Postpartum Psychosis

What postpartum psychosis is

Postpartum psychosis is a psychiatric emergency in which a woman loses touch with reality after having a baby. Most episodes are closely related to bipolar disorder: the mood is often high (manic), low (depressed) or a confusing mix of both, with psychotic symptoms on top. Many women have no history of mental illness before.

It is different from the common, mild "baby blues" and from postpartum depression. It is not caused by anything the mother did and is not a sign she is a bad parent.

Symptoms

Symptoms usually start abruptly, within days of birth, and can change hour by hour.

Early warning signs

• Not being able to sleep, or not feeling the need to, even when given the chance
• Feeling unusually excited, energetic or "high", or very anxious and restless
• Racing thoughts, talking much more or faster than usual
• Feeling that something is not right, or perplexity about everyday things

Psychotic and mood symptoms

• Delusions: strong false beliefs, for example that the baby has been swapped, is special or evil, that she has a special mission, or that people are plotting against her
• Hallucinations: hearing voices, seeing things or smelling things that are not there
• Confusion: disorientation, difficulty following conversations, appearing "not herself"
• Mania: grandiosity, overactivity, reduced need for sleep, impulsive or uninhibited behavior
• Depression: withdrawal, tearfulness, hopelessness, sometimes not speaking or eating
• Paranoia and suspicion, including of close family or health staff
• Lack of insight: she may not realize she is unwell

Postpartum psychosis vs depression vs baby blues

See postpartum depression and baby blues for those conditions.

Causes and risk factors

The exact cause is unknown. The rapid fall in pregnancy hormones after birth, sleep loss, immune changes and genetic vulnerability all seem to play a part.

Risk is highest with:

• Bipolar disorder: about 1 in 5 women with bipolar disorder have a severe postpartum episode
• Previous postpartum psychosis: around 1 in 2 chance of recurrence after a future birth
• Family history: a mother or sister with postpartum psychosis or bipolar disorder
• Schizoaffective disorder or past psychosis
• First baby
• Stopping mood-stabilizing medication during pregnancy
• Complications at birth and severe sleep deprivation may contribute

How it is diagnosed

Diagnosis is made by a psychiatrist based on symptoms, how they began, and history from the woman and her family. Doctors also check for physical causes of confusion or psychosis:

• infection, including postpartum infections and sepsis
• thyroid problems, including postpartum thyroiditis
• anemia, low sodium, low blood sugar, low calcium
• drug or alcohol effects, or withdrawal
• brain causes such as encephalitis, stroke or eclampsia (seizures from preeclampsia)

Blood tests, a physical exam and sometimes brain imaging or other tests are done.

Treatment

Hospital care

Most women need admission. Where available, a specialist mother and baby unit lets the baby stay with the mother while she is treated, supporting bonding and feeding. Otherwise, a general psychiatric ward is used with family caring for the baby.

Medicines

• Antipsychotics to reduce hallucinations, delusions and agitation
• Mood stabilizers such as lithium, often very effective for postpartum psychosis
• Benzodiazepines short-term for sleep and agitation
• Antidepressants if depression is prominent, usually combined with a mood stabilizer

Breastfeeding decisions depend on the medicines chosen and how unwell the mother is. Many medicines are compatible with breastfeeding; this is discussed individually.

Electroconvulsive therapy (ECT)

ECT works quickly and is used when symptoms are severe, life-threatening or not responding to medicines.

Psychological and family support

Once the acute illness settles, therapy, peer support and practical help at home aid recovery. Partners and family also need information and support.

Recovery and outlook

The most severe symptoms usually last 2 to 12 weeks. Full recovery can take 6 to 12 months, with periods of low mood, anxiety and lost confidence along the way. Most women recover completely and go on to bond well with their babies.

The risk of another episode after a future birth is about 50%, and some women later have episodes of bipolar disorder unrelated to pregnancy. Planning with a perinatal psychiatrist before or early in a future pregnancy, sometimes including preventive medication started right after birth and protecting sleep, can greatly reduce that risk.

Frequently asked questions

What are the first signs of postpartum psychosis?

Often severe insomnia, feeling unusually energetic or excited, racing thoughts, restlessness and acting out of character, usually within the first few days to 2 weeks after birth. These can quickly progress to confusion, hallucinations and delusions. Early signs need same-day medical assessment.

How long does postpartum psychosis last?

The most severe phase usually lasts 2 to 12 weeks with treatment. Full recovery, including mood and confidence, often takes 6 to 12 months. Most women recover completely, though some have later episodes of depression or bipolar disorder.

Can postpartum psychosis happen without a history of mental illness?

Yes. About half of women who develop postpartum psychosis have no previous psychiatric history. It can be the first sign of a bipolar-type illness. A family history of bipolar disorder or postpartum psychosis raises the risk.

Can you prevent postpartum psychosis?

Not always, but the risk can be reduced in women known to be at high risk. Planning care with a perinatal psychiatrist, deciding about preventive medicines such as lithium after birth, protecting sleep, and close monitoring in the first weeks all help catch and treat early symptoms.

Will a mother with postpartum psychosis harm her baby?

Most women with postpartum psychosis do not harm their babies. The risk of harm to self or baby is real but rare, and it falls greatly with prompt treatment. That is why it is treated as an emergency, with close supervision until the mother is well.