Synonym: puerperal psychosis
Postpartum psychosis is a severe mental illness which develops acutely in the early postnatal period. It is a psychiatric emergency. Identifying women at risk allows development of care plans to allow early detection and treatment. Management requires specialist care. Health professionals must take into account the needs of the family and new baby, as well as the risks of medication whilst breast-feeding.
Postpartum psychosis is a severe mental illness which develops acutely in the early postnatal period, usually within the first month following delivery. Psychotic features are present. There is a close link with bipolar disorder.
Postpartum psychosis occurs following 1-2 per 1,000 deliveries.[1, 2]Women have a higher risk of psychosis in the few weeks following childbirth than at any other time in their lives. Incidence is significantly increased in women with a history of hospitalisation for psychiatric illness, especially where the past history was related to pregnancy.Women with a family history of postpartum psychosis have been found to have a six-fold increased risk themselves.This is even higher if they have a first-degree relative with bipolar disorder.
Suicide and psychiatric conditions are known to be significant leading causes of late maternal death in the UK, and awareness of mental health problems in pregnancy and the postnatal period is vital.It is planned that psychiatric causes will be a focus of the 2015 report into maternal deaths, now published by Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK).
Women at high risk of postpartum psychosis include those with:
- A past history of postpartum psychosis.
- A past history of bipolar disorder.
- A family history of postpartum psychosis or bipolar disorder.
It is thought that postpartum psychosis may be a manifestation of underlying bipolar disorder. Possible contributing factors include sleep deprivation, hormonal changes, stress and genetic influences.
Presentation is typically within the first postnatal month. Previous publications of the Confidential Enquiry into Maternal Deaths have highlighted how rapid the transition can be between symptoms of mild anxiety to severe psychosis.As a result of this the diagnosis can be easily missed. All significant changes to mental state in the postnatal period should be closely monitored, and should trigger referral to specialist services.
Symptoms may be depressive in nature (withdrawal, confusion, loss of competence, distraction, catatonia) or manic (elation, lability, agitation, rambling). There may be delusions (paranoia, jealousy, persecution, grandiosity). There may be hallucinations which may be auditory, visual, olfactory or tactile. There may be odd beliefs about the baby.
Other psychiatric causes for symptoms include:
- Major depression with psychotic features.
- Bipolar disorder with postpartum onset (debatable whether this is indeed usually the case, or whether it is a condition in its own right).
- Ischaemic or haemorrhagic stroke.
- Electrolyte imbalance such as hyponatraemia or hypernatraemia.
- Hypoglycaemia or hyperglycaemia.
- Thyroid or parathyroid abnormalities (hyperthyroidism, hypothyroidism, hypercalcaemia, hypocalcaemia).
- B12, folate or thiamine deficiencies.
- Side-effects of medication.
Investigation to confirm the diagnosis will be in secondary care, and guided by presentation, but will include blood tests and possibly CT/MRI scanning.
Postpartum psychosis is a psychiatric emergency. It requires urgent assessment, referral, and usually admission, ideally to a specialist mother and baby unit.
Management is primarily pharmacological, using the same guidance as for other causes of psychosis. Medication would normally involve an antipsychotic and/or mood stabilising drug. However, choice of medication must take breast-feeding into account. Mothers requiring lithium treatment should be encouraged not to breast-feed, due to potential toxicity in the infant. Most antipsychotics are excreted in the breast milk, although there is little evidence of it causing problems. Where they are prescribed to breast-feeding women, the baby should be monitored for side-effects. Clozapine is associated with agranulocytosis and should not be given to breast-feeding women. Electroconvulsive therapy (ECT) may also be considered in some cases.
Education and supportive therapy for the woman and her family are important. There is no role for psychotherapy in the acute phase of the illness, but supportive psychotherapy may be of value during and after recovery. Child protection services may need to be alerted, and discharge should only occur with close follow-up in place.
Both National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) guidelines prioritise early detection of women at high risk of mental health illness during and after pregnancy. NICE guidelines advise that at first contact with health professionals in pregnancy and in the postnatal period, women should be asked about:
- Past or present mental illness.
- History of treatment by a specialist mental health team.
- History of severe perinatal mental illness in first-degree relatives.
Women with a history of severe mental illness should be referred to a secondary care mental health service. Women with a personal or family history of severe mental illness or perinatal illness should be monitored closely in the postnatal period. There should be a written care plan in place, involving the specialist mental health team, and decided in collaboration with the woman and her family. The woman and all involved professionals should have a copy. It should lay out key contact details, the monitoring plan, and goals/outcomes and how these will be assessed.
There is not yet evidence to support the use of prophylactic psychotropic medication to prevent postpartum psychosis in high risk women.
Prognosis for complete recovery is good, although there is significant risk of recurrence (1 in 2) after subsequent pregnancies. Women who have been diagnosed with postpartum psychosis should be monitored very closely and referred early if they become pregnant again.
Further reading and references
Bipolar disorder - the assessment and management of bipolar disorder in adults children and young people in primary and secondary care; NICE Clinical Guideline (Sept 2014, updated 2016)
Psychosis and schizophrenia in adults: treatment and management; NICE Clinical Guideline (Feb 2014)
Perinatal Mental Health Toolkit; Royal College of General Practitioners
Management of perinatal mood disorders; Scottish Intercollegiate Guidelines Network - SIGN (March 2012)
Antenatal and postnatal mental health: clinical management and service guidance; NICE Clinical Guideline (December 2014)
Harlow BL, Vitonis AF, Sparen P, et al; Incidence of hospitalization for postpartum psychotic and bipolar episodes in women with and without prior prepregnancy or prenatal psychiatric hospitalizations. Arch Gen Psychiatry. 2007 Jan64(1):42-8.
Munk-Olsen T, Laursen TM, Pedersen CB, et al; Family and partner psychopathology and the risk of postpartum mental disorders. J Clin Psychiatry. 2007 Dec68(12):1947-53.
Saving Lives, Improving Mothers’ Care - Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-2012; MBRRACE-UK, Dec 2014
Sit D, Rothschild AJ, Wisner KL; A review of postpartum psychosis. J Womens Health (Larchmt). 2006 May15(4):352-68.
Saving Mothers' Lives. Reviewing maternal deaths to make motherhood safer: 2006-2008; Centre for Maternal and Child Enquiries (CMACE), BJOG, Mar 2011
Jones I, Shakespeare J; Postnatal depression. BMJ. 2014 Aug 14349:g4500. doi: 10.1136/bmj.g4500.
Focht A, Kellner CH; Electroconvulsive therapy (ECT) in the treatment of postpartum psychosis. J ECT. 2012 Mar28(1):31-3. doi: 10.1097/YCT.0b013e3182315aa8.
Essali A, Alabed S, Guul A, et al; Preventive interventions for postnatal psychosis. Cochrane Database Syst Rev. 2013 Jun 66:CD009991. doi: 10.1002/14651858.CD009991.pub2.
Ian Jones, Sue Smith; Puerperal psychosis: identifying and caring for women at risk, BJPsych Advances, October 2009