= Solution
\b[Historical “acute mania” in women must be separated into a manic syndrome, psychosis associated with childbirth and disturbed behaviour caused by physical disease or drugs.] Reproductive events can be clinically relevant without making female anatomy a sufficient explanation for mental illness.
A typical <manic episode> involves a marked change from the person's usual state: elevated or irritable mood, increased activity, little felt need for sleep, rapid or pressured speech, distractibility, impulsive decisions and exaggerated confidence. Severe illness can include <delusions>, <hallucinations>, disorganization and dangerous loss of judgement. Physical exhaustion or failure to eat can follow sustained activity. These are possible features of the syndrome, not assertions about an unspecified woman.<Bipolar disorder: assessment and management by NICE>[CG185, assessment, risk and management of mania]{ref} Fluctuating attention, disorientation, <fever> or a changing level of consciousness instead prompts particular concern for <delirium> and its cause.
In an 1866 account, chief associations would include the puerperal period, prolonged nursing with exhaustion, previous attacks, family predisposition, severe emotional disturbance and general illness. Historical “puerperal insanity” also included depressive and psychotic presentations, not just what is now called <bipolar disorder>. A contemporary journal summary distinguished pregnancy, puerperal and lactational groups and noted hereditary associations, recurrence and suicidal behaviour. Its observed associations do not establish menstrual suppression or nursing itself as a single sufficient cause.<Puerperal insanity discussion in The American Journal of Insanity (1865)>[Volume 22, p. 138, summary of pregnancy, puerperal and lactational presentations]{ref}
The practical historical aims were protection from injury, restoration of sleep and nutrition, a calm environment, attentive nursing and treatment of physical illness. Someone unable to care safely for herself or an infant required continuous help. Opiates, baths and other sedating measures were tried; quietness after sedation did not prove cure. Depleting a person already exhausted by childbirth or <blood loss> could worsen the illness. Neither punishment nor treatment of an assumed uterine defect addresses a properly established mental disorder.
\b[Modern correction: assess risk and distinguish primary psychiatric illness from a medical emergency.] Consider <bipolar disorder>, medication- or substance-related illness, <thyroid disease>, neurological disease and <infection>. After childbirth, distinguish <postpartum psychosis> from <delirium> due to <sepsis>, metabolic disturbance or another obstetric complication. Protect the woman and baby while arranging prompt specialist assessment. NICE recommends immediate assessment, within four hours of referral, for sudden symptoms suggesting <postpartum psychosis>.<Antenatal and postnatal mental health by NICE>[CG192, recommendations 1.5.10–1.5.12 and risk assessment]{ref}
For established <mania>, current treatment may include an appropriate <antipsychotic>, specialist use of a mood stabilizer, and review of medicines such as an <antidepressant> that may be contributing. Pregnancy, breastfeeding, previous treatment response, physical disease and monitoring requirements affect the choice. In severe or treatment-resistant illness, additional specialist interventions may be needed. Treat <delirium> by addressing its physical cause alongside safe supportive care; it is not interchangeable with a manic episode.<Bipolar disorder: assessment and management by NICE>[CG185, differential assessment and section 1.5 on mania or hypomania]{ref}<Antenatal and postnatal mental health by NICE>[CG192, psychotropic medication and specialist perinatal management]{ref} The organizing principle is \b[a diagnosis and a safe care plan], not a presumption that all acute behavioural change in a woman is “uterine mania”.
Back to article page
