A woman with a previous episode of postpartum psychosis (associated with bipolar disorder) is now planning a second pregnancy. What is the evidence-based recommendation regarding prophylactic pharmacotherapy?

• A Begin lithium only if she develops symptoms in the third trimester
• B Prescribe haloperidol depot antenatally starting at 30 weeks
• C No prophylaxis is required; management should be reactive only
• D Prophylactic lithium should be initiated immediately postpartum (within hours of delivery) given ~50% recurrence risk ✓

Explanation

Women with a prior episode of postpartum psychosis (especially with underlying bipolar disorder) have a recurrence risk of ~50% with each subsequent delivery. Current evidence strongly supports prophylactic mood stabiliser therapy (lithium is first-line given its specific evidence base) initiated immediately postpartum (within hours to days of delivery), as this dramatically reduces relapse rates. Antepartum lithium initiation is also debated for high-risk women. Reactive management alone is unacceptable given the severity and rapid onset of postpartum psychosis.

Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.

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Written and medically reviewed by the StethoPrep medical team.