“Postpartum Psychosis”

She was 28 and pretty and sweet and came in for depression.  It was only systematic questioning that confirmed she was manic-depressive. Actually her next-door neighbor had seen a television show on manic-depression and had made the diagnosis a couple of years before, long before this woman had ever seen a psychiatrist.  Her episodes had curiously enough been regarded more as amusing than as dangerous, so nobody had ever done anything about treatment.

By the time I knew anything about her, she had already had one child, and was pregnant with her second.I always believe in coordinating forces with the obstetrician/gynecologist when caring for a pregnant woman.I rarely get phone calls returned, but this is the way it should be, especially if someone has brought up the question of psychotropic drugs. She had never seen a doctor; her first child, and this one, had been delivered by a nurse practitioner midwife. The one thing I am absolutely sure this woman did better than any physician (except me) is answer phone calls. She was obviously thumbing through the old chart on the other end of the line when she told me: “After the birth of her last child she ran after her husband with a kitchen knife.  She destroyed a bunch of stuff in the house.  We did not know whether or not to believe the husband.  After all, he had a serious history of drug abuse.  They were sent to counseling; there is nothing more in the notes.”

It took all I had to keep from yelling into the phone at the top of my lungs.

Alright, so this is a rare condition, compared to postpartum depression or the ever popular “baby blues” which seem to hit almost everybody. It has been well described since at least the nineteenth century.  It happens, and the afflicted woman may kill either herself or the baby. The problem here, which is alluded to in the article cited above, is that even though this is serious and should be treated quickly, less than 20% of the time is it even reported to the health provider.

I warned the nurse-midwife practitioner of the danger, how this woman would need to be watched like a hawk after giving birth, of the dangers, of how at least I should see her as soon as possible after the delivery.  Sure I know the statistics are that she is less likely to have an episode after this birth.  But we were not going to bank on that one. We had to be ready for anything.

I told this nurse practitioner midwife to have her supervising physician call me.  It hasn’t happened yet. I told the patient and husband, too. Nobody seemed to know who the supervising physician was.

Psychosis and erratic behavior of the level we are talking here are awfully hard to miss. I do not know why such things are not reported more vigorously.  Fear of stigma?  Or is it sexism?  I still remember a case of transient delirium I treated in Oklahoma where the husband just thought the wife was a “fun date.”  It could simply be that a lot of people reject the notion of specialized knowledge in medicine as elitist.  In the populist flowering of the internet, some people believe anybody can learn everything they want or need to know.  Some believe in asking friends and neighbors.

Aberrant behaviors can be dangerous.  Specialist medical knowledge can be truly helpful. The stupid question is, as always, the one not asked.