Alexis Totaro, MSN, on weighing outpatient versus inpatient postpartum treatment

The decision between outpatient counseling and emergency psychiatric evaluation in the postpartum period hinges on whether a patient is grounded in reality, the safety of the home environment, and the patient's psychiatric history, according to Alexis Totaro, MSN, RN, WHNP-c, CARN-AP, Vice President, Mental Health Operations, and Chief Nurse Executive, Christian Health.

Totaro emphasized that postpartum psychosis is a medical emergency requiring escalation in nearly all cases.

“One very important factor: Is the patient based in reality? Postpartum psychosis is truly a medical emergency, and almost without exception, inpatient hospitalization is required,” she said.

When outpatient treatment is under consideration, Totaro said a careful assessment of the home is essential.

“There has to be an assessment of the home and whether the home is a safe place for both the patient and for the infant and any other children or family members that might be in the house. So, is there a support person that will be there 24/7? Can we assure the family that the patient will not be left alone with the infant should their thinking change?” she said.

She underscored that a patient's condition can shift rapidly, warranting caution.

“You can flip from a postpartum depression into a postpartum psychosis very quickly and sometimes without warning,” Totaro said.

Adequate rest is another factor in determining whether a patient can safely be treated at home, as “Sleep is really, really important for someone to recover from postpartum depression and postpartum psychosis,” she said.

Totaro identified psychiatric history as a critical consideration in the decision.

“Did this person have a mental health diagnosis before the pregnancy? Have they been taken off the medications that they [using] for their mental health diagnosis? Have they had postpartum depression and/or postpartum anxiety or psychosis in the past?” she said, adding that all of these elements must be weighed to determine whether outpatient or inpatient treatment is needed.