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psych.postpartum-psychosis.v1

Postpartum psychosis — acute postpartum psychiatric emergency (ACOG 757 2018/2024; NICE NG192 2024; APA 2024; Bergink 2012; Sit 2006)

psychiatryacuteadultpregnancyacuteinpatienttransitionoutpatient
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Postpartum psychosis dossier — ACOG 757 2018/2024 + NICE NG192 2024 + APA 2024 postpartum-onset specifier + PSI 2024 + Bergink 2012 + Sit 2006 + Robertson 2005 + Brockington 2004 + Wesseloo 2016 + Titulaer 2013 (anti-NMDAR). SAFETY-CRITICAL: postpartum psychiatric emergency with elevated suicide (~ 5% lifetime) + infanticide (~ 4% during untreated severe episode) risk. Inpatient psych admission MANDATORY regardless of outward stability — explicit anti-pattern warning encoded in ED disposition_criteria. Distinct from postpartum depression (psych.depression.core.v1) — incidence 1–2 per 1000 vs 10–15% births; PPD-with-psychotic-features routes to this dossier per sibling_differentiation. Axis 1 acute pharmacotherapy: antipsychotic (olanzapine 5–10 / risperidone 2 / quetiapine 100–300 / aripiprazole 5–15) + mood stabiliser (lithium 300 TID target 0.8–1.2 acute, 0.6–1.0 maintenance; valproate avoided in reproductive-age without LARC) + ECT early in refractory / catatonia / severe SI / pharmacotherapy-restricted by lactation. Brexanolone / zuranolone off-label for mood-spectrum overlap. Axis 2 lactation-aware: risperidone / olanzapine / quetiapine compatible with breastfeeding (LactMed 2024); lithium acceptable in breastfeeding under monitoring per APA 2024 + NICE NG192 2024 UPDATE (departure from prior absolute-avoid) — infant serum lithium + TSH + hydration weekly × 4 wk then monthly; clozapine + long-acting benzodiazepines + topiramate avoided in breastfeeding. Axis 3 preconception / next-pregnancy prophylaxis: prophylactic lithium at delivery for prior PP — Bergink 2012 PMID 22407083 reduces recurrence from ~ 50% to ~ 10%; lifelong perinatal-psych + OB / MFM co-management for known bipolar-spectrum. Severity triggers (8): postpartum_psychosis_at_diagnosis (life-threatening — mandatory inpatient admission), infanticide_ideation_or_command_hallucinations (life-threatening — emergency hold + 1:1 + CPS), suicide_ideation_with_plan_or_recent_attempt_postpartum (life-threatening — cross-routes to psych.suicidality.ed.core.v1), postpartum_psychotic_features_with_delirium_signs (life-threatening — full organic workup mandatory), treatment_resistance_at_2_weeks (severe — ECT consideration; reconsider organic differential), lithium_in_breastfeeding_required (moderate — informed-consent + infant monitoring + do not separate mother-infant), prior_postpartum_psychosis_subsequent_pregnancy (severe — ~ 50% recurrence + preconception planning + prophylactic lithium at delivery), mother_baby_unit_unavailable_geographic_barrier (severe — coordinate non-MBU psych + obstetric + nursery + transfer plan). Three setting playbooks: ED (recognise + contain + organic-rule-out + mandatory admission), inpatient (MBU preferred; antipsychotic + mood stabiliser titration; lactation pharmacology; Q-shift C-SSRS + infanticide screen; Stanley-Brown safety plan; bridge ≤ 1 wk), outpatient (perinatal psych Q2 wk × 12 wk then monthly until 12 mo; lethal-means restriction reinforcement; pediatric coordination; preconception counselling). Sibling differentiation vs psych.depression.core.v1, psych.bipolar-disorder.core.v1, psych.suicidality.ed.core.v1, psych.first-episode-psychosis.core.v1, id.sepsis.core.v1 — cross-routes documented for organic differential (id.sepsis.core.v1, ob.postpartum-hemorrhage.core.v1, ob.pre-eclampsia.core.v1, endo.adrenal-crisis.core.v1 for sheehan, anti-NMDAR via workup.encephalopathy + workup.acute_psychosis umbrellas). Phenotype matrix (mood-spectrum vs primary psychotic × peak-window 3–10 d vs delayed × bipolar-history × prior-PP × suicidality / infanticide-ideation × breastfeeding-status × delirium-features × MBU-availability) encoded indirectly via severity_triggers + setting_playbooks + sibling_differentiation. First-class TS field for phenotype matrix is schema-blocked. Bayesian linkage: pre-test priors — PP incidence 1–2 per 1000 births (Sit 2006); known BP I 25–50% lifetime postpartum psychotic risk (Wesseloo 2016); prior PP 50–70% recurrence (Robertson 2005; Bergink 2012). LR+ — rapid-onset < 14 d postpartum + bipolar-history LR+ > 10 for PP vs PPD-with-psychotic-features; family history of bipolar / PP LR+ ~ 3 (Jones & Craddock 2001); sleep < 4 h / night × 2 d in known bipolar postpartum LR+ ~ 4 for impending PP (Bergink 2012). T_treat — any postpartum psychotic features = immediate inpatient + antipsychotic + mood stabiliser regardless of severity scoring. T_test (organic rule-out) — delirium features OR atypical presentation → full organic workup BEFORE primary psych diagnosis. Cross-dossier routing: psych.bipolar-disorder.core.v1 (long-term), psych.depression.core.v1 (PPD differential), psych.suicidality.ed.core.v1 (SI), psych.first-episode-psychosis.core.v1 (FEP if first lifetime), id.sepsis.core.v1 (if organic), neuro/anti-NMDAR via workup.encephalopathy + workup.acute_psychosis. ROS/DDx LR seed data audited by npm run audit:ros-ddx-coverage (cross-cutting; not touched by this shard). CRITICAL anti-pattern warnings baked in: (1) DO NOT discharge a postpartum psychotic patient home — admission mandatory regardless of outward stability; (2) NEVER antidepressant monotherapy in postpartum psychosis — manic-switch + worsening psychotic features (STEP-BD Sachs NEJM 2007); (3) DO NOT default to mother-infant separation for lithium alone — APA 2024 + NICE NG192 2024 update permits breastfeeding under monitoring; (4) valproate avoided in reproductive-age without LARC (FDA 2013 black-box); (5) explicit infanticide-ideation ask required at every encounter; (6) full organic workup (sepsis, sheehan, thyroiditis, anti-NMDAR, eclampsia / PRES) mandatory if delirium features; (7) ECT effective + safe in lactation — consider early in refractory; (8) prophylactic lithium at delivery for prior PP reduces recurrence ~ 50% → ~ 10%. PRODUCTION blockers: (1) prisma/seed/manifests/psych.postpartum-psychosis.v1.ts pointer out-of-shard-scope per peds.febrile-infant / psych.suicidality / psych.alcohol_withdrawal / psych.bipolar-disorder precedent — manifest field blanked; (2) calc.cssrs + calc.ymrs + calc.epds not in clinical-tools-registry — flagged for future calc-registry batch (C-SSRS workflow embedded via workup.suicide_risk umbrella; YMRS / EPDS workflow embedded in setting playbook narratives); (3) RxCUIs need RxNav validation via scripts/research/rxnav-validate.ts (brexanolone 2625139 + zuranolone 2570683 specifically flagged); (4) targeted test file pending (relies on dossier-contract.test.ts); (5) ECT not yet a registered workup atom — referenced inline in Axis 1 Step 3. Authored 2026-05-15 in shard-5-obped-id Phase C dispatch — companion brief at src/lib/dossiers/_briefs/psych.postpartum-psychosis.v1.md + research bundle at src/lib/dossiers/_research-bundles/psych.postpartum-psychosis.v1.md.

Entry points (8)

  • symptom
    Hallucinations, delusions, or grossly disorganised thought / behaviour within 12 weeks postpartum (DSM-5-TR 2022 brief psychotic disorder with peripartum onset; ACOG 757 2018/2024; NICE NG192 2024)
    postpartum_psychotic_features
  • symptom
    Rapid mood cycling, severe insomnia with decreased sleep need, mania-with-psychosis postpartum (APA 2024 postpartum-onset specifier; Sit 2006 PMID 16724884)
    postpartum_rapid_mood_cycling_with_psychosis
  • symptom
    Severe insomnia (< 4 h/night ≥ 2 d) + new confusion/fluctuating cognition in first 4 weeks postpartum — high-acuity prodrome (Bergink 2012 PMID 22407083; NICE NG192 2024)
    postpartum_severe_insomnia_with_dyscognition
  • symptom
    Thoughts, urges, or command hallucinations to harm self or infant in postpartum patient (Brockington Lancet 2004 PMID 14751705; ACOG 757 2018/2024)
    infanticide_or_self_harm_ideation_postpartum
  • problem_list
    Known bipolar I or II disorder in postpartum period — ~25–50% lifetime risk of postpartum psychotic episode (Wesseloo 2016 PMID 26514657; APA 2024)
    known_bipolar_postpartum_decompensation
  • history
    Personal history of prior postpartum psychosis — ~50% recurrence in subsequent pregnancy (Robertson 2005 PMID 15738508; Bergink 2012 PMID 22407083)
    prior_postpartum_psychosis
  • history
    First-degree relative with postpartum psychosis or bipolar disorder — familial loading (Jones & Craddock AJP 2001 PMID 11384899)
    first_degree_family_postpartum_psychosis
  • symptom
    Fluctuating cognition, autonomic instability, new-onset confusion in postpartum patient — mandates organic differential before primary psychiatric diagnosis (NICE NG192 2024; ACOG 757 2018/2024)
    postpartum_delirium_features

Required inputs (25)

  • agerequired
    demographic • used at CONTEXT
    Adolescent + advanced-maternal-age modifiers; baseline pharmacokinetic considerations for antipsychotic + lithium dosing (APA 2024; PSI 2024)
  • days_postpartumrequired
    demographic • used at FRAME
    Onset window — peak 3–10 d (median day 6); 90% within first 4 wk; up to 12 wk per DSM-5-TR peripartum specifier (Sit 2006 PMID 16724884; ACOG 757 2018/2024)
  • breastfeeding_statusrequired
    demographic • used at CONTEXT
    Drives antipsychotic + mood-stabiliser selection (olanzapine / risperidone / quetiapine vs lithium — lithium acceptable under monitoring per APA 2024 update; valproate avoided in reproductive-age) (APA 2024; NICE NG192 2024; PSI 2024)
  • cssrs_ideation_and_behaviorrequired
    symptom • used at RED_FLAGS
    Columbia Suicide Severity Rating Scale — postpartum SI carries elevated lethality; routine ED + admission + Q-shift inpatient (Posner 2011 PMID 22193671; ACOG 757 2018/2024)
  • infanticide_ideation_explicit_askrequired
    symptom • used at RED_FLAGS
    Explicit ask: "Do you have thoughts of harming your baby?" — never assume safety based on outward presentation; command hallucinations involving infant fire emergency containment + CPS notification (Brockington Lancet 2004 PMID 14751705; PSI 2024)
  • sleep_assessment_postpartumrequired
    symptom • used at CONTEXT
    Sleep deprivation < 4 h/night ≥ 2 d in known-bipolar postpartum carries LR+ ≈ 4 for impending postpartum psychotic episode (Bergink 2012 PMID 22407083; Sharma Bipolar Disord 2003)
  • prior_bipolar_or_psychosis_historyrequired
    history • used at CONTEXT
    Known BP I / BP II / schizoaffective / prior FEP — single strongest risk factor for postpartum psychosis (Wesseloo 2016 PMID 26514657; APA 2024)
  • family_history_bp_or_pprequired
    history • used at CONTEXT
    First-degree relative with bipolar disorder or postpartum psychosis — familial / genetic loading (Jones & Craddock AJP 2001 PMID 11384899)
  • obstetric_complicationsrequired
    history • used at CONTEXT
    Sheehan syndrome (postpartum hypopituitarism), retained products + sepsis, pre-eclampsia / eclampsia / PRES, postpartum hemorrhage — organic differential (ACOG 757 2018/2024; NICE NG192 2024)
  • substance_use_perinatalrequired
    history • used at CONTEXT
    Perinatal stimulant / opioid / alcohol use complicate presentation and differential — withdrawal can mimic psychosis (ACOG 757 2018/2024; SAMHSA TIP 51 2018)
  • current_medsrequired
    medication • used at CONTEXT
    Identify current antidepressant (can precipitate manic switch in unrecognised bipolar), antipsychotic, mood stabiliser; review for offending agents (steroids, stimulants, antidepressant switch) (APA 2024; STEP-BD Sachs NEJM 2007)
  • bmp_glucose_calciumrequired
    lab • used at INITIAL_WORKUP
    Baseline electrolytes, glucose, calcium — rule out hypoglycaemia / hypocalcaemia / dysnatremia mimicking psychosis (NICE NG192 2024; PSI 2024)
  • cbc_with_diffrequired
    lab • used at INITIAL_WORKUP
    Postpartum infection / sepsis screen (endometritis, mastitis, wound, UTI) — fluctuating cognition often delirium of sepsis (NICE NG192 2024; SSC 2026)
  • tsh_free_t4required
    lab • used at INITIAL_WORKUP
    Postpartum thyroiditis (5–10% of postpartum women) can present with thyrotoxicosis + anxiety + insomnia mimicking mania or with hypothyroidism mimicking depression (ATA 2017; ACOG 757 2018/2024)
  • lft
    lab • used at INITIAL_WORKUP
    Baseline for valproate (avoided in reproductive-age) or olanzapine hepatotoxicity monitoring (APA 2024)
  • renal_functionrequired
    lab • used at INITIAL_WORKUP
    Baseline creatinine + eGFR for lithium dosing (APA 2024; KDIGO 2024)
  • lithium_level
    lab • used at MONITORING
    Therapeutic drug monitoring — acute 0.8–1.2 mEq/L, maintenance / postpartum prophylaxis 0.6–1.0 mEq/L (APA 2024; Bergink 2012 PMID 22407083)
  • urine_drug_screenrequired
    lab • used at INITIAL_WORKUP
    Substance-induced psychosis differential; stimulant / sympathomimetic use perinatally (SAMHSA TIP 51 2018; ACOG 757 2018/2024)
  • ammonia
    lab • used at BRANCHING_WORKUP
    Hepatic encephalopathy or urea cycle disorder if AMS predominates (workup.encephalopathy umbrella)
  • cortisol_acth_prolactin
    lab • used at BRANCHING_WORKUP
    Sheehan syndrome screen (postpartum hypopituitarism) if hypotension + hyponatraemia + lactation failure + AMS (Endocrine Society 2016)
  • anti_nmdar_ab
    lab • used at BRANCHING_WORKUP
    Anti-NMDA receptor encephalitis — paraneoplastic + post-viral; pregnancy is a documented trigger; classic psychiatric prodrome → seizures + dyskinesias + dysautonomia (Titulaer Lancet Neurol 2013 PMID 23290630)
  • ct_head
    imaging • used at BRANCHING_WORKUP
    Focal neuro findings, headache, seizure, or atypical presentation (postpartum CVST / PRES / eclampsia differential) (NICE NG192 2024; AHA/ASA 2024)
  • mri_brain
    imaging • used at BRANCHING_WORKUP
    PRES, CVST, anti-NMDAR encephalitis, demyelinating disease — when CT non-diagnostic or specific concern (Titulaer Lancet Neurol 2013 PMID 23290630)
  • lp_csf
    imaging • used at BRANCHING_WORKUP
    CNS infection / autoimmune encephalitis when fever / meningismus / delirium-with-fluctuating-cognition (NICE NG192 2024; IDSA meningitis 2017)
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    QTc baseline before SGA initiation (FDA; APA 2024)

12-phase flow (12)

  1. 1FRAME
    Postpartum (≤ 12 wk; peak days 3–10) patient with new psychotic features, mania with psychosis, or rapid mood cycling — confirm peripartum-onset specifier (DSM-5-TR 2022); objective is rule out organic cause + mandatory inpatient containment + antipsychotic + mood stabiliser + suicide/infanticide screening (ACOG 757 2018/2024; NICE NG192 2024; APA 2024)
    inputs: days_postpartum
    advance: Postpartum context confirmed and presence of psychotic / rapid-cycling-with-psychosis features documented
  2. 2ENTRY
    Triggered by postpartum psychotic features, rapid mood cycling, severe insomnia + dyscognition, infanticidal ideation, command hallucinations, known-bipolar postpartum decompensation, or prior postpartum psychosis recurrence (Sit 2006 PMID 16724884; Bergink 2012 PMID 22407083; PSI 2024)
    inputs: age, days_postpartum, breastfeeding_status
    advance: Entry criteria documented with postpartum window + presentation pattern
  3. 3CONTEXT
    Prior bipolar / psychosis / postpartum-psychosis history (single strongest risk factor); family history (bipolar / postpartum psychosis); obstetric complications (PPH, sepsis, eclampsia, sheehan); breastfeeding status; sleep deprivation pattern; substance use; current meds (antidepressant switch differential); social supports and access to infant (Wesseloo 2016 PMID 26514657; Jones & Craddock AJP 2001 PMID 11384899; APA 2024)
    inputs: prior_bipolar_or_psychosis_history, family_history_bp_or_pp, obstetric_complications, substance_use_perinatal, current_meds, sleep_assessment_postpartum
    advance: Risk + protective + organic-context factors captured
  4. 4RED_FLAGS
    Active SI with plan/intent/means; infanticide ideation / urges / command hallucinations involving infant; severe agitation; refusal of admission with active risk; delirium features mandating organic workup; postpartum hemorrhage / sepsis / pre-eclampsia signs warranting medical co-management; access to means (firearm, large-quantity meds) (ACOG 757 2018/2024; Brockington Lancet 2004 PMID 14751705; Joint Commission NPSG.15.01.01)
    inputs: cssrs_ideation_and_behavior, infanticide_ideation_explicit_ask
    actions: workup.suicide_risk, workup.acute_psychosis
    advance: Containment in place AND admission decision being made (mandatory regardless of stated stability)
  5. 5INITIAL_WORKUP
    CBC + diff (sepsis), BMP (electrolytes, glucose, calcium), LFT, renal function, TSH + free T4 (postpartum thyroiditis), urine drug screen, ECG (QTc baseline before SGA), β-hCG retained-products workup if indicated (NICE NG192 2024; ACOG 757 2018/2024; ATA 2017)
    inputs: cbc_with_diff, bmp_glucose_calcium, tsh_free_t4, renal_function, urine_drug_screen, ecg
    advance: Baseline organic workup obtained
  6. 6BRANCHING_WORKUP
    Delirium features → expand: ammonia, cortisol/ACTH/prolactin (Sheehan), anti-NMDAR antibody panel (pregnancy-triggered autoimmune encephalitis — Titulaer Lancet Neurol 2013 PMID 23290630), CT head (focal/PRES/CVST), MRI brain when CT non-diagnostic, LP (meningitis / autoimmune encephalitis), EEG (NCSE if persistent AMS). Postpartum hemorrhage / sepsis / eclampsia signs → cross-route to obstetric medicine + critical care.
    actions: workup.encephalopathy, workup.delirium
    advance: Organic differential excluded OR cross-routed to the appropriate medical dossier
  7. 7DIFFERENTIAL
    Postpartum psychosis (primary psychiatric, often bipolar-spectrum) vs postpartum depression with psychotic features vs primary first-episode psychosis with peripartum onset vs postpartum delirium (sepsis, sheehan, postpartum thyroiditis with thyrotoxicosis, hyponatraemia, drug withdrawal) vs anti-NMDA-R encephalitis vs CVST / PRES / eclampsia with neuropsych features vs substance-induced psychosis vs brief reactive psychosis (DSM-5-TR 2022; NICE NG192 2024; ACOG 757 2018/2024)
    advance: Working differential narrowed; primary postpartum psychosis assigned only AFTER organic differential addressed
  8. 8RISK_STRATIFICATION
    C-SSRS for suicidality; infanticide ideation gating (command hallucinations involving infant = highest-acuity); psychotic features severity; sleep deprivation pattern; bipolar-history strength; access to infant; social supports; MBU availability; capacity for voluntary admission (Posner 2011 PMID 22193671; ACOG 757 2018/2024; Brockington Lancet 2004 PMID 14751705)
    inputs: cssrs_ideation_and_behavior, infanticide_ideation_explicit_ask
    advance: Severity tier assigned with explicit basis documented
  9. 9TREATMENT
    Mandatory inpatient psychiatric admission regardless of outward stability; antipsychotic (olanzapine 5–10 mg / risperidone 2 mg / quetiapine 100–300 mg titrated; breastfeeding-safety preference); mood stabiliser (lithium 600–1200 mg / d targeting 0.6–1.0 mEq/L acute, with infant level monitoring if breastfeeding); valproate avoided in reproductive-age (FDA 2013 black-box) but acceptable postpartum if effective contraception in place; ECT early consideration for treatment-resistance, severe suicidality, catatonia, or pregnancy/breastfeeding-restricted pharmacotherapy; brexanolone / zuranolone limited data in PP (APA 2024; NICE NG192 2024; Bergink 2012 PMID 22407083)
    inputs: current_meds, breastfeeding_status
    advance: Regimen selected; admission completed (voluntary or involuntary); safety plan + 24/7 supervision in place
  10. 10DISPOSITION
    Inpatient psychiatry MANDATORY for every postpartum psychotic episode; Mother-Baby Unit (MBU) PREFERRED — combines psychiatric + obstetric + nursery; if MBU unavailable, locate next-best co-located inpatient psych + obstetric service or transfer to MBU-capable center; involuntary hold if patient refuses; child-protective-services notification if infanticide ideation or command hallucinations involving infant; 24/7 supervision until psychotic features resolve (NICE NG192 2024 — UK MBU model; ACOG 757 2018/2024; PSI 2024)
    advance: Inpatient admission confirmed and MBU vs alternative documented
  11. 11MONITORING
    Q15-min checks initially in inpatient unit, then Q-shift; daily C-SSRS + explicit infanticide-ideation screen; daily mental-status + sleep pattern; antipsychotic + mood-stabiliser side effects (EPS, metabolic, QTc, lithium tremor); lithium level Q5–7 d during titration then weekly while inpatient; serum-level + thyroid + renal in mother; if breastfeeding on lithium, infant serum lithium + TSH + hydration assessment weekly × 4 wk then monthly (APA 2024; Bergink 2012 PMID 22407083; PSI 2024)
    advance: Psychotic features resolving + sleep restored + ideation absent on serial C-SSRS
  12. 12FOLLOWUP
    Bridge perinatal psychiatry appointment ≤ 1 week post-discharge; OB co-management for postpartum check; pediatric coordination if breastfeeding on psychotropics (infant pediatrician dosed-in on lithium / antipsychotic exposure); Stanley-Brown safety plan with means restriction + family supervision + infant supervision plan; ongoing antipsychotic + mood stabiliser maintenance for ≥ 12 months per APA 2024; preconception counselling for next pregnancy — ~50% recurrence; prophylactic lithium at delivery for known bipolar-spectrum or prior PP (Bergink 2012 PMID 22407083; Robertson 2005 PMID 15738508; ACOG 757 2018/2024)
    advance: Outpatient bridge + OB + peds coordination in place; preconception counselling documented when relevant