This handout is for postpartum psychosis — acute postpartum psychiatric emergency (acog 757 2018/2024; nice ng192 2024; apa 2024; bergink 2012; sit 2006). Your care team identified this based on: 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).
Other reasons your team may use this plan: rapid mood cycling, severe insomnia with decreased sleep need, mania-with-psychosis postpartum (apa 2024 postpartum-onset specifier; sit 2006 pmid 16724884); 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); thoughts, urges, or command hallucinations to harm self or infant in postpartum patient (brockington lancet 2004 pmid 14751705; acog 757 2018/2024).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| olanzapine | 5–10 mg PO QHS; titrate to 15–20 mg/day | PO | once daily | FDA-approved for acute mania + schizophrenia; sedation useful in severe postpartum insomnia; metabolic monitoring required (APA/ADA 2004; APA 2024; NICE NG192 2024 — preferred when severe insomnia component) |
| risperidone | 1 mg PO BID; titrate to 2–4 mg/day | PO | BID | Low relative-infant-dose in breastfeeding (~ 4%); FDA-approved for acute mania + schizophrenia; potent D2 — monitor EPS / prolactin (APA 2024; PSI 2024) |
| quetiapine | 50 mg PO BID day 1; titrate to 100–300 mg/day | PO | BID | Sedation useful in postpartum insomnia; FDA-approved across bipolar polarities; metabolic burden moderate (APA 2024; NICE NG192 2024) |
| aripiprazole | 5–10 mg PO daily; titrate to 15 mg | PO | once daily | Metabolically favourable but suppresses prolactin — caveat if breastfeeding maintenance desired; useful when olanzapine / quetiapine metabolic load undesirable (APA 2024) |
| lorazepam | 1–2 mg PO/IM/IV PRN q4–6h | PO/IM/IV | PRN q4–6h | Adjunct for sleep induction + agitation; first-line for catatonia lorazepam-challenge (Bush-Francis 1996); caution if patient breastfeeding — choose short-acting + monitor infant sedation (APA 2024; PSI 2024) |
Plan: Acute postpartum psychosis pharmacotherapy — antipsychotic + mood stabiliser combination (APA 2024; NICE NG192 2024; Bergink 2012 PMID 22407083)
Use these zones to know what to do based on how you feel.
Call 911 or go to the nearest emergency room right away if you have:
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)
Guideline: ACOG Committee Opinion 757 (2018, reaffirmed 2024) — Screening for Perinatal Depression + NICE NG192 (2014, last updated 2024) Antenatal and Postnatal Mental Health + APA Practice Guideline for Bipolar Disorder 2024 (postpartum-onset specifier) + Postpartum Support International (PSI) Perinatal Mental Health Certification 2024