Postpartum psychosis is the most severe form of postpartum psychiatric illness, occurring in approximately 1 to 2 per 1000 women after childbirth. Although bipolar disorder is a risk factor for postpartum psychosis, a substantial number of women who develop postpartum psychosis have no history of psychiatric illness and experience psychiatric illness only in the context of childbearing. What may cause or trigger postpartum psychosis in this population is not well understood.
A recent study suggests that autoimmune thyroid disease may be more common in women with postpartum psychosis. This rationale for this study comes from the finding in several studies that thyroid abnormalities are more prevalent among women with postpartum depression. Included in this study were 31 consecutive primiparous women with no prior psychiatric history who were admitted to an inpatient unit for the treatment of postpartum psychosis. Because parity is a potential risk factor for thyroid autoimmunity, only primiparous women were enrolled. The control group (n = 117) consisted of primiparous women with consecutive deliveries in a community hospital practice. Blood samples were obtained at 4 weeks and 9 months postpartum. Thyroperoxidase antibody levels were quantified as immunological measures of autoimmune thyroid disease (AITD). Thyroid-stimulating hormone (TSH) and free thyroxine levels were measured to assess for thyroid dysfunction.
At 4 weeks postpartum (prior to the initiation of mood stabilizer therapy), 19% of the women with postpartum psychosis had AITD compared to only 5% of the control group. Women with postpartum psychosis and AITD were more likely to progress to clinical thyroid dysfunction (67%) than control subjects with AITD (20%).
This study is the first to demonstrate that autoimmune thyroid disease is more prevalent in women with first-onset postpartum psychosis than in postpartum women from the general population. Furthermore, clinical thyroid dysfunction occurs significantly earlier and in a greater percentage of women with postpartum psychosis. While this study was small in size, one of the strengths of this study was that thyroid function was assessed prior to the use of mood stabilizers, including lithium. Based on these findings, the authors made several recommendations:
1. Check thyroid function and autoantibody titers in all women presenting with postpartum psychosis. It is recommended that testing occur at both 4 weeks and 6 months postpartum, as levels of autoantibodies are normally suppressed during pregnancy and often rebound after delivery.
2. Check thyroperoxidase antibodies in women with bipolar disorder or those with a history of postpartum psychosis. The authors hypothesized that women with elevated thyroid antibodies during pregnancy would be more likely to develop postpartum psychosis. However, it is important to note that this hypothesis has not been formally tested, and we cannot assume that women with low levels of thyroperoxidase antibodies are not at risk for postpartum illness. All women with histories of bipolar disorder or postpartum psychosis – regardless of their antibody status — should receive some type of prophylactic intervention and should be monitored closely after delivery.
3. Carefully weigh the risks and benefits of using lithium in women with postpartum psychosis, particularly in women with elevated thyroperoxidase antibody titers. Elevated thyroperoxidase antibody titers and lithium treatment are both independent risk factors for the development of thyroid dysfunction; however, lithium has been shown to be highly effective for the prevention and treatment of postpartum psychosis. This study did not have the statistical power to determine the influence of lithium treatment on risk for thyroid dysfunction.
While this study poses some interesting questions for further research, it does not substantially change the clinical management of women presenting with postpartum psychosis. There are no well-defined treatment guidelines for this disorder; antipsychotic medications and mood stabilizers are recommended and widely used in this setting. Whether or not a woman with postpartum psychosis has signs or symptoms suggestive of thyroid disease, the basic principles of psychiatric treatment remain the same.
Ruta Nonacs, MD PhD
Bergink V, Kushner SA, Pop V, Kuijpens H, et al. Prevalence of autoimmune thyroid dysfunction in postpartum psychosis. The British Journal of Psychiatry (2011) 198:264-8.
Pedersen CA, Johnson JL, Silva S, Bunevicius R, Meltzer-Brody S, Hamer RM, et al. Antenatal thyroid correlates of postpartum depression.Psychoneuroendocrinology (2007) 32: 235–45.
Robertson E, Jones I, Haque S, Holder R, Craddock N. Risk of puerperal and non-puerperal recurrence of illness following bipolar affective puerperal (post-partum) psychosis. The British Journal of Psychiatry (2005)186: 258-259.
Thanks for this information ! It is yet another example of how complex and interelated the body/mind systems are…I am constantly amazed by how predominant thoughts, mood, actions are influenced by the “hidden machine” behind the curtains of the body. This system of neurochemicals, hormones etc. construct a “stage” whereupon the mind’s thought capability is strongly influenced to fill that stage with a “play” written of a certain type and mood.
Along with medical treatments that reconstruct that “stage” to host more “euthymic” performances…..using mindfulness and awareness is extremely helpful. Developing that “little audience” member in the back of your theater that “sees” and exposes the performance for exactly what it is…merely a series of arising and diminishing thought patterns that are so transient – and never really “YOU” !
Hi, I suffered from PPP four years ago when I had my first daughter, 4 months following the onset of the illness, I was diagnosed with hypothyroidism, which I still suffer from. It is really neat to read that there was a study conducted on this because I suspected there was a connection between my PPP and my hypothyroidism.
Thank you to Teresa Twomey for providing me with this very important info!
I find this so interesting considering I had postpartum psychosis. The mind is amazing,its ability to heal and mend itself. I delivered in 2002 and I had to be hospitalized 2 weeks after delivery,I had auditory hallucinations and sensory hallucinations. I even thought my son was Jesus. I don’t know why these illnesses are religious based. I was diagnosed with bipolar disorder schizophrenia, I haven’t had an episode since. I am not on any medications and I believe it was my thyroid all along. I am just so thankful I recovered please feel free to contact me at email@example.com I will answer all questions related to my personal experience. I can recall all of my erratic thoughts from my episode, i was so sick and my hallucinations at the time were so vivid and seemed so real. I hope all doctors test for thyroid before any medications are administered.
My dtr at age 32 was hospitalized with psychosis and severe paranoia at 5 months post partum with her 2nd child. she had never had any psychiatric hx. the ER dr told me she probably has severe bipolar or schizophrenia and the hospitalist wanted to transfer her to a psychiatric hospital and start her on antipsychotics. I asked them to hold off on antipsychotics and the transfer and give her something to make her sleep ( she had not slept for 4 days). She slept all night with 2 doses of 1 mg of ativan, woke up the next morning no longer psychotic, but bewildered. When her vital signs were checked her pulse was 120 and BP 140/104, and she was down 10 # below her pre-preg wt, with a 10 # st loss in the 2-3 weeks preceding the hosp. She also presented with swelling in her neck and report neck pain that radiated into her ears. No one checked her thyroid fct at the hospital. when she went to her PCP a few days out to the hospital, the PCP thought I was crazy when I asked for her thyroid, adrenals, and pituatary to be checked. The psychiatrist she was referred to said that she was just overwhelmed and dismissed a possible medical cause for her psychiatric decompensation. It was her OB/GYN who knew her who pushed to get her into the endocrinologists ASAP. She was ultimately dx with hoshimoto’s thyroiditis,but it took 2 months of being put on zoloft before the correct dx of was made. She is now on synthroid, but she is still concerned about what caused the problem. the endocrinologist has not given her reassurance than she could have had a thyroiditis that caused hyperthyroid symptoms and she is now being treated for hypothyroid. She worries the bad symptoms will come back. My dtr has a PhD in Mathematics Education and Curriculum and is an Asst Professor and now lives in fear she is mentally ill. Any advise?? Her treatment was at a reputable KC hospital, but they were not even looking for an endocrine problem, but because of pushing from me her mother and her sister who is a nurse practioner student she finally got basic labs for thyroid and adrenal—-both abnormal. It is scarey to think she could have just been dx with a psychiatric illness, put on antipsychotics and who knows where that would have led.