REVIEW ARTICLE Recovery from postpartum psychosis: a systematic review and metasynthesis of women’s and families’ experiences R. Forde 1,2 & S. Peters 1 & A. Wittkowski 1,2 Received: 30 October 2019 /Accepted: 26 January 2020 # The Author(s) 2020 Abstract Postpartum psychosis is a serious disorder that can result in adverse consequences for the mother and baby. It is important that we understand the experiences of women, to develop effective interventions during this critical period. The aim of this systematic review was to conduct a metasynthesis of qualitative research exploring women’ s experiences of postpartum psychosis and factors involved in recovery from the perspective of women and family members. A comprehensive literature search of five databases was conducted and the findings were appraised and synthesised, following a thematic synthesis approach. Fifteen studies, capturing the views of 103 women and 42 family members, met the inclusion criteria. Four main themes incorporating 13 subthemes were identified following synthesis: (1) Experiencing the unspeakable, (2) Loss and disruption, (3) Realigning old self and new self and the integrative theme of (4) Social context. The findings offer new insight into the unique experience of postpartum psychosis and demonstrate that recovery does not follow a linear path. To improve clinical outcomes, a more integrative and individualised approach is needed which incorporates long-term psychological and psychosocial support, and considers the needs of the family. Further areas for staff training, service development and future research are highlighted. Keywords Literature review . Qualitative research . Perinatal mental health . Psychotic disorder . Childbirth Introduction Postpartum psychosis (PP) is one of the most severe mental health problems following childbirth, affecting 0.89 to 2.6 per 1000 women (Vanderkruik et al. 2017). It is characterised by a dramatic onset, and rapid deterioration, with symptoms in- cluding hallucinations, delusions, disorganised behaviour and depression (Di Florio et al. 2013; Heron et al. 2008; Sit et al. 2006). Continued poor maternal mental health is associ- ated with increased risk of adverse outcomes including suicide and decreased mother-infant bonding (Wilkinson et al. 2017). Immediate referral to a secondary mental health service for assessment is therefore recommended (NICE 2018 ). Inpatient care, ideally within a Mother and Baby Unit (MBU; Gillham and Wittkowski 2015) and pharmacological intervention, is almost always required (NICE 2018; Jones and Smith 2009). Family members are reported to be integral during this process and should be involved in care and treatment planning (Engqvist and Nilsson 2014; Mohamied 2019). With appropriate treatment, the most severe symptoms usu- ally resolve within 2 to 12 weeks (Bergink et al. 2015). However, women remain at increased risk of subsequent post- partum and non-postpartum episodes, including depression and anxiety (Robertson et al. 2005; Nager et al. 2013). PP is a highly stressful life event which can have a detrimental impact on well-being and long-term functioning and result in feelings of guilt, loss, fear and shame (Burgerhout et al. 2017; Plunkett et al. 2016; Wittkowski et al. 2014 ). Psychological intervention and psychosocial support has been recommended (Doucet et al. 2011), yet very little is known about the psychological factors underpinning recovery or the types of intervention found to be effective. Previous metasyntheses have explored individuals’ experi- ences of serious mental health problems and mental health * A. Wittkowski [email protected] 1 Divison of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, 2nd Floor Zochonis Building, Brunswick Street, Manchester M13 9PL, UK 2 Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK https://doi.org/10.1007/s00737-020-01025-z / Published online: 4 February 2020 Archives of Women's Mental Health (2020) 23:597–612
Recovery from postpartum psychosis: a systematic review and metasynthesis of women’s and families’ experiences
Nov 17, 2022
Postpartum psychosis is a serious disorder that can result in adverse consequences for the mother and baby. It is important that we understand the experiences of women, to develop effective interventions during this critical period. The aim of this systematic review was to conduct a metasynthesis of qualitative research exploring women’s experiences of postpartum psychosis and factors involved in recovery from the perspective of women and family members. A comprehensive literature search of five databases was conducted and the findings were appraised and synthesised, following a thematic synthesis approach. Fifteen studies, capturing the views of 103 women and 42 family members, met the inclusion criteria
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Postpartum psychosis (PP) is one of the most severe mental health problems following childbirth, affecting 0.89 to 2.6 per 1000 women (Vanderkruik et al. 2017).
Transcript
Recovery from postpartum psychosis: a systematic review and metasynthesis of women’s and families’ experiencesRecovery from postpartum psychosis: a systematic review and metasynthesis of women’s and families’ experiences
R. Forde1,2 & S. Peters1 & A. Wittkowski1,2
Received: 30 October 2019 /Accepted: 26 January 2020 # The Author(s) 2020
Abstract Postpartum psychosis is a serious disorder that can result in adverse consequences for the mother and baby. It is important that we understand the experiences of women, to develop effective interventions during this critical period. The aim of this systematic review was to conduct a metasynthesis of qualitative research exploring women’s experiences of postpartum psychosis and factors involved in recovery from the perspective of women and family members. A comprehensive literature search of five databases was conducted and the findings were appraised and synthesised, following a thematic synthesis approach. Fifteen studies, capturing the views of 103 women and 42 family members, met the inclusion criteria. Four main themes incorporating 13 subthemes were identified following synthesis: (1) Experiencing the unspeakable, (2) Loss and disruption, (3) Realigning old self and new self and the integrative theme of (4) Social context. The findings offer new insight into the unique experience of postpartum psychosis and demonstrate that recovery does not follow a linear path. To improve clinical outcomes, a more integrative and individualised approach is needed which incorporates long-term psychological and psychosocial support, and considers the needs of the family. Further areas for staff training, service development and future research are highlighted.
Keywords Literature review . Qualitative research . Perinatal mental health . Psychotic disorder .Childbirth
Introduction
Postpartum psychosis (PP) is one of the most severe mental health problems following childbirth, affecting 0.89 to 2.6 per 1000 women (Vanderkruik et al. 2017). It is characterised by a dramatic onset, and rapid deterioration, with symptoms in- cluding hallucinations, delusions, disorganised behaviour and depression (Di Florio et al. 2013; Heron et al. 2008; Sit et al. 2006). Continued poor maternal mental health is associ- ated with increased risk of adverse outcomes including suicide and decreased mother-infant bonding (Wilkinson et al. 2017). Immediate referral to a secondary mental health service for
assessment is therefore recommended (NICE 2018). Inpatient care, ideally within a Mother and Baby Unit (MBU; Gillham and Wittkowski 2015) and pharmacological intervention, is almost always required (NICE 2018; Jones and Smith 2009). Family members are reported to be integral during this process and should be involved in care and treatment planning (Engqvist and Nilsson 2014; Mohamied 2019).
With appropriate treatment, the most severe symptoms usu- ally resolve within 2 to 12 weeks (Bergink et al. 2015). However, women remain at increased risk of subsequent post- partum and non-postpartum episodes, including depression and anxiety (Robertson et al. 2005; Nager et al. 2013). PP is a highly stressful life event which can have a detrimental impact on well-being and long-term functioning and result in feelings of guilt, loss, fear and shame (Burgerhout et al. 2017; Plunkett et al. 2016; Wittkowski et al. 2014). Psychological intervention and psychosocial support has been recommended (Doucet et al. 2011), yet very little is known about the psychological factors underpinning recovery or the types of intervention found to be effective.
Previous metasyntheses have explored individuals’ experi- ences of serious mental health problems and mental health
* A. Wittkowski [email protected]
1 Divison of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University ofManchester, 2nd Floor Zochonis Building, Brunswick Street, Manchester M13 9PL, UK
2 Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
https://doi.org/10.1007/s00737-020-01025-z
Archives of Women's Mental Health (2020) 23:597–612
Method
A metasynthesis was deemed most appropriate to systemati- cally analyse and interpret multiple qualitative studies with the aim to develop new insight (Lachal et al. 2017). The review protocol was registered with PROSPERO on 19 December 2018 (Ref: CRD42018119145).
Inclusion and exclusion criteria
All published empirical studies exploring women’s or family members’ experiences of PP and/or recovery using a qualita- tive methodology were included. Studies published in any language were eligible for inclusion, as were studies using mixed methods, provided qualitative data could be extracted.
Studies were excludedwhen they (1) explored ‘schizophre- nia’ and other perinatal disorders, such as postnatal depres- sion; (2) did not stipulate the diagnosis; (3) used a mixed sample in which it was not possible to differentiate the find- ings based on diagnosis; (4) explored only health profes- sionals’ views; or (5) were unpublished research or grey literature.
Search strategy
Five databases CINAHL,MEDLINE, EMBASE, PsychINFO and Web of Science were searched from inception to 3 April 2019. An updated search was completed on 20 August 2019 which revealed no additional eligible studies. Only keywords relating to the ‘phenomenon of interest’ (Cooke et al. 2012) were applied to ensure all relevant studies were captured (‘postpartum psychosis’ OR ‘puerperal psychosis’ OR ‘post- natal psychosis’OR ‘psychosis after childbirth’) and no limits were applied. Additional studies were sought from the refer- ence lists of included studies using forward and backward searching (Horsley et al. 2011).
Study selection
The search process, following PRISMA guidelines (Moher et al. 2009) yielded 1782 unique studies (see Fig. 1). The title, keywords and abstracts of all studies were assessed for eligi- bility against the inclusion/exclusion criteria; 1728 studies were subsequently excluded. A random 20% of studies (n = 353) were checked by an independent rater and a strong level of inter-rater reliability was obtained (96%, κ 0.88 (95% CI, 0.82–0.95) McHugh 2012). Of the remaining 54 studies, 39 were excluded when reviewed in full, yielding a final sample of 15.
Critical appraisal
The methodological quality of the included studies was eval- uated using the Critical Appraisal Skills Programme (CASP 2018) checklist. The CASP comprises ten questions across three broad domains, relating to the validity, design and utility of the results. The CASP was used to determine rigour and trustworthiness in the outcomes (Hannes 2011).
Data analysis
All included studies were extracted electronically onto NVIVO 12 (2018) data management software and analysed using Thomas and Harden’s (2008) thematic synthesis (see Table 1). This approach enabled the researchers to integrate multiple qualitative findings and identify recurring themes, following three key overlapping stages (Noyes et al. 2018; Ring et al. 2011). Distinctions were made across the different samples when analysing the data and constant comparisons were made across and within the women’s and family mem- bers’ accounts to ensure similarities and differences were cap- tured. To test the credibility and applicability of the findings, a peer and member-checking exercise was completed during theme development stage (Lincoln and Guba 1985; Creswell and Miller 2000).
Results
Study characteristics
The qualitative synthesis comprised 15 studies reporting the experiences of 103 women and 42 family members, of which 32 were partners (see Table 2). All studies were published between 2003 and 2018. Ten studies were conducted in the UK, two in Sweden, two in the USA and Canada and one used online data (location unknown). A diverse sample was obtain- ed, in which women who participated in the studies were reported to be at different stages of their recovery, ranging from 2 months postpartum to 32 years. No women were
598 R. Forde et al.
reported to be actively psychotic during the interview and this was frequently cited as an exclusion criteria to ensure informed consent could be obtained. Engqvist et al. (2011) used online narratives as a data source and therefore the dura- tion since onset could not be determined. The duration since onset reported by family members was also broad, capturing experiences up to 19 years postpartum. One study (Boddy et al. 2016) specifically sought individuals’ experiences dur- ing the acute phase of psychosis and this was obtained from the perspective of fathers only.
Using the CASP checklist, no major methodological issues were identified and all 15 studies were rated to have high
methodological quality and low methodological bias (see Table 3).
Synthesis
Four main themes and 13 subthemes were conceptualised in the metasynthesis, representing the reported experience of PP and factors involved in recovery from the perspective of wom- en and family. A conceptual model was developed (see Fig. 2) to provide a visual representation and to illustrate the relation- ships between themes. This captured themes from both wom- en and family members, due to the similarities found in some
Table 1 Thematic synthesis process Stages of thematic synthesis
1 Free line-by-line coding completed inductively across all data contained within the ‘findings/results’ sec- tions of each study, including participant quotes, author narrative and interpretation. The women’s ac- counts were coded first, followed by those of family members. New concepts were created according to the meaning and content of each sentence.
2 These codes were then organized into related areas and descriptive themes were developed, using an iterative process which involved the refinement of codes, checking for consistency of interpretation.
3 Higher level analytical themes were generated with the aim of producing new interpretations and key messages as guided by the research aims. This was continuously reviewed until a final set of analytical themes that captured the key meanings across the women’s and family members’ accounts were agreed upon.
Id en
tif ic
at io
PsychInfo (n=532),
Additional records
identified through
hand searching
(n=5)
family perspective (n=6)
Not research (n=16)
Unpublished thesis (n=2)
Total records identified
Fig. 1 Summary flowchart of study selection and search outcomes
599Recovery from postpartum psychosis: a systematic review and metasynthesis of women’s and families’...
Ta bl e 2
Su m m ar y of
st ud y ch ar ac te ri st ic s
St ud y:
St ud y ai m
S am
M et ho d
M et ho d of
an al ys is
id en tif ie d th em
es
St ud ie s in ve st ig at in g w om
en ’s pe rs pe ct iv es
on ly
(i n re ve rs e ch ro no lo gi ca lo
rd er )
(2 01 8)
en ’s ex pe ri en ce s
du ri ng
ea rl y da ys
of PP
en — al li de nt i-
fi ed
2– 22
on A ct io n on
Po st pa rt um
Ps yc ho si s
(A PP
se m i- st ru ct ur ed
in te r-
et al .
20 09 )
ha pp en in g? :s le ep
de pr iv at io n an d
an xi et ie s an d lo si ng
to uc h w ith
re al ity
of th e se ri ou sn es s’ :
ke ep in g up
ap pe ar an ce s an d m is in te rp re ta tio
n 3. B re as ti s be st ?: di ff ic ul tie s an d an xi et ie s re la te d
to fe ed in g
4. ‘T ra um
an d du ri ng
bi rt h
et al .
st or yl in e
an d in cr ea se
in pu bl ic aw
ar en es s
by w om
PP
en — fu lly
re co v-
er ed
fr om
P P
T im
e si nc e on se t: at le as t
12 m on th s
A dv er tis ed
on A PP
(n = 1)
an d
se m i- st ru ct ur ed
in te r-
1. Pu
PP as
of im
pr ov in g un de rs ta nd in g
2. St ig m a: vi ew
ed as
de ep
ro ot ed
3. D is cl os ur e: di ff ic ul ty
sh ar in g ex pe ri en ce
of PP ,
st or yl in e fa ci lit at ed
di sc lo su re
4. R ea ss ur an ce :t he y w er e no ta lo ne
5. Fa m ily
ne ga tiv
di st re ss
an d tr au m a—
st or yl in e as
a ve hi cl e to un de rs ta nd in g PP
fr om
3 Pl un ke tt
et al .
th e ba by
fr om
PP Tw
el ve
A ge d 23 –5 6 ye ar s
T im
2 m on th s– 26
ye ar s
fo ru m s (n = 9)
an d
Fa ce -t o- fa ce
(n = 5)
an d
se m i- st ru ct ur ed
in te r-
1. T he
re co ve ry :m
ot iv at ed
ge tb
ba by
is a ba rr ie r: re sp on si bi lit y of
ca ri ng
ot io na ld
ex pe ct at io ns
de la ye d he lp -s ee ki ng
3. B ab y fa ci lit at es
re co ve ry :p
hy si ca lc on ta ct
re du ce d di st re ss
an d in cr ea se d m at er na l
se lf -e ff ic ac y
4 G lo ve r et al .
(2 01 4)
U K
G ai n fu rt he r in si gh ti nt o w om
en ’s
PP an d th e co nt ex t
in w hi ch
it
en A ge d 25 –4 5 ye ar s
A ll di ag no se d w ith
PP in
ye ar s
se rv ic es
an d ba bi es
Se m i- st ru ct ur ed
in te rv ie w s
L oc at io n no ts pe ci fi ed
(a pp ro xi m at el y 1 h)
TA (B ra un
1. T he
n of
an d se ns e of
de ta ch m en t
2. U ns pe ak ab le th ou gh ts an d un ac ce pt ab le se lf :
un be ar ab le th ou gh tc on te nt
3. Sn
ju dg ed ,e xa ce rb at ed
di st re ss
4. Pe rc ei ve d ca us es :P
P un av oi da bl e vs
‘s na p ou t
of it’ :a n un pr ev en ta bl e ill ne ss
5 M cG
D ev el op
a th eo re tic al un de rs ta nd in g
of re co ve ry
fr om
fo llo
bi rt h
Tw el ve
en A ge d 26 –4 5 ye ar s
T im
4 m on th s– 23
ye ar s
en ts
(n = 10 )
(n = 11 ) an d
se m i- st ru ct ur ed
in te r-
C on st ru ct iv is t
gr ou nd ed
th eo ry
(C ha rm
az 20 06 )
R ec ov er y co nc ep tu al is ed
as a pa ra lle lp
ro ce ss
1. T he
pr oc es s of
re co ve ry :f ro m ‘i m m ob ili sa tio n’
(u na bl e to
m ak e us e of
ac tiv e st ra te gi es ) to
re co gn is in g ch an ge s an d ac ce pt in g lo ss
se lf -e ff ic ac y an d ho pe
2. E vo lv in g an
un de rs ta nd in g:
dy na m ic pr oc es s,
re co gn is e m is m at ch
in ex pe ct at io ns
3. St ra te gi es
fo r re co ve ry :i ni tia lly
fe lt po w er le ss
an d tr ie d to
co nc ea ls ym
pt om
600 R. Forde et al.
T ab
le 2
St ud y ai m
S am
M et ho d
M et ho d of
an al ys is
id en tif ie d th em
es
U SA
U nd er st an d th e ex pe ri en ce
of PP
in an
O rt ho do x Je w is h w om
an O ne
w om
f P P :
sp ec if ie d
U ns tr uc tu re d Te le ph on e
in te rv ie w (1 .5
h) St ru ct ur al
an al ys is (G
ee 19 91 )
Fi rs td
is h ho lid
s be gi n—
ni gh ta nd
dr ea d
T hi rd
Fo ur th
m or e ag ita te d,
di re ct iv e an d lo ss
of tr us t
ex pe ri en ce
7 H er on
th e
re co ve ry
be lie fs ab ou tt he
se rv ic es
th em
3– 20
co nd uc tin g re se ar ch
vi a A PP
le d
se m i- st ru ct ur ed
in te r-
an al yt ic
ap pr oa ch
sy ch ol og ic al en or m ity
an d se ns e of
lo ss
2. R um
in at in g an d ra tio na lis in g:
a ne ed
to in te gr at e pe ri od s of
lo st tim
3. So
ui ld in g ne tw or ks
4. M ed ic al su pp or t: co ns id er ed
vi ta l
be ta ilo re d
6. Fa m ily
as pi vo ta l
7. G iv in g re co ve ry
tim e: no ta lw ay s lin
ea r
et al .
in si gh ti nt o w om
en ’s
PP ,a s de sc ri be d in
na rr at iv es
pu bl is he d on
th e
in te rn et
Te n pe rs on al na rr at iv es
ta ke n fr om
th e In te rn et
O f 28 ,1 0 m et th e D SM
-I V
fo r
w om
a da ta so ur ce
(3 06 –4 14 0 w or ds )
C on te nt
an al ys is
20 04 )
1. U nf ul fi lle d dr ea m s: sh at te re d ex pe ct at io ns
2. E nv el op ed
by da rk ne ss :w
om en
er e in
an un re al w or ld
an d ex pe ri en ce d di so rg an is ed
th in ki ng
3. D is ab lin g sy m pt om
s: lo ne ly ,s us pi ci ou s, lo ss of
sl ee p an d se lf -d es tr uc tiv e be ha vi ou rs
4. B ei ng
al lf el td
de ta ch ed
an d
en ’s ex pe ri en ce s of
PP an d ga in un de rs…
R. Forde1,2 & S. Peters1 & A. Wittkowski1,2
Received: 30 October 2019 /Accepted: 26 January 2020 # The Author(s) 2020
Abstract Postpartum psychosis is a serious disorder that can result in adverse consequences for the mother and baby. It is important that we understand the experiences of women, to develop effective interventions during this critical period. The aim of this systematic review was to conduct a metasynthesis of qualitative research exploring women’s experiences of postpartum psychosis and factors involved in recovery from the perspective of women and family members. A comprehensive literature search of five databases was conducted and the findings were appraised and synthesised, following a thematic synthesis approach. Fifteen studies, capturing the views of 103 women and 42 family members, met the inclusion criteria. Four main themes incorporating 13 subthemes were identified following synthesis: (1) Experiencing the unspeakable, (2) Loss and disruption, (3) Realigning old self and new self and the integrative theme of (4) Social context. The findings offer new insight into the unique experience of postpartum psychosis and demonstrate that recovery does not follow a linear path. To improve clinical outcomes, a more integrative and individualised approach is needed which incorporates long-term psychological and psychosocial support, and considers the needs of the family. Further areas for staff training, service development and future research are highlighted.
Keywords Literature review . Qualitative research . Perinatal mental health . Psychotic disorder .Childbirth
Introduction
Postpartum psychosis (PP) is one of the most severe mental health problems following childbirth, affecting 0.89 to 2.6 per 1000 women (Vanderkruik et al. 2017). It is characterised by a dramatic onset, and rapid deterioration, with symptoms in- cluding hallucinations, delusions, disorganised behaviour and depression (Di Florio et al. 2013; Heron et al. 2008; Sit et al. 2006). Continued poor maternal mental health is associ- ated with increased risk of adverse outcomes including suicide and decreased mother-infant bonding (Wilkinson et al. 2017). Immediate referral to a secondary mental health service for
assessment is therefore recommended (NICE 2018). Inpatient care, ideally within a Mother and Baby Unit (MBU; Gillham and Wittkowski 2015) and pharmacological intervention, is almost always required (NICE 2018; Jones and Smith 2009). Family members are reported to be integral during this process and should be involved in care and treatment planning (Engqvist and Nilsson 2014; Mohamied 2019).
With appropriate treatment, the most severe symptoms usu- ally resolve within 2 to 12 weeks (Bergink et al. 2015). However, women remain at increased risk of subsequent post- partum and non-postpartum episodes, including depression and anxiety (Robertson et al. 2005; Nager et al. 2013). PP is a highly stressful life event which can have a detrimental impact on well-being and long-term functioning and result in feelings of guilt, loss, fear and shame (Burgerhout et al. 2017; Plunkett et al. 2016; Wittkowski et al. 2014). Psychological intervention and psychosocial support has been recommended (Doucet et al. 2011), yet very little is known about the psychological factors underpinning recovery or the types of intervention found to be effective.
Previous metasyntheses have explored individuals’ experi- ences of serious mental health problems and mental health
* A. Wittkowski [email protected]
1 Divison of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University ofManchester, 2nd Floor Zochonis Building, Brunswick Street, Manchester M13 9PL, UK
2 Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
https://doi.org/10.1007/s00737-020-01025-z
Archives of Women's Mental Health (2020) 23:597–612
Method
A metasynthesis was deemed most appropriate to systemati- cally analyse and interpret multiple qualitative studies with the aim to develop new insight (Lachal et al. 2017). The review protocol was registered with PROSPERO on 19 December 2018 (Ref: CRD42018119145).
Inclusion and exclusion criteria
All published empirical studies exploring women’s or family members’ experiences of PP and/or recovery using a qualita- tive methodology were included. Studies published in any language were eligible for inclusion, as were studies using mixed methods, provided qualitative data could be extracted.
Studies were excludedwhen they (1) explored ‘schizophre- nia’ and other perinatal disorders, such as postnatal depres- sion; (2) did not stipulate the diagnosis; (3) used a mixed sample in which it was not possible to differentiate the find- ings based on diagnosis; (4) explored only health profes- sionals’ views; or (5) were unpublished research or grey literature.
Search strategy
Five databases CINAHL,MEDLINE, EMBASE, PsychINFO and Web of Science were searched from inception to 3 April 2019. An updated search was completed on 20 August 2019 which revealed no additional eligible studies. Only keywords relating to the ‘phenomenon of interest’ (Cooke et al. 2012) were applied to ensure all relevant studies were captured (‘postpartum psychosis’ OR ‘puerperal psychosis’ OR ‘post- natal psychosis’OR ‘psychosis after childbirth’) and no limits were applied. Additional studies were sought from the refer- ence lists of included studies using forward and backward searching (Horsley et al. 2011).
Study selection
The search process, following PRISMA guidelines (Moher et al. 2009) yielded 1782 unique studies (see Fig. 1). The title, keywords and abstracts of all studies were assessed for eligi- bility against the inclusion/exclusion criteria; 1728 studies were subsequently excluded. A random 20% of studies (n = 353) were checked by an independent rater and a strong level of inter-rater reliability was obtained (96%, κ 0.88 (95% CI, 0.82–0.95) McHugh 2012). Of the remaining 54 studies, 39 were excluded when reviewed in full, yielding a final sample of 15.
Critical appraisal
The methodological quality of the included studies was eval- uated using the Critical Appraisal Skills Programme (CASP 2018) checklist. The CASP comprises ten questions across three broad domains, relating to the validity, design and utility of the results. The CASP was used to determine rigour and trustworthiness in the outcomes (Hannes 2011).
Data analysis
All included studies were extracted electronically onto NVIVO 12 (2018) data management software and analysed using Thomas and Harden’s (2008) thematic synthesis (see Table 1). This approach enabled the researchers to integrate multiple qualitative findings and identify recurring themes, following three key overlapping stages (Noyes et al. 2018; Ring et al. 2011). Distinctions were made across the different samples when analysing the data and constant comparisons were made across and within the women’s and family mem- bers’ accounts to ensure similarities and differences were cap- tured. To test the credibility and applicability of the findings, a peer and member-checking exercise was completed during theme development stage (Lincoln and Guba 1985; Creswell and Miller 2000).
Results
Study characteristics
The qualitative synthesis comprised 15 studies reporting the experiences of 103 women and 42 family members, of which 32 were partners (see Table 2). All studies were published between 2003 and 2018. Ten studies were conducted in the UK, two in Sweden, two in the USA and Canada and one used online data (location unknown). A diverse sample was obtain- ed, in which women who participated in the studies were reported to be at different stages of their recovery, ranging from 2 months postpartum to 32 years. No women were
598 R. Forde et al.
reported to be actively psychotic during the interview and this was frequently cited as an exclusion criteria to ensure informed consent could be obtained. Engqvist et al. (2011) used online narratives as a data source and therefore the dura- tion since onset could not be determined. The duration since onset reported by family members was also broad, capturing experiences up to 19 years postpartum. One study (Boddy et al. 2016) specifically sought individuals’ experiences dur- ing the acute phase of psychosis and this was obtained from the perspective of fathers only.
Using the CASP checklist, no major methodological issues were identified and all 15 studies were rated to have high
methodological quality and low methodological bias (see Table 3).
Synthesis
Four main themes and 13 subthemes were conceptualised in the metasynthesis, representing the reported experience of PP and factors involved in recovery from the perspective of wom- en and family. A conceptual model was developed (see Fig. 2) to provide a visual representation and to illustrate the relation- ships between themes. This captured themes from both wom- en and family members, due to the similarities found in some
Table 1 Thematic synthesis process Stages of thematic synthesis
1 Free line-by-line coding completed inductively across all data contained within the ‘findings/results’ sec- tions of each study, including participant quotes, author narrative and interpretation. The women’s ac- counts were coded first, followed by those of family members. New concepts were created according to the meaning and content of each sentence.
2 These codes were then organized into related areas and descriptive themes were developed, using an iterative process which involved the refinement of codes, checking for consistency of interpretation.
3 Higher level analytical themes were generated with the aim of producing new interpretations and key messages as guided by the research aims. This was continuously reviewed until a final set of analytical themes that captured the key meanings across the women’s and family members’ accounts were agreed upon.
Id en
tif ic
at io
PsychInfo (n=532),
Additional records
identified through
hand searching
(n=5)
family perspective (n=6)
Not research (n=16)
Unpublished thesis (n=2)
Total records identified
Fig. 1 Summary flowchart of study selection and search outcomes
599Recovery from postpartum psychosis: a systematic review and metasynthesis of women’s and families’...
Ta bl e 2
Su m m ar y of
st ud y ch ar ac te ri st ic s
St ud y:
St ud y ai m
S am
M et ho d
M et ho d of
an al ys is
id en tif ie d th em
es
St ud ie s in ve st ig at in g w om
en ’s pe rs pe ct iv es
on ly
(i n re ve rs e ch ro no lo gi ca lo
rd er )
(2 01 8)
en ’s ex pe ri en ce s
du ri ng
ea rl y da ys
of PP
en — al li de nt i-
fi ed
2– 22
on A ct io n on
Po st pa rt um
Ps yc ho si s
(A PP
se m i- st ru ct ur ed
in te r-
et al .
20 09 )
ha pp en in g? :s le ep
de pr iv at io n an d
an xi et ie s an d lo si ng
to uc h w ith
re al ity
of th e se ri ou sn es s’ :
ke ep in g up
ap pe ar an ce s an d m is in te rp re ta tio
n 3. B re as ti s be st ?: di ff ic ul tie s an d an xi et ie s re la te d
to fe ed in g
4. ‘T ra um
an d du ri ng
bi rt h
et al .
st or yl in e
an d in cr ea se
in pu bl ic aw
ar en es s
by w om
PP
en — fu lly
re co v-
er ed
fr om
P P
T im
e si nc e on se t: at le as t
12 m on th s
A dv er tis ed
on A PP
(n = 1)
an d
se m i- st ru ct ur ed
in te r-
1. Pu
PP as
of im
pr ov in g un de rs ta nd in g
2. St ig m a: vi ew
ed as
de ep
ro ot ed
3. D is cl os ur e: di ff ic ul ty
sh ar in g ex pe ri en ce
of PP ,
st or yl in e fa ci lit at ed
di sc lo su re
4. R ea ss ur an ce :t he y w er e no ta lo ne
5. Fa m ily
ne ga tiv
di st re ss
an d tr au m a—
st or yl in e as
a ve hi cl e to un de rs ta nd in g PP
fr om
3 Pl un ke tt
et al .
th e ba by
fr om
PP Tw
el ve
A ge d 23 –5 6 ye ar s
T im
2 m on th s– 26
ye ar s
fo ru m s (n = 9)
an d
Fa ce -t o- fa ce
(n = 5)
an d
se m i- st ru ct ur ed
in te r-
1. T he
re co ve ry :m
ot iv at ed
ge tb
ba by
is a ba rr ie r: re sp on si bi lit y of
ca ri ng
ot io na ld
ex pe ct at io ns
de la ye d he lp -s ee ki ng
3. B ab y fa ci lit at es
re co ve ry :p
hy si ca lc on ta ct
re du ce d di st re ss
an d in cr ea se d m at er na l
se lf -e ff ic ac y
4 G lo ve r et al .
(2 01 4)
U K
G ai n fu rt he r in si gh ti nt o w om
en ’s
PP an d th e co nt ex t
in w hi ch
it
en A ge d 25 –4 5 ye ar s
A ll di ag no se d w ith
PP in
ye ar s
se rv ic es
an d ba bi es
Se m i- st ru ct ur ed
in te rv ie w s
L oc at io n no ts pe ci fi ed
(a pp ro xi m at el y 1 h)
TA (B ra un
1. T he
n of
an d se ns e of
de ta ch m en t
2. U ns pe ak ab le th ou gh ts an d un ac ce pt ab le se lf :
un be ar ab le th ou gh tc on te nt
3. Sn
ju dg ed ,e xa ce rb at ed
di st re ss
4. Pe rc ei ve d ca us es :P
P un av oi da bl e vs
‘s na p ou t
of it’ :a n un pr ev en ta bl e ill ne ss
5 M cG
D ev el op
a th eo re tic al un de rs ta nd in g
of re co ve ry
fr om
fo llo
bi rt h
Tw el ve
en A ge d 26 –4 5 ye ar s
T im
4 m on th s– 23
ye ar s
en ts
(n = 10 )
(n = 11 ) an d
se m i- st ru ct ur ed
in te r-
C on st ru ct iv is t
gr ou nd ed
th eo ry
(C ha rm
az 20 06 )
R ec ov er y co nc ep tu al is ed
as a pa ra lle lp
ro ce ss
1. T he
pr oc es s of
re co ve ry :f ro m ‘i m m ob ili sa tio n’
(u na bl e to
m ak e us e of
ac tiv e st ra te gi es ) to
re co gn is in g ch an ge s an d ac ce pt in g lo ss
se lf -e ff ic ac y an d ho pe
2. E vo lv in g an
un de rs ta nd in g:
dy na m ic pr oc es s,
re co gn is e m is m at ch
in ex pe ct at io ns
3. St ra te gi es
fo r re co ve ry :i ni tia lly
fe lt po w er le ss
an d tr ie d to
co nc ea ls ym
pt om
600 R. Forde et al.
T ab
le 2
St ud y ai m
S am
M et ho d
M et ho d of
an al ys is
id en tif ie d th em
es
U SA
U nd er st an d th e ex pe ri en ce
of PP
in an
O rt ho do x Je w is h w om
an O ne
w om
f P P :
sp ec if ie d
U ns tr uc tu re d Te le ph on e
in te rv ie w (1 .5
h) St ru ct ur al
an al ys is (G
ee 19 91 )
Fi rs td
is h ho lid
s be gi n—
ni gh ta nd
dr ea d
T hi rd
Fo ur th
m or e ag ita te d,
di re ct iv e an d lo ss
of tr us t
ex pe ri en ce
7 H er on
th e
re co ve ry
be lie fs ab ou tt he
se rv ic es
th em
3– 20
co nd uc tin g re se ar ch
vi a A PP
le d
se m i- st ru ct ur ed
in te r-
an al yt ic
ap pr oa ch
sy ch ol og ic al en or m ity
an d se ns e of
lo ss
2. R um
in at in g an d ra tio na lis in g:
a ne ed
to in te gr at e pe ri od s of
lo st tim
3. So
ui ld in g ne tw or ks
4. M ed ic al su pp or t: co ns id er ed
vi ta l
be ta ilo re d
6. Fa m ily
as pi vo ta l
7. G iv in g re co ve ry
tim e: no ta lw ay s lin
ea r
et al .
in si gh ti nt o w om
en ’s
PP ,a s de sc ri be d in
na rr at iv es
pu bl is he d on
th e
in te rn et
Te n pe rs on al na rr at iv es
ta ke n fr om
th e In te rn et
O f 28 ,1 0 m et th e D SM
-I V
fo r
w om
a da ta so ur ce
(3 06 –4 14 0 w or ds )
C on te nt
an al ys is
20 04 )
1. U nf ul fi lle d dr ea m s: sh at te re d ex pe ct at io ns
2. E nv el op ed
by da rk ne ss :w
om en
er e in
an un re al w or ld
an d ex pe ri en ce d di so rg an is ed
th in ki ng
3. D is ab lin g sy m pt om
s: lo ne ly ,s us pi ci ou s, lo ss of
sl ee p an d se lf -d es tr uc tiv e be ha vi ou rs
4. B ei ng
al lf el td
de ta ch ed
an d
en ’s ex pe ri en ce s of
PP an d ga in un de rs…
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