Overview

After childbirth, people assigned female at birth’s (AFAB) lives undergo many physical and hormonal changes, such as sleep deprivation and fatigue. The new journey of caring for a newborn is both physically and emotionally challenging. After giving birth, people AFAB may experience postpartum baby blues, which is characterised by mood swings and mild depression. Some might develop severe conditions such as postpartum post-traumatic stress disorder, major depression, or postpartum psychosis.^1,2 

Postpartum psychosis

Postpartum psychosis is a severe form of postpartum psychiatric illness. It is a mental health emergency associated with hallucinations, delusion, paranoia and other behavioural changes. Although it has a low incidence rate, it can have serious consequences such as suicide or filicide, if not detected promptly.³

Postpartum depression

Many people AFAB experience baby blues after childbirth. Baby blues involves a range of emotions like feelings of sadness, anxiety, restlessness, and other mood changes. These feelings can last up to two weeks and usually go away on their own. In people AFAB experiencing postpartum depression (PPD), the feelings of sadness, anxiety, and restlessness last longer than baby blues and affect women’s ability to function normally after giving birth. In severe cases, it may develop into chronic episodes of depression. PPD affects around one in seven people AFAB.⁴ Anxiety and depression in pregnant women can result in postpartum depression.

Postpartum psychosis

Postpartum psychosis (PPP) is a rare but serious mental illness that presents with the rapid onset of psychotic symptoms, including confusion, delusions, and hallucinations.⁵ Being a psychiatric emergency, it requires immediate medical and psychiatric attention and hospitalisation in case the risk of suicide or filicide exists. PPP may start a few weeks after giving birth. 

The symptoms of PPP may vary from person to person. The two main symptoms of PPP are hallucinations and delusions. Other common symptoms include insomnia, mood swings, agitation, fatigue, and paranoia. The symptoms of PPP are divided into three types:

Depressive symptoms

These symptoms are the most common and can be dangerous. People with depressive symptoms may inflict self-harm or hurt their baby. People with depressive PPP may feel anxiety or panic, lose their appetite, and have delusions or hallucinations.

Manic symptoms

These are the next most common type of PPP symptoms. The risk of harm to the baby is still present, but lower than with depressive PPP. Symptoms include agitation, disruptive or aggressive behaviour, talking more or faster than usual, reduced sleep, and delusions of grandeur (such as believing one's child to be a holy or religious figure).

Atypical/mixed symptoms

These are the least common type of PPP symptoms and may sometimes be a mix of depressive and manic symptoms. Patients with these symptoms are unaware of things around them. Symptoms may include behaving or speaking in a disorganised manner, appearing confused, disturbed consciousness, hallucinations or delusions. and catatonia in extreme cases, where they may stop speaking altogether.

Risk factors

A combination of factors may lead to PPP. Common risk factors include:

• People AFAB with a medical history or family history of mental health disorders like bipolar disorder and schizophrenia are at a higher risk of experiencing PPP ⁶
• PPP is more common in first-time mothers⁶
• People AFAB with a history of PPP have a greater risk of experiencing PPP in future pregnancies
• Discontinuation of psychiatric medications during pregnancy might trigger PPP
• Sleep deprivation may lead to PPP in people AFAB⁷
• Hormonal fluctuations postpartum might increase the risk of psychosis⁸

Treatment

In the case of PPP, prevention might be the best treatment. People AFAB with a medical history or family history of bipolar disorder should be informed about the risk of experiencing PPP. Prophylactic treatment is advised throughout pregnancy for people AFAB with bipolar disorder as they are at a higher risk of relapse.^9,10 Lithium has been identified as a prophylactic medication for PPP patients with a history of bipolar disorder or previous isolated episodes of postpartum psychosis. However, its use during pregnancy poses a risk of congenital malformations. Breastfeeding people AFAB with a history of bipolar disorder should abstain from lithium.¹¹ In breastfeeding people AFAB, antidepressants, antipsychotics and anti-seizure medications are considered a much safer option.¹² Non-pharmacologic treatments like psychotherapy and Electroconvulsive therapy (ECT) are considered safe and effective in treating PPP alongside or without psychiatric medications.¹³ 

Postpartum depression

Postpartum depression (PPD) is a relatively common condition which can affect people AFAB at any point after delivery. It can negatively impact the relationship between a parent and their infant. It may lead to difficulty in breastfeeding, marital problems, and might affect the physical and psychological development of a child. Clinical signs of PPD are similar to depressive episodes that can occur at any stage in a person AFAB’s life. 

The symptoms of postpartum depression include:

• Depressed or sad mood
• Frequent tearfulness
• Loss of interest in usual activities
• Feelings of guilt
• Feelings of worthlessness or incompetence
• Fatigue
• Disturbance in sleep patterns
• Appetite changes
• Difficulty in concentrating

Some of these symptoms might be missed in postpartum women because alterations in sleep patterns, energy levels, mood, and body weight are often perceived as a normal part of motherhood.

Causes and risk factors

No single cause of PPD has been established by research. However, there might be certain risk factors which may increase the chances of PPD. These risk factors are as follows:

Psychological risk factors: Factors such as maternal history of depression, anxiety, premenstrual syndrome (PMS), and a history of sexual abuse.

Obstetric risk factors: Emergency cesarean section and hospitalisations during pregnancy, or complications like umbilical cord prolapse, preterm or low birth weight infant, and low haemoglobin.

Social factors: Lack of support from family and friends can contribute to postpartum depression. Marital conflict and domestic abuse can also be causative factors. 

Lifestyle: Changes in appetite, disturbed sleep cycle, and lack of physical activity might increase the risk of PPD. Lifestyle risk factors such as smoking are a known risk for developing PPD.

Treatment

Psychotherapy is the first line of treatment for women with mild-to-moderate PPD. Participation in a support group is recommended for emotional support. For people AFAB with moderate-to-severe PPD, a combination of therapy and antidepressant drugs is recommended. Transcranial magnetic stimulation (TMS) is an alternative treatment option for breastfeeding people AFAB who are concerned about the adverse effects of medication on their baby. ECT is recommended for patients who do not respond to psychotherapy or medications. ECT is a favourable line of treatment in patients with suicidal or psychotic tendencies.¹⁴ A new line of treatment, intravenous brexanolone, is recommended for patients who decline or do not respond to ECT. 

Differences and similarities between postpartum psychosis and depression

Both PPD and PPP are serious mental health disorders that can occur after childbirth. PPP involves psychotic episodes like hallucinations and delirium, while PPD is a nonpsychotic condition which leads to depressive symptoms like sadness, anxiety, and exhaustion. PPP has a sudden onset, whereas PPD may start days or months after childbirth. Despite their differences, there are certain similarities between these two conditions and the impact that they have on mental health. They both occur following childbirth and can cause emotional and psychological distress, mood and sleep disturbances, and difficulty bonding with an infant.

FAQs

Is perinatal depression the same as postpartum depression?

Perinatal depression is a mood disorder which refers to depression that occurs during pregnancy (prenatal depression) and in the weeks after childbirth (postpartum depression). The term perinatal recognises that depression associated with giving birth often begins during pregnancy.

When to see a doctor for postpartum depression?

It's important to see a doctor if you feel sad and have difficulty with day-to-day activities for more than 2 weeks after giving birth, or if you experience thoughts of harming the baby or yourself.

Can fathers/co-parents get postpartum depression?

Partners with a medical history of depression or those with financial problems may also experience postpartum depression. Additionally, studies showed that paternal depression had a positive correlation with maternal depression.¹⁵ It has been estimated that 4% of partners experience depression in the first year after the birth of their child. 

Can you develop postpartum psychosis if you have no history of mental health disorders?

Yes. There is no clear evidence on the causes of postpartum psychosis. You can develop postpartum psychosis even without a history of mental health issues like bipolar disorder and schizophrenia.

What can your partner or family do?

Support from friends and family is crucial after childbirth. It is important to recognise early signs of depression and psychosis and seek immediate attention. People AFAB should be encouraged to consult with clinicians, healthcare professionals, and join support groups. Offering help to new parents and listening to their concerns can provide them comfort during difficult times. 

Summary

After childbirth, people AFAB change physically, have hormonal changes, experience sleep deprivation, and fatigue, which is challenging for them. While most experience mood swings and mild depression, some might develop severe conditions like postpartum depression and postpartum psychosis. Postpartum psychosis is a rare but serious mental health emergency characterised by hallucinations, delusions, or paranoia that requires immediate attention to prevent serious consequences. In contrast, postpartum depression is a common condition that lasts longer than baby blues and impairs daily functioning in new mothers.

Risk factors for postpartum psychosis include medical or family history of mental health disorders, first-time motherhood, discontinuation of psychiatric medications during pregnancy, sleep deprivation, and hormonal fluctuations postpartum. Risk factors for postpartum depression may be social, psychological, or lifestyle changes. Treatment for both these conditions commonly involves psychotherapy, support groups, and medications. It is important to detect both these conditions in the early stages for timely intervention.