Introduction 

Postpartum psychosis is defined as extreme post-childbirth confusion, paranoia, delusions, hallucinations, disorganised thoughts, or losing touch with reality. It is one of the most severe mental illnesses following childbirth and is categorised as a psychiatric emergency.¹ Often confused with postpartum depression, the distinctive symptom of postpartum psychosis is the presence of a psychotic episode. On the other hand, postpartum depression presents as a nonpsychotic depressive episode without manic or affective psychosis.² It is critical to recognise and understand the symptoms of postpartum psychosis so that patients are offered proper and appropriate care. 

Overview of postpartum psychosis

Postpartum psychosis is a rare disorder, affecting 1-2 out of 1000 mothers.² Despite this, it is crucial to highlight that the likelihood of a person assigned female at birth (AFAB) (with no prior history of psychosis) experiencing her first episode of affective psychosis is 23 times higher within the first 4 weeks after childbirth compared to any other period in her life.³ Symptoms for postpartum psychosis usually occur within the first 2 weeks after childbirth, but more often within days or even hours after giving birth.⁴ Postpartum psychosis has a detrimental impact not only on the patient, but also the infants, and their families.⁵ 

Symptoms of postpartum psychosis

Mood disturbances, cognitive symptoms, behavioural changes, and sleep disturbances are hallmark symptoms of postpartum psychosis. Additionally, these symptoms often revolve around the child or childbirth.⁶ 

Mood disturbances

• Rapid Mood Swings: Mood swings can present from depressive symptoms to hypomania, and feature the swiftness of the changes between the moods. For instance, the mother may have frequent shifts between crying and laughter⁴
• Irritability and Agitation: Frequently, mothers dealing with postpartum psychosis may encounter intense irritability, expressed through heightened sensitivity to others, engaging in arguments, experiencing feelings of anger, and diminished patience⁴ 

Cognitive symptoms

• Confusion and Disorientation: Possible symptoms include confusion and perplexity, where the patient may undergo unclear thinking and disorientation⁴ 
• Delusions and Hallucinations: Paranoid delusions (believing something is true against contrary evidence) or auditory or visual hallucinations may occur⁴

Behavioural changes

• Hyperactivity or Agitation: Postpartum psychosis can lead to noticeable behavioural changes characterised by heightened agitation, stress, or tenseness. Furthermore, there may be an increase in hyperactivity, expressed through energetic behaviours influenced by mood, thoughts, or manic states⁴ 
• Impulsivity and Risky Behaviours: Symptoms may involve disinhibition, leading to actions or statements that deviate from one's typical behaviour, such as increased spending or risk taking⁴ 

Sleep disturbances

• Insomnia or Excessive Sleep: Postpartum symptoms may manifest as a lack of desire for sleep, difficulty falling asleep, or alternatively, excessive sleeping⁴ 
• Disrupted Circadian Rhythms: Severe sleep disturbances are common, and these may stem in part from circadian disruption caused by labour and delivery³ 

Causes and risk factors

The development of postpartum psychosis is not attributed to a singular cause or risk factor. Instead, a combination of factors such as life events, medical history, family background, and biological changes can contribute to its onset. Nevertheless, having a history of bipolar disorder significantly increases the likelihood of experiencing postpartum psychosis, with prevalence being 100 times higher in bipolar people.¹

Hormonal changes

The hormones oestrogen and progesterone rise exponentially during pregnancy but then fall rapidly postpartum.^3,5 These shifts in oestrogen and progesterone combined with other risk factors may be a possible underlying cause of postpartum psychosis. 

Biological factors

A genetic predisposition based on family and medical history has been linked with postpartum psychosis. Research shows that multiple genetic variants, in combination with environmental factors, may cause functional changes in the brain and body to predispose someone to postpartum psychosis risk.⁷

Psychosocial triggers

Stressful life events are related to postpartum psychosis. These can occur as early as early childhood and therefore put the mother at risk later in life. However, research has shown that stressful life events that happen during or before the pregnancy do not put the mother at an increased risk for postpartum psychosis.⁵

Relationship with bipolar disorder

The strongest risk factor for postpartum psychosis is a previous history of bipolar disorder.⁶ In fact, some research suggests that postpartum psychosis is within the same spectrum as bipolar disorder.⁸ In some people whose first psychotic episode occurs post-partum, this may be the first episode of lifelong bipolar disorder.⁸

Diagnosis and screening

Diagnosis for postpartum psychosis can be challenging. It can be misdiagnosed as the “baby-blues” or postpartum blues, postpartum depression, or other psychological disorders.⁶ To diagnose, doctors will perform a variety of the following:⁶ 

• Familial and medical history
• Physical examination 
• Neurological examination 
• Depression indices and self-reporting mental health questionnaires 
• Blood tests
• Urine tests

Treatment approaches

Requires hospitalisation and inpatient care

A confirmed diagnosis of postpartum psychosis constitutes a psychiatric emergency, requiring immediate hospitalisation for the safety of both the mother and the infant.⁶ 

Necessary medication 

Pharmaceutical treatment involves prescribing antipsychotics, and mood stabilisers, including benzodiazepines and antipsychotics, until symptoms subside. Lithium is typically prescribed for several months following delivery and is advised for any subsequent pregnancies.⁶ Despite concerns about breastfeeding while on these medications, for mothers experiencing postpartum psychosis, the perceived risks are considered to outweigh the concerns related to breastfeeding.⁶ 

Psychotherapy and supportive interventions

Therapy, family support, and an emphasis on sleep are all forms of supportive interventions that are often implemented alongside the previously mentioned treatments.⁶ 

Electroconvulsive therapy 

Electroconvulsive therapy (ECT) can be recommended if other treatment options are not accessible or have failed. (REF)

Mother and infant safety

The primary focus in diagnosing postpartum psychosis is to prioritise the well-being of both the mother and the infant. Given the elevated rates of suicide and infanticide associated with postpartum psychosis, it is imperative to exercise caution. Infants under the care of someone experiencing acute postpartum psychosis may be at risk due to intentional actions or neglect.⁶ Seeking guidance from psychiatrists and collaborating with paediatric care providers can be beneficial. The development of a family safety plan is one proactive measure that can address the potential risks for someone deemed at risk.

Recovery and long-term management

The duration of postpartum psychosis symptoms varies, ranging from weeks to months, with one study reporting a median episode lasting 40 days.³ Continued monitoring is crucial. A systematic review revealed a 37% postpartum relapse risk in women with bipolar disorder and a 31% risk in women with a history of postpartum psychosis.⁸ There is approximately a 1 in 2 chance that a woman experiencing postpartum psychosis may have a recurrence in a future pregnancy. For at-risk women, preventive plans should be established in collaboration with healthcare providers during subsequent pregnancies. These plans include medication (with neonatal medical assessments), birthing plans, intervention strategies, feeding plans, and sleep strategies.⁸

Impact on family and relationships

The impact postpartum psychosis has on the mother, infant, spouse, and other family members cannot be overlooked. Research involving spouses and partners following a postpartum psychosis episode identified themes of fear, loss, powerlessness, and a sense of not being heard.⁵ These studies also underscored the lack of a clear diagnosis, empathy, and adequate care for the spouse's mental health.⁵ Inclusion of extended family and support systems in birthing plans and post-psychosis care can contribute to feelings of connection and belonging. Addressing stigma and providing education for those affected by this disorder is crucial for enhancing understanding, diagnosis, and treatment. 

Prevention strategies

Identifying high-risk populations

The most important prevention strategy for postpartum psychosis is identifying the high-risk populations - namely those with bipolar disorder. This can be challenging because only ⅓ of mothers who have postpartum psychosis have a prior psychiatric history; for many, this may only be their first episode.⁶ 

Early intervention and education programs

The second most important prevention strategy is early intervention.⁵ Monitoring at-risk people is key to identifying symptom changes and warning signs to prevent patients from reaching more severe stages of psychosis where suicide or infanticide may occur. 

Integration with prenatal and postpartum care

Developing plans as soon as risk factors are evaluated is critical for managing postpartum psychosis. These should be made with healthcare providers during prenatal care and continued throughout postpartum care.⁸ 

Summary

Postpartum psychosis is a psychiatric emergency that must be evaluated and treated immediately. Patients with prior psychiatric history, diagnosed bipolar disorder, or family history of psychiatric disorders are at the highest risk. Other causes include hormone changes, biological and genetic factors, and psychosocial triggers. 

Postpartum psychosis does not always present with the same symptoms, and diagnoses should differentiate from postpartum depression. A psychotic episode may include symptoms of mood swings, confusion, delusions, mania, or impulsivity. While not always present, suicide and infanticide should be considered the primary areas of concern. A healthcare provider can diagnose postpartum psychosis through a detailed medical screening.

The treatment for postpartum psychosis includes an inpatient hospitalisation with medications and psychological support. Mother and infant safety is the number one concern. In addition, it is imperative to acknowledge and support the spouse or partner and other family members during this time.

As people who have experienced postpartum psychosis have approximately a 50% chance of recurrence in future pregnancy, prevention strategies are critical. Making plans with a healthcare provider and family members is necessary for preventing and managing any potential relapses.