After she experienced a panic attack when her son was eight months old, Reiswig’s father-in-law—a family-practice doctor—encouraged her to seek help. She was taking one antidepressant for about 10 months until it stopped working and she switched to another.
Why one woman stayed on antidepressants while pregnant and nursing
“I started feeling the depression come back,” Reiswig said, “and I thought, ‘What is wrong with me? This is not normal, he’s like a year and a half , why am I still experiencing this? Something is really wrong with me because you don’t hear people talk about postpartum depression starting and then staying like that.’”
The severity and longevity of postpartum depression, says Snyder, hinge on a litany of factors: how quickly it is diagnosed and treated, and a woman’s sensitivity to the hormonal shifts of pregnancy and the postpartum period—as well as environmental stressors like financial hardship, a traumatic birth experience, or lack of a support system. And, of course, some women may be genetically predisposed to depression or other mood disorders.
But one thing is for sure: The longer the condition lasts after giving birth, the more likely it is that the woman will suffer from depression long-term. A study published in March found that most women who experience severe depression at two months and eight months postpartum still report depressive symptoms 11 years later.
Like Reiswig, Jessica, a mother of three who lives in Lee’s Summit, Missouri, had no personal or family history with depression prior to becoming a mom. (Jessica asked to be identified by her first name only because of ongoing legal proceedings with her ex-husband.) Then, after her first two children, twin girls, were born in 2005, Jessica started feeling anxious and overwhelmed—feelings she thought were just part of new motherhood and compounded by the fact that her then-husband was deployed overseas. As the months passed and her depression worsened, she mentioned her concerns to her children’s pediatrician. But the doctor dismissed her, telling her she had twins, so of course she was overwhelmed. Jessica continued to spiral downwards until she hit a breaking point.
“I remember very clearly both of them crying in the middle of the night and just sitting on the floor of their bedroom completely incapable of doing anything,” she says. “I was just like, ‘I can’t do this anymore.’” Her twins were a one and a half years old before she started feeling like herself again.
But the relief for Jessica proved illusory. When she got pregnant again in 2007, her obstetrician urged her to stop taking antidepressants for the health of the fetus—a recommendation that is now less common with more research about how antidepressants affect pregnancy. Jessica obeyed, but then her depression and anxiety returned almost immediately. This time, after her son was born, she didn’t hesitate to go back to her doctor.
- Postpartum Depression and the Baby Blues
- Depression is common in new moms. Learn about the signs and symptoms—and what you can do to feel better.
- Signs and symptoms of postpartum depression
- Postpartum depression causes and risk factors
- Signs and symptoms of postpartum psychosis
- Coping with postpartum depression tip 1: Create a secure attachment with your baby
- Tip 2: Lean on others for help and support
- Tip 3: Take care of yourself
- Tip 4: Make time for your relationship with your partner
- Treatment for postpartum depression
- Helping a new mother with postpartum depression
- Postpartum psychosis: what is it?
- What about future pregnancies
- What is the outlook for postpartum psychosis?
- Further information
- Postpartum Psychosis
- General Information:
- What Causes Postpartum Depression?
- Who is at Risk for Postpartum Depression?
- Treatment for Postpartum Illness
- Using Medications While Breastfeeding
- How to Prevent PPD
- Are There Different Types of Postpartum Depression?
- Post-partum psychosis
- Clinical features
- Short and longer-term management
- Case vignette one
- Case vignette two
- Case vignette three
- What Is Postpartum Psychosis?
- Who Gets Postpartum Psychosis?
- Postpartum Psychosis Symptoms
- Postpartum Psychosis Treatment
- Postnatal Psychosis
- A treatable illness
- Causes of postnatal psychosis
Postpartum Depression and the Baby Blues
Depression is common in new moms. Learn about the signs and symptoms—and what you can do to feel better.
Having a baby is stressful—no matter how much you’ve looked forward to it or how much you love your child. Considering the sleep deprivation, new responsibilities, and lack of time for yourself, it’s no surprise that a lot of new moms feel like they’re on an emotional rollercoaster.
In fact, mild depression and mood swings are so common in new mothers that it has its own name: the baby blues.
Is it the baby blues or postpartum depression?
The majority of women experience at least some symptoms of the baby blues immediately after childbirth. It’s caused by the sudden change in hormones after delivery, combined with stress, isolation, sleep deprivation, and fatigue. You might feel more tearful, overwhelmed, and emotionally fragile. Generally, this will start within the first couple of days after delivery, peak around one week, and taper off by the end of the second week postpartum.
The baby blues are perfectly normal, but if your symptoms don’t go away after a few weeks or get worse, you may be suffering from postpartum depression.
Signs and symptoms of postpartum depression
Unlike the baby blues, postpartum depression is a more serious problem—one that you shouldn’t ignore.
In the beginning, postpartum depression can look like the normal baby blues. In fact, postpartum depression and the baby blues share many symptoms, including mood swings, crying jags, sadness, insomnia, and irritability. The difference is that with postpartum depression, the symptoms are more severe (such as suicidal thoughts or an inability to care for your newborn) and longer lasting.
- You might find yourself withdrawing from your partner or being unable to bond well with your baby.
- You might find your anxiety out of control, preventing you from sleeping—even when your baby is asleep—or eating appropriately.
- You might find feelings of guilt or worthlessness overwhelming or begin to develop thoughts preoccupied with death or even wish you were not alive.
These are all red flags for postpartum depression.
The Edinburgh Postnatal Depression Scale is a screening tool designed to detect postpartum depression. Follow the instructions carefully. A score greater than 13 suggests the need for a more thorough assessment because you could have postpartum depression.
Postpartum depression causes and risk factors
There’s no single reason why some new mothers develop postpartum depression and others don’t, but a number of interrelated causes and risk factors are believed to contribute to the problem.
- Hormonal changes. After childbirth, women experience a big drop in estrogen and progesterone hormone levels. Thyroid levels can also drop, which leads to fatigue and depression. These rapid hormonal changes—along with the changes in blood pressure, immune system functioning, and metabolism that new mothers experience—may trigger postpartum depression.
- Physical changes. Giving birth brings numerous physical and emotional changes. You may be dealing with physical pain from the delivery or the difficulty of losing the baby weight, leaving you insecure about your physical and sexual attractiveness.
- Stress. The stress of caring for a newborn can also take a toll. New mothers are often sleep deprived. In addition, you may feel overwhelmed and anxious about your ability to properly care for your baby. These adjustments can be particularly difficult if you’re a first-time mother who must get used to an entirely new identity.
Risk factors for postpartum depression
Several factors can predispose you to postpartum depression: The most significant is a history of postpartum depression, as a prior episode can increase your chances of a repeat episode to 30-50%. A history of non-pregnancy related depression or a family history of mood disturbances is also a risk factor. Others include social stressors, such as a lack of emotional support, an abusive relationship, and financial uncertainty. Risk is also significantly increased in women who discontinue medications abruptly for purposes of pregnancy.
Signs and symptoms of postpartum psychosis
Postpartum psychosis is a rare, but extremely serious disorder that can develop after childbirth, characterized by loss of contact with reality. Because of the high risk for suicide or infanticide, hospitalization is usually required to keep the mother and the baby safe.
Postpartum psychosis develops suddenly, usually within the first two weeks after delivery, and sometimes within 48 hours. Symptoms include:
- Hallucinations (seeing things that aren’t real or hearing voices)
- Delusions (paranoid and irrational beliefs)
- Extreme agitation and anxiety
- Suicidal thoughts or actions
- Confusion and disorientation
- Rapid mood swings
- Bizarre behavior
- Inability or refusal to eat or sleep
- Thoughts of harming or killing your baby
Postpartum psychosis should be considered a medical emergency requiring immediate medical attention.
Coping with postpartum depression tip 1: Create a secure attachment with your baby
The emotional bonding process between mother and child, known as attachment, is the most important task of infancy. The success of this wordless relationship enables a child to feel secure enough to develop fully, and affects how he or she will interact, communicate, and form relationships throughout life.
A secure attachment is formed when you as the mother respond warmly and consistently to your baby’s physical and emotional needs. When your baby cries, you quickly soothe him or her. If your baby laughs or smiles, you respond in kind. In essence, you and your child are in synch. You recognize and respond to each other’s emotional signals.
Postpartum depression can interrupt this bonding. Depressed mothers can be loving and attentive at times, but at other times may react negatively or not respond at all. Mothers with postpartum depression tend to interact less with their babies, and are less likely to breastfeed, play with, and read to their children. They may also be inconsistent in the way they care for their newborns.
However, learning to bond with your baby not only benefits your child, it also benefits you by releasing endorphins that make you feel happier and more confident as a mom.
How to bond with your baby
If you didn’t experience a secure attachment as an infant, you may not know how to create a secure attachment—but you can learn. Our human brains are primed for this kind of nonverbal emotional connection that creates so much pleasure for you and your baby.
Tip 2: Lean on others for help and support
Human beings are social. Positive social contact relieves stress faster and more efficiently than any other means of stress reduction. Historically and from an evolutionary perspective, new mothers received help from those around them when caring for themselves and their infants after childbirth. In today’s world, new mothers often find themselves alone, exhausted and lonely for supportive adult contact. Here are some ideas for connecting to others:
Make your relationships a priority. When you’re feeling depressed and vulnerable, it’s more important than ever to stay connected to family and friends—even if you’d rather be alone. Isolating yourself will only make your situation feel even bleaker, so make your adult relationships a priority. Let your loved ones know what you need and how you’d like to be supported.
Don’t keep your feelings to yourself. In addition to the practical help your friends and family can provide, they can also serve as a much-needed emotional outlet. Share what you’re experiencing—the good, the bad, and the ugly—with at least one other person, preferably face to face. It doesn’t matter who you talk to, so long as that person is willing to listen without judgment and offer reassurance and support.
Be a joiner. Even if you have supportive friends, you may want to consider seeking out other women who are dealing with the same transition into motherhood. It’s very reassuring to hear that other mothers share your worries, insecurities, and feelings. Good places to meet new moms include support groups for new parents or organizations such as Mommy and Me. Ask your pediatrician for other resources in your neighborhood.
Tip 3: Take care of yourself
One of the best things you can do to relieve or avoid postpartum depression is to take care of yourself. The more you care for your mental and physical well-being, the better you’ll feel. Simple lifestyle changes can go a long way towards helping you feel like yourself again.
Skip the housework – Make yourself and your baby the priority. Give yourself permission to concentrate on yourself and your baby – there is more work involved in this 24/7 job than in holding down a full-time job.
Ease back into exercise. Studies show that exercise may be just as effective as medication when it comes to treating depression, so the sooner you get back up and moving, the better. No need to overdo it: a 30-minute walk each day will work wonders. Stretching exercises such as those found in yoga have shown to be especially effective.
Practice mindfulness meditation. Research supports the effectiveness of mindfulness for making you feel calmer and more energized. It can also help you to become more aware of what you need and what you feel.
Don’t skimp on sleep. A full eight hours may seem like an unattainable luxury when you’re dealing with a newborn, but poor sleep makes depression worse. Do what you can to get plenty of rest—from enlisting the help of your partner or family members to catching naps when you can.
Set aside quality time for yourself to relax and take a break from your mom duties. Find small ways to pamper yourself, like taking a bubble bath, savoring a hot cup of tea, or lighting scented candles. Get a massage.
Make meals a priority. When you’re depressed, nutrition often suffers. What you eat has an impact on mood, as well as the quality of your breast milk, so do your best to establish healthy eating habits.
Get out in the sunshine. Sunlight lifts your mood, so try to get at least 10 to 15 minutes of sun per day.
Tip 4: Make time for your relationship with your partner
More than half of all divorces take place after the birth of a child. For many men and women, the relationship with their partner is their primary source of emotional expression and social connection. The demands and needs of a new baby can get in the way and fracture this relationship unless couples put some time, energy, and thought into preserving their bond.
Don’t scapegoat. The stress of sleepless nights and caretaking responsibilities can leave you feeling overwhelmed and exhausted. And since you can’t take it out on the baby, it’s all too easy to turn your frustrations on your partner. Instead of finger pointing, remember that you’re in this together. If you tackle parenting challenges as a team, you’ll become an even stronger unit.
Keep the lines of communication open. Many things change following the birth of a baby, including roles and expectations. For many couples, a key source of strain is the post-baby division of household and childcare responsibilities. It’s important to talk about these issues, rather than letting them fester. Don’t assume your partner knows how you feel or what you need.
Carve out couple time. It’s essential to make time for just the two of you when you can reconnect. But don’t put pressure on yourself to be romantic or adventurous (unless you’re both up for it). You don’t need to go out on a date to enjoy each other’s company. Even spending 15 or 20 minutes together—undistracted and focused on each other— can make a big difference in your feelings of closeness.
Treatment for postpartum depression
If, despite the self-help and the support of your family, you’re still struggling with postpartum depression, you may want professional treatment.
Individual therapy or marriage counseling – A good therapist can help you successfully deal with the adjustments of motherhood. If you are experiencing marital difficulties or are feeling unsupported at home, marriage counseling can be very beneficial.
Antidepressants – For cases of postpartum depression where your ability to function adequately for yourself or your baby is compromised, antidepressants may be an option. However, medication should be closely monitored by a physician and has shown to be more effective when accompanied by psychotherapy.
Hormone therapy – Estrogen replacement therapy sometimes helps with postpartum depression. Estrogen is often used in combination with an antidepressant. There are risks that go along with hormone therapy, so be sure to talk to your doctor about what is best—and safest—for you.
Helping a new mother with postpartum depression
If your loved one is experiencing postpartum depression, the best thing you can do is to offer support. Give her a break from her childcare duties, provide a listening ear, and be patient and understanding.
You also need to take care of yourself. Dealing with the needs of a new baby is hard for the partner as well as the mother. And if your significant other is depressed, you are dealing with two major stressors.
How to help your wife or partner
Encourage her to talk about her feelings. Listen to her without judging her or offering solutions. Instead of trying to fix things, simply be there for her to lean on.
Offer help around the house. Chip in with the housework and childcare responsibilities. Don’t wait for her to ask!
Make sure she takes time for herself. Rest and relaxation are important. Encourage her to take breaks, hire a babysitter, or schedule some date nights.
Be patient if she’s not ready for sex. Depression affects sex drive, so it may be a while before she’s in the mood. Offer her physical affection, but don’t push if she’s not up for sex.
Go for a walk with her. Getting exercise can make a big dent in depression, but it’s hard to get motivated when you’re feeling low. Help her by making walks a daily ritual for the two of you.
Post-partum psychosis is a condition of multiple and varied etiology, a phenomenological cluster. Pre-existing bipolar affective disorder, previous postpartum psychosis, and possibly major depressive disorder in a patient predispose to its development, as does a family history of the same. But a patient without those antecedents may, however, in association with pre-eclampsia, develop a similar-appearing illness which may require a different treatment.
The patient’s illness fits the existing definition of puerperal psychosis: the abrupt onset of a psychotic illness within two weeks of childbirth, with associated hallucinations, delusions, thought disorganization, alienation from her child, and bizarre behaviors. Her illness, in addition, was associated with pre-eclampsia, conforming to the diagnosis of Donkin Psychosis. The case demonstrates some features atypical for post-partum psychosis, however, including her older age, her high parity, and the lack of puerperal or other known mood disorders in her family.
In addition to being a rare case of EPWS, this case importantly highlights the challenges to diagnosis and treatment in Malawi. Infrastructure and staffing are major limitations. Queen Elizabeth Central Hospital is a 1300+ bed tertiary referral center in southern Malawi. The hospital has a well-trained and skilled staff whose numbers are insufficient for the high patient census. There is frequently broken or absent equipment, absence of laboratory reagents, and occasional losses of electrical power or water. The census at times requires patients to stay in informal beds, including mattresses on ward floors or even on hall floors. Food, basic hygiene, personal care, and linens for patients are supplied by guardians — family or friends. There is little capacity for adequately monitoring patients, including catheters and intravenous lines, there are unpredictable pharmacy shortages, and patient care documentation is often rudimentary.
Post-care follow-up is challenged by the use of paper records that are sorted by date of admission but not alphabetically, by a medical record number, or another unique identifier. Telephones are not universally owned or used; addresses are often not recorded in patient files. The demographics of Malawi add an additional challenge as most of the population is rural and served by local health centers. Therefore, this patient needed to be located through her local clinic in order to interview her in her small hillside village.
An informal survey of 14 academic physicians, among them obstetricians, psychiatrists and internists, revealed that none were aware of a pre-eclampsia-associated puerperal psychosis, let alone its eponymous designation. Two current literature reviews of eclampsia and pre-eclampsia make no mention of puerperal psychosis in their list of symptoms, suggesting that this is not a well-known correlation. 5, 11
There is urgency in the treatment of puerperal psychosis. In the first instance, the baby must be protected and never left alone with the mother. In addition, haste is of the essence in order to facilitate nursing and to encourage maternal-infant bonding. For these reasons, electroconvulsive therapy (ECT) is often used, especially if the mother does not have adequate food and fluid intake. As often, antipsychotic medications are used to effect recovery.This patient’s psychosis resolved rapidly within three days of normalization of her blood pressure, without the use of antipsychotic medication. It is noteworthy that if a consultation had been performed for her during her second admission, she would likely have received risperidone, our most reliably available second-generation antipsychotic. When she had improved in three days, risperidone would have been credited for her recovery.
There are no controlled studies of the use of antipsychotic medications for the treatment of post-partum psychosis, although they and ECT are the standards of practice in the community. The possibility that the Donkin variation of post-partum psychosis may be successfully treated solely with antihypertensive medication is intriguing. Medications in low-resourced countries are frequently out of stock. The potential additional side effects of the antipsychotics, both for mother and nursing newborn, are unwanted. The use of unnecessary medication is an all-too-frequent occurrence in modern medical practice.
Postpartum psychosis: what is it?
Women suffering from postpartum psychosis can be prescribed:
anti-depressants to ease depression symptoms
anti-psychotics to help with hallucinations, mania and delusions
mood stabilisers to help prevent reoccurrence of symptoms.
Electroconvulsive therapy (ECT)
Electrical currents are passed through the brain to relieve the symptoms of postpartum psychosis. This is done under general anaesthetic. Electroconvulsive therapy is only used rarely for women who have severe symptoms or don’t respond to other treatment (NHS Choices, 2017; MIND, 2017).
Your GP might suggest you have Cognitive Behavioural Therapy (CBT) once you’re in recovery from postpartum psychosis (NHS Choices, 2017).
What about future pregnancies
If you suffer from postpartum psychosis with your first pregnancy, there is no reason why you can’t go on to have more children. There is a chance that you will get another episode. About 50% of women who have had postpartum psychosis experience it again if they have another baby (AAP, 2018).
With a future pregnancy, you’ll be more prepared to get the support you need. You won’t necessarily be able to avoid another bout but you can get help from the start to make it as easy to deal with as possible.
The key thing is planning. Ask your midwife or GP to refer you to a perinatal psychiatrist. You should get the help you need more quickly, meaning that you can recover more quickly too.
What is the outlook for postpartum psychosis?
The most severe symptoms last between two and 12 weeks. What often follows is a period of anxiety, depression or a lack of self-confidence.
Some women find it difficult to bond with their baby for a little while afterwards (NHS Choices, 2017). But with the right treatment, women who have postpartum psychosis will make a full recovery within six to 12 months (NHS Choices, 2017).
This page was last reviewed in June 2018
Our support line offers practical and emotional support with feeding your baby and general enquiries for parents, members and volunteers: 0300 330 0700.
You might find attending one of our Early Days groups helpful as they give you the opportunity to explore different approaches to important parenting issues with a qualified group leader and other new parents in your area.
Make friends with other parents-to-be and new parents in your local area for support and friendship by seeing what NCT activities are happening nearby.
For more information and help on postpartum psychosis, visit Action On Postpartum Psychosis.
Postpartum Psychosis is a rare illness, compared to the rates of postpartum depression or anxiety. It occurs in approximately 1 to 2 out of every 1,000 deliveries, or approximately .1 -.2% of births. The onset is usually sudden, most often within the first 2 weeks postpartum.
Symptoms of postpartum psychosis can include:
- Delusions or strange beliefs
- Hallucinations (seeing or hearing things that aren’t there)
- Feeling very irritated
- Decreased need for or inability to sleep
- Paranoia and suspiciousness
- Rapid mood swings
- Difficulty communicating at times
The most significant risk factors for postpartum psychosis are a personal or family history of bipolar disorder, or a previous psychotic episode.
Of the women who develop a postpartum psychosis, research has suggested that there is approximately a 5% suicide rate and a 4% infanticide rate associated with the illness. This is because the woman experiencing psychosis is experiencing a break from reality. In her psychotic state, the delusions and beliefs make sense to her; they feel very real to her and are often religious. Immediate treatment for a woman going through psychosis is imperative.
It is also important to know that many survivors of postpartum psychosis never had delusions containing violent commands. Delusions take many forms, and not all of them are destructive. Most women who experience postpartum psychosis do not harm themselves or anyone else. However, there is always the risk of danger because psychosis includes delusional thinking and irrational judgment, and this is why women with this illness must be quickly assessed, treated, and carefully monitored by a trained healthcare perinatal mental health professional.
Postpartum psychosis is temporary and treatable with professional help, but it is an emergency and it is essential that you receive immediate help. If you feel you or someone you know may be suffering from this illness, know that it is not your fault and you are not to blame. Call your doctor or an emergency crisis hotline right away so that you can get the help you need.
PSI also has a Postpartum Psychosis Coordinator to provide additional assistance to women and families who are not in an emergency situation. Contact Michele Davidson, at 703-298-3247, at [email protected]
The Postpartum Period
During the postpartum period, about 85% of women experience some type of mood disturbance. For most the symptoms are mild and short-lived; however, 10 to 15% of women develop more significant symptoms of depression or anxiety. Postpartum psychiatric illness is typically divided into three categories: (1) postpartum blues (2) postpartum depression and (3) postpartum psychosis. It may be useful to conceptualize these disorders as existing along a continuum, where postpartum blues is the mildest and postpartum psychosis the most severe form of postpartum psychiatric illness.
It appears that about 50 to 85% of women experience postpartum blues during the first few weeks after delivery. Given how common this type of mood disturbance is, it may be more accurate to consider the blues as a normal experience following childbirth rather than a psychiatric illness. Rather than feelings of sadness, women with the blues more commonly report mood lability, tearfulness, anxiety or irritability. These symptoms typically peak on the fourth or fifth day after delivery and may last for a few hours or a few days, remitting spontaneously within two weeks of delivery. While these symptoms are unpredictable and often unsettling, they do not interfere with a woman’s ability to function. No specific treatment is required; however, it should be noted that sometimes the blues heralds the development of a more significant mood disorder, particularly in women who have a history of depression. If symptoms of depression persist for longer than two weeks, the patient should be evaluated to rule out a more serious mood disorder.
PPD typically emerges over the first two to three postpartum months but may occur at any point after delivery. Some women actually note the onset of milder depressive symptoms during pregnancy. Postpartum depression is clinically indistinguishable from depression occurring at other times during a woman’s life. The symptoms of postpartum depression include:
- Depressed or sad mood
- Loss of interest in usual activities
- Feelings of guilt
- Feelings of worthlessness or incompetence
- Sleep disturbance
- Change in appetite
- Poor concentration
- Suicidal thoughts
Significant anxiety symptoms may also occur. Generalized anxiety is common, but some women also develop panic attacks or hypochondriasis. Postpartum obsessive-compulsive disorder has also been reported, where women report disturbing and intrusive thoughts of harming their infant. Especially with milder cases, it may be difficult to detect postpartum depression because many of the symptoms used to diagnose depression (i.e., sleep and appetite disturbance, fatigue) also occur in postpartum women in the absence of depression. The Edinburgh Postnatal Depression Scale is a 10-item questionnaire that may be used to identify women who have PPD. On this scale, a score of 12 or greater or an affirmative answer on question 10 (presence of suicidal thoughts) raise concern and indicate a need for more thorough evaluation.
Postpartum psychosis is the most severe form of postpartum psychiatric illness. It is a rare event that occurs in approximately 1 to 2 per 1000 women after childbirth. Its presentation is often dramatic, with onset of symptoms as early as the first 48 to 72 hours after delivery. The majority of women with puerperal psychosis develop symptoms within the first two postpartum weeks.
It appears that in most cases, postpartum psychosis represents an episode of bipolar illness; the symptoms of puerperal psychosis most closely resemble those of a rapidly evolving manic (or mixed) episode. The earliest signs are restlessness, irritability, and insomnia. Women with this disorder exhibit a rapidly shifting depressed or elated mood, disorientation or confusion, and erratic or disorganized behavior. Delusional beliefs are common and often center on the infant. Auditory hallucinations that instruct the mother to harm herself or her infant may also occur. Risk for infanticide, as well as suicide, is significant in this population.
Depression and Obsessive Compulsive Symptoms During the Postpartum Period
Despite several studies which have begun to demonstrate that maternal anxiety during pregnancy can negatively affect offspring neurodevelopment, little attention has been given to postpartum maternal anxiety both by clinicians and researchers. This may be because of the clinical overlap between depression and anxiety symptoms. Routine postpartum screening generally includes assessing symptoms of depression but anxiety disorders are often masked. Educating clinicians about postpartum anxiety can be very helpful for patients.
Recent studies show pregnancy and childbirth are frequently associated with the onset of the Obsessive Compulsive Disorder (OCD), one type of anxiety disorder. Some women do not have OCD but are bothered by obsessive-compulsive symptoms.
Miller and colleagues aimed to shed light on postpartum depression and anxiety, with and without obsessions, in their two recent studies (Miller, Hoxha, Wisner, & Gossett, 2015a, 2015b).
A prospective cohort study of 461 women was performed to examine the phenomenology and the most common obsessive and compulsive symptoms present in postpartum women without a diagnosis of obsessive compulsive disorder (OCD). Of the 461 women included, 11.2% screened positive for OCD at 2 weeks postpartum, while 37.5% reported experiencing subclinical obsessions or compulsions. Both at 2 and 6 weeks, among the women who screened negative for OCD, the most commonly reported obsessions were aggression and contamination, and the most common compulsions were cleaning/washing, checking. Women with compulsions, with aggressive, religious and somatic obsessions and obsessions with symmetry were more likely to screen positive for OCD . Miller and colleagues’ data also showed that women with subclinical obsessions or compulsions were much more likely to be experiencing depression, as nearly 25% of these women also screened positive for depression.
In a secondary analysis of their prospective cohort study, Miller and colleagues examined the clinical course of postpartum anxiety and they confirmed the clinical overlap between postpartum anxiety and depression. A large number of women with postpartum depression had anxiety symptoms and obsessive-compulsive symptoms in the immediate postpartum period. At 2 weeks postpartum 19.9% of women with depression were more likely to experience comorbid state-trait anxiety, compared to 1.3% women who screened negative for depression. At both at 2 and 6 weeks postpartum, women with depression were more likely to report obsessions and compulsions compared to women without depression. While state-trait anxiety symptoms tended to resolve with time, obsessive-compulsive symptoms persisted. By 6 months postpartum, there were no differences in anxiety symptoms in women with and without depression, but the difference in obsessive-compulsive symptoms persisted (p=0.017). All this means severe distress for women and therapeutic implications for clinicians.
Given the potential adverse effects of untreated mood and anxiety symptoms on both the mother and child, careful screening and early recognition of anxiety symptoms during the postpartum period is recommended.
What Causes Postpartum Depression?
The postpartum period is characterized by a rapid shift in the hormonal environment. Within the first 48 hours after delivery, estrogen and progesterone concentrations fall dramatically. As these gonadal steroids modulate neurotransmitter systems involved in the regulation of mood, many investigators have proposed a role for these hormonal shirts in the emergence of postpartum affective illness. While it appears that there is no consistent correlation between serum levels of estrogen, progesterone, cortisol, or thyroid hormones and the occurrence of postpartum mood disturbance, some investigators hypothesize that there is a subgroup of women who are particularly sensitive to the hormonal changes that take place after delivery. This population of women may be more vulnerable to PPD and to other hormonally driven mood disturbances, such as those occurring during the premenstrual phase of the menstrual cycle or during the perimenopause.
Other factors may play a role in the etiology of PPD. One of the most consistent findings is that among women who report marital dissatisfaction and/or inadequate social supports, postpartum depressive illness is more common. Several investigators have also demonstrated that stressful life events occurring either during pregnancy or near the time of delivery appear to increase the likelihood of postpartum depression.
While all of these factors may act together to cause PPD, the emergence of this disorder probably reflects an underlying vulnerability to affective illness. Women with histories of major depression or bipolar disorder are more vulnerable to PPD, and women who develop PPD will often go on to have recurrent episodes of depression unrelated to pregnancy or childbirth.
Who is at Risk for Postpartum Depression?
All women are vulnerable to postpartum depression, regardless of age, marital status, education level, or socioeconomic status. While it is impossible to predict who will develop PPD, certain risk factors for PPD have been identified, including:
- Previous episode of PPD
- Depression during pregnancy
- History of depression or bipolar disorder
- Recent stressful life events
- Inadequate social supports
- Marital problem
Treatment for Postpartum Illness
Postpartum depression presents along a continuum, and the type of treatment selected is based on the severity and type of symptoms present. However, before initiating psychiatric treatment, medical causes for mood disturbance (e.g., thyroid dysfunction, anemia) must be excluded. Initial evaluation should include a thorough history, physical examination, and routine laboratory tests.
Non-pharmacological therapies are useful in the treatment of postpartum depression. In a randomized study it was demonstrated that short-term cognitive-behavioral therapy (CBT) was as effective as treatment with fluoxetine in women with postpartum depression. Interpersonal therapy (IPT) has also been shown to be effective for the treatment of women with mild to moderate postpartum depression. Not only is IPT effective for treating the symptoms of depression, women who receive IPT also benefit from significant improvements in the quality of their interpersonal relationships. Read this 2004 blog post and this 2007 post to learn more about CBT as a treatment option.
These non-pharmacological interventions may be particularly attractive to those patients who are reluctant to use psychotropic medications (e.g., women who are breast-feeding) or for patients with milder forms of depressive illness. Women with more severe postpartum depression may choose to receive pharmacological treatment, either in addition to or instead of these non-pharmacological therapies.
To date, only a few studies have systematically assessed the pharmacological treatment of postpartum depression. Conventional antidepressant medications (fluoxetine, sertraline, fluvoxamine, and venlafaxine) have shown efficacy in the treatment of postpartum depression. In all of these studies, standard antidepressant doses were effective and well tolerated. The choice of an antidepressant should be guided by the patient’s prior response to antidepressant medication and a given medication’s side effect profile. Specific serotonin reuptake inhibitors (SSRIs) are ideal first-line agents, as they are anxiolytic, non-sedating, and well tolerated. For women who cannot tolerate SSRIs, bupropion (Wellbutrin) may be an alternative; although one pilot study suggests bupropion may not be as effective as SSRIs. Tricyclic antidepressants (TCAs) are frequently used and, because they tend to be more sedating, may be more appropriate for women who present with prominent sleep disturbance. Given the prevalence of anxiety symptoms in this population, adjunctive use of a benzodiazepine (e.g., clonazepam, lorazepam) may be very helpful.
Puerperal psychosis is considered a psychiatric emergency that typically requires inpatient treatment. Acute treatment with either typical or atypical anti-psychotic medications is indicated. Given the well-established relationship between puerperal psychosis and bipolar disorder, postpartum psychosis should be treated as an affective psychosis and a mood stabilizer is indicated. Electroconvulsive therapy (ECT) is well tolerated and rapidly effective for severe postpartum depression and psychosis.
Using Medications While Breastfeeding
The nutritional, immunologic and psychological benefits of breastfeeding have been well documented. Women who plan to breastfeed must be informed that all psychotropic medications, including antidepressants, are secreted into the breast milk. Concentrations in the breast milk appear to vary widely. The amount of medication to which an infant is exposed depends on several factors, including dosage of medication, rate of maternal drug metabolism, and frequency and timing of feedings (Llewelyn and Stowe).
Over the past five years, data have accumulated regarding the use of various antidepressants during breastfeeding (reviewed in Newport et al 2002). Available data on the tricyclic antidepressants, fluoxetine, paroxetine, and sertraline during breastfeeding have been encouraging and suggest that significant complications related to neonatal exposure to psychotropic drugs in breast milk appear to be rare. While less information is available on other antidepressants, there have been no reports of serious adverse events related to exposure to these medications.
For women with bipolar disorder, breastfeeding may be more problematic. First is the concern that on-demand breastfeeding may significantly disrupt the mother’s sleep and thus may increase her vulnerability to relapse during the acute postpartum period. Second, there have been reports of toxicity in nursing infants related to exposure to various mood stabilizers, including lithium and carbamazepine, in breast milk. Lithium is excreted at high levels in the mother’s milk, and infant serum levels are relatively high, about one-third to one-half of the mother’s serum levels, increasing the risk of neonatal toxicity. Exposure to carbamazepine and valproic acid in the breast milk has been associated with hepatotoxicity in the nursing infant.
Learn more in our Breastfeeding and Psychiatric Medication specialty area.
How to Prevent PPD
Although it is difficult to reliably predict which women in the general population will experience postpartum mood disturbance, it is possible to identify certain subgroups of women (i.e., women with a history of mood disorder) who are more vulnerable to postpartum affective illness. Current research indicates that prophylactic interventions may be instituted near or at the time of delivery to decrease the risk of postpartum illness. Several studies demonstrate that women with histories of bipolar disorder or puerperal psychosis benefit from prophylactic treatment with lithium instituted either prior to delivery (at 36 weeks gestation) or no later than the first 48 hours postpartum. For women with histories of postpartum depression, several studies have described a beneficial effect of prophylactic antidepressant (either TCAs or SSRIs) administered after delivery. Patients with postpartum psychiatric illness are offered a variety of services by clinicians with particular expertise in this area:
- Clinical evaluation for postpartum mood and anxiety disorders
- Medication management
- Consultation regarding breastfeeding and psychotropic medications
- Recommendations regarding non-pharmacological treatments
- Referral to support services within the community
For the latest information on postpartum psychiatric disorders, please visit our blog.
How do I get an appointment?
Consultations regarding treatment options can be scheduled by calling our intake coordinator at 617-724-7792.
If you are pregnant or planning pregnancy, you may be interested in enrolling in the National Pregnancy Registry. You may find more information on this registry here. To view the list of our other active studies please visit our research page.
Miller ES, Hoxha D, Wisner KL, Gossett DR.The impact of perinatal depression on the evolution of anxiety and obsessive-compulsive symptoms. Arch Womens Ment Health. 2015
Miller ES, Hoxha D, Wisner KL, Gossett DR. Obsessions and compulsions in postpartum women without obsessive compulsive disorder. J Womens Health (Larchmt). 2015
Are There Different Types of Postpartum Depression?
There are three types of mood changes women can have after giving birth:
- The “baby blues,” which occur in most women in the days right after childbirth, are considered normal. A new mother has sudden mood swings, such as feeling very happy and then feeling very sad. She may cry for no reason and can feel impatient, irritable, restless, anxious, lonely, and sad. The baby blues may last only a few hours or as long as one to two weeks after delivery. The baby blues do not usually require treatment from a health care provider. Often, joining a support group of new moms or talking with other moms helps.
- Postpartum depression (PPD) can happen a few days or even months after childbirth. PPD can happen after the birth of any child, not just the first child. A woman can have feelings similar to the baby blues — sadness, despair, anxiety, irritability — but she feels them much more strongly than she would with the baby blues. PPD often keeps a woman from doing the things she needs to do every day. When a woman’s ability to function is affected, she needs to see her health care provider, such as her ob-gyn or primary care doctor. This doctor can screen her for depression symptoms and develop a treatment plan. If a woman does not get treatment for PPD, symptoms can get worse. While PPD is a serious condition, it can be treated with medication and counseling.
- Postpartum psychosis is a very serious mental illness that can affect new mothers. This illness can happen quickly, often within the first three months after childbirth. Women can lose touch with reality, having auditory hallucinations (hearing things that aren’t actually happening, like a person talking) and delusions (strongly believing things that are clearly irrational). Visual hallucinations (seeing things that aren’t there) are less common. Other symptoms include insomnia (not being able to sleep), feeling agitated and angry, pacing, restlessness, and strange feelings and behaviors. Women who have postpartum psychosis need treatment right away and almost always need medication. Sometimes women are put into the hospital because they are at risk for hurting themselves or someone else.
Post-partum psychosis is a serious mental illness that starts soon after childbirth. Fortunately it is very rare and there are very effective treatments.
Psychosis essentially means a loss of reality. It usually comes on in a very quick and spectacular manner within the first few weeks after giving birth, but the onset can be within hours of deliveriy. It can be extremely scary, especially if you’ve never had it before, because you find it difficult to differentiate between reality and the illness playing tricks on your brain.
On this page:
Why do women have post-partum psychosis?
What are the signs of post-partum psychosis?
What to do
What your partner and family can do
Why do women have post-partum psychosis?
Things that are thought to contribute to post-partum psychosis include:
- a genetic predisposition (there is an increased risk in women with a family history of post-partum psychosis or bipolar disorder)
- severe sleep deprivation that can happen in the first little while after a baby is born
- the rapid hormonal changes around the birth
- physical stress of delivery – particularly if there are other medical problems.
There is also a relationship between post-partum psychosis and bipolar disorder. Women with bipolar disorder are at greatest risk of a relapse with psychotic symptoms soon after delivery. Conversely for some women, post-partum psychosis marks the first episode of a bipolar illness. However, this is not always the case. Some women will have only a single episode of post-partum psychosis, while others will have an episode of illness after each time they have a baby.
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What are the signs of post-partum psychosis?
Women who have post-partum psychosis may have a range of the following symptoms:
- confusion and disorientation, about the day and time and who people are
- concentration can be affected and your mind may feel foggy or that it is overloaded with too many thoughts
- severe physical anxiety or agitation, such that you cannot stay still
- variable mood, either on a high, irritable or depressed
- insomnia, feeling like you need less sleep and perhaps going days without sleeping
- delusions or thoughts that are not true and that are often paranoid – that the hospital staff are spies, that your partner is an imposter in disguise. These thoughts may seem bizarre or silly when you are well, but in the middle of the illness they can seem real
- hallucinations or impaired sensations where you either hear, see or smell things that are not present
- strange sensations that you are not really yourself and there are others controlling your actions and thoughts
- thoughts of and/or plans to harm yourself and your baby.
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What to do
Post-partum psychosis is a psychiatric emergency and you need immediate treatment for your safety and the safety of your baby.
Treatment will be provided in a hospital, in either a:
psychiatric mother–baby unit, where your baby will stay with you
general adult psychiatric unit, where your baby will need to be cared for by your partner, family or friends until you are well enough to go home.
Treatment usually involves medication, but sometimes, if the episode is very severe, electroconvulsive therapy (ECT) is the fastest and most effective treatment to get you on the path to recovery.
It may also be worthwhile to have counselling. The experience of psychosis can be very traumatic. You may be left grieving, scared or confused about the entire event. Talking through your experience can help you process and make sense of it.
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What your partner or family can do
Depending on how unwell you are, it may be up to your partner or another family member to organise medical help for you. It can be very hard for family members to support a woman who has post-partum psychosis because she may resist help or think that people are intending to harm her. Partners can get advice and support through Beyond Blue, the hospital where your baby was born, your local hospital emergency department or GP. A Crisis Assessment or Acute Treatment team (sometimes called a CAT team) can also be accessed in a mental health crisis. Your local hospital or community health centre can help you to access the right service.
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The Women’s does not accept any liability to any person for the information or advice (or use of such information or advice) which is provided on the Website or incorporated into it by reference. The Women’s provide this information on the understanding that all persons accessing it take responsibility for assessing its relevance and accuracy. Women are encouraged to discuss their health needs with a health practitioner. If you have concerns about your health, you should seek advice from your health care provider or if you require urgent care you should go to the nearest Emergency Dept.
Postpartum or ‘puerperal’ psychosis, the acute onset of severe psychiatric symptoms early postpartum, was first characterised in the 19th century. At that time, many cases were likely organic as a result of blood loss or sepsis. However, in some cases, there were no underlying medical risk factors and the concept of non-organic postpartum psychosis was developed. In the 21st century, the rate of postpartum psychotic episodes is 1–2/1000 deliveries in the parturient population, increasing dramatically to 30 per cent of women with a history of bipolar disorder and more than 50 per cent in women with a past postpartum psychosis (Figure 1).1 A woman has a 30-fold increased risk for acute psychosis in the first three weeks postpartum.2
Figure 1. Rates of postpartum psychosis in women
Very early signs of postpartum psychosis include increasingly anxious affect and poor sleep (independent of baby waking). As these symptoms are common in parturient women, it is important to review at regular intervals for symptom evolution. As psychosis evolves, women develop irrational and frightening beliefs (for example, harm will befall them, their family or infant; close family can no longer be trusted; they are ‘going mad’; or the baby will be removed because they are a ‘bad’ mother). Women are very likely to minimise symptoms and go undiagnosed early on. At mental state examination, they present as preoccupied, suspicious, difficult to engage, restless, distractable or disorganised. Depending on symptom severity, their speech may be illogical and difficult to follow, and they may experience frank delusions (for example, grandiose, persecutory, guilt). More often, these women may express vague suspicions that close family members can’t be trusted or concerns about their baby’s welfare. They may experience suicidal thoughts, especially if distressed by persecutory or depressive delusions. These women may have partial or no insight into their disturbed mental state. Psychotic symptoms and insight often fluctuate day to day, and, as the episode worsens, symptoms are associated with significantly impaired ability to care for the baby. Both suicidality and possible thoughts of harm to baby, as part of a psychotic belief system or severe depression, need to be specifically explored.
Diagnosis of acute psychosis is very straightforward when symptoms are severe. However, in milder cases where there is commonly symptom minimisation, partial insight and day-to-day fluctuation, these women may present well at cross-sectional assessment. It is thus critical to obtain corroborative history from significant others and, if possible, to review the woman at regular, close intervals. If unsure, urgent psychiatric consultation is essential.
An obstetrician’s immediate management plan:
- Engage both the woman and her significant other/s and try to destigmatise the mental health issues as much as possible while highlighting the need for urgent care.
- Ensure the safety of infant and mother.
- Discuss the diagnosis in broad terms: avoid the term psychosis; use terms like ‘more severe postnatal depression’.
- Emphasise that sleep deprivation is a key risk factor and highlight the need to urgently commence a hypnotic.
- Consider a hypnotic with a long half-life. For example, half to one tablet of zopiclone (Imovane) or doxylamine (Restavit). Temazepam is unlikely to be useful. Hypnotics are relatively safe in breastfeeding, as there is minimal secretion into breastmilk.
- Discuss possible admission to a mother and baby unit (MBU). Emphasise the value of the MBU for support with the baby. Again, try to reduce the mother’s/family’s stigma with a psychiatric admission.
- As soon as possible, seek advice from and hand over care to psychiatry and the local mental health team.
Short and longer-term management
Once the woman is engaged with psychiatry, a sedating antipsychotic, such as quetiapine (Seroquel), will need to be commenced. Initially, this is to reduce symptoms of agitation, distress and insomnia while the antipsychotic takes effect within one to three weeks. Response to the antipsychotic needs close monitoring and, all going well, reduction and cessation after six months (if this is the woman’s first episode of psychosis) can be undertaken.
Where a woman has a pre-existing diagnosis of bipolar disorder or schizophrenia or develops such a diagnosis, appropriate longer-term antipsychotic and/or mood stabilisers will need to be re/commenced. If lithium is to be commenced while breastfeeding, it is best to seek a second opinion, where possible from a perinatal psychiatrist.
It is important to explain the difference between postnatal depression and postpartum psychosis. Reassure the woman and her family about the overall good prognosis of postpartum psychosis, while emphasising the need for psychiatric monitoring and medication in subsequent months. Women and their families need to learn about the early signs of relapse of psychosis, most commonly: insomnia, independent of baby’s waking; racing thoughts; erratic mood shift or severe anxiety; distractibility; or unfounded preoccupation with the baby or family’s welfare.
Future pregnancy planning
Subsequent pregnancy is not contraindicated, but best deferred until the woman has been free of symptoms for over a year. Families also need to be aware that having had one postpartum psychosis increases a woman’s chance of a recurrence to about 50 per cent, but early management of postnatal insomnia with medication and close mental health monitoring is likely to reduce the chance of relapse substantially. It is important to devise a clear mental healthcare plan with the woman and her family for any subsequent pregnancy. Copies of this plan need to be made available to the woman and all key healthcare providers.
Postpartum psychosis usually responds fairly quickly (within two to three weeks) to antipsychotic medication and sleep restoration. However, some cases take much longer to resolve and it is possible these women are developing a longer-term psychiatric condition, either a bipolar disorder or, less commonly, a schizophrenia-like illness. While the majority of women with a de novo episode don’t relapse into psychosis later in life, 14 per cent will go on to develop a manic or depressive episode sometime in the next 15 or more years,3 consistent with an emerging bipolar disorder.
Case vignette one
A 35-year-old married woman with bipolar disorder, requiring several admissions in her teens, responded fully to lithium at the time, but ceased all medication and psychiatric follow-up in her 20s. She remained well on a regimen of regular sleep, supportive work situation and partner relationship, cessation of alcohol or drug use; and minimising of life stressors. Occasional bursts of mood lability lasting a few days would resolve with improved sleep. At enquiry in pregnancy, she reported having been ‘a bit depressed’ after a relationship breakup in her teens, but did not mention the bipolar disorder.
Pregnancy was uneventful until she was admitted to hospital at 26 weeks for management of severe hypertension. In hospital, sleep was broken. She missed the support of her husband and the structure of work. She became increasingly anxious about the delivery as her blood pressure worsened and had to stay in hospital to term. Following caesarean section, she became severely sleep deprived and suspicious of staff, labile in mood, wanting to go home against medical advice, and declining a hypnotic. By day three, she was chaotic and pressured in speech, irritable, voicing persecutory delusions (staff wanting to poison her with medication), unable to be contained on the postnatal ward and was transferred to a locked psychiatric unit. After several trials of antipsychotic and electroconvulsive therapy (ECT), she finally accepted lithium which rapidly led to full symptomatic recovery, though it took another year before she was functioning optimally and able to return to work. A great deal of planning took place for her second pregnancy, which was managed with low-dose seroquel in late pregnancy and postpartum to guarantee good sleep while her husband did expressed feeds at night. She did not relapse or need to recommence lithium and, two years later, remained well unmedicated, but vigilant around sleep hygiene and managing stress.
Case vignette two
A 40-year-old married woman was ambivalent about having a child. There was no past psychiatric history, but her sister had suffered severe postnatal depression. An unremarkable pregnancy was followed by a traumatic emergency caesarean section for fetal distress. She reported a sense of not being connected to the baby and not wanting to breastfeed or care for her baby. She was finding sleep deprivation very challenging, but declined a hypnotic. On the morning of postpartum day four, she expressed vague concerns about the presence of CCTV cameras in the hospital, was wanting baby to stay with staff, and worried that some staff had taken a dislike to her. That afternoon, however, she was settled and not voicing any concerns. On the afternoon of day five, she shoved the baby aside when it was brought in to feed and narrowly missed dropping the baby. She was scheduled to the psychiatric unit and discharged home three weeks later, much improved on a moderate dose of quetiapine.
Case vignette three
A 40-year-old married woman was having her first baby and did not report a psychiatric history. She had an induction and forceps delivery, with moderate postpartum haemorrhage of 700ml and Hb 9.5 (no prior level was available). At review 36 hours later, staff reported she had been ‘inappropriate’ during the second stage of labour and had not slept for two nights because of high anxiety levels. No hypnotic had been offered. She was concerned that her baby might not be safe on the ward unless she watched over it day and night. At times, she was noted to be walking up and down the corridor vaguely ‘looking for my baby’. At mental state examination, her affect was a little odd and fearful. It was difficult to follow her train of thought. She expressed fears for her baby’s welfare and a belief that he had been kidnapped by the Australian Security Intelligence Organisation (ASIO). She was intermittently confused about the date and time of delivery and whether she should breastfeed as ‘baby told me it was not hungry’. She lacked insight into her disturbed mental state.
A working diagnosis of acute confusional state was made, pending investigations, with differential diagnosis of postpartum psychosis. Hb that day returned as 5.3. After transfusion and regular hypnotic, her mental state settled back to normal over the next three days, confirming the diagnosis of acute confusional state.
The first two cases illustrate the need to carefully seek past or family psychiatric history (though this may be denied or understated). All cases demonstrate a lack of response by staff to severe sleep deprivation, with lack of use of hypnotic medication and the need to review symptoms at very regular intervals. Symptoms often rapidly evolve. The fluctuating nature and subtlety of symptoms was associated with difficulty with early detection in case two. Case three had some features suggestive of an acute confusional state, with fleeting auditory hallucinations, disorientation to time and worsening symptoms at night. However, it also met criteria for postpartum psychosis. Case three emphasises the need to routinely exclude organic pathology, however unlikely that might be.
Acute postpartum mental disturbance can range from mild symptoms, resolving with sleep restoration, through to more severe and florid presentations requiring antipsychotic treatment, and often hospitalisation. Severe cases are considered a psychiatric emergency, while possible incipient cases need to be assessed at close repeated intervals, ideally after sleep restoration and with as much corroborative history as possible.
Obstetricians and midwives must be mindful of the possibility of postpartum psychosis and the risk of rapid escalation, with the need for early involvement of a psychiatrist. In patients with a prior history, a multidisciplinary team approach, a management plan, attention to avoidance of sleep deprivation in the third trimester, early intervention with hypnotic or antipsychotic medication, and a low threshold for transfer to a psychiatric facility or mother and baby unit, should be considered.
I gratefully acknowledge feedback from Dr Vijay Roach, President-elect of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.
- Jones I, Chandra P, Dazzan P, et al. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the postpartum period. Lancet 2014 Nov 15;384(9956):1789-1799.
- Munk-Olsen T, Laursen T, Pedersen C, et al. New parents and mental disorders: a population-cased register study. JAMA 2006 Dec 06;296(21):2582-2589.
- Munk-Olsen T, Laursen T, Meltzer-Brody S, et al. Psychiatric disorders with postpartum onset: possible early manifestations of bipolar affective disorders. Arch Gen Psychiatry 2012 April; 69(4):428-434.
What Is Postpartum Psychosis?
A small number of new mothers experience disturbing thoughts and an emotional flatness — red flags that signal postpartum psychosis.
Postpartum psychosis is a severe mental illness characterized by extreme difficulty in responding emotionally to a newborn baby — it can even include thoughts of harming the child.
The condition is different from postpartum depression, though the two conditions may occur together.
“It usually represents a bipolar disorder, not just a depressive disorder,” says psychiatrist Charlotte Ladd, MD, associate professor of psychiatry at the University of Wisconsin in Madison.
In fact, Dr. Ladd qualifies postpartum psychosis as a “psychiatric emergency,” because of the potential for harm to the baby or the new mother.
Who Gets Postpartum Psychosis?
Postpartum psychosis is a relatively rare condition.
It’s estimated that 1 to 2 of every 1,000 new mothers faces postpartum psychosis, according to a report published in January 2014 in Psychiatric Times.
Approximately half of mothers with postpartum psychosis also have a history of mental illness — which means the other half have no reason to suspect it.
The causes of postpartum psychosis are not well understood. It’s possible that the abrupt shift in hormones after delivery could trigger the condition.
And some research suggests that being an older mother may increase risk, but a mother who has diabetes or gave birth to a large baby may, for some reason, be protected.
While postpartum depression is most likely to emerge in the three months after delivery (but can appear within the first year of the baby’s life), one of the hallmarks of postpartum psychosis is its early onset, often in the first 1 to 4 weeks after the baby’s birth.
Most mothers will be home from the hospital and away from the watchful eyes of their medical team when it strikes, but the depression symptoms are so worrisome, says Ladd, that a spouse or other caregiver almost always notices that something’s wrong and calls a doctor or a family member to express concern.
Postpartum Psychosis Symptoms
Symptoms go beyond those associated with postpartum depression.
Here are some signs to watch for:
- Sudden thoughts of throwing the baby or harming it in some way
- Delusions (beliefs that have no basis in reality)
- Hallucinations (seeing or hearing things that aren’t there)
- “Flat affect,” or a lack of emotional response or blank facial expression
- Difficulty responding emotionally to the baby
- Difficulty sleeping beyond the normal interrupted sleep of new motherhood
- Changes in appetite or eating
- An inability to bond with baby
- Thoughts of suicide, or the belief that the baby or the family would be better off without the mother
In extreme situations, a woman with postpartum psychosis may exhibit behaviors such as staring off into space, muttering to herself, refusing to eat, or making seemingly irrational statements.
“It’s usually pretty dramatic in the sense that the husband might call up and say she’s not responding to the baby, she’s not sleeping. It doesn’t usually go undetected,” says Ladd.
Ladd adds that any mom being seen by a doctor for a mood disturbance in the first days or weeks after delivery should be asked whether they have had any thoughts about harming themselves, their baby, or other people.
Postpartum Psychosis Treatment
While the mother herself is likely to know she has a problem, she may not want to seek help or treatment for postpartum psychosis.
“Intrusive thoughts of throwing a baby out the window or across the room often seem to come out of nowhere, and women are afraid to talk about them,” Ladd says.
These thoughts may be due to a “nesting instinct gone awry,” she notes, explaining that these moms sometimes feel almost obsessive in their baby-focus.
Women may keep these thoughts to themselves because they are afraid that doctors or family members will take their baby away, and this unwillingness to talk leaves women with postpartum psychosis feeling very alone.
In fact, one of the first things Ladd does when treating women with postpartum psychosis is let them know the thoughts are a normal part of their illness.
If caregivers or other family members suspect psychosis — or if you suspect it in yourself — an immediate response is necessary.
“If someone has psychosis, it’s important to get them to a psychiatric facility right away and to separate mom from baby during that assessment period,” she says.
This separation does not mean the baby will be permanently taken out of the mother’s care.
The goal is to move both mother and baby into a safe situation and then evaluate the mother so she can receive the appropriate medical treatment.
Treatment for postpartum psychosis generally includes:
- Antipsychotic medications
- Electroconvulsive therapy (ECT)
- Counseling with a psychiatrist, psychologist, or other qualified mental health professional
A treatable illness
Most people know little, if anything about postnatal psychosis so when one experiences it, it comes as a shock. It can often happen‘out of the blue’ to women without any previous history of mental illness. Changes in behaviour and thinking are often sudden and dramatic. Postnatal psychosis can cause a loss of contact with reality, and behaviour that seems out of character. Fortunately postnatal psychosis is temporary and treatable. Women generally experience a full recovery with time and appropriate treatment and go on to mother their children as they expected to.
Causes of postnatal psychosis
While we know little about what causes postnatal psychosis, we do know that women who experience bipolar disorder or who have experienced postnatal psychosis after previous births are at greater risk. There is also an increased risk in women with a family history of postnatal psychosis or bipolar disorder.
Severe sleep deprivation and rapid hormonal changes following childbirth may also be contributing factors. Many women will have only a single episode of postnatal psychosis, while others might experience it with more than one baby. For a smaller group of women, postnatal psychosis may mark the first episode of bipolar disorder.
*This condition is also known as puerperal or postpartum psychosis.
‘I experienced delusional thinking and at times felt paranoid. I had times of severe depression, some elevated moods and severe anxiety.