Clinical Case 14 of 15 · ~782 words
Clinical Case No. 14. Postpartum Mania with Psychotic Symptoms
The first days after childbirth
Mara is 31. She lives with her partner in New Westminster and has given birth to their first child. Pregnancy passed without a known psychiatric episode. Previously, she worked as a music teacher. Her partner has taken leave, and his mother helps with meals and household tasks.
On the fifth day after delivery, Mara almost stops sleeping, even while her partner cares for the baby. She does not feel tired, talks continuously, develops several grandiose plans, and alternates between joy and sharp irritability. Two days later, she becomes convinced that ordinary phone messages contain special instructions about the baby's future. Her partner notices the abrupt change and arranges emergency assessment.
By the seventh postpartum day, a manic syndrome with psychotic symptoms has developed. Following emergency assessment, the course is consistent with a first manic episode of bipolar I disorder with postpartum onset. [152]
Emergency assessment and safety
The department checks physical and neurological status, blood pressure, temperature, medication, and substance use. Obstetric complications, infection, and endocrine and neurological causes remain in the differential; examination findings determine investigations. Mara has no fever, severe hypertension, focal neurological signs, or evidence of intoxication. Attention is sufficiently sustained for conversation, although her own ideas distract her easily.
The team assesses the content of psychosis, impulsivity, self-care, and safety of contact with the baby. Her partner temporarily takes the primary caregiving role, with the grandmother helping at night. The family agrees with the team on visits and information sharing.
Mara agrees to assessment but, because of mania, denies needing to stay. The team assesses decision-making capacity and Mental Health Act criteria, completes the required procedure, and explains her rights. Mara remains on an acute psychiatric ward; the baby stays with family. Her partner maintains daily contact. [14, 152]
Treatment of the acute episode
Antimanic treatment begins with olanzapine; lorazepam is added briefly for acute agitation and restoration of sleep. After renal and thyroid function and other relevant measures are checked, lithium is added with concentration and tolerability monitoring. The clinical rationale draws on mania recommendations and separate perinatal guidance; the team selects the specific regimen. [43, 152]
Psychiatric, obstetric, and paediatric teams discuss medication, feeding, and possible infant monitoring. For the acute phase, the family chooses formula feeding: her partner takes nighttime feeds, allowing Mara longer sleep. Meetings also make room for her feelings about this decision.
During the first week, sleep improves partly, but marked psychosis persists; Mara eats little and cannot sustain a coherent conversation. Given the severity, the team discusses electroconvulsive therapy. The CANMAT perinatal guideline includes ECT among options for postpartum psychosis when rapid improvement is needed or other treatment is insufficiently effective. [152]
Electroconvulsive therapy within an actual care pathway
Referral to the Neurostimulation Clinic at the Mental Health and Substance Use Wellness Centre on the Royal Columbian Hospital campus in New Westminster is through a hospital or mental health service. The inpatient team coordinates assessment and treatment scheduling. [48]
The ECT team and anaesthesiologist assess Mara. They discuss benefits, alternatives, post-treatment confusion, and possible memory impairment; appropriate consent or legal authority is documented according to her condition and status. Concurrent medication, including lithium, is reviewed before the course.
Treatments take place under brief anaesthesia with muscle relaxation and subsequent observation. After several sessions, psychotic conviction weakens, eating improves, and conversation becomes more coherent. The course is adjusted according to response. Mara reports gaps in memory; important agreements are repeated and provided in writing.
Returning home
Before discharge, Mara can discuss her condition and participates in planning. Her partner shows a home schedule with sleep protected from nighttime interruptions. Contact with the baby resumes according to clinical improvement and safety assessment. The family receives clear early warning signs: a sharp reduction in the need for sleep, accelerated speech, and unusual certainty about special messages.
After discharge, a local psychiatrist and family physician continue care. If needed, Fraser Health or BC Women's perinatal mental health consultation services are involved, with the episode history and current plan transferred. [63, 153]
Over the following months, monitoring covers mood, sleep, renal and thyroid function, lithium levels, and tolerability of other prescriptions. Mara returns to short music lessons. Sometimes her partner checks too closely whether she has slept, and ordinary energy makes both anxious. A family meeting distinguishes support from constant surveillance: trust also needs rebuilding.
At one year, maintenance treatment is reviewed in light of the course, tolerability, and family plans. Mara will discuss any future pregnancy in advance with her psychiatrist and obstetrician, including relapse prevention and arrangements for sleep after childbirth.