What is postpartum psychosis?
Postpartum psychosis (also known as puerperal psychosis or postnatal psychosis) is a serious mental illness which occurs in a few women in the days or weeks following childbirth. It is extremely important to diagnose and treat it early, as it is a severe illness which puts both the mother and the new baby at risk.
It happens to about one out of every thousand women after having a baby. It is completely different to baby blues and postnatal depression. It usually starts within the first month after the baby is born.
What are the symptoms of postpartum psychosis?
"Postpartum" means "after childbirth". "Psychosis" means you lose touch with reality in a way which causes your thoughts and actions to become bizarre and, in some cases, dangerous. When psychosis happens after having a baby, there may be a number of symptoms, such as:
- Mood changes. Your mood may become low or excessively high. If you feel low, this may make you feel down and tearful. You may not want to do anything and you may not want to see other people. In other people with postpartum psychosis, mood may be excessively high, or "manic". If this is the case you may feel elated, jittery, agitated, and unable to keep still or stop talking. Your mood may suddenly change between being low and being high.
- Difficulty in concentrating or focusing. You may feel confused.
- Trouble sleeping.
- Paranoid thoughts. You may feel that you cannot trust family or friends, and that there is a conspiracy against you. You might feel people are going to harm you in some way, or stop you doing what you need to do.
- Hallucinations. This means experiencing things which aren't real. For example, you might hear voices which nobody else can hear, or see things or people nobody else can see. You may also smell or feel things which are not real.
- Odd beliefs. You might have unusual beliefs (delusions). For example, you might think you or your baby are possessed, or particularly special in some way. You might think you have lots of money which you don't actually have. You might develop a strong religious belief that you never had before. You might feel you have to harm yourself or your baby. You might feel you are getting messages from God, or from the radio or TV, telling you to do certain things.
- Losing normal social inhibitions. You may behave in a way which seems perfectly reasonable to you but that causes concern to everybody around you.
- Not recognising that you are unwell and not your normal self.
What causes postpartum psychosis?
Nobody really knows. It is more likely if someone in your family has had postpartum psychosis, so your genetic makeup may be part of the reason. It may be that hormones are involved, or the lack of sleep which tends to be part of having a new baby. Probably a number of things cause the condition when they come together.
You are more likely to develop postpartum psychosis if:
- You have had postpartum psychosis in the past, after a previous pregnancy.
- A close relative has had postpartum psychosis.
- You have been diagnosed with bipolar disorder in the past.
- You have been diagnosed with schizophrenia in the past.
Are any tests needed?
Usually postpartum psychosis is diagnosed by the specialist doctors talking to you and finding the typical type of symptoms. However, sometimes these symptoms can be caused by other conditions, so sometimes other tests may be needed to be sure there is not another cause. For example, sometimes the following might be done:
- Blood tests for sugar and sodium levels. Low sugar levels (hypoglycaemia) and low sodium levels (hyponatraemia) can cause odd behaviour.
- Thyroid blood tests. Very low or very high thyroid levels can cause mood changes.
- Blood tests for vitamin deficiencies (for example, vitamin B12, folate or thiamine).
- Computerised tomography (CT) or magnetic resonance imaging (MRI) scanning to rule out causes in the brain such as strokes.
How is postpartum psychosis treated?
Postpartum psychosis is regarded as an emergency, meaning it is a serious condition needing urgent treatment. If you are diagnosed with postpartum psychosis you would normally be admitted to hospital for specialist care. In the UK, ideally you would be admitted to a specialist mother and baby unit. Normally your baby would be admitted with you, and you would have help from the specialist staff on the unit with looking after your baby.
Usually medication is needed to treat postpartum psychosis. An anti-psychosis medicine is usually used. A mood-stabilising medicine may also be helpful. If you need one of these medicines and are breast-feeding your baby, your specialist will discuss options with you. For obvious reasons, most medicines cannot be tested on pregnant or breast-feeding women to find out whether they harm the baby. So there is limited information on how safe some of these medicines are in women who are breast-feeding. Some are known to be harmful, and if you need to take one of these medicines, you would be advised not to breast-feed. Examples include lithium and clozapine. Others are not known to be harmful, and if you choose to breast-feed, your baby would be closely monitored for any ill effects.
In some people, a type of shock treatment called electroconvulsive therapy (ECT) may be an option.
You and your baby will need plenty of support, both while you are an inpatient, and once you are discharged. In the UK, your health visitor and the community psychiatric nurse (CPN) from your mental health team will help keep an eye on you both and provide practical support and advice. You may also be referred to the Children and Families part of Social Services. Having postpartum psychosis does potentially put your child(ren) at risk of harm when your mind is not in its normal state. You are not being referred for your baby to be taken away, but so that the Social Services team can support you in keeping your baby (and any other children) safe.
What is the outlook?
The outlook (prognosis) is fortunately usually very good. As long as women with postpartum psychosis are treated early, they usually make a full recovery. Normally they return to being able to look after their family in a healthy state of mind. However, should you become pregnant again in the future, you are quite likely to develop postpartum psychosis once again.
Can postpartum psychosis be prevented?
Not as such. However, it is very important to flag up a risk of postpartum psychosis early on in pregnancy, and to pick it up very early should it occur. Doing so will prevent much of the harm which can be caused by postpartum psychosis.
You may find you are asked in early antenatal clinic appointments about your own and your family history of mental health problems. If you are at high risk of developing postpartum psychosis (if, for example, you or a close family member have had it in the past) a plan will be put in place early on. The professionals looking after you in your pregnancy, and the professionals from the mental health team, will make this plan with you and you will agree together how best to prevent any problems arising. This will include how you will be monitored during pregnancy and afterwards, and will give you contact details so you know who you should contact if you become unwell. You can also use this opportunity while you feel well in yourself to make decisions about medication and breast-feeding.
If you are considering pregnancy and are already on an antipsychotic or mood-stabilising medicine, you should discuss this with your specialist before becoming pregnant. You can discuss the pros and cons of staying on your medicine, and it may be necessary to change to a different medicine before you get pregnant.
Further reading and references
Management of perinatal mood disorders; Scottish Intercollegiate Guidelines Network - SIGN (March 2012)
Dennis CL; Preventing and treating postnatal depression. BMJ. 2009 Jan 15338:a2975. doi: 10.1136/bmj.a2975.
Antenatal and postnatal mental health: clinical management and service guidance; NICE Clinical Guideline (December 2014)
Depression in adults: recognition and management; NICE Clinical Guideline (April 2016)
Prenoveau JM, Craske MG, West V, et al; Maternal postnatal depression and anxiety and their association with child emotional negativity and behavior problems at two years. Dev Psychol. 2017 Jan53(1):50-62. doi: 10.1037/dev0000221.
Milgrom J, Holt CJ, Gemmill AW, et al; Treating postnatal depressive symptoms in primary care: a randomised controlled trial of GP management, with and without adjunctive counselling. BMC Psychiatry. 2011 May 2711:95. doi: 10.1186/1471-244X-11-95.
Dennis CL, Dowswell T; Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database Syst Rev. 2013 Feb 28(2):CD001134. doi: 10.1002/14651858.CD001134.pub3.
Depression - antenatal and postnatal; NICE CKS, September 2015 (UK access only)
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
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.
Gressier F, Rotenberg S, Cazas O, et al; Postpartum electroconvulsive therapy: a systematic review and case report. Gen Hosp Psychiatry. 2015 Jul-Aug37(4):310-4. doi: 10.1016/j.genhosppsych.2015.04.009. Epub 2015 Apr 16.
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