Postpartum psychosis: symptoms, causes and treatment

Key points

• Postpartum psychosis is a medical emergency affecting around 1 in 1,000 women after birth, and needs same-day assessment [1][2].
• Onset is sudden, usually in the first two weeks after birth and often within hours or days [1][3].
• Symptoms fluctuate. Seeming well for a few hours does not mean the episode has passed [4].
• Bipolar disorder or a previous episode means high risk, and specialist care before the birth [2][3].
• Inpatient care is usually needed, normally in a mother and baby unit, not a general ward [1][2].
• Most women recover fully, though recovery takes months [1][10].

What postpartum psychosis is

Postpartum psychosis, also called puerperal psychosis, is a severe mental illness that begins suddenly after childbirth. It affects around 1 in 1,000 women, usually within two weeks of birth, and causes delusions, hallucinations, confusion and extreme mood changes [1][3]. It is a medical emergency, and it is treatable [1][10].

This needs same-day assessment. NICE says a woman with sudden onset of symptoms suggesting postpartum psychosis should be referred to a secondary mental health service, preferably a specialist perinatal service, for immediate assessment within 4 hours of referral [2][9]. Contact the perinatal mental health team if a care plan exists, otherwise the GP the same day, NHS 111 out of hours, or A&E [5]. Call 999 if anyone is in immediate danger. Samaritans: call 116 123, free, 24/7. Shout: text SHOUT to 85258.

It is not the baby blues, which pass within about two weeks, nor postnatal depression, which builds slowly [7]. This comes on fast, with loss of contact with reality [1][4].

Symptoms

Symptoms start in the days after birth and can develop over hours. Families often notice first [1][3].

Psychosis

• Delusions, meaning beliefs very unlikely to be true, such as suspicion or fear of others [1]
• Delusions involving the baby, such as that the baby is not hers or is in danger [4]
• Hallucinations: hearing, seeing, smelling or feeling things that are not there [1]

Mood

• Mania: very high mood, overactivity, fast speech, racing thoughts [1][6]
• Depression: withdrawal, tearfulness, low energy, lack of interest [1]
• Rapid swings between high and low mood within a day [1][6]

Confusion and behaviour

• Confusion, or not knowing where she is [1][6]
• Being unable to sleep even when exhausted [6]
• Out of character behaviour, or loss of usual inhibitions [4][6]

Fluctuation matters. Symptoms change rapidly, which makes the illness hard to recognise [4]. A calm, lucid few hours does not mean it has ended, and is not a reason to delay assessment [4][5].

Commonly confused with. Exhaustion, the baby blues and postnatal depression. Speed of onset, confusion and loss of contact with reality set it apart [1][3].

Types

There are no formally agreed subtypes, and the NICE full guideline notes continuing debate over whether it is a distinct diagnosis at all [3]. Three presentations are recognised.

• Manic. Unusually high or irritable mood, overactivity, little need for sleep, racing thoughts [1][6].
• Depressive. Severe low mood, withdrawal and hopelessness, with psychotic beliefs such as guilt [1][6].
• Mixed or rapidly changing. Both moods together or alternating quickly, with marked confusion, and the picture can change within one episode [1][4][6].

Causes and risk factors

There is no single cause. The sudden hormonal change after birth, sleep loss and inherited vulnerability are all thought to contribute, and the mechanism is not established [3][4]. Some risk factors are known well enough to change care before the birth.

• Bipolar disorder. At least a 1 in 5 risk of severe recurrence after childbirth, and around 1 in 2 for any mood episode [3].
• A previous episode of postpartum psychosis. More than 1 in 2 later deliveries are affected [3].
• Family history of severe antenatal or postnatal mental illness in a first-degree relative [2].
• A diagnosis of schizophrenia or other severe mental illness [1].
• Stopping psychiatric medication in pregnancy, which should only be done with a prescriber [6].

Many women who have an episode have no previous mental health diagnosis, and it is not caused by anything the mother has done [4].

Because these risks are known in advance, women with bipolar disorder or a previous episode can be referred to a specialist perinatal service in pregnancy, with a written care plan covering birth and the weeks after. Preconception advice is available to those planning a pregnancy [2].

How it is diagnosed

A psychiatrist makes the diagnosis, usually in a specialist perinatal mental health service or through an emergency assessment [2][8]. A GP, midwife, health visitor, NHS 111 or A&E can all make the urgent referral [5].

Assessment is a clinical interview, not a test. It covers what she is experiencing, how fast it began, her mood and her physical health since the birth [2]. An account from a relative matters, because insight fluctuates [4].

NICE sets a standard of assessment within 4 hours of referral [2][9], though access to specialist perinatal services varies by area [8].

A diagnosis describes an acute episode needing urgent treatment, not a lifelong illness [10], though it does mean higher risk in a future pregnancy [3].

Treatment

NICE treats this as an emergency: immediate assessment by a secondary mental health service, preferably a specialist perinatal one, within 4 hours of referral [2].

Inpatient care. Most women need hospital treatment [1][5]. NICE says women needing inpatient care within 12 months of childbirth should normally go to a specialist mother and baby unit rather than a general psychiatric ward [2]. These units typically hold 6 to 12 beds and are staffed to care for the baby too, so treatment does not mean separation [2][8].

Medication. Antipsychotics, mood stabilisers and antidepressants may be used depending on the presentation [1][2]. NICE sets out no separate medicines pathway, so its perinatal recommendations for psychosis and bipolar disorder apply [2]. Choice accounts for breastfeeding and rests with the prescribing team.

Other treatments. ECT is sometimes used where illness is severe and a rapid response is needed. This is a decision for the treating team. NICE’s ECT recommendation in CG192 covers pregnancy rather than the weeks after birth [2]. CBT and family intervention form part of care, usually once the acute phase settles [6].

Living with postpartum psychosis

Recovery takes time. Severe symptoms usually last two to twelve weeks, and full recovery commonly takes six to twelve months or longer [1]. Depression and anxiety often follow, and are part of the pattern rather than a relapse [10].

Patchy or absent memory of the illness is usual, and so is guilt about time apart from your baby [10]. Action on Postpartum Psychosis runs peer support for women and partners [10].

• Ask who your named contact is, and keep that number visible at home.
• Tell your employer only what you choose. Sick leave and a phased return can be requested.

Sleep matters, so ask family or the ward to protect it at night. If you are planning another pregnancy, tell your GP early: preconception advice and a care plan agreed before the birth are the main tools for lowering risk [2][3].

When to speak to a professional

Seek help the same day if a woman who has recently given birth:

• Believes things that are clearly untrue, or is suspicious or frightened for no reason
• Hears or sees things others do not
• Is confused, or unsure where she is
• Is unusually high, agitated, talking very fast, or not sleeping
• Is severely withdrawn or hopeless
• Is behaving out of character

Contact the perinatal mental health team if a care plan exists, otherwise the GP the same day, NHS 111 out of hours, or A&E [5]. Call 999 if anyone is in immediate danger, including the baby [1][5]. Do not wait overnight, and do not stand down because she has seemed better for a few hours [4].

If you are pregnant and have bipolar disorder or a previous episode, ask for a referral to a specialist perinatal service now, not after the birth [2].

Common questions

How quickly does postpartum psychosis come on?

Usually very quickly. Most begin within two weeks of birth, often within hours or days, and some during labour [1][3]. Raised risk persists for about three months [3].

Is postpartum psychosis the same as postnatal depression?

No. Postnatal depression develops over weeks as low mood, without loss of contact with reality, and is usually treated in the community [7]. Postpartum psychosis is rarer, starts suddenly, involves delusions or confusion, and normally needs hospital care [1][2].

Will the baby be taken away?

Admission is normally to a mother and baby unit so mother and baby stay together, with staff able to care for the baby [2]. Safety is assessed case by case, and being unwell is not in itself a reason for separation.

Can postpartum psychosis be prevented?

Not always, but risk can be reduced. Women with bipolar disorder or a previous episode can be referred to specialist perinatal services in pregnancy and have a care plan agreed before the birth [2].

Clinical review pending

References

1. NHS. Postpartum psychosis. NHS. https://www.nhs.uk/mental-health/conditions/post-partum-psychosis/
2. National Institute for Health and Care Excellence. Antenatal and postnatal mental health: clinical management and service guidance. Clinical guideline CG192, 2014. https://www.nice.org.uk/guidance/cg192/resources/antenatal-and-postnatal-mental-health-clinical-management-and-service-guidance-pdf-35109869806789
3. National Collaborating Centre for Mental Health. Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance. NICE Clinical Guideline 192, NCBI Bookshelf, 2014. https://www.ncbi.nlm.nih.gov/books/NBK338568/
4. Action on Postpartum Psychosis. Symptoms. APP. https://www.app-network.org/postpartum-psychosis/symptoms-of-postpartum-psychosis/
5. Action on Postpartum Psychosis. Urgent help for postpartum psychosis. APP. https://www.app-network.org/get-help/urgent-help-for-postpartum-psychosis/
6. Mind. Postpartum psychosis. Mind. https://www.mind.org.uk/information-support/types-of-mental-health-problems/postnatal-depression-and-perinatal-mental-health/postpartum-psychosis/
7. NHS. Postnatal depression. NHS. https://www.nhs.uk/mental-health/conditions/post-natal-depression/overview/
8. National Institute for Health and Care Excellence. Quality statement 7 (developmental): Specialist multidisciplinary perinatal mental health services. Quality standard QS115, 2016. https://www.nice.org.uk/guidance/qs115/chapter/quality-statement-7-developmental-specialist-multidisciplinary-perinatal-mental-health-services
9. Maternal Mental Health Alliance. Antenatal and postnatal mental health: summary of updated NICE guidance (BMJ guidelines summary). https://maternalmentalhealthalliance.org/media/filer_public/a3/ab/a3abacfd-d33a-49af-88ed-40243fff59f1/bmj_summary_of_nice_pmh_guidance.pdf
10. Action on Postpartum Psychosis. Recovery from postpartum psychosis. APP. https://www.app-network.org/postpartum-psychosis/recovery-from-postpartum-psychosis/