and confusion raise concerns for conditions that organically affect the brain: this may include autoimmune processes resulting in various forms of encephalitis, embolism (and other vascular disorders), and infectious processes. physical causes as a result of chronic hormonal disease (e.g., thyroid diseases, hyperparathyroidism) or complications resulting from childbirth, such as sheehan's syndrome or other complications resulting from excess blood loss, should also be evaluated. other psychiatric conditions must also be considered: postpartum blues, postpartum depression, anxiety disorders, and postpartum ocd may have many overlapping symptoms with ppp. finally, psychosis as a result of various substances (including medications such as steroids), should be ruled out. if this is a first-onset episode of psychosis, new-onset bipolar disorder and schizophrenia cannot be ruled out; the diagnosis of these disorders is based on time and recurrence of episodes. treatment while each case is considered by individual circumstances, generally, ppp is assessed as a psychiatric emergency and requires admission to a psychiatric hospital for close care. this admission may be to a mother-baby psychiatric unit or a general adult psychiatric unit, depending upon the availability in one's country and area. because few units, especially in the united states, offer mother-baby services, patients may be discharged home as soon as the worst concerns for the safety of the patient and infant are cleared, even though the patient may still be experiencing some symptoms of ppp; in this way, patients receive care to prevent harm to self and others but return home to care for their children and promote bonding as soon as they are able. treatment plans are made up of a combination of education, medication, and close follow-up care and support; the major goals of care include improving sleep and psychotic symptoms while helping to minimize major shifts in mood, such as depression and mania. medical treatment typically involves ect, benzodiazepines, lithium, and/or antipsychotics. electroconvulsive therapy (ect) is one of the available treatments for postpartum psychosis. electroconvulsive therapy (ect) ect has a long and well-documented history as a psychiatric treatment, starting in 1938, with a large body of literature supporting its effectiveness and safety in various psychiatric conditions, including psychosis. however, while it has been used for ppp for over 50 years, the data on its efficacy in ppp specifically is limited to a significant number of case series and various retrospective matched-cohort studies. there are few adverse effects associated with ect, though short-term memory disturbance (< 6 months) has been reported. patients who are adverse to long-term psychiatric medications may prefer ect, particularly given the minimal and short-term impact that ect-related medications (e.g., drugs for muscle relaxation and anesthesia) appear to have on breastfeeding (as compared to psychiatric medications). per current recommendations, ect is considered an option for ppp when medications are ineffective. lithium lithium is a psychiatric medication commonly classified as a "mood stabilizer" and often used for the treatment of bipolar disorder. for ppp, lithium can be administered as a medication by itself ("monotherapy") or as an additional medication with other psychiatric drugs ("adjunctive therapy"). research has shown strong evidence for the effectiveness of lithium as monotherapy in preventing repeat episodes of psychosis, particularly when compared to antipsychotic use alone, and current recommendations suggest it as a first-line treatment for ppp in patients for whom this is safe (lithium is not advised for patients with severe kidney or heart disease, thyroid dysfunction, brugada syndrome, or who have known allergies to the drug). lithium has been associated with side effects to the fetus when taken during pregnancy, including body and heart abnormalities (e.g., ebstein's anomaly); these effects have been documented in all trimesters, but higher risks, particularly for structural heart problems and spontaneous abortion, are typically seen with exposure in the first trimester. lithium is also currently the recommended medication for prevention of psychotic episodes in individuals who have a known history of bipolar disorder and/or previous episodes of ppp. the preferred strategy for preventative medication is to begin lithium immediately following delivery of the infant, minimizing the exposure of the fetus to lithium while in the womb. treatment throughout pregnancy, however, may be warranted as appropriate for treatment of bipolar disorder, and is dosed according to appropriate medical advisory for the patient's trimester. lithium effectiveness is based on reaching an optimum level in the individual's blood, which usually requires more frequent bloodwork and adjustment of medication dosage to find and maintain an appropriate level. stopping lithium requires slow and gradual discontinuation; sudden removal of the medication may lead to symptom relapse and suicidal thoughts. benzodiazepines benzodiazepines are a class of drug commonly used for anxiety disorders and insomnia, though they also play a role as an additive medication for psychosis and delirium. according to a small study of 64 women, benzodiazepines had a minor but positive effect in reducing psychosis as a sequentially added medication for treatment of ppp (on top of lithium and antipsychotic medications); due to little supporting data, benzodiazepines are currently only recommended as an add-on medication to lithium and/or antipsychotic drugs, usually in the setting of continued sleep disturbance despite the use of the other medications. olanzapine (zyprexa), a second-generation antipsychotic medication, is a benzodiazepine that may be prescribed for postpartum psychosis. antipsychotic medications antipsychotic medications are the preferred class of drug used to treat general psychosis, including schizophrenia spectrum disorders. few studies provide evidence for the efficacy of antipsychotic use in ppp, with the exception of one study of 64 women which examined antipsychotic use as a drug by itself and combined with lithium. in this study, antipsychotic use was effective in both scenarios, but not as effective as lithium used by itself. despite this limited evidence in ppp specifically, current recommendations include antipsychotic use as an additional medication for patients receiving lithium, or antipsychotic use on its own for those who are unable to tolerate lithium. antipsychotic choice is physician- and case-dependent, with a large number of available medications offering a range of nuanced effects. treatment guidance is largely based on recommendations and data from patients with schizophrenia who become pregnant. first-generation antipsychotics have a longer history of use, efficacy and safety in pregnancy, particularly chlorpromazine and haloperidol. still, second-generation antipsychotics may be preferred over first-generation antipsychotics due to the reduced risk for extrapyramidal symptoms (e.g., uncontrollable movements, tremors or muscle contractions). breastfeeding disruption of continued contact with the infant may occur during hospitalization and treatment, which may impact breastfeeding capacity; hospital units may provide the use of a breast pump to mitigate this concern. strategies and concerns should also be discussed regarding breastfeeding and its impact on sleep, as poor sleep related to night feedings may worsen or delay patient recovery; alternatives may include social support and bottle-feeding through the night to allow the patient time for adequate rest. the effects of various medications during breastfeeding are poorly studied. according to one systematic review evaluating 37 different reports of antipsychotic use in 206 infants, olanzapine has the strongest supporting evidence for low infant exposure through breastmilk, while fewer reports support a similarly low exposure for quetiapine and ziprasidone use. chlorpromazine also demonstrates minimal transference to the infant through breastmilk. there is currently no consensus to the safety or level of lithium present in breastmilk, though several guidelines and reviews do not consider it an absolute danger to the infant which should exclude its use. several reports describe safe use of lithium during breastfeeding with no noticeable effects in the infant, though any lasting effects have not been well-studied. as in adults, lithium use with breastfeeding infants requires careful monitoring of the child for serum levels, dose adjustment, and any side effects; thus, the ability of the patient to maintain follow-up care should also be taken into consideration when lithium may be used. short-acting benzodiazepines, like lorazepam, are preferred from this class of drugs as they demonstrate lower levels passed through breastmilk and no reported side effects in infants. prognosis and outcomes symptoms may last for a variable length of time (up to one year in 25% of cases) despite adequate treatment. despite most individuals (50-80%) experiencing a relapse episode and development of chronic psychiatric disorders (such as bipolar spectrum disorder), these same individuals are expected to be able to resume normal activities of their daily life with the same level of function as previously experienced. of the minority of persons who experience ppp and choose to have another pregnancy, evidence has shown that about 33% will have a repeat psychotic episode. other factors that contribute to poorer prognosis include an experience of ppp that's limited to the postpartum period (rather than a diagnosis of bipolar disorder, for example), longer initial psychotic episodes, and a higher severity in the initial episode. infanticide (or filicide) is thought to occur in 1 to 4% of ppp cases, and some evidence suggests that these incidents are more commonly related to ppp episodes that feature more depressive symptoms. epidemiology ppp is rare, reported to occur in about 1 to 2 of every 1000 childbirths (0.9 to 2.6 per 1,000). reported cases are thought to underestimate the actual occurrence of ppp due to the probability of some individuals avoiding hospitalized care to avoid separation from their child (particularly in locations with no mother-baby units) or fear of stigma, as well as the likelihood of misdiagnosis with other postpartum disorders. the first month following childbirth is associated with a higher relative risk for hospital admission due to psychosis when compared to other times in an individual's life. while no specific genetic factors have been linked to ppp, a family history or personal history of bipolar disorder has been strongly associated with higher risk for ppp episodes (see risk factors). history postpartum psychosis had been recognized in earlier editions of the dsm (i and ii), first as involutional psychotic reaction and later as psychosis with childbirth. it was removed in the dsmiii following arguments that psychiatric disorders associated with pregnancy and childbirth were no different than other psychiatric illnesses; it has only been more recently recognized again with the 1994 release of the dsm-iv, when the specifier "with postpartum onset" was included for various diagnoses. between the 16th and 18th centuries, about 50 brief reports regarding postpartum psychosis were published; among them is the observation that these psychoses could recur, and that they occur both in breast-feeding and non-lactating women. in 1797, osiander, an obstetrician from tübingen, reported two cases at length that contributed significantly to the knowledge of this disorder during that time. in 1819, esquirol conducted a survey of cases admitted to the salpêtrière, and pioneered long-term studies. from that time, puerperal psychosis became widely known to the medical profession. in the next 200 years, over 2,500 theses, articles and books were published. among these many contributions were delay's unique investigation using serial curettage and kendell's record-linkage study comparing 2 years before and 2 years after the birth. in the last few years, two monographs reviewed over 2,400 works, detailing more than 4,000 cases of childbearing psychoses from the literature and a personal series of more than 320 cases. postpartum bipolar disorder signs and symptoms about 40% of patients experiencing postpartum bipolar disorder have puerperal mania,: 217 with increased energy or activity and sociability, reduced need for sleep, rapid thinking and pressured speech, euphoria and irritability, loss of inhibition, violence, recklessness and grandiosity (including religious and expansive delusions); puerperal mania is considered to be particularly severe, with highly disorganized speech, extreme excitement and eroticism.: 212–213 delusions have been associated with this disorder (including delusional parasitosis, delusional misidentification syndrome, and denial of pregnancy or birth), as well as hallucinations, disorders of the will and self, catalepsy and other symptoms of catatonia, self-mutilation and other severe disturbances of mood. historically, literature from the 18th century also describes symptoms not typically documented today, such as rhyming speech, enhanced intellect, and enhanced perception. another 25% have an acute polymorphic (cycloid) syndrome, which is a changing clinical state, with transient delusions, fragments of other syndromes, extreme fear or ecstasy, perplexity, confusion, and motility disturbances. in the past, some experts regarded this as pathognomonic (specific) for puerperal psychosis, but this syndrome is found in other settings, not just the reproductive process, and in men. these psychoses are placed in the world health organization's icd-10 under the rubric of acute and transient psychotic disorders. in general