Psychiatry & Psychotherapy Podcast - Postpartum Psychosis: Diagnosis, Treatment, Lithium, and Relapse Prevention with Dr. Veerle Bergink

Episode Date: September 18, 2026

In this essential episode of the Psychiatry & Psychotherapy Podcast, Dr. David Puder sits down with internationally renowned expert Dr. Veerle Bergink, Director of Mount Sinai's Women's Mental Health Center, for an in-depth discussion of postpartum psychosis. Covering early warning signs and symptoms, differential diagnosis including anti-NMDA receptor encephalitis and thyroid issues, a highly effective acute treatment algorithm using benzodiazepines, antipsychotics, and lithium, the remarkable 98% remission rates with proper care, lithium's superior role in preventing relapse during the first postpartum year, the simple but powerful prophylaxis strategy of "baby out, lithium in" for high-risk women with bipolar disorder or prior episodes, the urgent need for mother-baby psychiatric units in the U.S., and the ongoing push to formally classify postpartum psychosis in the DSM.   Link to blog Link to YouTube video

All right, welcome back to the podcast. I am joined today with Dr. Verla Berhink. She is the director of Mount Sinai's Women's Mental Health Center and an internationally renowned as an expert in psychiatric disorders in women. Her research started in 2008, where she established a prospective postpartum psychosis study, currently the largest first onset postpartum psychosis study. Currently, the largest first onset postpartum. psychosis and mania cohort in the world. She has a highly effective clinical treatment algorithm. We're going to discuss today for acute phase and also prevention, a postpartum relapse. And she has written tons of articles. She's someone who I've been excited to have on here. And so welcome to the podcast. Yeah, very happy to be here.

Yeah, so I was thinking I would start with kind of a case. and then we would kind of add to the case or change the case slightly and then see how that might change how you might handle it, okay? Yeah, sure. Okay. So this is someone who has had no previous pregnancies, no mania, no depression, no psychosis, day zero to two. She feels tired, happy, sleeping two to three hours stretches because of cluster feeds. partner is not worried on day three she cannot fall back asleep after 3 a.m. Mind will not turn off.

Mild irritability when her mother suggests that she stops nursing so she can sleep. Day four, she's checking obsessively the baby's breathing. She tells her husband something is wrong with her. I can feel it. She's still organized, breastfeeding every two to three hours. On day five, there's some mood swings within hours, tearful, then elated. She says she feels like she's been chosen,

sleeps 90 minutes in 24 hours. Day six, mood incongruent delusions appear. She says, my husband wants to take the baby. He's not who he says he is. Brief visual misconceptions of a shadow over the crib. and then day seven she's brought in after she kicks her mother in the abdomen when the mother tries to take the baby so that she can sleep on interviews she's pressured grandiose she's admiring of her ability to potentially nurse her baby for 24 hours straight she's slightly

disorganized lacks insight misrecognizes a nurse as a childhood friend oriented to name but not date. Okay, so walk me through the case, what your thoughts are, how you're approaching this. Yes, when I would see her, I would keep it very short because women are usually, you know, very irritable and she sounds manic and it's a very clear story that she has manic and psychotic features right after delivery. So the most important thing I would like to know if she has ever had hypomania mania before. and whether she has a family history of bipolar disorder. And after that, I would spend the time to establish a relationship with her,

to motivate her to be admitted as an inpatient so that we can do some diagnostics. And I would reassure her and her husband that we're thinking about postpartum psychosis, but that this is a very treatable condition, and that I expect her admission not to be too long, but that in my view it is very important that she will get admitted so that we can check her blood, rule out some somatic causes for psychosis and mania

and that we can treat her so that she can be reunited with her baby as soon as possible. Yeah, so that would be my first step. So only very shortly speak to her and mostly spend time with her and her husband to explain that she has postpartum psychosis and what we should rule out. And then one of the first things we should rule out is whether she has an infection and check her thyroid, whether she has a postpartum thyroiditis, which can be a major trigger as well.

and then, you know, do some broad standard metabolic lab work. And that is diagnostically the first step. And then I would explain to them that, you know, sleep loss has also contributed so that it's very important that we treat her first sleep. And in Europe, we start with a few days only sleep medication, but there we have mother-baby units. So we have a bit more times to treat moms, because occasionally someone gets better with only two nights of good sleep.

But given that she had these symptoms now for many days in a row, I probably would start if she could not be admitted with her baby, sleep medication together with antipsychotic medication, to get her out of her mania and psychosis as soon as possible. Okay, perfect. Okay, so you start her with some, let's say, some Haldol, and then... Yeah, or first generation or second generation,

I would either start her on Haldol. We have seen many women getting better at Haldol, but also O-Lensbeam is a good treatment option before the night. There is not much research to guiders here, what works. We basically know that all antipsychotics work if we dose them high enough in postpartum psychosis, as far as we know. But again, there is hardly any...

research supporting it, but that's my clinical experience. Okay, so let's say you started the howlal or antipsychotic, it doesn't matter, and soon after she develops rigidity, tremor, bradykinesia, what are you thinking at this point? Well, yeah, that obviously is a reason to not treat with for generatic antipsychotics, but that gives me also another reason to also look for NMDA. antibodies because we know that these neurological soft signs, we see those more often with women with posparenum psychosis who have an underlying autoimmune encephalitis. And that is not that common. That's only a few percent of the cases with postpartum psychosis, but it needs to be ruled out.

You can measure it in blood, but ideally you do a spinal tap if you can motivate the patient to actually do that. So in this scenario, then I would switch her to olensapin. Okay. And so I was using one of your papers where you studied anti-NMDA receptor encephalitis and kind of the tell is that rigidity, tremor, reticonegia after starting the antipsychotic. Okay. So that's what I was thinking about. Yeah, absolutely. And those patients who had autoimmune an encephalitis all had that. But the other way around, I know that, you know, 30% of our patient on first generation antipsychotics actually have some neurological subs sciences. So it's not, you know, it's not always, but it should be tested.

And I think it should be tested in all women with postharum glycosis because we know of NMDA encephalitis. But I think it could very well be, given that postpartum period is such a strong immune trigger that are way more women with an autoimmune encephalitis with unidentified antigen, if that makes sense. And, you know, one of our research, proposals is also to test this better because that actually has treatment consequences, right? That's just a different disease. If someone has a postpartum autoimmune and syphilitis is different than someone having a postpartum psychosis for which the cause is unknown. Okay, so during pregnancy, there's a huge immune system dampening. And then after delivery,

it just comes back. The immune system starts revving up again. Is that why you think there's like an over-reveving of the immune system and there's a lot of these kind of autoimmune issues that come? Yeah, absolutely. I think that's very clear, right? But I mean, we know this from all communities, then almost all the women do feel better after pregnancy, have a high risk of relapse.

And that is because, yeah, as you say, your pregnancy, the immune system is somehow suppressed, otherwise a mother would reject her own child. It's, of course, not completely down because otherwise pregnant women would die of infection, and that is not happening at all. So it's just that the immune system is differently organized, with more prominent role for the innate, a very basic line for defense, and not so much specific adaptive immune response.

So the professor in immunology, I work with say, you know, pregnant women have the basic immune system of a snail or so, very simple, basic immune defense. So what happens after delivery is that the innate immunity is still high, and the adaptive T-cell-mediated immunity comes back to where it was before. So we see it's an immune stimulation, and that is why people with rheumatoid arthritis feel worse after delivery, with multiple sclerosis, with ultimmune theraditis, or they have their first onset after delivery, whereas pregnancy is protective.

Well, in our first very recent research also in bipolar women showed, we looked at register, that pregnancy really seemed to be protective for first onset mania. There are quite a few papers out now, and ours was this year. And also for severe depression, we see that that is lower than at other times. So in particular within psychiatry, bipolar disorder seems to have this same pattern as old immunities of pregnancy being protective and postpartum being in high risk period. And why that is specifically for bipolar disorder and not for other diseases in psychiatry, such as schizophrenia or OCD or whatever disease, HD, I don't know.

I think it gives us an important clue about the underlying nature of the disorder. Very interesting. Okay. So let's say there was some sort of autoimmune thyroid disease. Are you more hesitant to use lithium? No, I would still treat her the same because we do not know how to treat otherwise. Yeah, of course lithium works on the thyroid, but via a different mechanism,

I think the most important thing is also monitoring the thyroid and referring to internal medicine doctors and especially, you know, after autoimmune thyroid, diet is typically characterized by first hyperthyroidism and then hypothyroidism, right? And all of these contribute to the psychiatric symptomatology. And we need to monitor it. And of course, if it really leads to clinical hypothyroidism, then the patient should get treated with thyroid supplicion. And that is very relevant. Also, for many women with postpartum depression, I've seen so many women in which physicians do not think about the tyrant.

And then it has such a major impact. And sometimes it helps also in the treatment of women still have the depression in addition to the postpartum thyroiditis, but it kind of helps them to understand that this contributes. And I think that helps as well, because then I explain like, yeah, but this is, I mean, often we do not know what causes it, right? But in this scenario, we know something that really likely contributes. it to not feeling mentally well. And that helps if I explain to women that most of these cases

are transient and the thyroid get back to normal and they will feel better and that we can also be very optimistic about their treatment of their postpartum mood disorder. So I think that's something most people do not know that actually postpartum depression is more easily treatable than depression at other times. So don't tell any. on, but our field is not that difficult. A lot of women actually do get better. Yeah, that was, that was some really interesting things from reading your papers. There's a, this if treated, it's very treatable. It's very treatable. And both postpartum psychosis and postpartum depression. So postpartum psychosis is like

amazing, like 98% gets fully better as in really our criteria for getting better restrict. We published the paper this year a letter in the American Journal and you know really no medic symptoms no psychotic symptoms but also I don't know if you know the EPDS that's a very simple

postpartum depression rating skill 10 items and they had to be really low on that skill as well you and I on a bad day score higher than these women so they were not only not manic and psychotic but also not depressed after the acute phase and

I think that is a very optimistic message to give, especially, of course, in these times where there's so much attention for the, you know, the potential tragic consequences of postpartum psychosis. And it's really discussed as, yeah, a very difficult condition and, you know, very high risk of suicide and infanticide. So there are so many myths out there. And I'm happy, you know, to be on this podcast because I think it's important to know that in many cases women get diagnosed in time. And then it's a very treatable condition with a better prognosis than women would have if they had that at other times in their life.

Is that makes sense. So. Yes. So from your research, what have you found in terms of? of like women who do not have a history of bipolar, who have their first episode postpartum, so the first episode of postpartum psychosis occurs, what percentage of those women will not have recurrence?

Yeah, in our own cohort more than half. Okay. So, and they, those women are treated in an academic center, excellent care, they are treated with lithium, closely monitored. So, but yeah, if we look at all studies done ever, then ours was quite recent, but all other studies are like, yeah, I don't ever, it's 30 years ago, like really old psychiatric literature, then we see everywhere the same pattern that roughly half of women get better and remain well until they get pregnant again, have another delivery, and then they're at

high risk again. So those women really have a postpartum only illness. Whereas for other women, they have these episodes and then they are treated with antipsychotics and lithium and they try to taper lithium, but you know, that doesn't work that well, they get depressed. And then in retro, and they have more mood episodes in their lives. And then in retrospect, this very severe postpartum episode was the first onset of a lifelong bipolar. disorder. Yeah, and of course, we would like to answer that question for those women being acutely ill, not only like what causes it and how do we get her better as soon as we can, but also how can we prevent that disease course, right? So, or how at least can we know

which women are at high risk for a lifelong bipolar vulnerability or mood disorder? And which women, yeah, I have this postpartum only disorder, which makes a bit difference for them as well, right? So, and unfortunately, the only way we can tell is by, you know, try after one year to start tapering the medication. And in that sense, at least in my experience, I don't know what your experience is, but it's not so different from, you know, mania, or affective psychosis at other times. If young people have this, they're treated, they're very sick, they get better. At some point, after they get better, they start asking themselves, like, do I need this medication long term, right?

And most people then at some point try to taper, and that's only the very hard way to figure out if you actually need it or not, because that means that you get sick. That means that you needed it. And at this point, we cannot tell, like, which patients, of course, we know some risk factors, but we really cannot tell which patients can safely taper or not. And especially for young, you know, people with bipolar disorder, that's a very difficult one. And same for those women I treat, right? I mean, these patients are a bit older, but not that old.

I think women get, you know, their first children. child often, and 20s, beginning 30s, and then it's quite something to think about having to use medication long term. Okay, so it sounds like you have, we've kind of talked about two categories, people with maybe history of bipolar and first onset, postpartum psychosis. And I think you also differentiated in your research, like postpartum psychosis that comes out of more of a depressed picture. and it's usually a little bit slower to start. Can you talk about that a little bit?

Yeah, so we try to figure out if women have depression with psychotic features or if they only have psychotic symptoms or if they're manic. Does that matter in terms of their treatment response? Does that matter in terms of their prognosis? Well, the short answer is no, as in all women get better. But women with depression with psychotic features, they have a longer disease episode than mania. And that's what we know from outside the perinatal period as well, right?

The depression with psychotic features is usually not so easy to treat. Those episodes are a bit longer. But, yeah, we know that also women with depression with psychotic features, yeah, in the long term, it doesn't, at least in our research, doesn't make a difference in terms of their prognosis, whether they, you know, they had a mania or a mixed episode or a depressed episode with psychotic features or a psychotic episode without much mood symptoms. So in a way, the phenomenology doesn't seem to matter that much.

It's more that, yeah, in some women, childbirth triggered severe mental health disorder with a variety of symptoms, basically. If that makes sense. To studying this make you hesitant to put on an SSRI on a woman who's just depression, you know, it's just more of the depressed picture. If it's just depression, I'm not hesitant to treat with an SRI. It really depends on the course. We know that many women with perspiring depression, well, honestly, already were depressed,

either during pregnancy or even before. But there are also some women who develop new onset depression after delivery. And then it really depends on the pattern. If a woman has like a very sudden acute onset, very severe depression in early weeks after delivery without clear trigger as her baby being severely sick on the NICU or. other disasters, yeah, then I'm really worried about, yeah, about a bipolar depression, honestly. And that has been described as well quite extensively that, you know, depressions occurring in the postpartum period are more often bipolar depressions than depressions at other times. That is an ultra ratio of two.

So let's say, yeah, if you had a depression, then you had a certain risk of that depression being the first onset of a bipolar disorder. But, yeah, well, that weren't happening to you. But if you had that depression postpartum, then the risk of that depression being bipolar depression is two times as high. So I think in general, yeah, we should always be a bit cautious with SSRI in the postpartum period. And of course, we saw in the Lindsay Clancy case how horrible some people react to SSRIs, right?

that's, I've seen that more often. I have a case series of patients who really had, like, you know, psychosuromania triggered by SSRIs in the postpartum period. And Farindar Sharma from Canada has published on that as well. So we know this. So we should also, you know, we should be a big cautious. On the other hand, we should not let severe postpartum depression be untreated, of course. but yeah, sometimes I see both a lot of under-treatment of postpartum depression and overtreatment.

And what I mean with overtreatment, if that is a woman, you know, this first week post-partum, women have mood swings, they have low moods. Sometimes they have sleep loss. They are told like, oh, if you see your baby, you're going to feel amazing and they don't experience that at all. They're low. And I have seen many women in which their healthcare provider immediately gave them an SRI, as in the first week after childbirth or the second week. And I'm always very, you know, not that fast, not so much in a hurry because you really want to see how that develops over time. This is such a period of rapid changes. You see what I mean that you don't not want to, and there is no need to, you know,

know, acutely treat depressive symptoms with SSRI. I think we should better carefully see, you know, see someone another time, see how it develops over time, really see if it's a depression before we start. Okay. And in your algorithm, you know, you were doing the benzo, the antipsychotic lithium, holding the lithium for nine months, right? but like my question is why not start the lithium right away or how do you like in this patient that I told initially like why not immediately lithium immediately yeah after we published the

papers we really tried to change that clinical practice and started earlier so we're trying to do this now and I haven't published on it yet but especially in the US lithium has not a good name I think that's not correct. But people are really hesitant to use lithium. They have all kinds of associations with lithium. So it's not used enough. So it also takes time because lithium is something for the longer term, right? You're not going to use it very short.

We know that antipsychotics have a more rapid anti-manic effect, honestly. So lithium is really, you know, for the long term, for this first year post-parum, So you want someone to be well informed and also motivated to actually take the lithium and to also understand why they need it. Yeah, because it's important in the treatment of postpartum psychosis because the women without lithium, we saw unfortunately that half of them relapsed within a year after delivery. Yeah, and that is a problem if you treat with electroconvulsion therapy, which some, you, you know, you know, just some people saying, like, okay, why shouldn't we treat immediately with ECT? You know, it's so severe.

Isn't that the fastest way? Well, I'm not sure if that is faster than medication. And the problem is ECT also gets women completely better, but then you still face the discussion. Like, yeah, and now what, you know, then I still would advise to start lithium for the first year postpartum after the ECP course. You see what I mean? So that's why if it was me or if it was my sister or my child, I would prefer lithium over ECT treatment.

Yeah, yeah. Okay, I want to share this from your study, which you were the first author of, amazing study, showing days of remission to relapse. And the lithium, when I saw this, I was like, oh, my God. goodness, this is incredible. And so what, for those who are listening to audio, maybe you can describe this figure once again and what it says. Yeah, so the orange line are women who use lithium

and antipsychotics in the acute face. And the green line is women who only used antipsychotics. And it's good to understand that this was not a randomized control trial. So it's not that we randomize women, no. We offered antipsychotics. and lithium during the acute phase, but some women recovered really fast, and those were women who only were on antipsychotics. And we did not get to the point that we discussed lithium with them. And of those women, we also thought, okay, they, you know, their disease episode was very short. They recovered fast on antipsychotic only, and we thought, well, perhaps we don't need

to start lithium. But then we analyzed our data. And then we saw that, you know, those women for, we were initially better off because they had a short episode and recovered really fast, we're actually more often have a relapse one year after delivery, which is, of course, not great. Because that means that after your depression with psychotic features, you have another depression or after your mania, you have this typical pattern. Of course, women, we see this in bipolar disorder as well. or people, patients getting out of their mania, and I'm being stable for a while, or sometimes even immediately going into a depression.

And we really see that lithium can prevent this pattern. And we know that lithium works well at other times as well, but I don't know why lithium works especially well postpartum. Because we know at other times that, you know, lithium is not for everyone, right? there are also many people being non-responders to lithium, where he is in the postpartum period, we don't see that that much. Yeah, it's incredible to think, I mean, for those of you who can't see the picture,

I'll just say, like, you can see that lithium, most of the people are not relapsing, whereas the people who are not on the lithium, 50% relapse. That's a huge difference. and so yeah we need to bring bring back lithium make lithium cool again have some drug reps maybe in America bringing lithium in a special colored expensive lithium pills I'm joking yeah I think that's the problem it's so cheap there's really no money to make with lithium so that's why people have not arguing hard for for treatments litter in general right because other treatments were were much more money makers.

But I'm not sure if the ultimate solution is making lithium more expensive, but... No, I'm joking. I'm joking. No, no, I know. Yeah. So I just had a bipolar patient just yesterday who I had started on lithium

two weeks before. And he had seen many different psychiatrists and he had never been on lithium. He had been on five or six different antipsychotics. He had been on Debecote, he had been on LeMotrigine. He had never been on lithium.

And he was completely a different person two weeks later after starting lithium. Yeah, no, absolutely. And it's so weird because all our guidelines say that, you know, Latif is first choice. So all guidelines say it in different countries. Basically, no one is doing it, especially not in the U.S. And, yeah, it's interesting because if you see, if you compare studies in the rest of the world, like Australia or Asia or Europe, bipolar studies

to US patients, then in many studies it has been shown that bipolar disorder in the US, the mortality is higher, people have more episodes, they are more on polypharmacy, as you say, like using so many medications and yet being unstable. And yeah, I always thought, yeah, that's just because, you know, in the U.S., like less than 20% gets lithium, whereas in the rest of the world, more than half of the bipolar patients get lithium. But there are also some alternative theories out there that back in the days, only the adventurous people emigrated to the U.S., right? So in order to emigrate, you had to be either miserable, depressed,

or, you know, being in a hypometic state, to think it was a good idea to, to embark on that shit so that somehow in the US we end up yeah and I might be one of those persons because I also emigrated from you know Europe to the US for whatever reasons I love it here but you know and so that was that has been even proposed as reason why we see worse outcomes here whereas I sometimes think well I think the more likely explanation is that we don't follow the guidelines that much and treat with lithium, right? And yeah, for my field, the problem that we don't have inpatient mother-baby units, that makes also a huge difference.

Do you have a mother-baby unit that you currently at your current institution? Or no? Yeah. No, we're looking for funding to start with like the first one in the US. Oh. We don't have, we have them in Western Europe, in Australia, in India is a very good one, and not in the US. And they're quite a few good day treatment centers, but not enough, not in every area in the country, only in California, in North Carolina, here in New York City. But in those, in those units, babies cannot stay overnight.

And that is a huge difference because, you know, women want to go home. Well, first of all, they don't want, no one wants to be admitted, of course, to a sideboard, right? Most people don't want that. But especially not if you're separated from your baby. So here we get the weird situation that both patients and clinicians are kind of getting in a rush to make women better by throwing, you know, so many medications at them. as a, you know, she needs to be reunited with her baby. And we see that for both severe postpartum depression and postpartum psychosis. And that's just not helpful.

And also women go home and I can't blame them nor they're clinicians before they are in full remission. So what happens, and we have those numbers out there as well, that women, you know, they're admitted to a psych ward. They go home while they're not fully recovered. And then they come home and they relapse again. And that leads ultimately, of course, to readmissions and worse outcome. So I'm a huge advocate of mother-baby units. But the problem is really the financing of the babies. Because here in the U.S.

insurance companies say we are not going to pay for healthy babies being in a hospital, basically. Yeah, I think, I think, I'm. I think if someone's listening to this and wants to fund your mother-baby unit, I'll put them in contact with you. That would be amazing. Because we need that. We really, really do need that. Yeah, it can have their name, everything.

No, I think we... Well, I think always the first step is more... Most difficult, because I think if we can show that we can open one such a unit and that it works, and that mothers get better, and also, honestly, that it says... money in the end. Even if you don't care about mothers and you don't think babies are sweet, then still, and you only are interested in money, then still is the cheaper option to, as society, to have a mother-baby unit. Well, yeah, because it's cheaper because of future outcomes, right? And that's the problem. Everything. Yeah, the mother doesn't get back to work.

You know, if she has more kids, the other kids are miserable as well. Don't forget how miserable the husbands are, right, with having a baby and a severely mentally ill wife. And this group is not mentioned a lot, but I think there is a huge pain and struggle for partners, men or women, but in most scenarios, it's a man. Yeah, they struggle as well. And yeah, so it's really a larger problem. So, okay, we're pushing this idea of a mother-baby unit and somehow we have to figure out how to make it work in our insurance model, which is awful. And to do that, we first probably need someone to donate to you or to your team, maybe three teams across the U.S. ideally, and then do some good research that shows, you know, the cost-effectiveness of it. and then subsequently, you know, there's some justification maybe, you know, that's how it works in the U.S. We did a money justification study of my IOP program.

We had medically complex adults, so people with lots of medical admissions for psychosomatic illness. And we found that we were able to cut the amount of money that insurance would spend after the program, right, compared to the U.S. before and you know that we we use this to argue with insurance companies to let us actually treat the patients right and sometimes it worked oh wow so you're the person we we as one of the first steps we should hire you as well well i could i could um give you the name of the the the guy that did the majority of the study at least yeah yeah any uh any help is welcome yeah yeah but um Yeah, so we, okay, so we're talking about the mother baby unit, but I also wanted to make sure the DSM. I understand you are like the ringleader of this new push for this to be introduced in the DSM.

You're writing the chapter. You sent me an outline of it. Do you want to mention what you're doing with this? And maybe I'll show, I'll kind of bring it up so you can kind of like. Yeah. Yeah. So postpartum psychosis is a disease that exists that has been among us, unfortunately, for thousands of years among all cultures. So it's simply said, very weird that it doesn't exist or is not acknowledged.

It's for us doing research a clear phenotype, mainly that you can define it well, given the onset is so clear. So there is a large push from psychiatrists, but also patients, to have this in our classification. system. And yeah, we started working on this six years ago, sending in a proposal that it has to have all kind of criteria. It was like 30 pages long. And since then, it just hasn't moved fast enough. It's now six years. There is fully agreement among all health professionals what the criteria should be like. There's also flexibility as in, okay, we're, you know, we're not rigid. And all patients' organizations bowed in on this ID.

So it just has to happen. We proposed postpartum psychosis to be placed in a bipolar chapter. The DSM steering committee said we would like to see an entire chapter dedicated to childbirth. So we made an eyedline, again, with a very large group of people. who worked a lot clinically and also research leaders to make a childbirth related chapter in DASM and give an outline what that should look like. And I think it's important that, you know, what we would like to see as a field is to make sure that people can classify the onset of any disorder, either being during pregnancy

or the first three months after delivery. And that is important because those periods are very different in terms of biology but also treatment. I mean, that's a bit of a no-brainer, right? Pregnancy is very different than postpartum, but also the prevalence and incidents is sometimes different. So, well, anyway, and in addition to that, I think given the depression is so common, and we would like to see depression with onset during pregnancy, and depression was onset within three months after delivery as a separate possibility to classify. And then the most important thing and how this all started, because that is really going to prevent

a maternal death and is having postpartum psychosis in there. Of course, if it's classified, it doesn't immediately solve all the problems, but it's kind of the other way around. if this is not solved, then we, as a first step, we need to classify to speak the same language, right? So have the criteria. And, you know, members of the DSM steering committee even said, yeah, they can write research proposals also without criteria. But that's a bit of a nonsense argument because, you know, in able to do studies, but also to replicate each other's work, we need to do the same thing and speak the same language.

So I think it's a problem that there are so few groups working on this, right, that I'm telling you all those things. And that is then taken as the truth, whereas in real science and in medicine, ideally, studies get replicated and replicated, and clinicians add to evidence. And then you can build solid guidelines, which people can. and follow. So, and all those steps needs to be taken. So we're, yeah, I said before we're in the

middle ages and I might regret some things I have said in public, but that's not one of them, because that's really how I feel about it. Yeah. Yeah. And I think what we need is we need like an ICU level billing code that comes along with this. You know, there's like inpatient stays, but a mother-baby unit should be like an ICU-level billing stay, you know? It should be like a level above, right? Absolutely. I think that's what I would go for. And that's totally justified because it's complex care, right?

I mean, we have a severely ill mother. Yeah. And you have an infant, so you need a nurse for the mother, a nurse for the baby. And you need to watch them 24-7 so that the infant is not hurt. I know, but honestly, the infant is, of course, separated from the mom during the night. The door is closed. So I have to say in Europe and the UK, we also have medical students looking after the babies because they're babies, they're healthy babies.

But I'm not sure if that is even, you know, I don't know the U.S. healthcare system well enough to see if that would fly, but that makes, of course, also a difference in terms of funding. No, they would volunteer for it. Yeah, I would volunteer for it. Yeah. Yeah, maybe not. If you just have your young children, as for me, it's long time ago. Many people volunteer looking after healthy babies.

Oh, they would, oh, it would be a great sublimation of the natural delay that medical school requires for a lot of people, right? Of having their own infants. Yeah, yeah. Well, I still think it's also helpful if doctors get children at some point in their career. But yeah. Right, right. Yeah, I mean, absolutely. Yeah.

And I'm not saying otherwise, yeah. No, no, no. But no, I know what you mean. But, yeah. Okay, so DSM, I'm surprised OCD isn't in this list here. That's like postpartum OCD. I don't know if that's like. Yeah, because.

it's extremely rare, honestly. So OCD doesn't have a peak postpartum. So everyone gets a bit more obsessed biologically after childbirth. So, you know, mothers check on their babies a few times. That's all very physiological. I think nature built that in to have the most relaxed, you know, not so spot on persons have taken care of their child well enough. So everyone gets a bit more obsessive during this period. And we see that, you know, women were, yeah, very perfectionistic, always function well at other times. Sometimes, yeah, struggle with that because then they even feel even more the need to be in control or to check on things. So that way we see that women with hyperfactionism have sometimes a higher risk of postpartum depression. And our research showed that as well.

And we see that women with OCD already diagnosed with OCD sometimes have, you know, more symptoms, but not always. But actually new onset postpartum OCD is very rare. I've only seen a few women in my lifetime. So, but, yeah, obsessive thoughts are very common. But like the first onset OCD is quite rare. So that is why we did not specify so many other disorder. Also, for example, PTSD, right? Some women have trauma after childbirth.

Their delivery was horrible. And they do not only have trauma. They also have nightmares and flashbacks. But that is also quite rare. We see that most women who struggle in this period are women who already had trauma. So we have PTSD in history. And in women that is often related to sexual trauma, unfortunately, right? And we see, and that makes sense then because the delivery is, you know, people re-experienced

sometimes that loss of control that they had in their lives before and that can revoke trauma. but that is in many cases not new onset PTSD. So that is why other disorders such as OCD and PTSD, we saw that it was better served by being able to specify the onset for any disorder. You see what I mean? Sure. Mental health disorder during pregnancy, PTSD with onset during pregnancy, or PTSD with onset postpartum, same for OCD.

So we propose that in our document as well. well. And yeah, the reason to take depression separately is that there has been so much, there's been done so much research on depression specifically. So there's a much larger evidence base. And another reason is that there is a big, a peak of, in incident depression cases. And especially there is a peak in severe depression. So that is really a thing if you look in epidemiological studies. Very good. That's very helpful. Wow. You're such an expert on this, and I can feel, I don't know if you're always this energetic, but I feel like your hyperthymia, you're like Roosevelt or Kennedy level energy. Oh, wow. That is tricky to speak with you as a psychiatrist before I know. I get a diagnosis on the spot.

No, no, no. There's a compliment. Hyperthymia is a compliment. Hyperthymia is a compliment. To answer your question, no, I'm not always that energetic, but it's a compliment. Yeah, if I know that I'm doing a podcast, then yes, I am. And with regards to this topic, I am very passionate. And that's sometimes also very unfortunate because I can't let it go, right? So I sometimes feel like, okay, it would be good for me if I now focus on something else and not the classification of postpartum psychiatric disorder. And I've also been working on postpartum psychosis now for 22 years.

years and sometimes I feel like, okay, it would be good to not do it, but yeah, I don't know how to do it, David. So, yeah, any tips there are welcomed. I would say it's a meaningful, it hits all the meaning buttons, you know. So like we talk about like logo therapy sometimes in the podcast, Victor Frankel, like finding one's purpose, one sense of meaning. And it's like if, if this is, if you get to the end of your life and you can look back and, and realize that there's a lot of, you know, there's a ripple effect of impact that you've had. I think, I think, you know, solving one issue is enough for a lifetime, right? And this is an issue worth solving. Yeah, and maybe that's it.

Because that's, I feel that it's really solvable, right? So that's why I might, yeah, not be thinking about other important themes, such as, you know, saving climate change or all the world's in the world, because those are all very, feasible for a human being and that I feel this is so, well, I won't say easily to be done, but it is really doable. Things as changing classification are doable and things as building a

mother-baby unit, those are not impossible things. And the same for, yeah, I feel if women at high risk for postpartum psychosis hear that or their doctors, that how they can prevent it, that's also relative easy, right? It's not difficult to prevent postpartum psychosis. And because it's so relative easy, I feel like, yeah, we should do it and get the word out. Well, it's maybe, the harder part is the education and the implementation, right? So I hope in some small part, you know, the four episodes that I put out on this can hopefully. Yeah, that hugely helps. a lot for doing that. Activate, and I think this episode in particular is especially helpful.

I'd love to have you back in the future. And yeah, but any final thoughts that you want to get out, anything that you haven't mentioned that you want to make sure is out there? Yeah, I want to make sure that women at high risk with bipolar disorder or with a prior history of cospharmine psychosis, know that if they have another child, that they really can prevent it by taking medication right after delivery. and so that we really can prevent those problems that goes. I think that is the most, you can forget everything,

that that's the most important take home message for... So do you start the lithium towards the end of the third trimester, or do you start it on the day of delivery? Yeah, we say baby out, lithium in. Okay. That's easy, you know, talking about education, if you're a high risk, then that works well. Baby out, lithium in.

Okay, that's a great place to leave people. It's not for everyone. Yeah. Yeah. Yeah. Awesome. Okay. All right.

Thank you back in the future. I love talking to you. Yeah. Thank you for having me. Bye.