important intervention. If she breastfeeds, lithium is usually avoided (high transfer, infant toxicity); an antipsychotic (olanzapine, quetiapine) is the safer mood stabiliser in breastfeeding. Close monitoring by the perinatal mental health team is essential.

Q5 (examiner's probe): The EPDS is being criticised for "over-screening" and pathologising normal motherhood. How do you respond?

I would respond that the EPDS is a screening tool, not a diagnostic test — a positive screen triggers a clinical assessment, not a diagnosis. Its purpose is to shift the threshold of recognition downward so that women with clinically significant depression — who are systematically under-detected in routine postnatal care (detected in under 50 percent of cases without screening) — are identified and offered treatment. The harms of untreated postnatal depression are well-established: persistent maternal morbidity, impaired mother-infant bonding, and lasting effects on the child's cognitive, emotional and behavioural development (Stein et al. 2014, Lancet).^[2] The cutoff of 13 is chosen to maximise sensitivity at acceptable specificity; false positives are reviewed clinically and either reassured or offered low-intensity interventions (self-help, peer support) — the over-treatment risk is small relative to the under-treatment harm.

I would also acknowledge the criticism's merit in one respect: the EPDS screens for depression, not the whole perinatal mental health picture — it does not capture postpartum anxiety, OCD, PTSD, or psychosis. A comprehensive perinatal mental health assessment is broader than the EPDS, and the scale should be used as one component of a holistic assessment, not as a tick-box.^[1][2]

Q6 (final probe): Suicide is described as a leading indirect cause of maternal death. Why is perinatal suicide different, and what are the implications for practice?

Perinatal suicide is different in three ways. First, the index episode is often the first presentation of an under-recognised bipolar-spectrum illness — postpartum psychosis carries a markedly elevated suicide risk, and many of these women had no prior psychiatric diagnosis. Second, the methods used are typically violent and effective (hanging, jumping, overdose with high-lethality drugs), in contrast to the lower-lethality self-harm seen in non-perinatal depression — meaning that suicidal ideation in the perinatal period must be treated as high-acuity regardless of apparent intent. Third, the time window extends to one year postpartum (MBRRACE-UK), not the classic 6-week puerperium — late postpartum suicide is a significant contributor to maternal mortality.^[2]

The implications for practice: ask about suicidal and infanticidal ideation directly in every perinatal presentation (EPDS item 10, plus a direct clinical question), maintain a low threshold for specialist perinatal mental health referral, ensure rapid access to a mother-and-baby unit for postpartum psychosis, and provide continuity of perinatal mental health care through the first postpartum year, not just the 6-week check. Structured perinatal mental health services, MBU capacity, and explicit risk-management planning for women with severe perinatal mental illness are the systems-level interventions that MBRRACE-UK has repeatedly recommended.^[2][3]

References7ShowHide

1. [1]Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 1987.PMID 3651732
2. [2]Stein A, Pearson RM, Goodman SH, et al. Effects of perinatal mental disorders on the fetus and child. Lancet, 2014.PMID 25455250
3. [3]Bergink V, Rasgon N, Wisner KL. Postpartum Psychosis: Madness, Mania, and Melancholia in Motherhood. American Journal of Psychiatry, 2016.PMID 27609245
4. [4]Patorno E, Huybrechts KF, Bateman BT, et al. Lithium Use in Pregnancy and the Risk of Cardiac Malformations. New England Journal of Medicine, 2017.PMID 28591541
5. [5]Alsdorf R, Wyszynski DF Teratogenicity of sodium valproate. Expert Opinion on Drug Safety, 2005.PMID 15794725
6. [6]Pinheiro E, Bogen D, Hoxha D, Wisner KL. Sertraline and breastfeeding: review and meta-analysis. Archives of Women's Mental Health, 2015.PMID 25589155
7. [9]Ward HB, Fromson JA, Cooper JJ. Recommendations for the use of ECT in pregnancy: literature review and proposed clinical protocol. Archives of Women's Mental Health, 2018.PMID 29796968