Episode 281: Postpartum Psychosis: Symptoms, Diagnosis, Treatment, and Prevention with Dr. Margaret Spinelli
This episode is awaiting CME Approval
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Dr. Spinelli and Dr. Puder have no conflicts to report.
Dr. Katrina Furey is the founder and educator of Repro Psych Academy, an on-demand educational platform providing case-based training in reproductive psychiatry for mental health professionals. She has no financial relationships with pharmaceutical companies or other commercial entities relevant to the content of this presentation.
Introduction (00:00)
Puder:
All right, welcome back to the podcast. I am joined today by Katrina Furey and Margaret Spinelli. Dr. Margaret Spinelli, Dr. Katrina Furey are both psychiatrists. Dr. Furey and I did a prior episode on postpartum psychosis [see episode 276], and we were talking afterwards about who we could invite back on, and we decided one of the leaders in the field, someone who's been fighting for women's rights for decades, Margaret Spinelli would be the perfect person to have on. And so, Dr. Furey and myself will be interviewing Dr. Spinelli and trying to draw out her expertise as someone who has treated and advocated for women in the midst of postpartum psychosis for decades. So, welcome to the show.
Puder:
Thank you for coming.
Spinelli:
Thank you.
Dr. Margaret Spinelli’s Journey Into Perinatal Psychiatry (00:51)
Puder:
Yeah, I think maybe we should start by hearing a little bit about how you got into this, kind of your background and how you got kind of thrust into this space.
Spinelli:
Yes. Well, I actually didn't get thrust in. I really had to search for it. I was a nurse in OB for like 12 years, and then I went to med school. And my idea was always to go into psychiatry and treat mothers. I have never actually determined the reason for that.
Spinelli:
With lots of therapy, I have never determined the reason, but I wanted to do so fiercely. And so, in my last year at Cornell Medical School, and I say that because this wasn't like unknown where people wouldn't know, and I went to one of my faculty members as I was leaving medical school and looking for, let's say, any component of a residency or any kind of training for maternal mental health or anything for postpartum illnesses. And he said to me, "There is no such thing." And the fact was for psychiatry, there was no such thing back then. Let me just tell you, it's very quick, but I think it's important. There were two psychiatrists back in [circa] 1926 who basically said they had a “study.” And what they had done was they looked at 50 charts.
Spinelli:
Half of them were postpartum psychosis and half of them were another diagnosis of a psychotic episode. And what they determined was that there was no difference between postpartum psychosis and other psychosis. Now, they never met these women. They never evaluated these women. And that was their determination from that quote unquote “study.” And they suggested that postpartum should be excluded from the words, be excluded from psychiatry, the words postpartum, perinatal. So that was in 1926. Their names were Strecker and Ebaugh (1926). Strecker then, in 1952, was on the committee, the DSM committee, and he had a very strong movement against postpartum illness. And so it was never put into the DSM. It was put in, in another way, in the first two, like childbearing and something. But there was nothing further about postpartum for all the years we know of it.
[Although the Strecker and Ebaugh study is sometimes characterized as supporting an approximately 50:50 distinction between psychoses associated with the puerperium and those attributable to other causes, such a summary may overstate or oversimplify the authors’ findings. Their discussion challenged the conceptualization of “puerperal psychosis” as a distinct clinical entity, emphasizing the heterogeneity of psychotic disorders occurring during the puerperium.]
Spinelli:
And, most psychiatrists would say there's no such thing. And at Columbia I would ask people, who I knew were on the DSM committee, they would say, "Well, there's research on that." And the fact is, the idea that that was “researched” carried over and followed all of us into our psychiatric training. But I knew, actually, that there was such a thing. And when I was working in a lab in med school, a very nice attending put a book next to my lab table, and it said, Motherhood and Mental Illness by [Ramesh] “Channi” Kumar and Ian Brockington (1982).
Furey:
I recognize that name.
Spinelli:
Yes. So, after a brief time, I decided, “I have to go to England and learn.” And I did. I had a clerkship in which I worked on Channi Kumar's mother-baby unit in London at the Maudsley and Bethlehem Royal Hospital. It was one of the best experiences I had in my career. It was just wonderful. So Channi continued to be my mentor when I came back here. And I suppose, a first movement, in my fellowship, I designed IPT, interpersonal psychotherapy for pregnant depressed women. But soon after, we were prescribing medications. And that was pretty wonderful. And I did the IPT study during the fellowship, and after that, I continued with my research and private practice. And it was completely on perinatal psychiatry, and that's been, it's been wonderful.
Puder:
So, okay, so then I know you did an early study where you looked at women after, specifically, the very early portion of pregnancy, the first day when they took their child's life, right? You did a study where…
Spinelli:
Oh, yes.
Neonaticide, Pregnancy Denial, and Dissociation (06:44)
Puder:
It was a 2001 article called “A Systematic Investigation of 16 Cases of Neonaticide.”
Spinelli:
Yes.
Puder:
And I'm curious, I don't know how much of this episode we’ll spend on this specific topic, but this seemed very different to me, and I think that you found some very interesting things. Can you tell me about what you found in regard to the pattern of childlike demeanor, and la belle indifférence: depersonalization, denial of pregnancy, dissociation, and that ego disorganization?
Spinelli:
Yeah. Well, I must say there are many people who have disagreed with me, although I think now this characterization is having some impact today on neonaticide. What I found, just for the public, neonaticide is due to denial of pregnancy, and then these women will often deliver in a bathroom, in a bedroom, and some will kill, and some will just leave a baby in such a way that the baby dies. And they are then charged with murder just like we see in women with postpartum psychosis today.
Spinelli:
And the thing that struck me was that they all seem to have the same personality characteristics, and even their families were similar. Their personalities were something like a little childish. For example, when I interviewed the woman they called back then, “the prom mom,” who had her baby at the prom and put her in a trash bag, when I asked her about delivering, she said, "I thought I was having number two." Now, this was a pretty grown young woman. She was at her senior prom. And so many of them seemed very naive about their pregnancies. The first one I saw actually was from England, and it was Channi Kumar who called me and [asked if I] would go to Rikers Island and evaluate this woman. I wasn't too thrilled about going to Rikers Island.
Spinelli:
A lot of guys from my old neighborhood went there, so I knew what it was like, but of course, I would never say no to Channi. He was such a special man, so devoted. He was devoted, and so empathic, and a wonderful teacher. So anyway, I went to Rikers Island and I met, Carolyn. I could feel from the story there was a lot of innocence around it. And so as I saw each one, I heard the same story. And, you know, they didn't realize they were pregnant. Some just thought they gained some weight, and the delivery was a surprise.
Spinelli:
So the bottom line was I started to look into more serious dissociation and realized that that was how they got through their pregnancy. But what was interesting, is the family never knew. Their fiancés, that they were still with, never knew. So, I know that there's been a lot more, you know, clinical… I wouldn't say clinical study, but reports that support this picture of dissociation. So that was….
Puder:
Yes. And you looked at the dissociative experience scale [DES-II]. I think the mean was 28.89.
Spinelli:
Yes.
Puder:
Which suggests a very high level of dissociation. 10 of the 16 scored above 15. One of the quotes from the paper was, "All women described watching themselves during birth" (Spinelli, 2001, p. 811).
Spinelli:
Yes.
Puder:
Eleven denied pain, which is very common with dissociation. Five, described pain as “not bad.” Twelve experienced dissociative hallucinations as internal commentary of critical and argumentative voices. Nine reported childhood sexual trauma history. Seven independently corroborated. Six, physical abuse (Spinelli, 2001, p. 811).
Puder:
So I think that sort of dissociative piece is important to think about as clinicians, when we're thinking about that, specifically the first 24-hours. And I think postpartum psychosis, it seems it's a very different picture, right?
Spinelli:
Yes, it's a very different picture. I suspect one might think of the neonaticides as somewhat more characterological, you know, the symptoms. The only reason I hate to say that is it was once advertised as being, you know, in some sort of accusing way, saying they were just “borderlines” and they were doing this and there wasn't...but I didn't find that there was anything. I didn't test for borderline personality disorder. I was just looking at the dissociation. And that's what I wanted to report, basically.
Furey:
Yes. So it would be used in more of a pejorative way?
Spinelli:
Yes. Definitely. And I found that was so offensive. And I didn't think it seemed too similar. You know, the stories were so similar. The families were kind of too enmeshed, you know? Especially the fathers with the girls, I found.
Furey:
How do you mean?
Spinelli:
Well, they kind of had special relationships. Now, there was a certain amount of sexual abuse in this group, but the fathers were not necessarily identified in that. But I mean, just to give you an example of a certain kind of naive or ignorance in the family, when one father came, because I wanted to interview him, my office was probably 20 feet wide, and he was there. And when I started to speak with him, he moved his chair up almost so that his knees were touching mine.
Furey:
Oh.
Spinelli:
Yes. So it was just this kind of inappropriate.
Furey:
Yes.
Spinelli:
You know, mechanisms that they used.
Furey:
That's interesting that you described the family unit as so enmeshed, and yet there was, it sounds like also so much dissociation. You know, in the woman or the girl, but also in the family, with this total denial of the pregnancy. That's just such an interesting dichotomy to me.
Spinelli:
Well, you know, even I had… I mean, one woman who was raped, actually, she was like a "champion swimmer." She was in the pool the day before with her teacher, her mentor, and they never noticed a pregnancy. So it's something about, even their posture. Now, I know there have been, you know, I haven't kept up with the latest information on neonaticide because I've been so invested in postpartum psychosis. But I know they're even looking at the way the baby lies in the womb. Could that be a reason why, you know, they don't tend to look as pregnant as they are? But, you know, what's so impressive is that Caroline, for example, the woman from England, eventually she went home. She was in Rikers for quite a long time, and then the judge agreed to send her home to England where she would have, quote unquote, "probation." And as Channi Kumar said to me if she had…
Spinelli:
I mean, she was arrested at the airport and charged with murder. If she had just made it to Heathrow, there would have been psychiatrists at the airport for her.
Mother-Baby Units and the Impact of Postpartum Mental Illness (15:54)
Puder:
America seems to be different from a lot of European countries, and how we kind of treat this population, filicide.
Spinelli:
Yes. Yes, we're so punishing. We really are so punishing. I mean, I remember working on the mother-baby unit, and there were women who actually had attempted infanticide. And let me just say, the staff was impressive and large. There was a psychiatric nurse for each mother-baby and a pediatric nurse for each mother-baby. So that was pretty incredible. Now, they have universal healthcare, and that's why they could do it. That's why they could afford to have this kind of working process. When I first left residency, before I had decided to do the fellowship, Kathy Wisner, I don't know if you know Kathy Wisner. Kathy Wisner is really a pioneer in it.
Furey:
I've read a lot of her papers.
Spinelli:
Yes. She's terrific. So she wanted me to come, and they were going to start a mother-baby unit, so we would've started, quote unquote, "the first mother-baby unit," and that was in Pittsburgh. However, they determined that they couldn't do it because of insurance. Insurance is not going to cover.
Furey:
Yes. It's so interesting you say that. You know, me, being of a different generation, I've literally asked so many of my mentors, "I want to start a mother-baby unit. Where do I need to go? Where do I need to move? Who do I need to talk to? Where are they?" And I'm told the same thing, that they just won't make the hospital money. It's never going to happen. We're trying. And it just drives me nuts.
Spinelli:
Yes, it's very sad.
Furey:
Yes.
Spinelli:
As I said, even women who attempted infanticide, they were there. They were there with their babies and the staff, and they would learn infant massage, and bonding, and that's what I said. It was such a moving experience for me. I could almost cry just….
Spinelli:
Describing it again, you know?
Furey:
I have a friend and colleague who's a reproductive psychiatrist. Her name's Jamie Sorenson, out of Florida, and she was telling me that there's a whole team [in New Zealand] who help moms learn how to read the baby's cues. And this is just part of what everyone learns. And I thought, "Wow. Wow."
Furey:
It's a totally different world.
Spinelli:
Oh, boy, is it ever?
Puder:
It's really sad. It's really sad. It hits home, really, for me. I haven't mentioned this on my podcast before, but my mom had postpartum psychosis. And she was on Thorazine and lithium. And basically, my grandpa took over parenting while she was in the hospital for a very long time. And I think it would've been a different world if there was support.
Spinelli:
Yes. And that's the other thing about postpartum psychosis. Of course, infanticide is the worst, I won't say side effect, but outcome.
Furey:
Of course, yes.
Spinelli:
But all of our patients who have postpartum psychosis are really adversely affected. They're not able to take care of their baby. Usually for about a month, other people are caring for the baby, and they feel kind of pushed aside, you know. If there's not a grandparent, then the father will often take over, but then can't go to work. I mean, there's a lot of complications with all of this. And then when they finally are starting to mother, they feel very insecure about it. They feel like the baby's more attached to that other caregiver.
Furey:
Such a ripple effect, I think, you know, in doing reproductive psychiatry, that's one thing that really drew me to it in my private practice. I love doing therapy, and it's such a rich time for that. And you also see that ripple effect now this other way about how much more adversity and struggle, and David in sharing about your story. I appreciate you sharing that, because I can see in your eyes how much it has affected you. All these generations later, it really does ripple down.
Spinelli:
Yes. Well, I mean, I'm so happy that there are fellowships and there's so much activity around the subject. It's just wonderful compared to…and I should tell you that when I came back here, Kathy Wisner and I, and Barbara Parry, and Kim Yonkers, Mike O'Hara, we were like, oh (I hope I'm not leaving someone out), but we were like the early postpartum experts, you know? And where we got that from was the English model, because it was the Marcé Society [The International Marcé Society for Perinatal Mental Health]. And Marcé was very small back then, and we were the Americans who went to the Marcé Society meetings, which were very different, as you can imagine, than they are now when they're so large, which is wonderful. Yes. And look, I had started. I put in an application and a protocol for postpartum psychosis probably five years ago.
Spinelli:
Now, Veerle Bergink then took it over, and she and the group have gotten it through. I mean, it's only an email that we have, but it's an email, you know? And, it always comes up in court. The prosecutor would say, "Dr. Spinelli, well, postpartum psychosis is not a diagnosis, isn't that true?" But, it wouldn't matter because we would use an underlying diagnosis anyway, like bipolar.
Postpartum Psychosis and the Bipolar Spectrum (22:56)
Puder:
When did you guys realize that it was kind of more on the bipolar spectrum?
Spinelli:
I think the first paper that came out, although I don't know if she's practicing perinatal anymore, was Linda Chaudron, who said, "On the other hand, I've looked at some very old studies which talk about mood fluctuation" (Chaudron & Pies, 2003). Ian Brockington had a very old story in the 1980s, and James Hamilton also. They had recognized that there was this bipolar picture. And then there was this very large study, I forget. Give me one minute. Because the paper I'm writing is right here, James Hamilton. Well, you know, and it's so interesting because even that fluctuation was recognized when Hippocrates recognized the diagnosis. And of course, Marcé identified it in his treatises on pregnant and postpartum women.
Confusion, Cognitive Changes, and the Delirium-Like Presentation (24:04)
Puder:
And how about the cognitive fluctuations and kind of the delirium-like picture, the confusion? When did that really come into the knowledge base of this is a little bit different than even a normal mania?
Spinelli:
Yes. So I have those, because I have this paper. I have the cognitive studies here, just happened to have the cognitive impairment. Marcé, he brought it up in his treatises. And then there were many others who did studies comparing non-postpartum.
Puder:
Can you describe some of the symptoms that you've seen personally, the confusion and the cognitive issues.
Spinelli:
Confusion, which is one, and perplexity, which I guess is the same thing. I've seen misidentification and delirium. And this identification of cognitive symptoms is important for me because in the courtroom it can be used in the United States when the verdict is decided by knowing right from wrong. You know, my feeling is, and I usually include that in my report, there's about 13 studies that have been completed, which describe all of the symptoms. Kathy Wisner actually did a very nice study, and it was a comparative study. Most of the studies are comparative, which is really interesting.
Puder:
One of the things about the waxing and waning, is that there can be lucid moments. Moments where the person might look normal. And we see this often in delirious patients in the hospital. If you see them one moment, they may seem like they have it together. Maybe they're a little bit hypoactive delirium, so they look more depressed or lethargic, but then the next moment, they're more hyperactive. They're seeing things, they're hearing things. Is this the kind of picture that you've seen?
Spinelli:
Absolutely. And it's as if she doesn't know me or the people who are caring for her. So it really is being psychotic at one moment and then lucid in the next. And, it is thought to be part of a delirium, in those circumstances. And you often wonder, I often wonder, because it all does go back, obviously, to hormone fluctuations. I wonder how much those changes contribute to the delirious aspect of it.
Puder:
Yes, I always think about sensorium, delirium, delirium being the worst portion of a sensorium issue. We all have sensorium issues, you know? 2:00, 3:00 PM, we're all a little bit more tired, we're all a little bit - yawning, or I don't know, a lot of us are. Whereas, you stretch that and you sleep deprive someone, you put them through a lot of pain, a lot of discomfort, you put them through a lot of stress, and all of a sudden now, you could take a normal person and now shove them into delirium.
Spinelli:
Absolutely. Yes. And even when you think of it, the lack of sleep for women, let's say, who have an underlying bipolar diathesis, right? And when they go into labor, they're awake for a long time and then they go right into possibly, well, feeding, if not breastfeeding, and that prolongs that association with light and lack of…
Puder:
Yes.
Spinelli:
Yes.
Lithium and Preventing Postpartum Psychosis (28:14)
Puder:
Circadian rhythm dysfunction. And you talk about wanting to start the treatment sooner than later. I think in one of my previous episodes, one of the psychiatrists was mentioning starting a loading dose of lithium on the day of delivery, but it sounds like in one of your lectures, and I'm curious where you're at in this, where you would start the lithium in the third trimester. What's your sort of protocol?
Spinelli:
Well, you know, there are two groups of women who get postpartum psychosis, and it's almost split. Half of them have a history of bipolar disorder in their family or somewhere; and others do not, and they're kind of looked at as an isolated postpartum psychosis.
Spinelli:
And those are women who only have episodes with the postpartum period, not in between. So the bipolar women, of course, will have episodes in between. So they are usually on medication during pregnancy. Not always, but often. The women who've had isolated postpartum psychosis, they don't need it. So it's not as if we know about it and expect them to have an episode. You can start them the day after. You can start before as a kind of preventive measure, but it's reasonable to start them on the day of delivery.
Furey:
I'm curious how you counsel patients who have their first episode of postpartum psychosis, when at that point, you don't know if it's going to become a bipolar disorder or not. That's one of the most common questions I hear from my patients. And also, then the follow-up is, "Will I experience this again when I go through perimenopause?"
Spinelli:
Well, you know, there's no good prediction of it.
Furey:
I know. Right?
Spinelli:
But, they want to know, and it's understandable. And it's likely that they'd have another one in the postpartum period and perimenopause. It's hard to say. I mean, I have patients who have had it, because again, you're having fluctuations, right? So yes, it can, it definitely can happen. But the important thing I would say to them is that you know to look out for it.
Spinelli:
You can report it to your psychiatrist.
Furey:
Yes. Usually, the way I've been handling it so far is to, again, expand to look at their family history, really try to see if there's any family history of bipolar or something that happened postpartum that maybe decades ago they didn't know what to call it. And then also kind of ask them if they had any maybe more mild symptoms around their periods either before or after just to try to get [an idea]. And then that's the conversation I have is, we don't really know, but this is what it shows and we're going to keep a close eye on you and, and I'm going to bring your partner in and tell him about all this stuff too.
Spinelli:
Well, there's often a history, not all the time. Some history of hypomania, whether it has to do with being a leader at work or an overworker, overachiever, those kinds of patients. Now, something interesting was a study done by Ariadna Forray.
Furey:
She's one of my bosses in the access program here in Connecticut.
Spinelli:
Really? Oh. That's wonderful. Because do you know about her study on first-onset postpartum psychosis? She looked at women who had first onset. She looked at women, and this was done in London, I believe. She looked at women who had bipolar disorder, and then there was a large control group. And, this was in the bipolar group, there were like a thousand. And what she found was, I'm so not great with genetics, she found that there was a variant in those women that was similar to the ones with bipolar disorder, suggesting that there was a similar risk factor in those women, even though we don't know whether they actually had one or not.
[Correction: The abovementioned study was conducted by Arianna De Florio et al. (2021).]
Furey:
It's so fascinating.
Spinelli:
I know. It really, really is.
How Postpartum Psychosis Can Rapidly Progress (33:02)
Puder:
I have paraphrased, from your 2009 article, the story of the 34-year-old female. I could read that and then we could discuss it. Would that be alright?
Spinelli:
Okay.
Puder:
Okay. Here we go:
Mrs. A is a 34-year-old married female with a five-year-old daughter, history of a mother with bipolar and prior postpartum depression. She has a planned pregnancy, some depression at 28 weeks. She has a healthy boy, starts breastfeeding. Day two, she cannot sleep, cannot get out of bed, cannot attend to hygiene. She's suspicious her husband will harm the baby. She has ego-dystonic images of throwing him out the window. She believes her milk is hurting him, even after the pediatrician says no. She will not bathe him. She thinks something bad is inside him and he cannot be moved.
So if you were hearing this story at this point, what would you be thinking?
Spinelli:
Definitely psychosis. A lot of paranoid thinking. And what was interesting about this patient was that her ego-dystonic symptoms ultimately became psychotic. And I almost hate to say it because people might get over-concerned about that, but I think it's worth it to be aware that these kinds of things do happen. She was actually one of the first patients in whom I identified the delusion of influence.
Puder:
I can read your quote if you….
Spinelli:
Yes, please do.
Puder:
Okay. Well, let me just go through every day, day-by-day, because I feel like the progression is helpful for us to kind of get a picture of how things progress, right? So, okay. Day two, even on that day, you're seeing some paranoia. That's what I appreciate. Okay, so:
Day 12, alone in the car with her baby, she thinks, without knowing why, of killing herself and the infant. Day 13, she has an overdose. She sleeps through the night, tells no one, abruptly weans the baby. Then she's disorganized, wrong formula, wrong bottles, calling friends day and night. Day 15, she tries to smother him. [In] her words, "I don't believe it was a thought. It was autopilot." Her husband comes upstairs. She says his presence shook her out of the state. After that evening, the compulsion is gone. She thinks she is not thinking straight.
He knows she is not herself. He does not know why she is psychotic. She is not treated. That was day 15. Day 20, husband and daughter kiss her goodbye and leave for school and work. She feels taken over, dazed, trance-like. Her words are, quote, "Something internal, like a force. It was not a voice, but I did not have control. It was an instant. I don't recall any. I don't recall thinking anything. I had no feelings. It was happening, but I wasn't there. At the time, nothing came into my head saying, ‘No, do not do this.’ My inside was gone and it was something else.” She's not connected with her own hand. The infant dies. She then washes him, changes his diaper, leaves the room, and tries to cut her wrists (Spinelli, 2009, p. 405).
Delusions of Influence and Loss of Control (37:02)
Spinelli:
So, shall I comment or did you want…? Okay. So this was one, probably one case where I found that the ego-dystonic thoughts became psychotic. She was the first person that I identified the delusions of influence with. And when she was talking about the force, I thought, "Oh, well, this must be an OCD component to it, because she feels like she's being forced. She's got to do it. She doesn't wanna do it." But there was something different. So I asked her to draw a picture of herself before and during, at the time of the killing and then afterwards. I wish I could show it to you because I do still have it. And, you know, she talks about the middle picture being the time when she killed the baby, and that middle picture she had an arrow with the force going through it.
Spinelli:
Since that time, each woman that I have evaluated has had the same kind of thing. Often, they don't identify it as a symptom because they don't know. And it is. They become a puppet. They become a puppet, and this delusion is causing them to kill.
Spinelli:
So as a matter of fact, I was pleased when Phil Resnick used the term now. And what's interesting is one of our colleagues, you'll recognize her, she saw that picture several years ago at a PSI [Postpartum Support International] conference, and I used the term, and she identified it. She was having a lot of infanticidal thoughts, and she identified it as what happened to her. Like she had no control over her movements. And she said she folded the paper and kept it because that really identified it as a symptom. And often the symptom is not identified.
Furey:
Yes, I think this just really points to how important it is, and I feel like, Dr. Spinelli, you've just done this so remarkably well over your career. While you're evaluating your patients, also really learning from them what it's really like, what they're actually experiencing and helping them even find words to describe it. I think it's such a catch-22, wanting someone who's so ill to be able to tell you exactly what they're experiencing so we can diagnose them the right way. But that's really expecting a lot of someone who is so ill, you know? So we really do have to do a better job at knowing what to ask, how to ask, what to look for, and all of that.
Recognizing and Diagnosing Postpartum Psychosis (40:13)
Spinelli:
And I think what's most important is not to make your diagnosis at that time, when she's feeling depressed or agitated, but to do a mental status exam, sometimes that's really missing, you know? And to ask questions about psychosis, and even to do our questions, whether they have abstract thinking and all of that, because it can really determine whether they are psychotic without even asking them. And sometimes they're not asked. I think they're not asked because sometimes the physician, the practitioner, doesn't want to know. You know, it's like it's going to create a big problem. I know that sounds weird, but I almost feel [it’s this way] because it's neglected so much.
Puder:
Are you talking specifically about cases where you've maybe represented the victim in a court case, like, as you look at records, as you hear testimony from different physicians, these are questions that are neglected?
Spinelli:
Yes, and definitely not in the records. You know, we're all very fortunate that we're in institutions that teach us state-of-the-art… we have a state-of-the-art kind of education. And when I've had to look at charts from smaller institutions, or places in the Midwest, that they don't maybe know that much about it, the charting and evaluations have been minimized, and you don't necessarily get a sense of even that visit, you know? And I don't mean to pick on any states in particular, I'm really just talking about, in fact, I'm talking about those of us who are very lucky to be in institutions that will teach us about something like postpartum psychosis.
Puder:
Yes. And I think that's why I'm passionate about putting these things out there right now, especially as people are finally waking up to, "Oh, we should really…." You know, there's all these memes on social media about how physicians are charting nowadays, for example, and how carefully they're charting. Like, memes, as in we're all a little bit petrified to make sure we're doing the right charting.
Spinelli:
And there's always the “if you didn't write it, you didn't do it”, right?
Puder:
Yes. I think, for me, charting is always one of these things when I've, you know, I used to teach residents quite a bit. I found that they spent almost too much time charting and not enough time with the patients, right? So I was always trying to get them to be like, "Okay, chart for five minutes, spend 50 minutes with the patient instead of chart for 50 minutes, spend five minutes with the patient."
Spinelli:
Yes, definitely. But now, also with insurance, there are such limits on time.
Puder:
Oh, yes.
Spinelli:
They're supposed to do a complete evaluation in 15 minutes or that kind of thing.
Puder:
Yep.
Furey:
When I was coming out of residency, about eight years ago and interviewing for jobs, I interviewed for one of the big telehealth companies and I immediately said no, because they wanted me to do initial evals in 15 or 20 minutes. And then they said, "And most of your patients are going to be in the geriatric age range." And I said, "What?" But I think as a physician kind of watching everything going on, that part, I feel like, isn't getting enough attention about just the limitations that are really put on care delivery these days and how so much of it feels really out of our control.
Spinelli:
Yes, it really does feel out of control. And for those of us who are in larger cities, for whom people pay cash, or, you know, straight, not just from their pocket, they get better evaluations.
Furey:
Yes. That's a big reason I went into private practice, so I could do my 90-minute evals and things like that.
Spinelli:
Yes, of course.
Puder:
Let me get your thoughts on this. A lot of women postpartum will have thoughts that are distressing. Some women will have postpartum OCD, or they'll have distressing images. And I'm wondering about the shift from distressing images to psychosis. Like, once again, reiterate what you're looking for, how you're making that assessment.
Spinelli:
Okay. Well, you just heard about the patient who did have that switch. I haven't seen many like that, but she definitely did. My advice to a physician who's seeing a patient who's having thoughts, and it sounds like it's obsessional OCD, I think first, ask them, "Is there any voice attached to this?" Because obsessional thoughts are thoughts, right? If there's a voice, that's concerning. And then to do a full mental status exam, and ask questions like, you know, not direct questions, but let her just speak. You know, do the things you would normally do to evaluate whether someone is having psychotic symptoms. Look at even serial sevens, you know? We don't tend to do that as much, but with someone like this, like, let's say this woman is disorganized, that would be important. And, I think the thoughts versus the voice is very important.
Spinelli:
And, you know, if you have questions with a patient like this, you should see her frequently.
Furey:
Right. Yeah.
Spinelli:
And collateral. Speak to the families. That's so important. If there's a husband or partner, that is very important. I mean, then you're kind of covering all your bases. I know what has come down is, well, you ask the patient if she wants to harm the baby. If she doesn't want to harm the baby, then it's OCD, but if she does, it's postpartum psychosis. Well, that's not true because psychotic women don't want to hurt their babies.
Furey:
Right. Right. And, I think in this day and age with social media being what it is, people are very quick to want to put out something so cut and dry. Aisha and I laugh about this sometimes, like, in a dark sense of humor way that, well, if only postpartum psychosis was that simple. But it's just, not, you know? Like you just really can't say if it's this way or it's that way. It's really the whole picture, which takes time to elicit.
Spinelli:
It takes time and connection. I mean, one of the things that's very important as we've learned, because when I was doing my depression study in Columbia, I had a lot of immigrant moms from Colombia, from the country of Colombia, and they were very worried about telling me any of their symptoms, even if they were just depression, because they thought their child would be taken away from them. So I would have a discussion with moms about this and tell them first, if they're not psychotic, tell them that's not going to happen. And if they are, you may have to say it's going to happen, but it would be with a loved one.
Furey:
Temporary.
Spinelli:
Yes. Yes.
Puder:
Yes. So, Wisner terms “cognitive disorganization/psychosis” (Wisner et al., 1994).
Spinelli:
Right.
Hallucinations, Delusions, and Infant-Focused Psychotic Symptoms (49:05)
Puder:
So you're checking the mental status because of the cognitive impairment, the thought disorganization, the lack of insight, delirium-like appearance, which, you know, they wouldn't be able to do serial sevens, spell “world” backwards, draw a clock. All of those are impaired in delirium-like pictures.
Spinelli:
I love Kathy Wisner's study.
Puder:
And then also the delusions of reference, delusions of persecution, homicidal ideation behavior, visual, tactile, olfactory hallucinations, she also mentions.
Spinelli:
Yes. And that probably has to do with that delirium picture. Right? I mean, you don't usually see that, but in postpartum psychosis you do.
Furey:
And one way that I've heard a couple, like a handful of my patients with postpartum psychosis describe the confusion/delirium like pictures. They say it's like this weird déjà vu sensation. I've had two [patients] independently describe it like that, where it's like they can't remember, "Did that really happen? Did it not? Like, what day is it? Did..." It's just like this…and I thought that was a really interesting way to describe it.
Spinelli:
It is.
Puder:
You also quote, in one of your papers, Chandra et al. (2006) saying that the majority of women with postpartum psychosis, 53% have delusional ideas that are related to the infant specifically. So someone would kill the infant, or the baby would be harmed by the breast milk, stuff like that.
Spinelli:
Yes. I mean, I thought that was a very interesting paper of hers, because it makes sense that they would have those kinds of psychotic thoughts. And if they do, of course, you want to separate them from the baby. And I would say, just as part of this, it is so important, at least that's how we do it at Columbia. If a woman comes in with a postpartum psychosis, you separate her from the baby. Because things can happen very quickly. The other thing I wanted to mention, and there has not been a good study, and there should be, because you see it or hear it in cases, is weaning. When mothers wean from breastfeeding, they will have an increase in their symptoms or new symptom onset. And that's especially important in things like postpartum psychosis where they will give you…I mean, the new data will give 12 weeks before the beginning of symptoms.
Spinelli:
But even if it's that later, they can also have it. They might have depression first and somebody may not recognize it. They might have hypomania where people will think it's relatively normal, what they're saying. And so they don't have anything florid until later on. And often, the practitioner will say, "Well, it's not that because it didn't start within X weeks."
Furey:
Yes. They haven't really traced it back. I find, especially that hypomania picture, I think is so risky because a lot of people from the outside might think, "Oh, she's doing really great after having a baby." And I always think, "You're not supposed to do that great after having a baby." I think that can just fly right under the radar if you're not, you know, talking to the collateral information. And one way I like to ask about it is just asking them to tell me how she's spending her time. What's she doing all day? Just have them tell you, right? Because they might not realize that's a lot of goal-directed behavior. They're not going to use those phrases.
Spinelli:
She feeds the baby and then paints a wall.
Furey:
Yeah, exactly. That's where you're like…
Puder:
And what's baseline?
Furey:
Yes. Good point, good point.
Puder:
If this person is chronically a little bit hyperthymic, maybe it's not hypomania, but if this is a very unusual behavior for them, it's like….
Puder:
You also cite this author. I'm going to butcher this name.
Spinelli:
Oosthuizen.
Puder:
Yes. Found when comparing 20 women with postpartum psychosis versus bipolar disorder, that postpartum psychosis had more rapid, intense mood shifts, more confusion, more delusions of control such as overpowering force that made them act completely out of their own control (Oosthuizen et al., 1995).
Spinelli:
So, which essentially could be just like we're talking about, right? Delusions of influence. There are several studies done. I think hers was in the 80s, but there are several. That's where I was able to collect the 13 who had cognitive impairment. And the picture of postpartum psychosis is very different. And maybe not very different, but it's different. You know, as we spoke of before, a patient comes in…I know postpartum psychosis is a bipolar disorder, so they're looking for mania history. And that's not always the case. And they do their investigation or evaluation based on that visit, but don't go back. I mean, the previous pregnancy is so important to look at. The postpartum period, because they may have had subtle hypomanic symptoms, right? And the mania is not so much like the mania of non-postpartum women.
Spinelli:
It's kind of they may have euphoria, but they're not giddy or happy, you know, at least most of them aren't. And it's also more likely to be hypomania or mixed states, particularly a mixed state. And people miss those kinds of things.
Hypomania, Mixed States, and Antidepressant Considerations (56:01)
Puder:
I think as just an outpatient psychiatrist who sees postpartum patients now, I'm very concerned…is an SSRI a good idea? Someone comes in, knowing that postpartum psychosis is more of a bipolar spectrum, you don't really want to give an SSRI to someone who's postpartum psychosis. But if they're coming and all you see is that depression picture, or that OCD-like picture, you may be thinking SSRI. Any thoughts on that?
Spinelli:
Yes. What I would do if I thought an SSRI was even, without the history or anything, if you give an SSRI, talk to her about the activation. And tell them to call you either the next day or the one after. Then I would bring them back. Let's say they did have the symptoms. I would bring them back and do one more test with either an SSRI or another antidepressant. And again, speak to them, call them, have them call you and let you know how they're feeling. You know, because if somebody does have depression and anxiety, it's very likely going to make the anxiety worse, right? But you want to make sure that the anxiety is not a component of any kind of psychotic episode. So if they did not have activation, I would leave them on it, but I would check in with them at least twice a week….
Spinelli:
For a couple of weeks. If they did have [activation], then I would put them on a mood stabilizer. I mean, you don't want to label people with something that's not necessary, so that's why I like to do it at least twice.
Puder:
And Katrina, anything else? Any other questions come into your mind?
Postpartum Psychosis, Infanticide, and Forensic Psychiatry (58:16)
Furey:
Oh, my gosh, a zillion. I guess, Dr. Spinelli, I'm just curious to hear, now looking back on the past few decades, working in this forensic space, what has that been like, and how does the next generation of trainees who, hopefully still want to go into reproductive psychiatry, how do we empower the next generation to keep talking about this moving forward? So there's more experts to draw on as we go forward.
Spinelli:
Well, all those years, nobody would do it at all. Or, you know, maybe somebody in the South, maybe somebody, [in the] Midwest. I would recommend, you know, I didn't have forensic training. I kind of learned on the way, which is not always the best way to do it. But you learn, it's better than them not having anybody sticking up for them. One of the things that I keep in mind, and when people ask me about this, it's really about saving lives. I mean, you talk about, "Well, there are two dead babies, and why are you sticking up for her?" That kind of thing. Because while we might not save those children, there are other children that can be saved if people identify this illness. As far as the forensic piece, it's tough because the forensic fellowship is another year or two.
Spinelli:
And if you've had good training in perinatal psychiatry, it should be a reasonable time, also. You know, for people who say, "Well, this organization, I had three days of education on perinatal illness or postnatal illness," it's really not enough because if you're doing a fellowship or training, you are also seeing patients and you're getting an idea, a good sample of patients that you're going to be medicating. It isn't enough to say, "Oh, well, she's pregnant. SSRIs are quote unquote “safe," right? That's not the only thing you learn. It's such a mixed….it can be such a mixed picture.
Puder:
I think it would be good to give the audience an update where we are going with the DSM, with the diagnosis. You have some inside information.
Spinelli:
Yes. It's positive. The [DSM] committee wrote an email to Dr. Veerle Bergink. There's Veerle, and maybe 20 more of us on this committee, and said that they agree that the specifiers are not useful, except in some cases, and they will place it in the DSM. So that will be, hopefully, the next DSM TR, DSM-5 TR. So there was that sentence, which is very, very positive. In addition, which is actually a positive thing, because they didn't know where to put it, they decided that all of us should write a chapter. I mean, this group should submit a chapter on illnesses associated with childbearing. So that's a very positive thing.
Puder:
What do you think it would take for our laws in the US to mirror other European laws that are a little bit more compassionate?
Spinelli:
Yes. We don't have a very compassionate legal system, as you know. So it's hard to answer that. But, you know, Susan Feingold got one passed in Illinois.
Spinelli:
That was kind of special. It was essentially written with Susan and her partner, by a woman who had served 30 years already. You know, I don't know what the answer is because it's not in our purview, you know?
Puder:
Sure.
Spinelli:
It may be the fact that it goes into the DSM.
Puder:
I think that's a good step.
Spinelli:
Do it. Yes, definitely.
Puder:
And I think educational things, like this, as well. That if more people understand it, and more people understand the delirium aspect, the confusion aspect, the delusional feeling like you're being controlled like a puppet, there really is a loss of, I talk about free will on my podcast [see episodes 84, 85, 86]. And I see free will as a spectrum, and I see the more severely ill you are, you have less choice.
Spinelli:
Yes.
Puder:
And if you are at the fringe of the most severe place cognitively, emotionally, psychologically, you have almost no choice.
Spinelli:
I would suggest to anybody who's going to be giving lectures, or anything else, that they pull up the picture of the HPO Axis [hypothalamic-pituitary-ovarian axis] because it explains it. You know, it explains how the neurotransmitters in the base of the brain, the hypothalamus, will interact with the thyroid, et cetera, and the ovaries. And that there is a reciprocal relationship and that keeps the menstrual cycle going. But that's so important, so that when there is a loss of hormone, it has quite an impact on the brain and the neurochemicals in the brain.
Spinelli:
And so I feel that gives people a biological foundation. I mean, it's not because your father beat you, or it's not because her mother yelled at her. But that this is biology, and there's no other way to explain it.
Puder:
Yes, there's hormones, there's inflammation, there's genes, there's all these things coming together and if you understand delirium. There are very few studies on postpartum psychosis compared to things like delirium. But if you understand delirium, there's a huge hormone…huge neurotransmitter imbalances in the brain during delirium. It's not just like a couple neurotransmitters, it's like hundreds, if not thousands of things going wrong all at once.
Spinelli:
Yes.
Puder:
Yeah. And so we… I don't know if there are any studies where they stick postpartum psychosis people, actively in the psychotic state, in an MRI, but there's some in bipolar that I've seen, who are just in a manic state, and their brain is not a normal brain. Their brain is a very disturbed brain.
Spinelli:
So, I remember. Well, there was one study about, I think she was psychotic or depressed, where there were a few women and they went into the MRI or the CT scan, and they put a picture of their baby up next to the scan and then they took pictures of the brain. And the women without depression, the amygdala and something else lit up. And for the women with depression, it did not. I was always so impressed with that study. And I agree with what you're saying with inflammation. The reason I bring up the hormones, it explains it for people. I mean, they can see it. They're not going to get it right now until we have more data. They're not going to get the inflammation so much.
Puder:
I think my point is that there's so many things going on, right? There's so many things.
Spinelli:
Great point.
Puder:
This is like the frontier of psychiatry. We need people, hopefully, people listening to this that want to do more research, that want to join research teams, that are looking at more mechanisms of understanding. But I would point to the other literature that we do have, bipolar, mania, what's going on, memory issues in the midst of mania. I have patients, all the time, that lose weeks of time. I had a patient, just today, a manic patient, in the psychiatric hospital, who doesn't remember three weeks of her life. Completely blank. She has little moments where she'll remember just a teeny bit here and there, but for the vast majority, when she was in a psychiatric hospital, she's like, "I asked my husband how long I was in there, and he said three weeks.”
Puder:
“And I said, ‘Three weeks?’ I only remember, like, two things happening in that whole hospitalization.” She was blown away that it was three weeks. So, yeah, there's a lot of things going on. Well, it was a pleasure having you on, Dr. Spinelli, Dr. Furey, as always. I know we should probably wrap this up here. Any last sort of advice, last input?
Safety, Hospitalization, Recovery, and Hope (01:08:34)
Spinelli:
Yes. If you see a woman and you believe she has postpartum psychosis, separate her from the baby, get in touch with the family, and if she does, hospitalize her. That's the best prevention. You know, I think this is such a wonderful thing that you're doing. And I appreciate your invitation.
Puder:
Well, I appreciate you coming on and taking the time with us and Dr. Furey as well. Dr. Furey, any last thought? Any last things you want to…?
Furey:
Oh, I could just sit and listen to you all day and try to soak it all in. I think, just thank you for being such a pioneer in the field and being so warm and open and educating all of us leaves me feeling a lot of hope that this condition….
Spinelli:
There is. You guys have so much to work with now. Right?
Furey:
Yes. And I think that's the final thought I'd want to leave people with, is that postpartum psychosis is very severe. It's very scary. The potential outcomes are tragic, and yet, most women get better. If you diagnose it and you treat it, it's very treatable, it's very reversible, and I think that speaks to the underlying biological nature of it, and that is what makes doing this work so rewarding. You really do feel like you're saving lives.
Spinelli:
You do. You do, and you are. And again, if you testify, you're not, as some people would say, testifying for a murderer. You're testifying because you're going to save lives in the future. But you're also testifying for a murderer who is ill, of course.
Puder:
You're trying to explain very complex, very nuanced things that it's taken me, as a psychiatrist, years to understand. If it's taken me years to understand, we have to be patient with the public, with the jury that is just hearing this for the first time, is trying to understand it for the first time. And we need to continue to speak in such a way that it makes sense, and we can present our case, having research studies showing, by the way, very hopeful that with treatment, the majority of women can recover.
Spinelli:
They can, and do. Very well.
Furey:
Exactly.
Spinelli:
There's also something important, just as an addition, when you do your evaluation, remember to to look at thyroid studies with the rest of it, urine culture, there should be a whole metabolic panel.
Furey:
Yes.
Spinelli:
But people might forget thyroid and thyroid antibodies.
Puder:
Yes. And if there's other neurological issues, anti - NMDA, which is about 2 to 4%, it's a small amount. But if there are other glaring symptoms, neurological symptoms, then we should consider that. postpartum thyroiditis.
Furey:
And that's one way, in my practice at least, that I've had some success when women don't want to go to the ER. If they don't want to be separated from their baby, or there can be a whole host of reasons why, I will often say, "You just had a baby. We really need to do a full medical workup to make sure everything checks out." And I really believe that, and I think, again, it points to how important it is to do that full medical workup. And as the doctor, like we talked about last time, Dr. Puder, call ahead and talk to the ER physician directly, so that they don't show up and wait and then get discharged because they quote unquote “look fine.”
Puder:
My other thought is, think about what university hospital you send them to.
Furey:
Good point.
Puder:
Because I think that not everywhere has a Columbia or UCLA. Unfortunately, right? So it's like we have to think about where we're sending the people. Hopefully, they have some sort of reproductive psychiatry presence on site. Like, if the university has that, that's probably where you want to send them. And you want to, of course, coordinate care and….
Spinelli:
Even if they don't have that, if they know state-of-the-art treatment, you know that they know how to treat psychosis even. But yes, if you can get to a reproductive site, that's wonderful. But to end, let's just say, this is a tragic illness.
Puder:
Yes. Well, thank you so much once again, Dr. Spinelli, Dr. Furey. Thank you so much for coming on. I appreciate you guys. And we'll leave it there for today.
Spinelli:
Thank you both. Thank you. Bye.
Puder:
Bye.
Additional Pregnancy and Postpartum Episodes
Episode 013: Postpartum Depression with Dr. Pereau
Episode 033: Perinatal Mood and Anxiety Disorders
Episode 184: Pregnancy Planning for Patients Taking Psychiatric Medications or with a Mental Health History
Episode 276: Postpartum Psychosis: Symptoms, Warning Signs, Risk Assessment, and Treatment with Dr. Furey and Dr. Puder
Episode 278: Postpartum OCD vs Postpartum Psychosis: Intrusive Thoughts of Infant Harm, How to Screen, and Lithium Prevention with Dr. Katie Unverferth
Episode 279: Postpartum Depression and Problem-Focused Psychodynamic Psychotherapy: Understanding the Five Core Conflicts
Episode 280: Postpartum Psychosis: Diagnosis, Treatment, Lithium, and Relapse Prevention with Dr. Veerle Bergink
References
Brockington, I. F., & Kumar, R. (Eds.). (1982). Motherhood and mental illness. Academic Press. https://archive.org/details/motherhoodmental0000unse_t9j8
Chandra, P. S., Bhargavaraman, R. P., Raghunandan, V. N. G. P., & Shaligram, D. (2006). Delusions related to infant and their association with mother-infant interactions in postpartum psychotic disorders. Archives of Women’s Mental Health, 9(5), 285–288. https://doi.org/10.1007/s00737-006-0147-7
Chaudron, L. H., & Pies, R. W. (2003). The relationship between postpartum psychosis and bipolar disorder: A review. Journal of Clinical Psychiatry, 64(11), 1284–1292. https://doi.org/10.4088/jcp.v64n1102
Di Florio, A., Mei Kay Yang, J., Crawford, K., Bergink, V., Leonenko, G., Pardiñas, A. F., et al. (2021). Post‑partum psychosis and its association with bipolar disorder in the UK: A case‑control study using polygenic risk scores. The Lancet Psychiatry, 8(12), 1045–1052. https://doi.org/10.1016/S2215-0366(21)00253-4
Oosthuizen, P., Russouw, H., & Roberts, M. (1995). Is puerperal psychosis bipolar mood disorder?: A phenomenological comparison. Comprehensive Psychiatry, 36(1), 77–81. https://doi.org/10.1016/0010-440X(95)90102-2
Spinelli, M. G. (2001). A systematic investigation of 16 cases of neonaticide. American Journal of Psychiatry, 158(5), 811–813. https://doi.org/10.1176/appi.ajp.158.5.811
Spinelli, M. G. (2009). Postpartum psychosis: Detection of risk and management. American Journal of Psychiatry, 166(4), 405–408. https://doi.org/10.1176/appi.ajp.2008.08121899
Strecker, E. A., & Ebaugh, F. G. (1926). Psychoses occurring during the puerperium. Archives of Neurology and Psychiatry, 16(2), 237–255. https://doi.org/10.1001/archneurpsyc.1926.02200020003001
Wisner, K. L., Peindl, K., & Hanusa, B. H. (1994). Symptomatology of affective and psychotic illnesses related to childbearing. Journal of Affective Disorders, 30(2), 77–87. https://doi.org/10.1016/0165-0327(94)90034-5