Estradiol in Postpartum Psychosis
ABSTRACT & COMMENTARY
Source: Ahokas A, et al. Positive treatment effect of estradiol in postpartum psychosis: A pilot study. J Clin Psychiatry 2000;61:166-169.
Postpartum psychiatric disorders are often under-recognized with significant adverse sequelae, especially if psychotic symptoms are present. In this recent open study, 10 women who experienced postpartum psychosis received sublingual 17beta-estradiol treatment for six weeks. Baseline serum estradiol levels (mean, 49.5 pmol/L) were below the threshold for the gonadal failure. Psychiatric symptoms diminished significantly in response to treatment with 17beta-estradiol.
Improvement was noted during the first week of treatment. There was a rebound of psychotic symptoms in one patient and the only patient who discontinued estradiol treatment. Six of the 10 patients had previously undergone treatment with psychotherapy (n = 2) or antipsychotic medications (n = 4) before estradiol treatment, without adequate effect. None of the patients were breast feeding at the time of the study and none had resumed menstruation at the time of recruitment. Serum estradiol concentration was measured from morning blood samples between 7 a.m. and 9 a.m. and were measured by the standard radioimmunoassay. Estrogen treatment was carried out by micronized 17beta-estradiol, 1 mg sublingually 3-6 times daily and titrated with the goal of reaching a concentration of 400 pmol/L. The mean daily dose during the first week was 3.8 mg and thereafter 4.7 mg.
Of the four patients receiving antipsychotic medication at baseline, medication was tapered over the first week of estradiol treatment. The primary outcome was the brief psychiatric rating scale (BPRS). Mean baseline score on the BPRS was 78.3, which was consistent with severe psychiatric symptoms. At the end of one week the mean BPRS was 18.8, which is consistent with a dramatic improvement.
COMMENT BY LAUREN B. MARANGELL, MD
Given the small number of subjects in the open design, these results should be considered preliminary. Specifically, it is premature to recommend 17beta-estradiol as a first line treatment for postpartum psychosis. However, the results are remarkable in several respects. As noted by Ahokas and colleagues, estrogen has been observed effective for the treatment of postnatal depression and has a preventive effect on postpartum affective disorders. This is the first study to show a connection between low serum estradiol concentrations and clinical response to estradiol treatment in women with postpartum psychosis. The overall change in symptoms within one week of estradiol treatment is clinically significant. Clearly, this is an area that warrants further study. In the meantime, it may be reasonable to consider augmentation of standard treatment with 17beta-estradiol. For select cases, clearly early intervention is of paramount importance.
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