Postpartum psychosis is rare—but dangerous

What is postpartum psychosis? 

While postpartum psychosis (PPP) is very rare, it is considered a medical emergency, requiring immediate medical treatment. The condition occurs in approximately 3 to 6 of every 1,000 deliveries, which equates to 0.3% to 0.6% of women. 

In contrast, postpartum depression (PPD) is much more common and tends to occur in 1 in 8 women, with some estimates estimating PPD occurrence in 10% to 15% of women. 

Because mothers who experience postpartum psychosis experience hallucinations and alternate versions of reality, while the majority of women do not harm themselves or their baby, some instances may result in suicide (5%) or infanticide (1% to 4.5%). But with adequate treatment, nearly all women may achieve full remission, say the authors of one study. 

Here’s more about how to recognize the symptoms and find help if you or someone you know is suffering.  

Signs and symptoms

According to Postpartum Support International, symptoms of postpartum psychosis may include:

• Delusions or strange beliefs
• Hallucinations (seeing or hearing things that aren’t there)
• Feeling very irritated
• Hyperactivity
• Decreased need for or inability to sleep
• Changes in appetite or refusal to eat
• “Flat” affect, or an emotionless or blank expression
• Inability to bond with the baby
• Thoughts of harming the baby or themselves
• Paranoia and suspiciousness
• Rapid mood swings
• Difficulty communicating at times

Because the early days of new motherhood can be fraught with sleepless nights and hormonal changes, some of these symptoms could simply be chalked up to the stress of early motherhood. However, it’s important to note that the hallmark signs of PPP are paranoia and delusions, plus symptoms of mania, such as a decreased need for sleep and hyperactivity. Mood swings may shift rapidly, even over the course of an hour, and women may experience confusion and trouble remembering things. 

Risk factors

While it’s impossible to determine pre-pregnancy or during pregnancy whether you’ll experience PPP, there are some risk factors that may make you more susceptible to the condition, namely having had a history of a mental health condition. That said, not all women who experience PPP will have had a previous mental health risk factor, which means there’s often no reason to suspect it. 

Risk factors for PPP include:

• Having a previous diagnosis of bipolar disorder
• Having a previous diagnosis of major depression with psychosis, schizophrenia or schizoaffective disorder
• A history of postpartum psychosis in a previous pregnancy
• First-time birth
• Sleep deprivation in the postpartum period 
• Discontinuing psychiatric medications during pregnancy

Causes

In some cases, PPP is viewed as a rare subset of bipolar spectrum disorder that sets in during the postpartum period. As stated above, a history of mental health conditions can be pinpointed as a risk factor of PPP in some, but not in all. According to one 2021 review study, more than 40% of women who experience PPP will have had no prior psychiatric history. 

The significant hormonal changes that occur during the postpartum period may trigger the onset of PPP. After birth, levels of hormones required to maintain the pregnancy plummet, “ likely impacting dopaminergic and serotonergic systems in the brain and causing psychotic and mood symptoms,” writes Dr. Richard Seeber II for Massachusetts General Hospital. “Indeed, other times of hormonal shifts, such as pre-menstruation and perimenopause represent times of psychiatric vulnerability.”

Some women may be both more susceptible to those physiological changes and have a genetic predisposition for the condition. In other cases, an autoimmune condition or infection may contribute to the onset. Sleep deprivation may be both a potential trigger for and also a symptom of PPP.

Treatment

Postpartum psychosis is a medical emergency. Once diagnosed, PPP is very treatable, and full remission of symptoms is possible. However, it can be hard for some women to admit that they are struggling and ask for help, so recognizing the signs is important. 

The first step of treatment is usually inpatient hospitalization, with a temporary separation of mother and child to ensure everyone’s safety until a treatment plan is established. The goal is not to permanently separate the mother and baby, but to protect the safety of both while the mother is being cared for and evaluated.

Treatment may include:

• Antipsychotic medications to reduce the incidence of hallucinations
• Mood stabilizers to reduce manic episodes
• Antidepressants and anti-anxiety medications to support daily mood fluctuations

Counseling and support groups may also be recommended. In some cases, electroconvulsive therapy (ECT) may help. ECT has been safely and effectively used for years in treating bipolar disorder. There’s no one treatment that will suit every person’s needs, so working with an expert can help identify a workable plan going forward. PPP may last anywhere from 2 to 12 weeks, and recovery can take longer, from 6 to 12 months.

“If you see a new mother struggling, ask her if she’s okay,” writes actor Sarah Wynter, also an executive producer on A Mouthful of Air, in an essay outlining her own experience with postpartum psychosis for Vanity Fair. “If she says yes, but you still see her struggling, ask again. Depression looks different on everyone, and everybody experiencing it needs different kinds of help.” 

A note from Motherly

Experiencing signs of postpartum psychosis doesn’t mean you’ll feel this way forever—help is available. If you think you or a loved one may be struggling with postpartum depression or postpartum psychosis, reach out to the following resources. 

Resources for those dealing with postpartum psychosis

Sources

Bergink V, Bouvy PF, Vervoort JS, Koorengevel KM, Steegers EA, Kushner SA. Prevention of postpartum psychosis and mania in women at high risk. Am J Psychiatry. 2012;169(6):609-615. doi:10.1176/appi.ajp.2012.11071047

Centers for Disease Control and Prevention (CDC). Depression during and after pregnancy. Updated Dec. 15, 2021. 

Postpartum Support International. Postpartum Psychosis. 

Rommel AS, Molenaar NM, Gilden J, et al. Long-term outcome of postpartum psychosis: a prospective clinical cohort study in 106 women. Int J Bipolar Disord 9, 31 (2021). doi:10.1186/s40345-021-00236-2

Payne J. Postpartum psychosis: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. UpToDate. Updated July 23, 2021.

Perry A, Gordon-Smith K, Jones L, Jones I. Phenomenology, Epidemiology and Aetiology of Postpartum Psychosis: A Review. Brain Sciences. 2021 Jan;11(1):47. doi:10.3390/brainsci11010047
Wesseloo R, Kamperman AM, Munk-Olsen T, Pop VJ, Kushner SA, Bergink V. Risk of Postpartum Relapse in Bipolar Disorder and Postpartum Psychosis: A Systematic Review and Meta-Analysis. Am J Psychiatry. 2016;173(2):117-127. doi:10.1176/appi.ajp.2015.15010124