Introduction To Postpartum Psychosis And Hormones

Pregnancy and labour itself is an emotionally, mentally, and physically taxing event for all women (assigned female at birth AFAB). Postpartum, meaning post-pregnancy, comes with ups and downs, especially with physiological hormones. 

Postpartum psychosis is a condition where the woman becomes mentally unstable after birth. It is an acute illness of multifactorial origin, and it can be considered as a psychiatric emergency. Most women experience fluctuations in their mental states postpartum, ranging from mild depression (which is also known as post-baby blues), post-traumatic stress disorder, and severe depression, to full-blown psychosis. 

While there is no direct cause of postpartum psychosis, some women (AFAB) are more susceptible to it. Those with a personal or family history of mental disorders like bipolar disorder or schizoaffective disorder have a higher chance of suffering from postpartum psychosis.¹ Hormones have a large influence on not only daily life but especially fertility and pregnancy. After labour, levels of progesterone and oestrogen fall rapidly, causing fluctuations and imbalances in the body. It is also paired with stress and lack of sleep, posing a risk of developing postpartum disorders like depression and psychosis.²

Understanding Postpartum Psychosis

Based on the description given by National Health Service (NHS), some symptoms of postpartum psychosis are as follows:

• Hallucinations

Seeing, sensing, smelling, or feeling nonexistent things. 

• Mania

Experience of mania is when one may feel restless, “high”, or overactive. 

• Low mood

Showing signs of depression, including lethargy, loss of appetite, and agitation. 

• Severe Mood Swings

Rapid changes with short intervals between mania and low mood. 

• Delusions

Having high suspicions, fear, anxiety, and likely untrue beliefs. 

Several factors increase the risk of postpartum psychosis. 

• Bipolar disorder specifically, is considered one of the most crucial factors that increases the risk of postpartum psychosis.¹ The symptoms of postpartum psychosis are similar to those of bipolar disorder, but with increased hormonal imbalance due to pregnancy, the symptoms could appear more severe and extreme. 
• Another risk factor is having a poor socio-economic background, to which a study has found that it may contribute to the development of postpartum psychosis.⁴ Raising a child with a poor socio-economic situation can prove to be challenging and stressful as daily needs are to be fulfilled constantly. 

Mothers who have perinatal and neonatal complications are also more prone to stress and pressure, making them increasingly susceptible to postpartum psychosis.⁵ 

If postpartum psychosis, or any disorders for that matter, are left untreated, the mother is more than likely to develop persistent depression and anxiety. 

Two studies had shown that the infants of mothers with higher depressive symptoms displayed more frequent night-time awakenings and had more inadequate sleeping patterns.^{7 8} Postpartum disorders like psychosis have led to poor quality of home environment and maternal caregiving, ultimately reflecting a direct and indirect negative effect on the development of the child.⁹ This study shows that a child’s development and growth are closely associated with the health of their mother. 

Hormonal Influences

Needless to say, hormones play a large part in physiological actions including the entire process of pregnancy. Some of the most important and well-known hormones that play a part in this process are; progesterone, oestrogen, and oxytocin. 

• Progesterone

Progesterone is produced in the corpus luteum during the first 10 weeks of pregnancy, and then its high level is sustained with the placenta for the rest of the pregnancy. Progesterone supports the pregnancy by maintaining the uterine structure and function, supporting the mammary growth and development of the blastocyst, and suppressing of pituitary gonadotropin (GnRH) secretion.¹¹ Progesterone also stimulates the growth of blood vessels to supply the womb lining and also prevents lactation which occurs after progesterone levels drop after pregnancy.¹²

• Oestrogen

Like progesterone, oestrogen is also produced by the corpus luteum for the first 10 weeks and then from the placenta for the rest of the pregnancy duration. Oestrogen produced in the placenta is responsible for the production of precursors such as estrone (E₁ and E₂) and much of estriol (E₃) synthesis.¹¹ E₃ helps the uterus expand as the foetus grows and also prepares the woman’s body for labour and lactation. Along with progesterone, oestrogen also inhibits the pituitary gland from secreting GnRH. 

• Oxytocin

Oxytocin is a neurohypophysial hormone that is specific to the end of pregnancy and is crucial to labour. While we are still uncertain whether oxytocin is only facilitative to human labour or the initiating factor, it plays an important part in uterine-contracting action.¹¹ 

Changes In Hormone Levels Postpartum

After labour, levels of all three hormones fall rapidly, especially progesterone, being initially the most abundant during pregnancy. The dramatic drop in progesterone could be a major reason for the development of postpartum depression.¹¹ One of the cerebral metabolites of progesterone is allopregnanolone (also known as brexanolone), which helps decrease irritability. With the rapid drop in progesterone, allopregnanolone also decreases accordingly. Brexanolone, also commercially known as Zulresso ®, is a drug approved by the FDA for the treatment of postpartum depression through intravenous administration.¹² 

Estradiol, a type of oestrogen, can facilitate serotonergic transmission through the increase of the synthesis of serotonin and decreasing serotonin reuptake, prolonging the presence of serotonin in extracellular space. Simply said, it can alleviate depressive symptoms, and with decreased oestrogen levels, the opposite effect occurs, where the mother is deprived of natural defences against depression. 

High testosterone levels are also found postpartum along with high prolactin production, low oestrogen, and low progesterone.¹¹ Hence potentially lower dopamine and variations in thyroid hormones. All of this hormonal imbalance is bound to cause psychological instability and increase susceptibility to developing postpartum disorders. 

Postpartum does not only cause imbalance in sex hormones, but also fluctuations in corticosteroid hormones like cortisol. Plasma corticosteroid levels reach their peak during labour and alongside sex hormones, they fall significantly postpartum.¹¹ With a dysregulated stress response, there would naturally be an impact on mood regulation and also cognitive functioning. Alongside all other hormonal imbalances, the body's physiology takes a hit, especially in the dysregulation of the hypothalamic-pituitary-gonadal axis. The serotonin imbalance and dopamine dysregulation contribute to amplifying vulnerability to psychosis symptoms and mood disturbances. While its symptoms should only be prevalent for 6 to 8 weeks after delivery, each case and pregnancy experience differs.

Treatment implications

Many treatments can alleviate the symptoms of postpartum psychosis. They are as follows: 

• Medication 

While each patient differs, some could benefit from different treatment plans including the administration of antidepressants, antipsychotic medications, mood stabilisers, or hormone treatments. Some medications could include Zulresso ® aforementioned. 

• Psychotherapy and support groups

This includes Cognitive-behavioural therapy (CBT) which can address distorted thoughts and beliefs. Group therapy also facilitates peer support, and family therapy to address family dynamics and enhance support systems. 

• Long term plan 

By developing a relapse prevention plan with the mother and their support network, and addressing underlying risk factors such as previous psychiatric history or family history of mental illness, the mother can slowly progress toward improvement of both physical and mental health. 

• Early intervention 

Early intervention is crucial to a speedy recovery. Postpartum psychosis poses significant risks to both the mother and the infant. With early intervention, it helps ensure the safety of both mother and child.

Future Directions

The main cause of postpartum psychosis is still unknown or uncertain. Hence, there is ongoing research on hormonal interventions. One mentioned a future research probing the relationship between decreased oestrogen levels and psychotic symptoms to understand how hormonal changes affect the brain and consequently psychotic symptoms, as well as understand how and why individuals vary in each their sensitivity to hormonal changes.¹³ 

There are also developments in targeted and personalised treatment. As each female's biology is different, hence targeted treatment would be beneficial to their recovery. In addition, more education and awareness initiatives are taking place to provide adequate support and knowledge to women towards this stigmatised topic. Hopefully, with decreased communication barriers, more women are able to reach out for help and support through the difficult yet gratifying journey of post pregnancy.¹³ 

Summary

Postpartum psychosis is a severe and rare psychiatric condition that affects a small percentage of new mothers, typically within the first few weeks after childbirth. It usually manifests as delusions and hallucinations. Hormonal changes play a major role in its onset, particularly the sharp decline in progesterone and oestrogen levels after giving birth, which affects stress response, neurotransmitter activity, and brain function. Understanding these hormonal changes is essential for managing conditions effectively, providing viable paths for intervention, and lowering stigma related to them. To improve our understanding and create focused interventions, more research into the complex interactions of hormones, neurotransmitters, genetics, and environmental factors is essential. Improved understanding, instruction, and assistance programmes are also critical for early identification and treatment, which will ultimately lead to improved results for those suffering from postpartum psychosis.