Postpartum psychosis — structured clinical viva

This is postpartum psychosis until proven otherwise: early puerperal onset, severe insomnia, manic/psychotic content involving the infant, and bipolar family history. Treat as emergency.^[1]

Assessment. Full MSE; collateral; dual risk (maternal suicide/impulsivity and infant safety); capacity; substances; domestic safety. Organic screen: FBC, U&E, LFT, glucose, TSH, urine drug screen; escalate imaging/EEG if red flags.^[1][6]

Setting. Urgent admission. Prefer mother-baby unit when joint care is safe; otherwise general adult ward with supervision plan for the infant. Least-restrictive Mental Health Act process if needed without inventing section numbers.^[5][6]

Treatment algorithm. Sleep restoration (time-limited benzodiazepine, e.g. lorazepam 1–2 mg oral/IM per protocol); antipsychotic (e.g. olanzapine 5–10 mg nocte, titrate); lithium after renal/thyroid baseline with level monitoring; ECT if life-threatening, catatonia, poor intake or non-response. Lactation risk-benefit individualised; safety may favour temporary formula.^[2][7][6]

Prevention counselling. Very high recurrence risk next pregnancy; preconception plan, sleep protection, early-warning signs, postpartum lithium prophylaxis discussion, obstetric-psychiatric joint care.^[3][4]