Postpartum Psychosis

Postpartum Psychosis (PPP) is a rare but serious condition that occurs in the postnatal period, affecting a new mum’s thinking and behaviour. PPP occurs in approximately one or two in every 1,000 births. The condition must be identified as quickly as possible, and in most cases with specialist treatment, the person can fully recover.

For pregnant women it’s uncomfortable to imagine such conditions happening, but the more knowledge people have, the more they can look after themselves or others if they suspect PPP is occurring.

Signs and symptoms of postpartum psychosis

Psychosis essentially means a loss of reality, and women with PPP experience delusions (strange and irrational beliefs) and/or hallucinations (seeing or hearing things that do not exist). Delusions can impair their ability to make decisions and care for themselves and their baby.

PPP symptoms tend to come on suddenly, most often within the first two to six weeks after childbirth. In rare cases, they can develop several weeks after the baby is born.

PPP can be difficult to diagnose especially in the early phases, where the new birthing parent can appear reasonably OK. Many with postnatal psychosis will try to maintain an externally together appearance to avoid having their fears realised (e.g. child taken into care).

The birthing partner may also be frightened and feel overwhelmed. As it progresses though, the individual will have less awareness of their own condition and start acting in a way that is out of character.

An early symptom of PPP is being unable to sleep. Being awake day and night is an early warning sign to be aware of.

There may be signs of a manic mood. This can be talking quickly or experiencing racing thoughts. The person can feel "high" or "on top of the world” and be extremely energetic.

Although not as common, some women present as more depressed. Symptoms include low mood, losing interest in normal activities, having trouble sleeping, being more tearful, lacking energy, having a loss of appetite, anxiety, agitation or doubting their ability to be a mother.

Sometimes there can be a mixture of both a manic mood and a low mood. She could rapidly shift from feeling energetic, overly confident, and powerful to depressed and anxious, typically several times a day. Consequently, she could present as confused due to jumbled or disconnected thoughts. She may too for periods of time, appear to be her usual self.

Postpartum psychosis is associated with an increased risk of both suicide and infanticide compared to birthing parents who are not experiencing postpartum psychosis; however, recovery remains the expected outcome. Suicide during an acute episode of psychosis is estimated to be below 0.1%, however the rate is higher later in the mother’s life. Infanticide is estimated be less than 1% during psychosis without depressive features, and 4.5% during depressive psychoses (Brockington 2017).

It is important to be aware that the vast majority of women with PPP are in fact not a threat to themselves and/or their babies, and that there are many successful treatments available.

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Why does postpartum psychosis happen?

It is presumed that the physiological changes after birth can result in PPP in genetically vulnerable women. For example, sleep disruption resulting from labour and delivery may initiate the circadian rhythm disruption which leads to the psychotic symptoms as can rapid hormonal changes, or a stressful delivery.

Having a history of a psychotic episode or bipolar disorder increases the risk of postpartum psychosis; however, some may have no prior mental health history. For some women it may be a one-off experience.

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Treatment for postpartum psychosis

Getting help early is key. Any delays in identifying and treating PPP can lead to a longer and more complex episode, and significant safety risks for both the mother and baby. It is also essential that partners/friends and family members play a key role in both treatment and recovery.

Despite the seriousness of symptoms, a full recovery is possible with the right treatment. In fact, nearly all patients (98.4%) in a 2015 study (Bergink at al) achieved complete remission, with an average duration of an episode lasting 40 days. The most severe symptoms can last 2 to 12 weeks, and it can take 6 to 12 months or more to fully recover, depending on severity of symptoms and response to treatment.

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Hospital admission for PPP

Usually, inpatient care is required to ensure mother and baby are safe and to ensure a thorough evaluation can take place and treatment can begin. Ideally, this would be with the baby in a specialist psychiatric unit called a mother and baby unit (MBU). But if an MBU is not available, an admission to a general psychiatric ward is an alternative.

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Medication

There are commonly prescribed medications with a supportive evidence base. It is recommended that this is discussed with appropriate knowledgeable professionals.

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Psychological therapy

A therapist can help by talking through the trauma of the experience of psychosis. Women may feel sad, scared, confused, or even feel a great loss about the entire period. Talking through the experience can help them process and make sense of it as well as addressing any other concerns such as bonding with the baby.

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Future pregnancy

Many people who have had postpartum psychosis go on to have more children. Whilst there is an increased risk that they may experience another episode in future pregnancies, with the right support and interventions and reducing the risks there can be a more positive postpartum experience and recovery.

Having a supportive team including a perinatal psychiatrist is the best chance of achieving positive future pregnancy. A pre-birth planning meeting with all the care providers including partner, family or friends, mental health professionals, midwife, obstetrician, and GPs are essential, and post-birth sleep must be monitored closely.

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References

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_{Essali A, Alabed S, Guul A, Essali N. (2013) Preventive interventions for postnatal psychosis. Cochrane Database Syst Rev. (6):CD009991. Available at:}_{https://doi.org/10.1002/14651858.CD009991.pub2}

_{Gilden J, Kamperman AM, Munk-Olsen T, Hoogendijk WJ, Kushner SA, Bergink V. (2020a) Long-term outcomes of postpartum psychosis: a systematic review and meta-analysis. J Clin Psychiatry. 81(2):19r12906. Available at:}_{https://doi.org/10.4088/JCP.19r12906}

_{Gilden J, Molenaar NM, Smit AK, Hoogendijk WJ, Rommel AS, Kamperman AM, Bergink V. (2020b) Mother-to-infant bonding in women with postpartum psychosis and severe postpartum depression: a clinical cohort study. J Clin Med. 9(7):2291. Available at:}_{https://doi.org/10.3390/jcm9072291}

_{Heron J, McGuinness M, Blackmore ER, Craddock N, Jones I. (2008) Early postpartum symptoms in puerperal psychosis. BJOG. 115(3):348-353. Available at:}_{https://doi.org/10.1111/j.1471-0528.2007.01563.x}

_{Jones, Ian & Smith, Sue. (2009). Puerperal psychosis: Identifying and caring for women at risk. Advances in Psychiatric Treatment. 15. 411-418. 10.1192/apt.bp.107.004333.}

_{Raza SK, Raza S. Postpartum Psychosis. [Updated 2022 Jun 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Availa}

_{APP. (no date) Frequently asked questions. Available at:}_{https://www.app-network.org/what-is-pp/faq/}_{[Accessed 25th January 2022]}

_{Sit D, Rothschild AJ, Wisner KL. A review of postpartum psychosis. J Womens Health (Larchmt). 2006 May;15(4):352-68. doi: 10.1089/jwh.2006.15.352. PMID: 16724884; PMCID: PMC3109493.}

_{Veerle Bergink}_{, M.D., Ph.D.,}_{Natalie Rasgon}_{, M.D., Ph.D.,}_{Katherine L. Wisner}_{, M.D., M.S. Postpartum Psychosis: Madness, Mania, and Melancholia in Motherhood}