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Patient Case 3


Date of Presentation: 07/31/2008

35F   WHITE   AB+  BMI25.3  OUT-PT


DST Recommendations: Aifred Health

Treatment Names Chance of Remission
Bupropion SR + Escitalopram ** Bupropion is often used clinically in cases of hyperphagia or when weight gain is to be avoided. 60.43%
Citalopram 38.03%
Venlafaxine XR + Mirtazapine 35.63%

Patient Information

Basic Information
PRM DX Postpartum psychosis with bipolar disorder SX Postpartum Confusion, Agitation, and Delusions
FH Positive for severe depression ALGY No allergies to medications

Current Medications
Names Doses Frequency
Valproic acid 500 mg b.i.d
Lorazepam 1 mg t.i.d
Haloperidol 5 mg q.h.s

Other Information
Five most important features for this patient and attendant responses were as follows:

•Have you ever witnessed a traumatic event? No
•Did reminders of a traumatic event make you shake, break out into a sweat, or have a racing heart? No
•Have you had any trouble falling asleep when you go to bed? Takes at least 30 minutes to fall asleep, more than half the time.
•Have you been feeling down, blue, sad or depressed? Feels sad less than half the time.
•Do you eat a lot when not hungry? Yes

Examination Result
No Examination Result.

Literature Evidence

Please click on Literature Name for PICO summary, or enter keywords for each PICO category.

P:   I, C:   O:

Below table displays the matchable literatures from PubMed and Google Scholar filtered by patient's SX.

Literature Names Year

A 35-year-old mother of a newborn, who had been diagnosed with PP and been hospitalized on psychiatric unit after a postpartum psychotic episode.

The postpartum period is a clearly identified trigger for late-onset hyperammonemia related to a urea cycle disorder. Routine monitoring of plasma ammonia levels in women with postpartum psychosis, a severe mood disorder, or de-lirium is recommended.

Multidisciplinary management must be started once hyperammonemia is confirmed.


Postpartum patients

Intervention may be needed if a mother is at risk for prolonged symptoms, since adverse obstetric events can be a risk factor for PPD, unresolved grief as measured by the Adult Attachment Interview, GAD, social phobia, and posttraumatic stress disorder (PTSD)

The reasons for psychiatric consultation to the obstetrics service, important steps for evaluation, diagnosis, and treatment of the most common conditions encountered postpartum, and the importance of assessing maternal capacity are addressed.


Postpartum women

Postpartum psychosis should be suspected in any patient presenting with postpartum depression or mania and a previous history of missed or misdiagnosed mood episodes and a family history of bipolar disorder.

The inclusion of postpartum delirium and stupor introduces unnecessary heterogeneity. The limits of onset of postpartum bipolar/cycloid disorders are important in the identification of the trigger.


Midwives that care for women with postpartum psychosis.

The Recovery Advisory Group Model by Ralph et al. is defined as a consumer-driven, dynamic, constantly evolving, nonlinear process that may provide a theoretical framework to assist midwives in providing care for women experiencing postpartum psychosis.

Midwives can play a critical role in facilitating the recovery of women experiencing postpartum psychosis and reducing the fragmentation that exists between obstetric and mental health care.


Postpartum patients

This study prospectively assessed a wide range of symptoms in cases of postpartum depression in a cohort of women and used a person-centered analytic approach and distinguished mutually exclusive subgroups of women related to demographic and clinical characteristics.

The most prevalent subgroup of PP patients is the depressive profile, which can easily remain undetected. Describe Postpartum patients, and identify subgroups of patients based on symptom profiles.


Women in the postpartum period who are vulnerable to psychiatric disorders like postpartum blues, depression, and psychosis.


Healthcare professionals should regularly screen mothers during antepartum and postpartum visits for perinatal mental illness, if left undiagnosed and unmanaged, can have far reaching ramifications for both the mother and the infant.


Women who present with mood decompensation, excessive anxiety, or psychosis during the perinatal period.

Intervene for women who present with mood decompensation, excessive anxiety, or psychosis during the perinatal period

Imminent and emergent psychiatric symptoms in the perinatal period including management and risk reduction


Pregnant index women with and without a history of nonorganic psychosis

This paper discusses different forms of postpartum psychosis with varying psychopathology and duration, and the early onset of bipolar/cycloid episodes.

Uncommon cases are rare but important to clinical practice and research, as they might be less rare if their existence was recognized.


women with postpartum psychosis

PPPs were found following 28% of the index deliveries, almost all of these 25 cases being psychiatrically hospitalized. PPPs were especially frequent among cases with total illness diagnoses of Cycloid Psychosis and Affective Illness.

Confusion was part of the current episode symptomatology in about one third of the cases and was well distributed across the different diagnostic groups.


women with postpartum psychosis

A clinical cohort study tracked the phenotypic characteristics of 130 consecutive cases of PPP, and used latent class analysis to describe three separate symptom profiles.

Women with a history of bipolar disorder or who are first-time mothers are at heightened risk for postpartum psychosis, which requires inpatient hospitalization and treatment with lithium, antipsychotics, and benzodiazepines.


women with postpartum psychosis

This study looked at the incidence of postpartum psychotic and bipolar episodes in women with and without a history of prepregnancy or psychiatric hospitalization.

The need for obstetricians to assess history of psychiatric symptoms and to optimize the treatment of mothers with psychiatric diagnoses through childbirth was found.