Postpartum psychosis

What is postpartum psychosis?

Postpartum psychosis is also referred to as postnatal psychosis or more formally, puerperal psychosis. While postnatal depression affects around 1 in 7 new mothers, postpartum psychosis affects around 1 to 2 in every one thousand mums.  

Postpartum psychosis is considered a psychiatric emergency that requires urgent attention and treatment.

Postpartum psychosis often occurs in the first few days or weeks after a baby is born, but can also appear later within the first year. 

It is very important that postpartum psychosis is identified, and treatment sought urgently. The condition is very serious and places the mother at risk of harming herself, the baby and/or other children – due to its impacts on her thinking and behaviours.

There are effective treatments available and a full recovery is possible.

Risk factors

While we don’t really know what causes the condition, we do know that women who have a prior diagnosis of bipolar disorder, or who have experienced the condition after previous births, are at greater risk. Some women may however experience the condition with no prior history.

The below table from Royal College of Psychiatrists outlines other known risk factors.

Symptoms of postpartum psychosis

Postpartum psychosis (postnatal psychosis) leads to marked changes in the mother’s behaviour, and can be highly distressing both for the mother experiencing them, and their families. 

Because many people are not aware of the disorder or what the symptoms are, it can be very confusing and alarming for the mother and family.

Early signs or symptoms of postpartum psychosis

Some of the early signs of postpartum psychosis include:

• Finding it hard to sleep

• Feeling full of energy or restless and irritable

• Feeling invincible – strong, powerful and unbeatable

• Having strange and irrational beliefs such as that someone is trying to harm the baby

These symptoms typically begin to emerge from within 2 days to two weeks after giving birth. In some cases the symptoms can develop later.

Over time, the range of symptoms may be followed by a combination of manic, psychotic and/or depressive symptoms which can affect a woman’s energy, thinking, behaviour and mood. 

If you are noticing these symptoms and they seem out of character for you or your partner, talk to your health professional.

Psychotic symptoms

Postpartum psychosis can affect a mother’s thinking and perceptions, resulting in what is known as psychotic symptoms. There are different types of psychotic symptoms. For example, women may state that they are hearing voices or seeing things that are not there (hallucinations) or start to believe things that are not based in reality (delusions).

Experiencing or seeing these symptoms can be very distressing – both for the mother herself, and for the partner and other family members.  At times like this, it is important to remember that they are all part of the condition which can be treated and managed.

Management of postpartum psychosis

Seek help immediately

Postpartum psychosis is a serious mental health condition, and a psychiatric emergency. It's crucial to seek urgent and immediate professional help from a GP, mental health service or hospital emergency department so that timely and appropriate management can stabilise the woman’s energy, thinking, behaviour and moods.

Delays in identification and treatment can mean that treatment becomes longer and more complex. Delays can also pose significant safety risks for both the mother and her baby.

Partners and family members are likely to have to take the lead in accessing treatment. This is because the condition can make it very confusing for the mother and make it difficult for her to see things in perspective; she may not be aware that something is wrong, nor be capable of accessing timely and appropriate help.

Partners and family members are often the first to notice that something isn't quite right and may need to advocate on behalf of their loved one. In addition to accessing help, partners and family members will also need to continue to play a key role in the mother’s ongoing treatment, recovery and care of the baby/children. 

Accessing treatment for Postpartum psychosis

Treatment will almost always require admission to a psychiatric hospital.  This will allow the woman to be in a safe environment where she can be closely monitored by health professionals. 

Some hospitals have mother and baby units which enable the baby to stay with the mother and where both mother and baby can be monitored by health professionals. This allows the mother to remain close to her baby, ensure the needs of the baby are being met and encourages ongoing close contact between them.

Medical treatment

Medication is necessary for the treatment and management of postpartum psychosis. Use of medications requires ongoing monitoring – both on the impact on the mother and her infant. Being in a hospital setting provides this opportunity for close monitoring while the woman stabilises.

A specialist psychiatrist should be consulted when prescribing medications for postpartum psychosis. There are three different types of medications that may be used to treat the range of symptoms.

Mood stabilisers

Mood stabilisers work to stabilise mood and help reduce the likelihood of the symptoms recurring (relapse).The most common mood stabiliser is lithium. Other types of mood stabilisers (which are also used to manage epilepsy) that may be used are sodium valporate, carbamazapine and lamotrigine.

Antidepressants

Antidepressants are used to treat the symptoms of depression that are part of the ‘depression’ part of the disorder.

Antipsychotics

Antipsychotics assist with both manic and psychotic symptoms such as delusions or hallucinations.

It is also important to note that medications should not be prescribed, changed or stopped without discussion with a specialist psychiatrist. They are best placed to assess the risks and benefits of the range of treatments for the mother and her baby.

Medications and Breastfeeding

If breastfeeding, it is important to discuss this with the specialist health professional. Some particular medications (sodium valporate and clozapine) are not recommended. Other medications (such as lithium) should be used cautiously, and their impact on the mother and baby (if breastfeeding) needs to be monitored closely.

Recovery from postpartum psychosis

It's common to feel a range of emotions following postpartum psychosis, including grief, confusion, shame and sadness. Recovery can be slow and take time.

Recovering from the most severe symptoms of postpartum psychosis generally takes  between two weeks to twelve weeks (three months) depending on the individual, severity of your symptoms and your response to treatment. The time taken for a full recovery, however, can be much longer and stem from between six to twelve months or even longer.

It is recommended that recovery requires a low stimulus environment, with minimum stress and maximum sleep. An extensive network is essential to provide the necessary medical, emotional and practical support. However, too many visitors can be overwhelming.

Recovery and future pregnancies

For some people, deciding whether or not to have another baby after postpartum psychosis takes some consideration. It can be helpful to speak to your health professional team about your thoughts and feelings around this or to connect with peers.

If you remain on medication over time and are considering becoming pregnant again, it is vital to discuss this with a specialist. If you are taking mood stabilisers, it is also recommended that high levels of folate are taken prior to becoming pregnant and in the first trimester of pregnancy. This can help to reduce the small chance of increased birth defects associated with these medications. 

Relapse prevention plan

Developing a relapse prevention plan with a specialist is strongly advised. This can help you and your family identify and prepare, should the condition reoccur.

A relapse prevention plan may also contain information including:

• Your early warning signs – e.g. sleeplessness, elevated mood, very active/busy, skipping meals, being overly suspicious, feeling agitated

• Your vulnerable periods – such as returning to work

• Your self-care strategies – good sleep, daily exercise, eating well, working part time, socialising with friends, taking holiday

• Identifying your sources of help and assistance in advance – this is likely to include additional social supports as well as appointments with specialists throughout pregnancy to monitor your mood and identify and possible symptoms

A tailored relapse prevention and early response plan shared with the treatment team can provide assurance and an important safety net – for the whole family.