Postpartum Psychosis: Warning Signs, Symptoms and Treatment

Postpartum psychosis (PPP) is a rare but serious mental health emergency that can develop suddenly after childbirth. Recent national attention surrounding a high-profile criminal case has brought greater awareness of the condition, to the importance of recognizing its warning signs and getting prompt treatment.

Postpartum psychosis is uncommon, affecting 1 to 2 women out of every 1,000 births in the U.S. That adds up to as many as 9,400 cases each year. Some might confuse it with postpartum depression, or the milder version referred to as “baby blues,” but that would be a mistake.

“Postpartum depression is a different animal altogether,” says Samuel Mowerman, M.D., a psychiatrist with the University of Miami Health System.  PPP, though reversible, “is very serious. It’s a mental health emergency.”

Postpartum psychosis and postpartum depression differ in symptoms, severity and risk. A case of the “baby blues” is mild and short-lived, depression is more intense and lasts longer, while psychosis is rare, sudden and life-threatening to both the mother and the baby. In spite of its gravity, the disorder does not appear in the Diagnostic and Statistical Manual, though Dr. Mowerman expects that to change soon. Currently, clinicians use mood or psychotic disorder diagnoses with a peripartum onset as a diagnosis.

Many women will suffer from the baby blues within the first four weeks of giving birth, due to fluctuations in hormones, explains Dr. Mowerman. As many as 10% might be involved in a depressive episode, which is more persistent and can interfere with everyday functioning. But for new mothers who suffer from PPP, the onset is sudden and its severity can last for weeks. Because of the risk of self‑harm or harm to the infant, it’s considered an emergency.

The recent criminal case has brought renewed attention to the challenges of recognizing postpartum mental health conditions soon after delivery. Most women stay only one or two days in the hospital after giving birth, providing little time for assessment of their moods and emotions. Yet, several studies have reported that symptoms can show up three to five days after delivery, usually when hormonal fluctuations are most sudden. They can also appear as late as two weeks post-delivery. In a few cases, the onset of symptoms can show up to 12 weeks postpartum.

A Swedish study, for example, found 32% of cases occurred within 7 days, and 59% within 14 days. But most sleep-deprived mothers spend this window of vulnerability alone with their new infant, missing out on potential life-saving diagnosis and treatment.

“We should be having a chat with everyone having a baby,” Dr. Mowerman says. “It should be part of regular maternal care.”

He cites the importance of using the Edinburgh Postnatal Depression Scale (EPDS), a 10‑item screening questionnaire that can help clinicians determine if further evaluation is needed. The handy tool asks questions about a mother’s mood, anxiety, sleep, and thoughts of self-harm. Though it’s standard protocol for postpartum depression, not PPP specifically, it’s still a useful screening.

Because postpartum psychosis can come on suddenly, the scale’s usefulness may be limited. What’s more, a mother suffering from PPP may not recognize that her experience is not the norm. It’s usually up to a partner or a mother’s immediate family or her obstetrician to detect the telltale signs. A clinical guide provided by the National Library of Medicine for obstetrical caregivers can also be helpful for family members.

“You really have to be on top of this for four to six weeks,” Dr. Mowerman says. “It comes on so quickly, like turning on a switch.”

He advocates for more education and awareness to help spouses or significant others living in the same household spot the changes in a mother’s sense of reality and how she sees the world around her. Symptoms include:

• Hallucinations. A mother may hear voices that are not real, but she can’t tell the difference. “The most dangerous are the command hallucinations, a voice saying, ‘Do this or do that,’” says Dr. Mowerman. “Sometimes they belong to a ‘divine figure,’ but most often they’re from no one recognizable. We do know that patients feel almost obliged to follow the commands. There is the big danger.”
• Delusions. The woman will believe certain things so strongly that even convincing evidence won’t dissuade her otherwise. She may think someone is out to get her or that something is controlling her body.
• Mood changes. This can include mania as well as depression. A mother may also appear agitated or irritable.
• Insomnia. Mothers may not sleep for two to three days, even if they’re exhausted. They might complain about racing thoughts or not being able to shut off their brain.
• Thoughts of self-harm or harming others, particularly their infant. One 2004 study found that infanticide occurs in about 1% to 4% of cases of postpartum psychosis. Another reported that 19% of women who were hospitalized during an episode experienced suicidal ideation, though research has shown that about 2 out of 1,000 will actually act on the thought. That said, even if the woman doesn’t suffer from these thoughts, the danger exists both to the child and the mother because of erratic behavior.

The welcome news, however, is that postpartum psychosis is not only treatable but also partially preventable. Clinicians and partners can reduce risk by recognizing the warning signs and helping identify who is more susceptible. This allows for intervention before full psychosis emerges.

Women with bipolar disorder or a family history of bipolar disorder have the highest risk. A history of other mental health conditions, such as a previous major depressive disorder, can also raise the risk. In fact, the 2009 Swedish study that examined almost one million births found that a third of the women with PPP had a previous psychiatric diagnosis.

PPP is more common in women who are first-time mothers. However, the risk of recurrence may be as high as 50% in future childbirths. In cases involving high-risk patients, Dr. Mowerman will prescribe a mood stabilizer two months before delivery.

During a PPP episode, the mother needs inpatient care that includes round-the-clock supervision as well as the appropriate therapy. Hospitalization usually lasts about two weeks, namely because that’s how long it takes for prescribed medications to take effect. An inpatient stay is followed by monitoring of the mother’s condition for up to one year as she continues her drug regimen.

Dr. Mowerman and other psychiatrists treat PPP patients with antipsychotic medications, mood-stabilizing drugs, and electroconvulsive therapy (ECT), which applies a mild electrical current to the brain while the patient is under anesthesia. Though ECT has been negatively portrayed in popular culture, it can be highly effective by changing brain activity to reduce or stop the effects of PPP when administered appropriately.

Written by Ana Veciana-Suarez. Reviewed by Samuel Mowerman, M.D.

Pregnant or just had a baby? The National Maternal Mental Health Hotline is free, confidential, and ready to help. Call 1-800-TLC-MAMA or visit their website.

Tags: Dr. Samuel Mowerman, postpartum mental health, postpartum psychosis symptoms, postpartum psychosis warning signs