Postpartum Psychosis

What is postpartum psychosis?

Postpartum psychosis is also called postnatal psychosis or puerperal psychosis and is a very rare mental illness that occurs in just 1-2 out of every 1000 women who give birth ^[1]. It is a serious psychiatric emergency that warrants immediate medical attention and can rapidly become more severe. Furthermore, postpartum psychosis can put the mother and baby at risk of harm. Postpartum psychosis is very rare, but if someone is going to develop this psychiatric disorder, they will usually know within the first two weeks following pregnancy because it tends to develop rapidly within the first few days. In rarer cases, symptoms can also present later ^[2]. The causes of postpartum psychosis, and the reasons why such a small percentage of women develop this mental health condition following pregnancy while others do not, are largely unknown. However, research shows that women with a history or familial history of psychosis, schizophrenia and bipolar are the most at risk.

Symptoms of postpartum psychosis

Postpartum psychosis can manifest differently from person to person, and no two people will have the same experience. However, below are listed some of the symptoms that are typical of postpartum psychosis. People who experience this mental health condition will have a combination of some of the symptoms included below. 

Postpartum psychosis is not currently defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) as a unique diagnosis. Still, it is listed in the ‘short psychotic disorder’ section as a subset of schizophrenia and other psychotic disorders. In addition, work is currently underway by various groups specializing in this field to give it its separate diagnosis. 

Some of the symptoms of postpartum psychosis include the following:

• Insomnia or not wanting to sleep
• Hypomanic mood, including feelings of excitement
• Loss of inhibitions
• Severe mood changes,such as fluctuating between a depressive mood and a manic mood
• Depressed mood or feeling tearful
• Obsessive thoughts about the baby
• Delusions
• Lack of touch with reality
• Hallucinations
• Disorganized behavior and confusion
• Paranoia or suspicious behavior or thinking
• Psychomotor agitation
• Change in appetite (usually decreased)
• Catatonia (a disruption of one’s awareness of the world around them characterized by abnormal movements, immobility, abnormal behaviors, and withdrawal)
• Suicidal or homicidal ideation in rarer cases 

Symptoms usually develop very rapidly after pregnancy. A recent study observed that 73% of women developed symptoms within the first 3 days after giving birth. These symptoms were most commonly hypomanic symptoms, with women noticing initial signs developed as feeling excited, elated or high (52%), feeling unable to sleep or not needing to sleep (48%), being more talkative (31%) and feeling more energetic (37%) ^[2]. These can later develop into delusions, hallucinations and other symptoms of postpartum psychosis.

Postpartum psychosis is one of the rarest mental disorders, and, in very severe cases, it can lead to infanticide or suicide and is considered a serious medical emergency. Around 4% of women who experience postpartum psychosis commit infanticide and 5% commit suicide ^[4],^[3]. These very rare, shocking and severe symptoms are due to the lack of judgment, rationality, and delusions experienced during postpartum psychosis.

It is important to state that most people who experience this disorder’s delusions are very rarely harmful or destructive. However, these delusions contribute to the significance of this psychiatric illness as a medical emergency.

Who is at risk of getting postpartum psychosis?

The risk of experiencing postpartum psychosis is very small. Still, evidence suggests that women with a personal or family history of schizophrenia and bipolar are significantly more at risk of developing postpartum psychosis than those without. Studies show that women who have already experienced schizophrenia have a 25% chance of developing postpartum psychosis ^[5], while women with bipolar disorder have a 20-30% chance of developing postpartum psychosis ^[6]. Furthermore, those women who have both bipolar disorder, as well as a first-degree relative with schizophrenia, have the highest rate of developing postpartum disorder at 74%. People who have already experienced postpartum psychosis in a previous pregnancy are also at risk of experiencing it again, with the rate of recurrence exceeding 50% ^[7].

If you are thinking of having a baby and have experienced bipolar, schizophrenia, psychotic disorders or have a family history of any of these, it is advised to speak to a medical professional like your local primary care provider, midwife, or a mental health provider to get the appropriate support during this life-changing time. Suppose you are already taking medication for these, such as antidepressants, antipsychotics, or mood stabilizers. In that case, your healthcare provider can support you in safely adjusting your medication, if necessary, to meet the needs of both you and your baby during the pregnancy and breastfeeding periods. You must consult your healthcare provider and adhere to their advice before making any changes.

Your primary or other healthcare provider will arrange staggered check-ups to ensure that you are on track and receiving the appropriate medical care to prepare you for having a baby. This might include meeting regularly with your midwife, primary, and a mental health professional such as a counselor or therapist to get the support you need.

You can do many things to reduce the risk of postpartum psychosis when having a baby, and your doctor will support you in taking the most effective steps.

Diagnosing postpartum psychosis

Due to the severe nature of this rapidly developing disorder, if you think you might be exhibiting symptoms of postpartum psychosis or know anyone that is, you must seek medical advice immediately by going straight to the doctor (on the same day) or calling emergency medical services. Postpartum psychosis is generally temporary, and the sooner it is treated, the better. However, it can deteriorate your mental health rapidly if left untreated. If you have already seen the doctor and been told that you do not have a postpartum diagnosis, but your symptoms get worse, make sure you go back to the doctor for reassessment.

Diagnosing postpartum psychosis usually entails an assessment with a medical professional. If your doctor finds it appropriate, then blood tests or other physical tests such as MRI testing might also be relevant in order to rule out any other causes of your symptoms.

Treating postpartum psychosis

If someone is diagnosed with postpartum psychosis, they are usually taken to a mother and baby unit (MBU) so that the person with the diagnosis can be treated with their baby. In some cases, if no beds in the MBU are available, the mother would be taken to a psychiatric ward until a bed becomes available. In these cases, a partner, friend or a member of the family would need to care for the baby while the mother is being treated in the psychiatric ward. Social workers can find temporary care for your baby if this is not an option.

In most cases, postpartum psychosis is treated with a combination of talking therapy and medication. It is most often treated in a hospital or other medical facility, i.e., MBU or psychiatric ward for the first few days.

Common medications used to treat postpartum psychosis are listed below and are used on their own or in combination with each other:

• Antipsychotics help to treat psychotic and manic symptoms, including hallucinations and delusions. Examples include risperidone, aripiprazole, olanzapine, and ziprasidone.
• Mood stabilizers include medications such as lithium to calm extreme manic and depressed moods. Other examples include lamotrigine, divalproex sodium, and carbamazepine.
• Antidepressants, such as SSRIs, can be used alongside mood stabilizers to treat symptoms of depression and help to support an improved night’s sleep.

Certain medications cannot be taken while breastfeeding, so it is important to ensure your doctor or psychiatrist is aware if you are in this situation so that they can ensure prescribed treatment is safe for both you and the baby.

Talking therapy is also recommended during and after experiencing postpartum psychosis. It can be distressing and confusing both during the experience of postpartum psychosis and after, so it is advised to seek support from a therapist specializing in people who have experienced bipolar, schizophrenia or psychosis. There are lots of effective therapeutic approaches for and following this type of condition, and they might include cognitive behavioral therapy (CBT), solution-focused therapies, or acceptance and commitment therapy (ACT).

It might also be helpful to speak to peers or others who have had similar experiences of postpartum psychosis. You can do this by joining a support group, either in person or online, of people who have experienced postpartum psychosis or other disorders involving temporary psychosis or symptoms of postpartum psychosis.

In rare cases, if none of these treatments result in sufficient improvement, electroconvulsive therapy (ECT) may be an effective treatment. This treatment is used as a last resort or in very extreme cases.

Most people with postpartum psychosis fully recover once treated, and this disorder is generally thought of as temporary. However, if you have experienced postpartum psychosis and are planning on having another baby, the recurrence rate is higher.

How does postpartum psychosis differ from postnatal depression?

Both postpartum psychosis and postnatal depression are mental health disorders after pregnancy. Postpartum depression occurs at least two weeks after giving birth, while postpartum psychosis usually develops within the first days or week after giving birth. Postpartum depression gradually gets worse, while postpartum psychosis usually becomes more acute rapidly. While postpartum depression is very common, postpartum psychosis is extremely rare. Usually, it involves hypomanic moods, delusions, hallucinations and a confused sense of reality (see the symptoms section above for more details). Depression typically has symptoms of depressed or low mood, lack of energy and loss of interest in usual activities.

How common is postpartum psychosis?

Postpartum psychosis is an extremely rare disorder that only occurs in around 0.1-2% of women who give birth. It most commonly develops among those who have a history of bipolar, schizophrenia or psychotic episodes or among those with a familial history of these disorders. Therefore, for most women planning to give birth, postpartum psychosis is not something to worry about. However, if you have had a history of any of these conditions or have family members who have experienced them, it is recommended to seek support prior to having a baby in order to get the help needed throughout this process.

How to help someone with postpartum psychosis

If you know someone who might be experiencing postpartum psychosis, remember that it is not their fault and they are experiencing a mental disorder. They might behave out of character or be experiencing any of the symptoms listed above. The best thing you can do is ensure they seek immediate medical support, as the psychotic symptoms of this condition can increase in severity quickly. It can be disturbing, confusing and isolating to experience postpartum psychosis. Here are some things you can do to support someone who is going through this challenging time:

• Stay calm and encourage them to seek medical attention
• Offer soothing support in the form of someone to listen to them
• Help them to remove stressors in their life and ensure their environment is as safe and relaxing as possible
• Offer to help them in caring for their baby
• Offer to support them with household tasks such as doing the shopping and cleaning
• Offer to help them to get as much sleep as possible - this might include helping with nighttime feeds and caring for the baby at night
• Help them to find a peer support group once they have returned home

Supporting someone exhibiting signs of postpartum psychosis can be stressful, and there are support groups for partners and people supporting others with postpartum psychosis. If you find it challenging and want support, speak to your medical provider or look for peer support groups. They can provide beneficiary advice and support during this time.