Recognizing signs of postpartum psychosis, with Alexis Totaro, MSN

While standardized postpartum depression and psychosis screening is routine and important, it does not replace the clinical exam in identifying patients at risk, according to Alexis Totaro, MSN, RN, WHNP-c, CARN-AP, Vice President, Mental Health Operations, and Chief Nurse Executive, Christian Health.

Totaro emphasized that the earliest warning signs are often subtle deviations from a patient's baseline.

“Nothing really replaces the clinical exam. And very often, the signs of an impending depression or psychosis are really in the invisible signs that people are not necessarily seeing, and they may be subtle, or they may be very obvious in nature,” she said.

Recognizing those signs depends on knowing what is normal for the individual patient, Totaro said.

“When you're talking about the clinical exam, you'd be looking for something that's just off from the patient's baseline, something that is unique and different than what their baseline was before,” she said, citing unclear communication, incoherent sentence structure, isolation, agitation, altered hygiene, and changes in the tone or speed of speech. She added that a patient may approach infant care in a mechanical way that differs from what a clinician would expect.

“Patients often, even when they're struggling, do have that innate survival instinct, and they can be very adept at hiding their symptoms. It's very important that the clinician involves family and friends who know the patient and can weigh in on whether something is just off, and they're just not the same person they were before,” she said.

Addressing how to distinguish normal postpartum sleep disruption from an emerging psychiatric concern, Totaro described sleep behavior as a key differentiator.

“When you're looking at a normal adaptation to having a new infant or another infant in the house, or sleep deprivation from an infant, patients are exhausted. So when given the opportunity to sleep, if it's just sleep disruption from having a new baby, they will usually readily fall asleep,” she said, noting that such patients welcome the chance to rest and feel refreshed and happy afterward.

An impending postpartum depression or anxiety presents differently, she said.

“That usually involves unwanted and intrusive thoughts. They're constantly worried about the baby, and so sleep does not come readily to them at all. There is not a feeling of feeling refreshed once they have slept, and it's ongoing, unwanted, intrusive thoughts,” Totaro said.