Postpartum Psychosis is a serious condition which should be treated as an immediate medical emergency. The presentation of symptoms can unexpectedly appear and escalate quickly. Psychosis impacts an individual’s judgment and causes changes in behaviors, thought processes, speech, and mood. Individuals and families who are impacted by Postpartum Psychosis are typically frightened by the experience but help is available and recovery is possible.
What Is Postpartum Psychosis?
Postpartum Psychosis is a diagnosis used to categorize an episode of mania or psychosis with onset following childbirth. This diagnosis represents a spectrum of psychotic disorders varying in duration, onset, and intensity.1 One or two of 1,000 postpartum women will develop Perinatal Psychosis within the first 2-4 weeks following birth.2 According to a study conducted in 2017, 5% of women diagnosed with Postpartum Psychosis commit suicide and 4.5% commit infanticide, which is defined as killing a child within the first year of birth.3
During a psychotic episode, the woman is experiencing a disconnect from reality and delusions. This disorder must be treated as an emergency with treatment being sought immediately.
Common Symptoms of Postpartum Psychosis
There are varying symptoms that can occur with Postpartum Psychosis which may change rapidly in a short period of time. Having a personal history of being diagnosed with bipolar disorder, depression, schizoaffective disorder or other mood disorders may cause some confusion as the presentation can initially appear to be similar to these disorders.
However, more than half of the women who experience Postpartum Psychosis have no prior history of mental illness and the presenting symptoms are totally new. The onset for Postpartum Psychosis is typically within the first 2-4 weeks following childbirth.
Some of the symptoms of Postpartum Psychosis in their respective categories include:1
Cognitive Features:
- Disorientation
- Poor concentration
- Impaired sensorium
Behavioral Features:
- Hyperactivity
- Agitation
- Emotional distance or coldness
- Lack of self care
Mood:
- Disorganized behavior
- Elated
- Dysphoria
- Depressed (less often)
Speech:
- Rambling
- Tangential (i.e., can’t stay on topic)
Thought Content:
- Thoughts of broadcasting (i.e., belief that others can hear their thoughts)
- Ideas of reference (i.e., drawing personal connections to things that are general and unrelated to their specific state)
- Thoughts of the infant being harmed or killed
- Persecutory delusions (i.e., deep belief that harm is occurring or will occur)
- Jealousy
- Paranoia of being controlled
- Delusions of grandiosity
Thought Process:
- Disorganized
- Flight of ideas (may include continuous rapid and unfocused speech or ideas)
Perceptions:
- Hallucinations
- Commanding auditory
- Visual, olfactory, tactile (e.g., seeing, smelling, feeling things that are not actually present)
Signs of Postpartum Psychosis
Postpartum Psychosis usually presents suddenly, with most cases identified within the first 4 weeks following childbirth. Symptoms and presentations can vary with some common signs including strange beliefs (delusions) and/or hallucinations, heightened irritability, hyperactivity, significant mood changes, poor decision making, decreased need for sleep, and time periods that the individual seems to be acting and responding differently from how they normally would.
It is possible for this presentation to look different based on the individual, and, therefore, it is a good idea to seek a professional evaluation if there is any concern that your loved one is exhibiting these signs.
Some behaviors or changes that could indicate postpartum psychosis include:
- Being more talkative or on the phone an excessive amount
- Racing thoughts or a busy mind
- Trouble sleeping or no need to sleep
- Heightened energy or agitation
- Behaviors that appear to be out of control or out of the normal scope
- Paranoia or being suspicious of others
- Uncharacteristic fixation on religious topics
- Beliefs that the baby is possessed or connected with god or demons in some way
It is important to note that during a psychotic episode, the person fully believes their reality and does not have the same self awareness that they normally would about their mental state.
Postpartum Psychosis vs. Postpartum Depression
More than half of new moms will experience mood changes due to hormonal fluctuations following childbirth. Four of five women will experience “baby blues” categorized by symptoms of tearfulness, mood swings, and exhaustion. Baby blues last anywhere from 2 days to 2 weeks after birth and usually peak between 3 and 5 days after delivery. About 1 or 2 of 10 women will experience Postpartum Depression (PPD).
Some common symptoms of PPD include:
- Depressed mood most of the day
- Feelings of anger
- Irritability or postpartum rage
- Lack of interest in the pregnancy or baby
- Crying and sadness
- Appetite and sleep disturbances
- Loss of interest or pleasure in things that are usually enjoyable
- Feelings of guilt, shame, or hopelessness
- Thoughts of harming the baby or oneself
Postpartum Psychosis is both rarer and more severe than Postpartum Depression. Postpartum Psychosis typically begins a few days after giving birth through the first few weeks—it is not typical for symptoms to begin later. Symptoms can cycle within the span of a few hours. Presentation usually includes mood changes such as depression, mania, or a mixture of the two before progressing to psychosis.
One similarity between Postpartum Depression and Postpartum Psychosis is the presentation of suicidal or homicidal thoughts. One of the main differences between these symptoms is the impairment to thought content and processes (i.e., the belief during a psychotic episode) which can result in a higher possibility of acting on these thoughts.
What Causes Postpartum Psychosis?
While there is no definitive answer regarding the cause for Postpartum Psychosis, we do know that genetics, pregnancy hormones, and clinical circumstances all play a role. Women with a history of bipolar disorder (or postpartum bipolar disorder), psychotic illness, or previous postpartum psychosis are at higher risk of relapse in the postpartum period.4
Studies have shown that sleep deprivation can produce symptoms of acute psychosis in healthy individuals, thus adding to the evidence linking sleep and psychosis, as well as the implications of prolonged sleep loss being a precursor of psychosis.6 The postpartum period is a time where sleep deprivation is very common and, therefore, support and resources during this time are important as quality sleep is essential in reducing the risk for postpartum psychosis.4
Risk Factors that Increase Likelihood of Postpartum Psychosis
The following factors can increase the likelihood of postpartum psychosis:
- Previous Postpartum Psychosis, General Psychosis, or Bipolar Episodes
- Family history of bipolar disorder or postpartum psychosis
- First baby
- Perinatal or neonatal Loss
- Sleep deprivation
- Discontinuation of mood stabilizers for bipolar disorder
- Obstetric complications
When & How to Get Help for Postpartum Psychosis
A psychotic episode is considered a life-threatening psychiatric emergency, therefore requiring immediate medical attention. Since the individual is at risk for harming herself, her baby, or others, being seen for an evaluation by a medical professional immediately is very important. Women who have a history of psychosis should seek treatment as soon as possible to ensure that they are monitored for any relapse in symptoms.
Getting treatment for Postpartum Psychosis episodes early allows for a greater chance of recovery and lessens the chances of the episode becoming severe.
When to Seek Treatment
When Postpartum Psychosis is present, the woman is experiencing delusions and beliefs that are not aligned with reality but usually do make sense to her in the moment. These delusions can take on many different forms and can present in destructive ways. Even if the presentation is primarily non-harmful to herself and others, there is still a risk for danger because the woman is most likely experiencing delusional thoughts and has impairments to her judgment.
For this reason, it is recommended that assessments are completed quickly and that the individual is monitored by a trained perinatal mental health professional well into the postpartum period.
Treatment for Postpartum Psychosis
Treatment for Postpartum Psychosis most commonly involves an introduction of psychotropic medications to eliminate psychotic symptoms. Women who have recovered from this illness have noted that having the right medication regimen was the key to successful recovery. In some cases, more than one medication is used and a period of hospitalization may be indicated for stabilization.
Studies have found that individuals experiencing a first episode of psychosis usually show a good symptomatic response to antipsychotic treatment.5 The most severe symptoms of Postpartum Psychosis often last between 2 and 12 weeks, although full recovery can take up to a year.
Following the birth of a baby, sleep is drastically interrupted and this can cause worsening of mental health symptoms, including psychosis. If there is a history of psychosis or any of the associated risk factors, it is crucial to protect sleep during this very delicate time. Due to the safety risks involved, treatment for Postpartum Psychosis almost always requires continuous treatment throughout pregnancy and postpartum.4
In addition to medications, some treatment modalities that can help in the recovery process include intensive outpatient groups, as well as individual therapy with a trained mental health professional. These modalities assist the woman in processing the events of the psychotic episode, identify and treat mental health symptoms that may arise, establish routines that support her recovery, promote healing and wellness in relationships/new roles, and help to maintain stability as she moves forward.
Medications Used to Treat Postpartum Psychosis
There are various groups of medications that are used to treat Postpartum Psychosis. Two of these groups include Atypical Antipsychotics and Typical or First-Generation Antipsychotics. It is recommended that women with histories of Bipolar Disorder, psychotic illness, or previous Postpartum Psychosis remain on medication throughout pregnancy to avoid postpartum relapse.4 Although there were no significant differences between atypical and typical antipsychotic agents in discontinuation rates or symptom control, studies have found differences in adverse effects.5
- Typical, or First-Generation Antipsychotics: This group of drugs were developed in the 1950s. Some common examples include Haldol (haloperidol) and Thorazine (chlorpromazine). These medications are often not used in pregnancy unless needed for sedation in a psychotic episode.
- Atypical, or Second-Generation Antipsychotics: This group of drugs were developed in the 1990s. Some common examples include Risperdal (risperidone), Seroquel (quetiapine), Abilify (aripiprazole), Geodon (ziprasidone), and Zyprexa (olanzapine)
Other Treatments for Postpartum Psychosis
Medications are a first line of defense when it comes to the treatment of Postpartum Psychosis, however there are several other treatments or lifestyle choices that promote wellness and recovery from psychosis. Sleep is an integral part in any individual treatment plan. Without sleep, medications can not work effectively. It is hard for new mothers to feel better without adequate sleep.
Ongoing treatment with a trained perinatal mental health professional can also provide the support that is needed to recover from a psychotic episode in the postpartum period. Some examples of the treatment objectives include:
- Support for bonding with the baby
- Processing feelings of shock, guilt, embarrassment, or shame related to the episode
- Adjusting to taking medication(s) daily
- Balancing new roles in motherhood
- Learning how to improve confidence
- Coming to terms with any shocking or traumatic behavior
Another helpful tool for moms who have gone through Postpartum Psychosis is to join a support group of other women who have had similar experiences. Loneliness, isolation, and shame are often difficult to let go of. Hearing other people share their stories, experiences, and triumphs can help to build up confidence and strength in a time when it is hard to find it on your own. It is normal for moms to feel sadness about losing time in the early weeks of their baby’s life due to Postpartum Psychosis. Talking with a therapist, physician, support group, or loved one can help to process these feelings of loss.
Outlook for Those With Postpartum Psychosis
With the right treatment in place, women do recover from Postpartum Psychosis. The year following a psychotic episode can have many ups and downs. Re-establishing confidence can take time. It is recommended that healthy routines are established to promote a sense of security and progress.
Depression can often occur and is a common reaction to traumatic experiences. Changes in brain chemistry and hormonal shifts also contribute to ongoing symptoms. Staying committed to treatment modalities that improve symptoms and progress is crucial during this time.
Thinking about subsequent pregnancies can be really difficult for a couple who has gone through Postpartum Psychosis. It is important to remember that there is no right or wrong answer in regards to family planning decisions and the consideration of Postpartum Psychosis. Since the likelihood of experiencing a psychotic episode again is elevated, if a couple does decide to try for another baby, the recommendation is to include their healthcare providers—including therapists—in all steps of the process.
Close monitoring of medication, symptom management, and support will be crucial to ensure safety through the process. Action on Postpartum Psychosis offers a free guide for pregnancy planning and can be a helpful support.
Postpartum Psychosis is temporary and treatable with professional help. It is an emergency and requires immediate attention. If you or someone you know may be suffering from Postpartum Psychosis, call your medical provider or an emergency crisis hotline right away so that you can get the help you need.
People in Crisis: Call your local emergency number or The National Suicide Prevention Hotline at 1-800-273-TALK (8255)
For Further Reading
If you or a loved one are impacted by Postpartum Psychosis, these resources may be helpful:
- Postpartum Support International (PSI): Provides support, local resources, and information for perinatal mood and anxiety disorders. PSI also has Postpartum Psychosis Coordinators to provide additional assistance to women and families who are not in an emergency situation.
- Action on Postpartum Psychosis (APP): Charity for women and families affected by Postpartum Psychosis (PP). Provides peer support, information, training and research.
- The Postpartum Psychosis Program at Massachusetts General Hospital (MGHP3): Postpartum Psychosis information, resources, research, and survivor’s stories
- MothertoBaby: Information about medications during pregnancy and breastfeeding
Postpartum Psychosis Infographics
