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psych.postpartum-psychosis.v1PRODUCTION
psych.postpartum-psychosis.v1

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

psychiatryacuteadultpregnancy
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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)

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Postpartum context confirmed and presence of psychotic / rapid-cycling-with-psychosis features documented

Patient inputs (25)

Adolescent + advanced-maternal-age modifiers; baseline pharmacokinetic considerations for antipsychotic + lithium dosing (APA 2024; PSI 2024)

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)

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)

Known BP I / BP II / schizoaffective / prior FEP — single strongest risk factor for postpartum psychosis (Wesseloo 2016 PMID 26514657; APA 2024)

First-degree relative with bipolar disorder or postpartum psychosis — familial / genetic loading (Jones & Craddock AJP 2001 PMID 11384899)

Sheehan syndrome (postpartum hypopituitarism), retained products + sepsis, pre-eclampsia / eclampsia / PRES, postpartum hemorrhage — organic differential (ACOG 757 2018/2024; NICE NG192 2024)

Perinatal stimulant / opioid / alcohol use complicate presentation and differential — withdrawal can mimic psychosis (ACOG 757 2018/2024; SAMHSA TIP 51 2018)

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)

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)

Baseline electrolytes, glucose, calcium — rule out hypoglycaemia / hypocalcaemia / dysnatremia mimicking psychosis (NICE NG192 2024; PSI 2024)

Postpartum infection / sepsis screen (endometritis, mastitis, wound, UTI) — fluctuating cognition often delirium of sepsis (NICE NG192 2024; SSC 2026)

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)

Baseline creatinine + eGFR for lithium dosing (APA 2024; KDIGO 2024)

Substance-induced psychosis differential; stimulant / sympathomimetic use perinatally (SAMHSA TIP 51 2018; ACOG 757 2018/2024)

QTc baseline before SGA initiation (FDA; APA 2024)

Columbia Suicide Severity Rating Scale — postpartum SI carries elevated lethality; routine ED + admission + Q-shift inpatient (Posner 2011 PMID 22193671; ACOG 757 2018/2024)

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)

Hepatic encephalopathy or urea cycle disorder if AMS predominates (workup.encephalopathy umbrella)

Sheehan syndrome screen (postpartum hypopituitarism) if hypotension + hyponatraemia + lactation failure + AMS (Endocrine Society 2016)

Anti-NMDA receptor encephalitis — paraneoplastic + post-viral; pregnancy is a documented trigger; classic psychiatric prodrome → seizures + dyskinesias + dysautonomia (Titulaer Lancet Neurol 2013 PMID 23290630)

Focal neuro findings, headache, seizure, or atypical presentation (postpartum CVST / PRES / eclampsia differential) (NICE NG192 2024; AHA/ASA 2024)

PRES, CVST, anti-NMDAR encephalitis, demyelinating disease — when CT non-diagnostic or specific concern (Titulaer Lancet Neurol 2013 PMID 23290630)

CNS infection / autoimmune encephalitis when fever / meningismus / delirium-with-fluctuating-cognition (NICE NG192 2024; IDSA meningitis 2017)

Baseline for valproate (avoided in reproductive-age) or olanzapine hepatotoxicity monitoring (APA 2024)

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)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationallife_threateningpostpartum_psychosis_at_diagnosis
    Confirmed postpartum psychosis (≤ 12 weeks postpartum with psychotic features, mania-with-psychosis, or rapid mood cycling with psychotic features) — MANDATORY inpatient psychiatric admission regardless of outward stability; 24/7 supervision; explicit SI + infanticide-ideation screening at admission and Q-shift (ACOG 757 2018/2024; NICE NG192 2024; APA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninginfanticide_ideation_or_command_hallucinations
    Thoughts, urges, or command hallucinations to harm infant in postpartum patient (Brockington Lancet 2004 PMID 14751705; ACOG 757 2018/2024; PSI 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsuicide_ideation_with_plan_or_recent_attempt_postpartum
    C-SSRS Ideation 4 or 5 with plan, intent, or means OR documented suicide attempt within 90 days postpartum (ACOG 757 2018/2024; APA 2024; Posner 2011 PMID 22193671)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpostpartum_psychotic_features_with_delirium_signs
    Fluctuating cognition, autonomic instability, or new confusion with postpartum psychotic features — mandates full organic workup BEFORE primary psychiatric diagnosis (NICE NG192 2024; ACOG 757 2018/2024; Titulaer Lancet Neurol 2013 PMID 23290630)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretreatment_resistance_at_2_weeks
    Failure of antipsychotic + mood-stabiliser combination at therapeutic levels at 14 days — ECT consideration; reconsider organic differential (APA 2024; NICE NG192 2024; Pagnin 2004 PMID 15087991)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereprior_postpartum_psychosis_subsequent_pregnancy
    Patient with prior postpartum psychosis planning or in subsequent pregnancy — ~50% recurrence risk per Robertson 2005 PMID 15738508 + Bergink 2012 PMID 22407083; preconception planning + prophylactic lithium at delivery (APA 2024; NICE NG192 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremother_baby_unit_unavailable_geographic_barrier
    Mother-Baby Unit (MBU) unavailable in catchment — coordinate with available inpatient psychiatric + obstetric + nursery service; consider transfer to MBU-capable centre when stable (NICE NG192 2024; PSI 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatelithium_in_breastfeeding_required
    Lithium initiated or continued in breastfeeding patient with postpartum psychosis — informed-consent + infant-pediatrician coordination + infant monitoring (APA 2024 update; NICE NG192 2024; PSI 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.

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CONTEXToptionalDrives screening
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Recommended regimen

Acute postpartum psychosis pharmacotherapy — antipsychotic + mood stabiliser combination (APA 2024; NICE NG192 2024; Bergink 2012 PMID 22407083)
axis: postpartum_psychosis_acutestep 1 - Step 1 — Antipsychotic monotherapy or with benzodiazepine for sleep / agitation (APA 2024; NICE NG192 2024)
Selected step "Step 1 — Antipsychotic monotherapy or with benzodiazepine for sleep / agitation (APA 2024; NICE NG192 2024)" — Initial admission with psychotic features without prominent mania; or where mood-stabiliser load is contraindicated pending labs (APA 2024)
  • olanzapine
    first line
    atypical_antipsychotic
    5–10 mg PO QHS; titrate to 15–20 mg/day • PO • once daily (max: 20 mg/day)
    triggers: postpartum_psychosis_acute, severe_insomnia_with_psychosis
    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)
    rxcui 61381
  • risperidone
    first line
    atypical_antipsychotic
    1 mg PO BID; titrate to 2–4 mg/day • PO • BID (max: 6 mg/day)
    triggers: postpartum_psychosis_acute, breastfeeding_low_relative_infant_dose
    Low relative-infant-dose in breastfeeding (~ 4%); FDA-approved for acute mania + schizophrenia; potent D2 — monitor EPS / prolactin (APA 2024; PSI 2024)
    rxcui 35636
  • quetiapine
    first line
    atypical_antipsychotic
    50 mg PO BID day 1; titrate to 100–300 mg/day • PO • BID (max: 800 mg/day (rarely needed in PP))
    triggers: postpartum_psychosis_acute, severe_insomnia_with_psychosis, mood_spectrum_features
    Sedation useful in postpartum insomnia; FDA-approved across bipolar polarities; metabolic burden moderate (APA 2024; NICE NG192 2024)
    rxcui 51272
  • aripiprazole
    second line
    atypical_antipsychotic
    5–10 mg PO daily; titrate to 15 mg • PO • once daily (max: 30 mg/day)
    triggers: postpartum_psychosis_metabolically_favourable, prolactin_concern_breastfeeding
    Metabolically favourable but suppresses prolactin — caveat if breastfeeding maintenance desired; useful when olanzapine / quetiapine metabolic load undesirable (APA 2024)
    rxcui 89013
  • lorazepam
    rescue
    benzodiazepine
    1–2 mg PO/IM/IV PRN q4–6h • PO/IM/IV • PRN q4–6h (max: 8 mg/day)
    triggers: severe_insomnia_adjunct, agitation_adjunct, catatonia_lorazepam_challenge
    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)
    rxcui 6470

outpatient playbook — drug actions (6)

  1. 1. continue inpatient-initiated antipsychotic at maintenance dose ≥ 12 months postpartum
    Per discharge agent and dose • PO • daily
    trigger: Maintenance phase postpartum psychosis (APA 2024; NICE NG192 2024)
    Minimum 12 months antipsychotic continuation postpartum per APA 2024 even after remission; relapse risk in first 12 mo elevated (APA 2024; NICE NG192 2024)
  2. 2. lithium maintenance target 0.6–1.0 mEq/L
    300–900 mg PO total daily, divided • PO • BID-TID
    trigger: Mood stabiliser maintenance; prophylaxis for known bipolar / prior PP (APA 2024; Bergink 2012 PMID 22407083)
    First-line maintenance + future-pregnancy prophylaxis; lifelong recommended for confirmed BP I (BALANCE Geddes Lancet 2010; APA 2024)
  3. 3. taper antipsychotic at 12–24 mo if euthymic + remitted + supports in place
    Slow taper over 4–8 weeks under monitoring • PO • tapered
    trigger: Sustained euthymia ≥ 12 mo postpartum + protective factors in place (APA 2024)
    Avoid abrupt discontinuation — rebound risk; maintain mood stabiliser per BP I maintenance guidance (APA 2024)
  4. 4. continue / introduce lamotrigine for depression-predominant residual symptoms
    Slow titrate to 200 mg/day • PO • daily
    trigger: Depressive predominant polarity OR transition from acute to maintenance (APA 2024; CANMAT/ISBD 2018)
    Better at depressive relapse prevention; slow titration mandatory (SJS); breastfeeding generally acceptable (LactMed 2024)
  5. 5. naloxone Rx (take-home) for any patient with co-occurring OUD or opioid prescription
    rxcui 7242
    4 mg intranasal × 2 sprays per kit • intranasal • PRN suspected overdose
    trigger: Co-occurring OUD or opioid prescription (ASAM 2020)
    Standard discharge co-prescription for high-risk patients (ASAM 2020)
  6. 6. no new benzodiazepine initiation for "anxiety" in postpartum patient with SI history
    N/A • N/A • N/A
    trigger: Anxiety symptom in postpartum patient with prior SI / psychosis (APA 2016 Guideline Watch)
    Disinhibition risk in active or recently-active SI; choose buspirone / SSRI titration / CBT / hydroxyzine (APA 2016)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: 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); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Postpartum psychosis — acute postpartum psychiatric emergency (ACOG 757 2018/2024; NICE NG192 2024; APA 2024; Bergink 2012; Sit 2006)** (psych.postpartum-psychosis.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute postpartum psychosis pharmacotherapy — antipsychotic + mood stabiliser combination (APA 2024; NICE NG192 2024; Bergink 2012 PMID 22407083)** — step "Step 1 — Antipsychotic monotherapy or with benzodiazepine for sleep / agitation (APA 2024; NICE NG192 2024)".
1. olanzapine 5–10 mg PO QHS; titrate to 15–20 mg/day PO once daily (atypical_antipsychotic, first line) — 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)
2. risperidone 1 mg PO BID; titrate to 2–4 mg/day PO BID (atypical_antipsychotic, first line) — Low relative-infant-dose in breastfeeding (~ 4%); FDA-approved for acute mania + schizophrenia; potent D2 — monitor EPS / prolactin (APA 2024; PSI 2024)
3. quetiapine 50 mg PO BID day 1; titrate to 100–300 mg/day PO BID (atypical_antipsychotic, first line) — Sedation useful in postpartum insomnia; FDA-approved across bipolar polarities; metabolic burden moderate (APA 2024; NICE NG192 2024)
4. aripiprazole 5–10 mg PO daily; titrate to 15 mg PO once daily (atypical_antipsychotic, second line) — Metabolically favourable but suppresses prolactin — caveat if breastfeeding maintenance desired; useful when olanzapine / quetiapine metabolic load undesirable (APA 2024)
5. lorazepam 1–2 mg PO/IM/IV PRN q4–6h PO/IM/IV PRN q4–6h (benzodiazepine, rescue) — 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)

Setting playbook (outpatient) — Bridge perinatal-psychiatry care after inpatient discharge; maintain antipsychotic + mood stabiliser for ≥ 12 months postpartum; serial C-SSRS + infanticide screening; lethal-means restriction reinforcement; OB / pediatric coordination; preconception counselling for next pregnancy; ongoing lithium prophylaxis discussion for known bipolar-spectrum (APA 2024; NICE NG192 2024; Bergink 2012 PMID 22407083; PSI 2024)
6. continue inpatient-initiated antipsychotic at maintenance dose ≥ 12 months postpartum Per discharge agent and dose PO daily — Maintenance phase postpartum psychosis (APA 2024; NICE NG192 2024) (Minimum 12 months antipsychotic continuation postpartum per APA 2024 even after remission; relapse risk in first 12 mo elevated (APA 2024; NICE NG192 2024))
7. lithium maintenance target 0.6–1.0 mEq/L 300–900 mg PO total daily, divided PO BID-TID — Mood stabiliser maintenance; prophylaxis for known bipolar / prior PP (APA 2024; Bergink 2012 PMID 22407083) (First-line maintenance + future-pregnancy prophylaxis; lifelong recommended for confirmed BP I (BALANCE Geddes Lancet 2010; APA 2024))
8. taper antipsychotic at 12–24 mo if euthymic + remitted + supports in place Slow taper over 4–8 weeks under monitoring PO tapered — Sustained euthymia ≥ 12 mo postpartum + protective factors in place (APA 2024) (Avoid abrupt discontinuation — rebound risk; maintain mood stabiliser per BP I maintenance guidance (APA 2024))
9. continue / introduce lamotrigine for depression-predominant residual symptoms Slow titrate to 200 mg/day PO daily — Depressive predominant polarity OR transition from acute to maintenance (APA 2024; CANMAT/ISBD 2018) (Better at depressive relapse prevention; slow titration mandatory (SJS); breastfeeding generally acceptable (LactMed 2024))
10. naloxone Rx (take-home) for any patient with co-occurring OUD or opioid prescription 4 mg intranasal × 2 sprays per kit intranasal PRN suspected overdose — Co-occurring OUD or opioid prescription (ASAM 2020) (Standard discharge co-prescription for high-risk patients (ASAM 2020))
11. no new benzodiazepine initiation for "anxiety" in postpartum patient with SI history N/A N/A N/A — Anxiety symptom in postpartum patient with prior SI / psychosis (APA 2016 Guideline Watch) (Disinhibition risk in active or recently-active SI; choose buspirone / SSRI titration / CBT / hydroxyzine (APA 2016))

Non-pharmacologic actions:
- Perinatal psychiatry visit Q2 wk × 12 wk postpartum then monthly until 12 mo (APA 2024; PSI 2024)
- IPSRT / CBT / family-focused therapy — circadian rhythm stabilisation + relapse prevention (Frank Int J Bipolar Disord 2015; Miklowitz JAMA Psych 2007)
- Mother-infant interaction therapy / dyadic therapy where available — bonding recovery (PSI 2024)
- Caring Contacts call cascade 24 h / 72 h / 1 wk continuing past initial bridge per Motto / Stanley/Brown protocol (Motto 2001 PMID 11376235; Stanley/Brown 2018 PMID 29998307)
- Family / partner psychoeducation — recognition of early warning signs (sleep < 4 h, irritability, racing thoughts, paranoia, infant-focused intrusive thoughts) (NICE NG192 2024; PSI 2024)
- Lethal-means restriction reinforcement at every visit — firearm + large-quantity meds; dispense in 1-wk quantities if active concerns (VA/DoD 2019)
- OB postpartum check coordination — 1 wk + 6 wk visits with shared psychiatric/obstetric communication (ACOG 757 2018/2024)
- Pediatric coordination — infant pediatrician shared visit notes; if breastfeeding on lithium / antipsychotic, infant lithium + TSH + hydration weekly × 4 wk then monthly (PSI 2024)
- 988 Suicide & Crisis Lifeline + Postpartum Support International 1-800-944-4773 numbers reinforced (SAMHSA TIP 50 2015; PSI 2024)
- Preconception counselling — explicit discussion of ~ 50% recurrence in next pregnancy + prophylactic lithium at delivery + perinatal-psych co-management plan (Bergink 2012 PMID 22407083; Robertson 2005 PMID 15738508; APA 2024)
- Advance directive / crisis plan for future pregnancy — collaboratively developed with patient, partner, and care team (NICE NG192 2024; APA 2024)
- Mother-baby support group referral (Postpartum Support International, MotherToBaby) (PSI 2024)

AVOID / contraindication checks:
- Valproate_avoid_in_reproductive_age_without_effective_contraception (FDA 2013 black box; APA 2024)
- Lithium_renal_thyroid_baseline_required (APA 2024; KDIGO 2024)
- Lithium_dehydration_NSAID_ACE_diuretic_toxicity_risk (APA 2024)
- Olanzapine_IM_no_concurrent_IM_benzodiazepine_respiratory_depression (FDA; APA 2024)
- Carbamazepine_HLA_B1502_asian_ancestry_SJS_screen (FDA 2007; CANMAT/ISBD 2018)
- SGA_metabolic_monitoring_APA_ADA_2004
- Do_not_use_antidepressant_monotherapy_in_postpartum_psychosis (APA 2024; STEP BD Sachs NEJM 2007 — manic switch risk and worsening of psychotic features)
- Mother_baby_separation_not_required_for_lithium_alone_if_infant_monitored (APA 2024; PSI 2024)

Monitoring

Regimen monitoring:
- Daily C-SSRS and explicit infanticide ideation screen (Posner 2011; Brockington 2004; ACOG 757 2018/2024)
- Q-shift psychotic features severity during inpatient admission (APA 2024)
- Sleep pattern nightly log (Bergink 2012; NICE NG192 2024)
- Lithium level q5 7d during titration then weekly inpatient (APA 2024)
- BMP and renal q3 5d on lithium (APA 2024)
- TSH q3mo on lithium (APA 2024)
- Valproate level at day5 then q5 7d inpatient then q3mo (APA 2024; CANMAT/ISBD 2018)
- CBC and LFT q3mo on valproate (APA 2024)
- SGA metabolic panel baseline 3mo 6mo annual (APA/ADA 2004)
- ECG baseline then QTc periodic on SGA (FDA; APA 2024)

Setting (outpatient) monitoring:
- C-SSRS + infanticide ideation at every visit (Posner 2011; Brockington 2004)
- EPDS / PHQ-9 at every visit during first 12 mo (ACOG 757 2018/2024)
- Lithium level Q3–6 mo steady state + Q5–7 d after any dose change (APA 2024)
- Renal function + TSH Q6–12 mo on lithium (APA 2024; KDIGO 2024)
- Valproate level + CBC + LFT Q3–6 mo (APA 2024)
- SGA metabolic panel — A1c + lipids + weight Q3–6 mo (APA/ADA 2004)
- Sleep + circadian rhythm log (Bergink 2012; Harvey 2008)
- Mother-infant attachment / bonding (PSI 2024)
- If breastfeeding on lithium: infant serum lithium + TSH + hydration weekly × 4 wk then monthly (PSI 2024)
- Pregnancy testing at every visit for women of reproductive age (FDA 2013; APA 2024)

Follow-up plan: 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)
- Close-out criterion: Outpatient bridge + OB + peds coordination in place; preconception counselling documented when relevant

Monitoring phase: 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)

Disposition

Current setting: outpatient — Bridge perinatal-psychiatry care after inpatient discharge; maintain antipsychotic + mood stabiliser for ≥ 12 months postpartum; serial C-SSRS + infanticide screening; lethal-means restriction reinforcement; OB / pediatric coordination; preconception counselling for next pregnancy; ongoing lithium prophylaxis discussion for known bipolar-spectrum (APA 2024; NICE NG192 2024; Bergink 2012 PMID 22407083; PSI 2024)

Disposition criteria:
- Continued perinatal psychiatry follow-up indefinitely for known bipolar-spectrum or prior PP — no clean exit; transition to general bipolar maintenance after 12 mo postpartum + euthymia + supports in place (APA 2024; Bergink 2012 PMID 22407083)
- Preconception planning visit when patient considers next pregnancy — coordinated perinatal-psych + OB / MFM plan (ACOG 757 2018/2024; APA 2024)
- Prophylactic lithium at delivery for next pregnancy if known bipolar / prior PP (Bergink 2012 PMID 22407083; Wesseloo 2016 PMID 26514657)
- Re-admit to ED or inpatient psych per escalation triggers — outpatient pathway can fail without indicating prior outpatient care was wrong; re-stabilise (APA 2024)

Escalation triggers (move to higher acuity):
- Rising C-SSRS Ideation ≥ 4 OR new attempt OR command hallucinations involving infant → IMMEDIATE ED evaluation (APA 2024; Brockington 2004)
- New psychotic features OR sleep < 4 h × 2 nights in known bipolar postpartum → urgent perinatal-psych evaluation same-day; consider re-admission (Bergink 2012; APA 2024)
- Failed engagement with safety plan or means restriction → strengthens admission rationale; escalate to ED same-day (Stanley/Brown 2018 PMID 29998307)
- Substance-use relapse with concurrent rising SI / psychotic features → ED + dual-diagnosis admission consideration (SAMHSA TIP 51 2018)
- Pregnancy detected in patient on valproate → urgent psych co-management for medication reconciliation; do NOT abruptly discontinue mood stabiliser; reproductive-psychiatry consult (APA 2024; FDA 2013)
- Lithium toxicity signs (coarse tremor, ataxia, confusion, vomiting) → hold lithium; check level; ED if severe (APA 2024)
- Anti-NMDA-R encephalitis features emerging post-discharge → neurology + autoimmune workup (Titulaer 2013 PMID 23290630)

Patient Action Plan

**Postpartum psychosis self + family management plan + warning signs (ACOG 757 2018/2024; NICE NG192 2024; PSI 2024; APA 2024)**
Personalised values: current_antipsychotic_and_dose, current_mood_stabiliser_and_dose, breastfeeding_status, support_people_names_numbers, infant_caretaker_arrangement, lethal_means_restriction_plan, perinatal_psychiatrist_contact, OB_contact, pediatrician_contact, sleep_target, crisis_lines.

**Doing well — euthymic, no psychosis, stable sleep, bonding with infant (APA 2024; PSI 2024)** (green):
Triggers:
- Mood stable + euthymic (APA 2024)
- Sleeping 6–8 h on regular schedule (Bergink 2012; Harvey 2008)
- Bonding and engaging with infant (PSI 2024)
- Taking antipsychotic + mood stabiliser as prescribed (APA 2024)
- No suicidal or infanticide thoughts (C-SSRS; Posner 2011)
- Family supports engaged (PSI 2024)
Actions:
- Take medications every day at same time — NEVER stop without provider (APA 2024)
- Keep consistent sleep schedule — sleep deprivation is a relapse trigger (Bergink 2012; Harvey 2008)
- Attend perinatal psychiatry + OB + pediatric appointments on schedule (APA 2024; ACOG 757 2018/2024; PSI 2024)
- Keep lab monitoring on schedule (lithium / TSH / renal / valproate / CBC) (APA 2024)
- Avoid alcohol + recreational drugs + new prescription stimulants without provider (APA 2024; SAMHSA TIP 51 2018)
- Confirm lethal-means restriction is in place (firearm + medications) (VA/DoD 2019)
- Keep crisis lines accessible — 988 + 1-800-944-4773 (PSI) (SAMHSA TIP 50 2015; PSI 2024)
- Engage in IPSRT / CBT / family-focused therapy as scheduled (Frank 2015; Miklowitz 2007)

**Warning — early warning signs of relapse (sleep loss, irritability, racing thoughts, intrusive infant-focused thoughts) (NICE NG192 2024; APA 2024; PSI 2024)** (yellow):
Triggers:
- Sleeping < 5 h/night × ≥ 2 d (Bergink 2012; Harvey 2008)
- Racing thoughts, talking faster, increased goal-directed activity (APA 2024)
- Increasing irritability or paranoia (APA 2024)
- New low mood / hopelessness / withdrawal (APA 2024)
- Intrusive thoughts about the infant (even without intent to act) (PSI 2024)
- Missed medication doses (APA 2024)
- Increased alcohol or substance use (SAMHSA TIP 51 2018)
Actions:
- Use your personal early-warning-sign list + crisis plan IMMEDIATELY (NICE NG192 2024; PSI 2024)
- Tell partner / trusted family AND your perinatal psychiatrist within 24 h (PSI 2024)
- Prioritise sleep — partner to take infant overnight if needed; consider PRN if prescribed (Bergink 2012; APA 2024)
- Check medication adherence — resume immediately if missed; do NOT double dose (APA 2024)
- Avoid major decisions, new commitments until reviewed (APA 2024)
- Confirm someone safe is with you AND with infant (PSI 2024)
Contact provider when:
- Sleep < 4 h × 2 consecutive nights (Bergink 2012)
- Any warning signs persist > 24 h despite self-management (NICE NG192 2024)
- Return of any suicidal or intrusive infanticide thoughts (Brockington 2004; APA 2024)
- Missed > 2 doses of medication (APA 2024)
- Inability to sleep, eat, or care for self / infant (APA 2024; PSI 2024)

**Medical alert — active psychosis, infanticide / suicide thoughts, command hallucinations, severe insomnia with confusion (ACOG 757 2018/2024; NICE NG192 2024; APA 2024; Brockington 2004)** (red):
Triggers:
- Not sleeping at all for ≥ 2 nights (Bergink 2012)
- Hearing voices, paranoia, grandiose beliefs not reality-based (DSM-5-TR 2022; APA 2024)
- Thoughts or urges to harm yourself OR your baby (Brockington Lancet 2004 PMID 14751705; ACOG 757 2018/2024)
- Command hallucinations directing self-harm or harm to baby (APA 2024; PSI 2024)
- Severe confusion, fluctuating cognition, autonomic symptoms (NICE NG192 2024)
- Lithium toxicity signs (severe tremor, ataxia, vomiting, confusion) (APA 2024)
- High fever + rigid muscles + confusion on antipsychotic — possible NMS (Caroff 2015)
Actions:
- Call 988 (US) / your local crisis line / 911 NOW (SAMHSA TIP 50 2015)
- Postpartum Support International HelpLine 1-800-944-4773 (text / call) (PSI 2024)
- Go to nearest emergency department immediately; do NOT drive yourself if confused (APA 2024)
- Make sure baby is with another safe caretaker BEFORE you go OR call 911 to coordinate (PSI 2024)
- Hand any firearms, excess medications, car keys to a trusted person (VA/DoD 2019; APA 2024)
- Activate your advance directive / crisis plan; bring medication list (NICE NG192 2024)
- If lithium toxicity suspected — stop lithium, hydrate, go to ED (APA 2024)
Contact provider when:
- Any red zone trigger — emergency department immediately (ACOG 757 2018/2024; NICE NG192 2024; APA 2024)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Confirmed postpartum psychosis (≤ 12 weeks postpartum with psychotic features, mania-with-psychosis, or rapid mood cycling with psychotic features) — MANDATORY inpatient psychiatric admission regardless of outward stability; 24/7 supervision; explicit SI + infanticide-ideation screening at admission and Q-shift (ACOG 757 2018/2024; NICE NG192 2024; APA 2024)
- [LIFE_THREATENING] Thoughts, urges, or command hallucinations to harm infant in postpartum patient (Brockington Lancet 2004 PMID 14751705; ACOG 757 2018/2024; PSI 2024)
- [LIFE_THREATENING] C-SSRS Ideation 4 or 5 with plan, intent, or means OR documented suicide attempt within 90 days postpartum (ACOG 757 2018/2024; APA 2024; Posner 2011 PMID 22193671)

Citations

- 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 [PMID:22407083](https://pubmed.ncbi.nlm.nih.gov/22407083/)
- Cited evidence (PMID 16724884) [PMID:16724884](https://pubmed.ncbi.nlm.nih.gov/16724884/)
- Cited evidence (PMID 15738508) [PMID:15738508](https://pubmed.ncbi.nlm.nih.gov/15738508/)
- Cited evidence (PMID 11384899) [PMID:11384899](https://pubmed.ncbi.nlm.nih.gov/11384899/)
- Cited evidence (PMID 14751705) [PMID:14751705](https://pubmed.ncbi.nlm.nih.gov/14751705/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 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 — PMID:22407083
  • Cited evidence (PMID 16724884) — PMID:16724884
  • Cited evidence (PMID 15738508) — PMID:15738508
  • Cited evidence (PMID 11384899) — PMID:11384899
  • Cited evidence (PMID 14751705) — PMID:14751705