What Is Postpartum Psychosis?

Introduction

Approximately 1 in 5 will experience mental health problems in the 12 months after giving birth.¹ Mental health conditions after birth can include baby blues, postnatal depression and postpartum psychosis. These can affect anyone but disproportionately affect women of colour, those of lower deprivation and those with a history of domestic abuse and trauma.¹

Postpartum psychosis, also known as puerperal psychosis, is a mental health emergency. It has a rapid onset and leads to a state of distorted reality, such as seeing or hearing things and having paranoid thoughts. Approximately 1 to 2 in 1000 will experience postpartum psychosis.² Symptoms can also include extreme mood changes, confusion and disorganised thinking. In severe cases, symptoms can last up to 12 months, but they often significantly improve within the first few weeks.³ 

Those with a family history of postpartum psychosis, previous psychiatric conditions and first-time mothers are all at an increased risk. Urgent treatment is required with potential admission, antipsychotics, mood stabilisers and psychological interventions to prevent harm to self or baby. Please continue reading to understand more about postpartum psychosis, treatment and the impact on mother and baby.

Symptoms of postpartum psychosis

Psychosis refers to a mental health condition where an individual can become disconnected from reality; seeing, hearing or believing things that aren’t true. Postpartum refers to the period after giving birth. Postpartum psychosis has a rapid onset and typically occurs within a few days to 4 weeks after giving birth.²

Symptoms include:

• Hallucinations - This involves seeing or hearing things that others can’t. For example, hearing voices talking about you or to you. This sensation can be extremely frightening as it is hard to differentiate scenarios from reality. Often, hallucinations can be noticed by others as individuals might be seen responding to unseen stimuli.³
• Delusions - These are false beliefs that can’t be shaken, despite the lack of evidence.³ There are many different types of delusions including grandiose delusions, where an individual has a believed power or heightened sense of self-importance. For example, a grandiose delusion would be an individual believing they are an important world leader with special powers.
• Paranoid thoughts - Paranoid thoughts are where individuals believe others are against them or planning to harm them. This can also be a type of delusion called persecutory delusion, where an individual believes they are being targeted despite no evidence. This can lead to the individual having suspicions of family or friends and may lead to withdrawal.
• Extreme mood changes -  Postpartum psychosis can present with elevated mood or low mood. These changes can be described as:
  • Mania - elevated mood, impulsivity and restlessness
  • Depression - loss of enjoyment, poor appetite, poor sleep, tearful, hopelessness

• Anxiety - this can present in many ways, including anxious thoughts and physical symptoms of palpitations, nausea and shaking.
• Baby blues - This is the most common experience following pregnancy and typically starts within a few days of birth. Symptoms include feeling tearful, irritable, tired or apathetic and are usually mild, resolving within 2 weeks.

These symptoms can lead to incoherent speech and impaired judgement, which may result in risky behaviours that can put the mother or baby at risk. Some have thoughts of harming themselves, the baby or others around them. If any of these thoughts are present, it is extremely important to seek urgent medical help.⁵

Diagnosis

It is important to seek urgent medical attention via a GP, emergency department or crisis line, where they can direct mothers to the appropriate mental health services for admission or community support.

The symptoms of postpartum psychosis can be recognised by partners, friends or family. A formal diagnosis can be made by a mental health professional performing a mental state examination. This involves careful observation of the mother, in addition to questions to establish mood, thought content and risk. Many symptoms can be established with clear observation of appearance, speech, body language and thought flow.⁵ For example, acceleration of speech and jumping between topics can be associated with mania, whereas depressed individuals will often have slow, quiet speech.

Differential diagnosis

It is important to differentiate postpartum psychosis from other postpartum conditions. The key postpartum mental health conditions include:

Postpartum depression: 

Postpartum depression typically affects around 10% of mothers.⁴ The symptoms of postpartum depression are similar to baby blues but are more severe and last longer than 2 weeks. Symptoms can include severe hopelessness, loss of enjoyment, poor appetite, anxiety and tiredness. These symptoms impact everyday life and may impact the ability to look after themself and their baby.

Postpartum psychosis:

Postpartum psychosis has a rapid onset, usually within the first few days of giving birth and lasts for longer than 2 weeks. It is rare and typically affects 1-2 in 1000 mothers.² As discussed, these symptoms include hallucinations, delusions and mood changes. These symptoms are severe and may require significant support to help safeguard the mother and baby until symptoms resolve. 

Regardless of which condition, it is important to seek early support from friends, family, and health professionals. Health professionals can provide individuals with a diagnosis which can help mothers understand the condition and find community support. Early intervention with psychological techniques and medications can help improve the prognosis and reduce the severity of symptoms. 

Risk factors 

Causes of postpartum psychosis are not well defined but may be linked to a drop in hormone levels after pregnancy, combined with poor sleep.^3,5 Certain risk factors have been identified; these include:

• History of a mental health condition -  those with bipolar disorder are particularly at an increased risk, with approximately 25-50% of women with bipolar disorder developing an episode of postpartum psychosis.⁶
• Family history of postpartum psychosis
• First-time mothers⁶
• Personal history of postpartum psychosis^2,6

Treatment

If you have been diagnosed with postpartum psychosis, then you should be referred to perinatal mental health services to obtain the relevant psychological and medical support. Mothers requiring admission for postpartum psychosis should be admitted to a mother-baby unit where possible.⁷ A mother-baby unit is a type of mental health facility made up of consultant psychiatrists, mental health nurses, nursery nurses and psychologists. Mothers can receive treatment for their mental health condition without separation from their baby. Treatment for postpartum psychosis includes:

• Psychological intervention - Techniques such as cognitive behavioural therapy (CBT) can be useful to talk through your thoughts and reframe your worries. There are also types of psychological therapies that provide family support specific to perinatal mental health cases.
• Antipsychotics - these can be useful in reducing symptoms of hallucinations and delusions.
• Mood stabilisers - medications can be given to help balance any large fluctuations in mood. Some of these medications, such as lithium, can pass into the baby during breastfeeding. Therefore a careful discussion is needed before starting medications.
• Antidepressants -  If depression is a prominent symptom, antidepressants such as sertraline may also be used. Side effects can occur with these medications, such as nausea, shaking and tiredness.
• Support from others - there are many online communities of mothers who have experienced postpartum psychosis. It can be beneficial to speak to others who can personally understand the impact of postpartum psychosis. These are linked at the end of the article.

Mother-baby units are often seen as advantageous compared to general psychiatric facilities due to specialist staff, the ability to maintain mother-baby bonding, breastfeed and gain a sense of community from other mothers in similar situations.^8,9 The number of mother-baby units has increased over the last few years to a total of 22 in the United Kingdom but are scattered, meaning the closest could be some way from home.¹⁰ Some mothers may opt for a general psychiatric unit to remain closer to their community support networks or to have some time away from their baby while they receive treatment. Others may be forced into a general psychiatric hospital due to the lack of available spaces in a mother-baby unit. 

Impact of postpartum psychosis

Impact on mothers

There is still a large amount of stigma around postpartum difficulties, as some mothers

have concerns others will perceive them to be a ‘bad mum’.^8,9 Additionally, fears of separation from their baby can lead to delays in consulting health services, which can result in mothers reaching crisis point sooner. Many mothers find it difficult to adjust back to family life following discharge from a psychiatric facility and express feelings of guilt or a weakened bond with the baby. 

Unfortunately, the risk of future psychosis is high, and half will go on to experience recurrence in future pregnancies.² This may result in mothers choosing not to have another pregnancy, despite their initial wishes, and can result in feelings of loss. 

Despite these challenges, it is important to remember postpartum psychosis is no one’s fault, and it certainly does not make anyone a ‘bad mum’. With the appropriate help and support, most will make a full recovery and many will go on to have more children.² Health professionals will understand the increased risk and can provide support plans to ensure if it were to happen again, it would be recognised and treated quickly.

Impact on baby

Mother-infant bonding can be affected by postpartum depression and postpartum psychosis, especially in those with depressive symptoms.¹¹ Impaired bonding can lead to long-term problems such as delayed emotional development and behavioural problems.¹¹ Bonding can take time to develop and there should be no shame in getting professional support.

Impact on the partner

It is important to consider the crucial role of partners in these scenarios. Partners of those with postpartum psychosis may have to take on additional responsibilities to maintain balance at home and may find themselves separated from their partner and baby. This can impact work, social life and overall well-being. With approximately 5-10% of fathers experiencing mental health challenges in the postpartum period, psychological support for partners is essential.¹³ Action on Postpartum Psychosis is a national charity, which has some useful guidance for partners during this stressful time. 

Prevention

Health professionals should remain vigilant to mental health symptoms during pregnancy and should ask questions throughout pregnancy to identify hopelessness, low mood and anxiety.⁷ Individuals who are identified as high risk of postpartum psychosis should have perinatal mental health support. This can allow the wider team, such as midwives, health visitors, mental health nurses and doctors to identify triggers and form a support plan in case postpartum mental health problems occur. The written plan will also contain details of where to access support and crisis numbers.²

Summary 

Postpartum psychosis is a rare but serious condition that results in symptoms such as hallucinations, delusions and mania. These symptoms can be scary and cause significant impacts on the family, including feelings of guilt, anxiety and a weakened mother-baby bond. It is important to highlight that postpartum psychosis is not anyone's fault. Reaching out for support and treatment is crucial to regain confidence and work towards recovery. Most will make a full recovery, and many will go on to have future pregnancies.

Funding for perinatal mental health has improved in the UK in recent years, with increasing mother-baby units and an aim for all to access specialist perinatal mental health services in the 24 months following pregnancy.¹² As well as an increase in services, there needs to be greater awareness of postpartum psychosis to encourage mothers to get support without fear. 

Useful resources

There are many online resources to help you further understand postpartum psychosis with reflections on personal experiences. These resources are also beneficial to further understand how to support those around you who may be experiencing postpartum psychosis. Some useful websites are:

• NHS - Postpartum psychosis: https://www.nhs.uk/mental-health/conditions/post-partum-psychosis
• Mind - a mental health charity - Postnatal depression and perinatal mental health: https://www.mind.org.uk/information-support/types-of-mental-health-problems/postnatal-depression-and-perinatal-mental-health/postpartum-psychosis/
• Tommy’s - a pregnancy charity - Postpartum psychosis: https://www.tommys.org/pregnancy-information/after-birth/your-mental-health/postpartum-psychosis