Back in 202O, Margaret Spinelli, MD presented a proposal to the DSM-V committee of the American Psychiatric Association arguing for the inclusion of postpartum psychosis as a unique diagnosis in the DSM based on the unique features that accompany postpartum psychosis. The proposal clearly laid out the rationale for the inclusion of postpartum psychosis in the DSM, highlighting the distinctive features of postpartum psychosis and describing how the failure to appreciate these features may hinder the diagnosis and treatment of postpartum psychosis.

If you saw the recent article in The New York Times, you are aware that the debate is still ongoing. According to the article, there is not debate as to whether postpartum psychosis belongs in the DSM, but we are just not sure exactly where to put it:

The bigger problem is that it does not fit perfectly into any of the manual’s chapters, which are used to train doctors to understand a disorder and directly affect the treatments patients receive. … there had been objections from committee members who saw it as a depressive or psychotic disorder and resisted classifying it on the bipolar spectrum.

It might take us a very long time to figure out exactly where postpartum psychosis belongs. Postpartum psychosis is a remarkably heterogeneous disorder with so many different presentations. Furthermore, it is rare, occurring only in 1 to 2 per 1000 women who have given birth, so it is difficult to study. 

In the most recent version of the DSM, postpartum psychosis was incorporated using the specifier “with peripartum onset” which could be used to describe a brief psychotic disorder or a major depressive, manic, or mixed episode with psychotic features that occurs within four weeks of childbirth. Not perfect, but it works.

Many call the DSM “Psychiatry’s Bible”. This makes the DSM feel iron-clad, a text we cannot disobey. However, the DSM was designed to guide clinicians in a field where there are no diagnostic tests to confirm a particular diagnosis. First published in 1952, the DSM was an effort to create order in a chaotic, evolving field. In our daily practice, so many of the patients we see do not fit neatly into the categories provided in the DSM.

That’s where clinical judgment fits in. When a patient presents with signs and symptoms that do not precisely meet the criteria specified by the DSM, a clinician must rely also on their experience and judgment, making the best decisions provided incomplete information. Over time, and an opportunity for more prolonged observation, we will either confirm or change our initial diagnosis. 

Do Emergency Providers Read the DSM?

It is true that postpartum psychosis is frequently missed or misdiagnosed, and this can lead to significant delays in treatment. Giving postpartum psychosis its own place in the DSM may help to increase awareness, but it is probably not enough.

Mental health providers are trained using the DSM and use it as a reference; however, the situation is different for first line providers — the emergency personnel, obstetricians, midwives, and obstetric nurses who are most likely to first come into contact with a woman with postpartum psychosis. It is not enough to have postpartum psychosis listed in the DSM. We must also make sure that first-line providers have the tools to recognize postpartum psychosis. New mothers with postpartum psychosis, especially those with no psychiatric history, are not first taken to a mental health provider. They are in crisis, and end up in emergency rooms and in obstetric offices. 

Including postpartum psychosis may help to improve awareness, but it is only the first step. 

MGH Postpartum Psychosis Project (P3)

The MGH Postpartum Psychosis Project (mghp3.org) at the Center for Women’s Mental Health is currently investigating the treatment and long-term course of postpartum psychosis, while contributing to advocacy efforts to reduce stigma of this illness. We are studying people who experienced an episode of psychosis within six months of giving birth in the past 10 years. Study participation involves a telephone interview and providing a DNA sample with a saliva collection tube sent by mail. If you or your patient would like to participate in MGHP3, fill out this interest form or email us at mghp3@partners.org.

Resources

https://www.mghp3.org/resources

The National Maternal Mental Health Hotline – 1-833-TLC-MAMA – is a free and confidential space for pregnant women and new moms to get the emotional and mental health support they need. Trained counselors are available 24/7 by phone and text in English, Spanish, and translation services in over 60 languages.

Postpartum Support International’s Perinatal/Postpartum Psychosis Help

—Ruta Nonacs, MD PhD