A 28-year-old Asian woman is evaluated by psychiatry on postpartum day 2 secondary to exhibiting unusual behavior. The obstetrics staff noticed that the patient was talking loudly to the mirror in her room and was not showing affection to her newborn child. She had not breastfed her newborn for over 6 hours even though that was the plan before delivery. The patient is inattentive to staff directions and appears internally preoccupied. The patient has been seen cleaning the bathroom mirror multiple times and will not elaborate on why she is doing this. If she is not allowed to clean the mirror continuously, she displays increased agitation and appears extremely restless.

Upon arrival at the obstetrics unit, the patient’s husband insisted on speaking to the psychiatry consult before the evaluation of his wife. The husband states that he and the patient have been married for 3 years and emigrated from India to the United States 8 months ago. They had an arranged marriage and he had only met his wife twice before their wedding. The husband states that his wife is the daughter of a prominent psychiatrist. The husband is a computer engineer and lived in a village approximately 50 miles from the city where his wife lived. The patient received a bachelor’s degree in biology from a university in India and is an only child.

The husband reports that the patient was agitated the first day after she moved into his house following their marriage. Initially, the husband and his family thought that this was because she missed her family in the city and had trouble adjusting to her new surroundings. The patient’s mental status deteriorated rapidly over the next few days and the husband contacted the patient’s father to appraise him of the situation. It was then revealed to the husband that the patient was diagnosed with schizophrenia a few years ago and had not received her antipsychotic medication since the wedding 1 week ago. The patient’s father said that the patient often was nonadherent with her antipsychotic medication and the family would mix the medicine in her food. The husband stated that this diagnosis was not disclosed to him prior to the marriage.


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Examination

The patient had a normal vaginal delivery at 39 weeks and the baby was noted to be healthy per obstetrics. The patient is agitated and appears disheveled and malodorous and unable to fully be redirected during the psychiatric evaluation. Her speech is pressured and tangential, and she is noted to be internally preoccupied. The patient has limited eye contact with the clinician evaluating her and also appears to be religiously preoccupied. Per the nursing staff, the patient refuses to take care of her activities of daily living and talks about “building a bridge through the mirror.” Staff reports that the patient is unable to be redirected, can be impulsive, and needs 1:1 care for her safety. She has not shown any affection towards her child and has not attempted to breastfeed. The child is being fed formula in the neonatal intensive care unit (NICU) as the staff does not feel that the child will be safe with the patient.

During the initial presentation during the psychiatry consult, the patient is extremely agitated and is chemically restrained (haloperidol 5 mg and lorazepam 2 mg intramuscularly) as she is having difficulty following directions and is potentially dangerous to other patients on the floor. The patient is not cooperative with psychiatric assessment and is selectively mute at times. She refuses any medications offered to decrease her agitation stating, “It was not allowed.” She received the haloperidol/lorazepam combination several hours ago for similar behavior and then dozed off.

Vital signs are taken after the patient is calmer and show an elevated pulse of 115 beats per minute; respirations, 19 breaths per minute; blood pressure, 170/100 mm Hg, temperature, 98.9 ⁰F. Electrocardiography shows tachycardia with sinus rhythm (corrected QT interval is 408 ms). All other physical examination findings are within normal limits.

Medical History and Laboratory Tests

The patient’s husband reports that his wife does not use any nicotine products, alcohol, or illicit drugs. The patient was receiving haloperidol tablets, which the patient’s husband would crush and mix in her morning cereal as recommended by the patient’s father. The patient’s father would send a month’s supply of haloperidol tablets addressed to the patient’s husband. As long as the patient was unknowingly compliant with the medication, the patient did not exhibit any overt psychosis, according to her husband although she was selectively mute and appeared withdrawn at times.

The patient has no significant medical or surgical history (other than schizophrenia) as relayed to the patient’s husband by her family. A computed tomography scan was performed and was unremarkable; no white matter changes, hemorrhages, or lesions were observed. Urinalysis was normal and urine toxicology was negative. All other laboratory study findings were not significant or suggestive of any pathology. Mental status examination was performed and the patient scored 22/30.

What is your diagnosis?

  1. Alcohol withdrawal
  2. Schizophrenia-chronic paranoid type
  3. Drug-induced psychosis
  4. Postpartum depression

Diagnosis and Treatment

The psychotic symptoms exhibited by the patient in this case, in conjunction with the history obtained from the husband, raised the suspicion of schizophrenia-chronic type. The patient met the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for schizophrenia. The husband was initially adamant that the patient be given the antipsychotic medication without her knowledge, which he believed would help calm the patient so she could be discharged home with the baby. The husband mentioned that he did not have any other family or friends who could take care of the baby at this time in the US. He believed that if the patient was told that she is taking a psychiatric medication, she would not adhere to the treatment.

After a discussion between the psychiatric and obstetrics team, the patient was admitted to the inpatient psychiatric floor because of her decompensated mental health. Although the patient was initially reluctant to be admitted, she finally consented to do so and was informed that she was taking psychiatric medication before her hospitalization, would continue to be prescribed this agent on the inpatient unit, and would only be discharged when stable.

The patient was started on a standing dose of haloperidol 5 mg orally twice daily with a plan to switch her to a long-acting antipsychotic medication on an outpatient basis with a referral to a psychiatrist. The patient responded well to the haloperidol and was discharged home to her husband after 1 week. The patient’s family participated in these discussions and was agreeable to the plan. Follow-up with an outpatient psychiatrist after discharge was planned.

The newborn was discharged in the custody of the patient’s husband; the child’s paternal grandparents came from India to help the father with the care of the newborn. The plan entailed that once the baby was safe to fly, the child would be sent to India in the custody of her paternal grandparents and spouse.

Discussion

Up to 85% of women exhibit signs/symptoms of mood disorders during the postpartum period such as mood lability, irritability, anxiety, feelings of being overwhelmed, and anhedonia.1 Typically, these symptoms start a few hours after childbirth, peak on days 4 to 5, and usually resolve by the end of the second week postpartum. If these symptoms continue, the patient may have a diagnosable mental health condition requiring treatment. Although less common, women may develop postpartum psychosis, which has a sudden and acute onset and should be considered a psychiatric and obstetrical emergency.1,2 Risk factors for postpartum psychosis include a history of bipolar disorder or schizophrenia, young age, lack of support from partner or family, financial difficulties, first pregnancies, and lack of prenatal support.2

However, in this case, the patient was previously diagnosed with schizophrenia and has a history of nonadherence to medication. These were the primary causes of psychotic decompensation, likely coupled with the stress and hormonal changes connected to childbirth.1

Multiple aspects regarding ethical care need to be considered during the postpartum period in an individual with severe postpartum depression and/or psychosis as there is a possibility of harm to the infant.3 It behooves the clinician and the medical team to ensure that all due diligence and protocols for such scenarios be implemented.3 In this case, an ethical consult (in conjunction with psychiatry and the obstetrics team) was initiated and the team decided that the patient needed to be medically/psychiatrically stable before she could be with her newborn child. The plan proposed by the family and accepted by the team involved close relatives taking care of the infant until the patient was stabilized. Regardless, opportunities must be allowed for the infant and mother to bond under strict supervision.

Recognition has been made at the local, state, and national levels regarding the physical safety of and subsequent emotional development challenges of infants born to mothers with severe mental health conditions. New Jersey was the first state to pass a law requiring all new mothers to be screened for depression in the first 24 hours after birth and before their discharge from the hospital.4 Although many states have adopted legal requirements regarding this issue, legislation has not been universally adopted. In 2010, the US Congress passed the Patient Protection and Affordable Act, which included Section 2952A that directs states to ensure patient education regarding mental health conditions in the postpartum mother, focused on the safety of the newborn, and initiated protocols for the hospital to enhance screening of the mothers for depression prior to discharge.4

Comment

This case displayed how the stigma of mental health illness can lead to failure to disclose medical information to clinicians. The patient’s father and husband gave the patient antipsychotic medications without her knowledge to ensure adherence, but failure to disclose this information to the medical staff put the patient’s newborn at risk for neglect and physical harm. The obstetrics staff did their due diligence to protect the newborn.

Shinu Kuriakose, DHSc, PA-C, is an associate professor in the Department of Physician Assistant Studies New York Institute of Technology in Old Westbury, New York.

References

  1. Rai S, Pathak A, Sharma I. Postpartum psychiatric disorders: early diagnosis and management. Indian J Psychiatry. 2015;57(Suppl 2):S216-221. doi:10.4103/0019-5545.161481.
  2. Perry A, Gordon-Smith K, Jones L, Jones I. Phenomenology, epidemiology and aetiology of postpartum psychosis: a review. Brain Sci. 2021;11(1):47. doi:10.3390/brainsci11010047
  3. Băcilă C, Anghel C, Vulea D. Ethical aspects in the management of postpartum depression. Saeculum. 2019;47(1): 227-231. https://doi.org/10.2478/saec-2019-0022
  4. Rhodes AM, Segre LS. Perinatal depression: a review of US legislation and law. Arch Womens Ment Health. 2013;16(4):259-270. doi:10.1007/s00737-013-0359-6