Overview

We all know how important sleep is for our bodies, but how often do we stop considering its effect on our minds? You’ll likely be able to recall several times when a single bad night’s sleep has turned your whole day upside down.

For many people, however, one restless night can turn into several - an experience perhaps no one knows better than new parents. Facing a prolonged struggle with sleep can develop into a condition that most don’t expect and few discuss openly - one that casts a shadow on the otherwise joyful time of welcoming a new life into the world: postpartum psychosis.¹ 

A rare and intense mental health condition, postpartum psychosis can surface as several distressing symptoms including hallucinations, delusions and paranoia that arise during the postpartum period. Notably, it goes beyond the common but short-lived baby blues, requiring immediate medical attention due to the serious risk of harm it poses to both the parent and baby. But what might make us more likely to encounter the condition? One key factor may be poor sleep.^1,2 

Sleep problems are both of the most common symptoms of postpartum psychosis and a possible trigger, often found to make their unwelcome entry before the onset of the condition. Understanding the importance of sleep and its interactions with other, more well-established risk factors (such as mental health history) can therefore go a long way in protecting against postpartum psychosis.¹ 

So if you're stepping into parenthood, expecting, or looking to support a loved one through this sensitive time, read on to learn the “why's” and the “how’s” of safeguarding sleep to secure a strong start for a growing family.

What is postpartum psychosis?

Postpartum psychosis is a rare but severe mental health condition, affecting around one to two individuals in every 1000 births. As defined by the NHS, psychosis describes a state in which a person loses some of their sense of reality. Postpartum psychosis typically occurs in the period right after childbirth, usually up to six to eight weeks, but most cases emerge within the first three days to four weeks post-birth.^1,3

Its onset is immediately noticeable, arriving suddenly and causing a rapid, overt change in behaviour that may lead them to harm themselves or their newborn. Importantly, the person themselves isn’t aware that they have the condition. Friends and family members therefore play a crucial role in spotting the signs of postpartum psychosis.^1,3 

REMEMBER: Postpartum psychosis carries a high risk of harm both to the parent and baby. As such, it’s vital to seek immediate medical attention if you or someone close to you is displaying signs of postpartum psychosis, even if they have no history of mental health conditions. 

Symptoms 

Symptoms of postpartum psychosis can include drastic mood changes, such as mania, where an individual experiences an abnormally elevated mood, energy, or activity level that others can observe, and psychotic depression, characterised by severe depression with psychotic features. Delusions, or strongly held false beliefs, and hallucinations, involving seeing, hearing, or sensing things that aren’t real, are also common. Additionally, affected individuals may display disorganized thinking and speech, along with marked confusion and disorientation, making it difficult for them to function or communicate effectively.²

Bipolar disorder and sleep as risk factors

It’s currently unclear what the exact causes behind postpartum psychosis are and why childbirth is a trigger. However, a personal or family history of mental health issues, especially bipolar disorder (BD) or a previous episode of postpartum psychosis, is considered a major risk factor.² 

BD shares some of its symptoms, with postpartum psychosis, in particular mania and depression. Factors that may worsen or trigger BD appear to overlap considerably with those linked to postpartum psychosis - sleep being one of these.^1,2,3

Concerning sleep as a possible trigger, there’s evidence to suggest that longer labourers and night-time deliveries may increase the likelihood of postpartum psychosis due to their negative impact on sleep. However, this could also be attributed to insomnia.¹

How your sleep is affected during the postpartum period

The quality of your sleep can be reduced by some issues, such as:

• Not getting enough sleep
• Interruptions during sleep (sleep fragmentation)
• Insomnia 
• Sleep-related disorders (parasomnias)
• Taking a long time (20 minutes +) to fall asleep (prolonged sleep latency)
• Changes to your sleep-wake cycle (circadian rhythm)¹

These problems are largely accepted as part and parcel of early parenthood. Studies exploring parent’s experience of postpartum psychosis show that sleep issues are consistently found during the postpartum period.⁴

Difficulties included challenges with both falling and staying asleep, which was partly attributed to newborn-related anxiety and from being awoken to breastfeed.⁵ Sleep disruption therefore coincides with the arrival of postpartum psychosis; scientists believe that this shared timing might hint at a link between the two.³

The link between sleep, bipolar disorder (BD) and postpartum psychosis

Poor sleep is considered a possible trigger or contributor to BD. Sleep loss often precedes mania - a major symptom in both postpartum psychosis and BD - suggesting that the poor sleep experienced after birth might indeed be a trigger for the condition. Disrupted sleep-wake cycles, common in BD and linked to increased relapse risk, may also contribute to the depression and mania seen in postpartum psychosis.¹

In a study of 870 individuals with BD who’d given birth, a quarter reported sleep loss as a trigger for an episode of either depression or mania. The same individuals were twice more likely to experience postpartum psychosis, indicating that sensitivity to sleep loss and/ or a history of this being a triggering factor for mania might increase susceptibility to postpartum psychosis.⁶

However, it’s worth noting that mental health conditions like BD, depression and schizophrenia which might elevate the risk of postpartum psychosis, are also associated with sleep disorders. Therefore, it could be the presence of these conditions that are contributing towards the development of postpartum psychosis rather than sleep problems alone.¹

Sleep - cause or symptom? 

As you might’ve noticed, compromised sleep can be seen both as a common symptom of, and a potential trigger for, postpartum psychosis. This brings us to the classic "chicken and egg" dilemma: does poor sleep cause postpartum psychosis, or do the condition's severe symptoms interfere with getting a good night's rest?

The answer to this question is still unclear. So far, researchers have mainly studied how sleep problems impact parents by asking them to recall their experiences of postpartum psychosis. Our memories aren’t always perfect, which makes it hard for scientists to confidently conclude whether sleep issues were a cause of, or resulted from the condition. To figure out if poor sleep can trigger postpartum psychosis, we need future studies to:

• Take place over a longer timeframe
• Use more objective measures of sleep
• Include parents with and without a history of BD who do and don't develop the condition
• Look into these parent’s experience of specific types of sleep problems (such as those mentioned previously)^1,7

With this information, we can start to better understand how specific sleep issues might influence postpartum psychosis, especially in those more prone to the condition. Coupled with research into the impact of sleep on mental health issues related to postpartum psychosis (e.g. postpartum depression), these future findings could also aid scientists in developing targeted sleep intervention programmes to support pregnant and postpartum individuals at a higher risk of developing postpartum psychosis.^1,7 

Regardless of whether sleep is a cause or symptom, however, managing sleep may still be a key strategy to reduce the chances, or perhaps the severity, of postpartum psychosis.^1,7

Using sleep to help prevent and manage postpartum psychosis

Fortunately, postpartum psychosis is highly treatable and reversible, especially when addressed early. An estimated 98% of people improve with treatment, which can take a few weeks.⁸ The most common treatments include medications such as antipsychotics, antiseizure drugs (anticonvulsants) and lithium, or electroconvulsive therapy (ECT). Regular check-ins with your doctor are essential during the treatment period for monitoring both your health and your baby's, particularly if you're breastfeeding or have been advised to take preventive medications during pregnancy.⁹

For parents without a history of postpartum psychosis, treatment usually comes after the condition arises. What about preventing it in the first place? 

Getting better sleep is a safe and drug-free approach that may help to reduce the chances of postpartum psychosis by supporting your overall physical and mental health. While it’s far easier said than done, below are a few practical tips for improving your sleep quality both during your pregnancy and after giving birth.⁷ 

• Communicate with your support system: Ask for help from your partner, family, or friends; sharing nighttime duties can allow you to get a longer stretch of uninterrupted sleep
• Prioritise sleep: While it might be tempting to catch up on housework or other tasks while your baby sleeps, taking naps during these moments of peace can help reduce your sleep debt
• Embrace a sleep-conducive lifestyle: In line with giving sleep the priority it deserves, practise good sleep hygiene. This usually involves small changes to your daytime and nighttime routine that help prepare your body and mind for a better night’s rest, e.g. keeping your bedroom cool, dark and quiet, creating a relaxing pre-sleep routine, exercising regularly, avoiding caffeine and heavy meals before bed
• Integrative approaches: Consider therapies that address both sleep and mental health simultaneously, such as cognitive-behavioural therapy for insomnia (CBT-I). This can help you to both build positive sleep habits and control the negative thoughts and worries that might be keeping you up at night
• Consult your healthcare provider: If sleep disturbances persist, consider talking to your doctor - especially if it’s contributing to feelings of depression or other symptoms of postpartum psychosis. They can offer advice specific to your situation or explore if there's an underlying issue affecting your sleep. Early intervention is an important part of managing postpartum psychosis

Summary

Poor sleep, while experienced by new parents all too often, is a common symptom of, but also a potential trigger for, postpartum psychosis - in particular for parents with a history of BD. Although additional, well-designed studies are needed to get a clearer picture of the role of sleep problems in postpartum psychosis, prioritising a good night’s rest is an important part of ensuring a healthier transition into parenthood.

Bear in mind that postpartum psychosis, while daunting, is highly treatable through seeking prompt medical attention. Focusing on improving sleep quality, staying informed and seeking support from your loved ones can empower you through your postpartum journey, helping to protect your mental well-being while you care for your little one.