Postpartum psychosis and ill-advised discharge

Muslim Bangladeshi female presents

The patient is a 31-year-old married Muslim Bangladeshi female homemaker admitted to an inpatient unit in a private hospital in a large urban area in the northeastern United States because of postpartum psychosis. She recently had immigrated to the United States and spoke no English. She lived with her husband, his parents, and his siblings in a city neighborhood predominantly comprised of South Asian immigrants. Her sole source of financial support was her husband, who worked as a cab driver. Both patient and her husband were uninsured. They identified strongly with their religion and culture of origin.

Key questions

Communication was a challenge and was accomplished using an interpreter, who was not always available. The patient did not seem to respond to treatment, and there was a question about the possibility that she was “cheeking” her medications. Her husband requested her discharge against medical advice, despite her still showing signs of psychosis. He appeared ambivalent about outpatient follow-up.

What is the duty of care in this situation, given the complexities inherent in a cross-cultural situation, the presence of communication barriers, the question of patient and infant safety, the husband’s role (given the understanding that his actions were probably culturally sanctioned and consistent with his role), issues regarding financing their current and follow-up care, and their ambivalence toward follow-up care?

Family perspective

Working with a qualified medical interpreter is imperative, and hospitals and health care providers who accept federal funds are obliged to provide language assistance services under Title VI of the Civil Rights Act of 1964.

First, it is important to accurately assess the woman’s psychosis, including risk of self-harm, risk of harming the infant or others, and capacity to care adequately and safely for the infant.

Second, the team should assess the patient’s and husband’s beliefs about the illness, hospitalization, and treatment. For some Muslim patients, the daily practice of Islam may necessitate the separation of sexes, meaning that female nurses and physicians might be optimal. Accessing professional spiritual or pastoral care in meeting the patient’s and family’s religious needs should be considered. Additional cultural practices that might help increase the acceptability of inpatient psychiatric care for the family include practices regarding diet, dress, hygiene, and prayer. The husband also might want to stay and sleep in the patient’s room during her hospitalization.

It also might be challenging for some North American therapists to understand and focus on the entire family as a functioning unit, rather than seeing the issues as only between husband and wife. Learning about how “normal family functioning” is defined, especially in terms of roles, hierarchy, and intimacy, is critical to supporting this mother and baby. Cultivating “cultural humility” in working with patients and families from diverse backgrounds is extremely important.

During the hospitalization as the patient improves, a plan for care needs to be developed with the patient and her family. This plan should include adequate support of the mother and her baby. The husband should bring his parents and siblings to an initial meeting early during the hospitalization, being mindful of addressing any HIPAA-related issues. This will allow for a uniform understanding of the patient’s illness and treatment. At this meeting, all family members should express their concerns, worries, beliefs, and perceived barriers to optimal care. If the family members feel listened to, they are more likely to feel understood and adhere to recommendations.

At the initial meeting and subsequent ones, the following questions might be helpful to ask to gather information in negotiating a mutually acceptable treatment plan:

1. What is the family’s understanding of her illness? What do they think may have caused it? How do they understand postpartum psychosis? Do they think there is a role for medication? Are any other alternative healing modalities being considered or used?

2. Who is caring for the baby now? Is the baby healthy? Does the family understand how the mother’s illness affects the baby? Can the family provide adequate care for the baby?

3. How are decisions made in the family? Are there any other issues in the family, such as ill health in a parent?

4. Was this an arranged marriage? How long have they known the patient? Do they care for her? What is the family’s attitude toward her?

5. Besides the mother-in-law, are there other adult females (for example, her husband’s sisters and his brothers’ wives) living in the household? How old is the mother-in-law? Who runs the household? Who does all the work? If possible, it will be important to interview anyone else in the household. How long have the couple and the family been in the United States? Did they all come at the same time?

6. Does the family have a supportive community? What are their beliefs about mental illness? Whom do they trust in their community? A religious leader? A local doctor? Who treats the women in the community?

7. If there is time, other issues can be explored. For example, what were the circumstances of their immigration? What has the transition from Bangladesh to life in the United States been like for the family?

8. Who will care for her at home? Who will ensure she takes her medications? Who will take her to follow-up visits?

There are many unknowns in this case that require further exploration. Time taken to arrange for a medically qualified interpreter and an extended family meeting will help the physician and psychiatric team understand the current situation and set up an appropriate plan of care.

Cultural perspective

The case material raises many questions. In the first place, there is no need to assume that the husband was behaving in a “culturally sanctioned and consistent way.” In a large population like that of Bangladeshi Muslims, significant heterogeneity exists, and there are more ways than one to respond. Although access to care is increasing for some population segments, Bangladesh still has limited mental health services and resources.

What were the reasons for the patient to be admitted to a psychiatric unit? How many days after the delivery? Were there any hostile actions or reactions to the baby? What is the patient’s pregnancy history? What meaning was ascribed to the symptoms and behavior that the patient manifested prior to hospitalization? Was this the first episode of psychiatric illness for the patient? Has she shown any dangerous behaviors before?

The reason why the husband is taking the wife home against medical advice is unclear. What reason did the husband give for this decision? Could stigma toward mental illness or hospitalization play a role? Was an interpreter used to help understand his reasoning? Was the husband dissatisfied about something? This is important, because it is likely that the husband brought the wife for hospitalization in the first place. Were the inpatient physician and nurses male or female, and could gender-related issues have been a barrier to accepting care? Might there have been a Muslim chaplain in the hospital or in the community or someone else who could have served as a cultural broker earlier in the hospitalization to have prevented this impasse?

The Cultural Formulation Interview (CFI) in the DSM-5 and the CFI-Informant Version for family members provide a framework to explore these questions and the questions recommended in the Family Perspective throughout the course of treatment.

Additional relevant questions include the following: What are cultural norms for their expectations for support of a new mother during the postpartum period? What are the norms for who, besides the mother, provides infant care? Are normative postpartum practices possible, or have they been disrupted in the hospital setting and/or in their home? If the mother and baby are both on the unit, is the request motivated by a desire to bring the baby home? If the baby is not on the unit, is this driving the family’s concern?

How isolated will the woman feel when she is home with the baby and her husband is out working as a taxi driver? Are there community-based organizations that the clinicians could collaborate with to provide resources and support for this woman (for example, women’s groups, immigrant groups, religious groups)? This would require learning more about what appeals to her, which groups she might identify with, and what is available in her neighborhood/community that aligns with what appeals to her.

It also would be important to determine if the patient was having any side effects from her psychotropic medications. Many South Asians have a low tolerance for side effects. Did the patient or family have any religious or cultural concerns about how the medications were manufactured or their composition (for example, worries about alcohol content)? Could any of these factors be related to the patient’s possible “cheeking” of her medications?

The major ethical/legal question to address is the patient’s attitude toward and relationship with the baby, and whether she was and is currently a danger to herself or others. Was the baby with the patient in the hospital? Did she feed the baby? What were the signs of psychosis that the patient exhibited, and what were the bases of her diagnosis? Was there an opportunity to discuss these issues with the husband? If so, what was his response?

Unless the patient is found to be dangerous to herself or others, including the baby, there is no option but to discharge. If a Bengali-speaking psychiatrist/therapist could be located within a reasonable driving distance, every effort should be made to connect the two. Husband and wife certainly should be instructed at the first sign of trouble to seek medical/psychiatric assistance, with or without insurance. Is there a possibility of home visits with an interpreter given the potential risks of patient and infant safety? Close follow-up and coordination of care with the patient’s and baby’s primary care physician is needed. Seeking support from the patient’s religious community also is worth considering.

Contributors

Alison M. Heru, M.D. – University of Colorado Denver, Aurora

Ellen Berman, M.D. – University of Pennsylvania, Philadelphia

Annelle B. Primm, M.D., M.P.H. – Johns Hopkins University, Baltimore (adjunct faculty)

Anne E. Becker, M.D., Ph.D. – Harvard Medical School, Boston

Robert C. Like, M.D., M.S. – Rutgers University, Robert Wood Johnson Medical School, New Brunswick

Resources

Farooq S., Fear C. Working Through Interpreters. (Adv Psychiatr Treat. 2003 Mar;9[2]:104-9. doi: 10.1192/apt.01.12 http://apt.rcpsych.org/content/9/2/104.full.)

Chandra P.S. Postpartum Psychiatric Care in India: The need for Integration and Innovation. (World Psychiatry. 2004;3[2]:99-100.)

Ahmad F., Shik A., Vanza R., Cheung A.M., George U, Stewart D.E. Voices of South Asian Women: Immigration and Mental Health. (Women Health 2004; 40[4]:113-130.)

Mantle F. Developing a Culture-Specific Tool to Assess Postnatal Depression in the Indian Community. (Br J Community Nurs. 2003;8[4]:176-180.)

To read about the goals of Curbside Consult, the guiding principles for assessment, and the guidelines for case submission, see “Considering patients’ family, culture,” Clinical Psychiatry News, January 2015, p. 12. The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they are employed by or affiliated with or the Group for the Advancement of Psychiatry (GAP).

This column is in memory of Dr. Prakash N. Desai, who contributed to this piece before his death earlier this year.

Muslim Bangladeshi female presents

The patient is a 31-year-old married Muslim Bangladeshi female homemaker admitted to an inpatient unit in a private hospital in a large urban area in the northeastern United States because of postpartum psychosis. She recently had immigrated to the United States and spoke no English. She lived with her husband, his parents, and his siblings in a city neighborhood predominantly comprised of South Asian immigrants. Her sole source of financial support was her husband, who worked as a cab driver. Both patient and her husband were uninsured. They identified strongly with their religion and culture of origin.

Key questions

Communication was a challenge and was accomplished using an interpreter, who was not always available. The patient did not seem to respond to treatment, and there was a question about the possibility that she was “cheeking” her medications. Her husband requested her discharge against medical advice, despite her still showing signs of psychosis. He appeared ambivalent about outpatient follow-up.

What is the duty of care in this situation, given the complexities inherent in a cross-cultural situation, the presence of communication barriers, the question of patient and infant safety, the husband’s role (given the understanding that his actions were probably culturally sanctioned and consistent with his role), issues regarding financing their current and follow-up care, and their ambivalence toward follow-up care?

Family perspective

Working with a qualified medical interpreter is imperative, and hospitals and health care providers who accept federal funds are obliged to provide language assistance services under Title VI of the Civil Rights Act of 1964.

First, it is important to accurately assess the woman’s psychosis, including risk of self-harm, risk of harming the infant or others, and capacity to care adequately and safely for the infant.

Second, the team should assess the patient’s and husband’s beliefs about the illness, hospitalization, and treatment. For some Muslim patients, the daily practice of Islam may necessitate the separation of sexes, meaning that female nurses and physicians might be optimal. Accessing professional spiritual or pastoral care in meeting the patient’s and family’s religious needs should be considered. Additional cultural practices that might help increase the acceptability of inpatient psychiatric care for the family include practices regarding diet, dress, hygiene, and prayer. The husband also might want to stay and sleep in the patient’s room during her hospitalization.

It also might be challenging for some North American therapists to understand and focus on the entire family as a functioning unit, rather than seeing the issues as only between husband and wife. Learning about how “normal family functioning” is defined, especially in terms of roles, hierarchy, and intimacy, is critical to supporting this mother and baby. Cultivating “cultural humility” in working with patients and families from diverse backgrounds is extremely important.

During the hospitalization as the patient improves, a plan for care needs to be developed with the patient and her family. This plan should include adequate support of the mother and her baby. The husband should bring his parents and siblings to an initial meeting early during the hospitalization, being mindful of addressing any HIPAA-related issues. This will allow for a uniform understanding of the patient’s illness and treatment. At this meeting, all family members should express their concerns, worries, beliefs, and perceived barriers to optimal care. If the family members feel listened to, they are more likely to feel understood and adhere to recommendations.

At the initial meeting and subsequent ones, the following questions might be helpful to ask to gather information in negotiating a mutually acceptable treatment plan:

1. What is the family’s understanding of her illness? What do they think may have caused it? How do they understand postpartum psychosis? Do they think there is a role for medication? Are any other alternative healing modalities being considered or used?

2. Who is caring for the baby now? Is the baby healthy? Does the family understand how the mother’s illness affects the baby? Can the family provide adequate care for the baby?

3. How are decisions made in the family? Are there any other issues in the family, such as ill health in a parent?

4. Was this an arranged marriage? How long have they known the patient? Do they care for her? What is the family’s attitude toward her?

5. Besides the mother-in-law, are there other adult females (for example, her husband’s sisters and his brothers’ wives) living in the household? How old is the mother-in-law? Who runs the household? Who does all the work? If possible, it will be important to interview anyone else in the household. How long have the couple and the family been in the United States? Did they all come at the same time?

6. Does the family have a supportive community? What are their beliefs about mental illness? Whom do they trust in their community? A religious leader? A local doctor? Who treats the women in the community?

7. If there is time, other issues can be explored. For example, what were the circumstances of their immigration? What has the transition from Bangladesh to life in the United States been like for the family?

8. Who will care for her at home? Who will ensure she takes her medications? Who will take her to follow-up visits?

There are many unknowns in this case that require further exploration. Time taken to arrange for a medically qualified interpreter and an extended family meeting will help the physician and psychiatric team understand the current situation and set up an appropriate plan of care.

Cultural perspective

The case material raises many questions. In the first place, there is no need to assume that the husband was behaving in a “culturally sanctioned and consistent way.” In a large population like that of Bangladeshi Muslims, significant heterogeneity exists, and there are more ways than one to respond. Although access to care is increasing for some population segments, Bangladesh still has limited mental health services and resources.

What were the reasons for the patient to be admitted to a psychiatric unit? How many days after the delivery? Were there any hostile actions or reactions to the baby? What is the patient’s pregnancy history? What meaning was ascribed to the symptoms and behavior that the patient manifested prior to hospitalization? Was this the first episode of psychiatric illness for the patient? Has she shown any dangerous behaviors before?

The reason why the husband is taking the wife home against medical advice is unclear. What reason did the husband give for this decision? Could stigma toward mental illness or hospitalization play a role? Was an interpreter used to help understand his reasoning? Was the husband dissatisfied about something? This is important, because it is likely that the husband brought the wife for hospitalization in the first place. Were the inpatient physician and nurses male or female, and could gender-related issues have been a barrier to accepting care? Might there have been a Muslim chaplain in the hospital or in the community or someone else who could have served as a cultural broker earlier in the hospitalization to have prevented this impasse?

The Cultural Formulation Interview (CFI) in the DSM-5 and the CFI-Informant Version for family members provide a framework to explore these questions and the questions recommended in the Family Perspective throughout the course of treatment.

Additional relevant questions include the following: What are cultural norms for their expectations for support of a new mother during the postpartum period? What are the norms for who, besides the mother, provides infant care? Are normative postpartum practices possible, or have they been disrupted in the hospital setting and/or in their home? If the mother and baby are both on the unit, is the request motivated by a desire to bring the baby home? If the baby is not on the unit, is this driving the family’s concern?

How isolated will the woman feel when she is home with the baby and her husband is out working as a taxi driver? Are there community-based organizations that the clinicians could collaborate with to provide resources and support for this woman (for example, women’s groups, immigrant groups, religious groups)? This would require learning more about what appeals to her, which groups she might identify with, and what is available in her neighborhood/community that aligns with what appeals to her.

It also would be important to determine if the patient was having any side effects from her psychotropic medications. Many South Asians have a low tolerance for side effects. Did the patient or family have any religious or cultural concerns about how the medications were manufactured or their composition (for example, worries about alcohol content)? Could any of these factors be related to the patient’s possible “cheeking” of her medications?

The major ethical/legal question to address is the patient’s attitude toward and relationship with the baby, and whether she was and is currently a danger to herself or others. Was the baby with the patient in the hospital? Did she feed the baby? What were the signs of psychosis that the patient exhibited, and what were the bases of her diagnosis? Was there an opportunity to discuss these issues with the husband? If so, what was his response?

Unless the patient is found to be dangerous to herself or others, including the baby, there is no option but to discharge. If a Bengali-speaking psychiatrist/therapist could be located within a reasonable driving distance, every effort should be made to connect the two. Husband and wife certainly should be instructed at the first sign of trouble to seek medical/psychiatric assistance, with or without insurance. Is there a possibility of home visits with an interpreter given the potential risks of patient and infant safety? Close follow-up and coordination of care with the patient’s and baby’s primary care physician is needed. Seeking support from the patient’s religious community also is worth considering.

Contributors

Alison M. Heru, M.D. – University of Colorado Denver, Aurora

Ellen Berman, M.D. – University of Pennsylvania, Philadelphia

Annelle B. Primm, M.D., M.P.H. – Johns Hopkins University, Baltimore (adjunct faculty)

Anne E. Becker, M.D., Ph.D. – Harvard Medical School, Boston

Robert C. Like, M.D., M.S. – Rutgers University, Robert Wood Johnson Medical School, New Brunswick

Resources

Farooq S., Fear C. Working Through Interpreters. (Adv Psychiatr Treat. 2003 Mar;9[2]:104-9. doi: 10.1192/apt.01.12 http://apt.rcpsych.org/content/9/2/104.full.)

Chandra P.S. Postpartum Psychiatric Care in India: The need for Integration and Innovation. (World Psychiatry. 2004;3[2]:99-100.)

Ahmad F., Shik A., Vanza R., Cheung A.M., George U, Stewart D.E. Voices of South Asian Women: Immigration and Mental Health. (Women Health 2004; 40[4]:113-130.)

Mantle F. Developing a Culture-Specific Tool to Assess Postnatal Depression in the Indian Community. (Br J Community Nurs. 2003;8[4]:176-180.)

To read about the goals of Curbside Consult, the guiding principles for assessment, and the guidelines for case submission, see “Considering patients’ family, culture,” Clinical Psychiatry News, January 2015, p. 12. The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they are employed by or affiliated with or the Group for the Advancement of Psychiatry (GAP).

This column is in memory of Dr. Prakash N. Desai, who contributed to this piece before his death earlier this year.

Muslim Bangladeshi female presents

The patient is a 31-year-old married Muslim Bangladeshi female homemaker admitted to an inpatient unit in a private hospital in a large urban area in the northeastern United States because of postpartum psychosis. She recently had immigrated to the United States and spoke no English. She lived with her husband, his parents, and his siblings in a city neighborhood predominantly comprised of South Asian immigrants. Her sole source of financial support was her husband, who worked as a cab driver. Both patient and her husband were uninsured. They identified strongly with their religion and culture of origin.

Key questions

Communication was a challenge and was accomplished using an interpreter, who was not always available. The patient did not seem to respond to treatment, and there was a question about the possibility that she was “cheeking” her medications. Her husband requested her discharge against medical advice, despite her still showing signs of psychosis. He appeared ambivalent about outpatient follow-up.

What is the duty of care in this situation, given the complexities inherent in a cross-cultural situation, the presence of communication barriers, the question of patient and infant safety, the husband’s role (given the understanding that his actions were probably culturally sanctioned and consistent with his role), issues regarding financing their current and follow-up care, and their ambivalence toward follow-up care?

Family perspective

Working with a qualified medical interpreter is imperative, and hospitals and health care providers who accept federal funds are obliged to provide language assistance services under Title VI of the Civil Rights Act of 1964.

First, it is important to accurately assess the woman’s psychosis, including risk of self-harm, risk of harming the infant or others, and capacity to care adequately and safely for the infant.

Second, the team should assess the patient’s and husband’s beliefs about the illness, hospitalization, and treatment. For some Muslim patients, the daily practice of Islam may necessitate the separation of sexes, meaning that female nurses and physicians might be optimal. Accessing professional spiritual or pastoral care in meeting the patient’s and family’s religious needs should be considered. Additional cultural practices that might help increase the acceptability of inpatient psychiatric care for the family include practices regarding diet, dress, hygiene, and prayer. The husband also might want to stay and sleep in the patient’s room during her hospitalization.

It also might be challenging for some North American therapists to understand and focus on the entire family as a functioning unit, rather than seeing the issues as only between husband and wife. Learning about how “normal family functioning” is defined, especially in terms of roles, hierarchy, and intimacy, is critical to supporting this mother and baby. Cultivating “cultural humility” in working with patients and families from diverse backgrounds is extremely important.

During the hospitalization as the patient improves, a plan for care needs to be developed with the patient and her family. This plan should include adequate support of the mother and her baby. The husband should bring his parents and siblings to an initial meeting early during the hospitalization, being mindful of addressing any HIPAA-related issues. This will allow for a uniform understanding of the patient’s illness and treatment. At this meeting, all family members should express their concerns, worries, beliefs, and perceived barriers to optimal care. If the family members feel listened to, they are more likely to feel understood and adhere to recommendations.

At the initial meeting and subsequent ones, the following questions might be helpful to ask to gather information in negotiating a mutually acceptable treatment plan:

1. What is the family’s understanding of her illness? What do they think may have caused it? How do they understand postpartum psychosis? Do they think there is a role for medication? Are any other alternative healing modalities being considered or used?

2. Who is caring for the baby now? Is the baby healthy? Does the family understand how the mother’s illness affects the baby? Can the family provide adequate care for the baby?

3. How are decisions made in the family? Are there any other issues in the family, such as ill health in a parent?

4. Was this an arranged marriage? How long have they known the patient? Do they care for her? What is the family’s attitude toward her?

5. Besides the mother-in-law, are there other adult females (for example, her husband’s sisters and his brothers’ wives) living in the household? How old is the mother-in-law? Who runs the household? Who does all the work? If possible, it will be important to interview anyone else in the household. How long have the couple and the family been in the United States? Did they all come at the same time?

6. Does the family have a supportive community? What are their beliefs about mental illness? Whom do they trust in their community? A religious leader? A local doctor? Who treats the women in the community?

7. If there is time, other issues can be explored. For example, what were the circumstances of their immigration? What has the transition from Bangladesh to life in the United States been like for the family?

8. Who will care for her at home? Who will ensure she takes her medications? Who will take her to follow-up visits?

There are many unknowns in this case that require further exploration. Time taken to arrange for a medically qualified interpreter and an extended family meeting will help the physician and psychiatric team understand the current situation and set up an appropriate plan of care.

Cultural perspective

The case material raises many questions. In the first place, there is no need to assume that the husband was behaving in a “culturally sanctioned and consistent way.” In a large population like that of Bangladeshi Muslims, significant heterogeneity exists, and there are more ways than one to respond. Although access to care is increasing for some population segments, Bangladesh still has limited mental health services and resources.

What were the reasons for the patient to be admitted to a psychiatric unit? How many days after the delivery? Were there any hostile actions or reactions to the baby? What is the patient’s pregnancy history? What meaning was ascribed to the symptoms and behavior that the patient manifested prior to hospitalization? Was this the first episode of psychiatric illness for the patient? Has she shown any dangerous behaviors before?

The reason why the husband is taking the wife home against medical advice is unclear. What reason did the husband give for this decision? Could stigma toward mental illness or hospitalization play a role? Was an interpreter used to help understand his reasoning? Was the husband dissatisfied about something? This is important, because it is likely that the husband brought the wife for hospitalization in the first place. Were the inpatient physician and nurses male or female, and could gender-related issues have been a barrier to accepting care? Might there have been a Muslim chaplain in the hospital or in the community or someone else who could have served as a cultural broker earlier in the hospitalization to have prevented this impasse?

The Cultural Formulation Interview (CFI) in the DSM-5 and the CFI-Informant Version for family members provide a framework to explore these questions and the questions recommended in the Family Perspective throughout the course of treatment.

Additional relevant questions include the following: What are cultural norms for their expectations for support of a new mother during the postpartum period? What are the norms for who, besides the mother, provides infant care? Are normative postpartum practices possible, or have they been disrupted in the hospital setting and/or in their home? If the mother and baby are both on the unit, is the request motivated by a desire to bring the baby home? If the baby is not on the unit, is this driving the family’s concern?

How isolated will the woman feel when she is home with the baby and her husband is out working as a taxi driver? Are there community-based organizations that the clinicians could collaborate with to provide resources and support for this woman (for example, women’s groups, immigrant groups, religious groups)? This would require learning more about what appeals to her, which groups she might identify with, and what is available in her neighborhood/community that aligns with what appeals to her.

It also would be important to determine if the patient was having any side effects from her psychotropic medications. Many South Asians have a low tolerance for side effects. Did the patient or family have any religious or cultural concerns about how the medications were manufactured or their composition (for example, worries about alcohol content)? Could any of these factors be related to the patient’s possible “cheeking” of her medications?

The major ethical/legal question to address is the patient’s attitude toward and relationship with the baby, and whether she was and is currently a danger to herself or others. Was the baby with the patient in the hospital? Did she feed the baby? What were the signs of psychosis that the patient exhibited, and what were the bases of her diagnosis? Was there an opportunity to discuss these issues with the husband? If so, what was his response?

Unless the patient is found to be dangerous to herself or others, including the baby, there is no option but to discharge. If a Bengali-speaking psychiatrist/therapist could be located within a reasonable driving distance, every effort should be made to connect the two. Husband and wife certainly should be instructed at the first sign of trouble to seek medical/psychiatric assistance, with or without insurance. Is there a possibility of home visits with an interpreter given the potential risks of patient and infant safety? Close follow-up and coordination of care with the patient’s and baby’s primary care physician is needed. Seeking support from the patient’s religious community also is worth considering.

Contributors

Alison M. Heru, M.D. – University of Colorado Denver, Aurora

Ellen Berman, M.D. – University of Pennsylvania, Philadelphia

Annelle B. Primm, M.D., M.P.H. – Johns Hopkins University, Baltimore (adjunct faculty)

Anne E. Becker, M.D., Ph.D. – Harvard Medical School, Boston

Robert C. Like, M.D., M.S. – Rutgers University, Robert Wood Johnson Medical School, New Brunswick

Resources

Farooq S., Fear C. Working Through Interpreters. (Adv Psychiatr Treat. 2003 Mar;9[2]:104-9. doi: 10.1192/apt.01.12 http://apt.rcpsych.org/content/9/2/104.full.)

Chandra P.S. Postpartum Psychiatric Care in India: The need for Integration and Innovation. (World Psychiatry. 2004;3[2]:99-100.)

Ahmad F., Shik A., Vanza R., Cheung A.M., George U, Stewart D.E. Voices of South Asian Women: Immigration and Mental Health. (Women Health 2004; 40[4]:113-130.)

Mantle F. Developing a Culture-Specific Tool to Assess Postnatal Depression in the Indian Community. (Br J Community Nurs. 2003;8[4]:176-180.)

To read about the goals of Curbside Consult, the guiding principles for assessment, and the guidelines for case submission, see “Considering patients’ family, culture,” Clinical Psychiatry News, January 2015, p. 12. The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they are employed by or affiliated with or the Group for the Advancement of Psychiatry (GAP).

This column is in memory of Dr. Prakash N. Desai, who contributed to this piece before his death earlier this year.