Understanding postpartum psychosis: what do we currently know?
Co-written by Katie Hazelgrove.
This is the third week of our Maternal Mental Health series, and it is dedicated to Postpartum Psychosis — a rare but extremely severe postnatal mental illness, which must be treated as a medical and psychiatric emergency to protect the safety of the mother and baby.
This week we are publishing two blogs: one by Eve Canavan on her personal experience, and another by researchers Alessandra Biaggi and Katie Hazelgrove from King’s College London, focusing on what is known about the illness and what further research is needed to help the women affected and their children.
What is postpartum psychosis?
Postpartum psychosis is the most severe psychiatric disorder associated with childbirth. It is so severe that it is considered a psychiatric emergency, requiring specialist care and, in most cases, hospitalisation.
As we have read in Eve Canavan’s blog about her experience, postpartum psychosis typically develops soon after childbirth, often within days or weeks of the delivery. Symptoms include mania (feeling elated/high), depression, or rapid fluctuations between manic and depressed moods. As a result, women may be more talkative and active than usual or restless and agitated, or they might be more withdrawn, tearful and anxious, or a mixture of all of these. They may also have difficulty sleeping or feel like they don’t need any sleep.
As the name suggests, women may experience psychotic symptoms in the form of delusions (unusual thoughts or beliefs that are unlikely to be true) and hallucinations (seeing, hearing, smelling or feeling things that are not there). Confusion is also common, and women may appear not to know who or where they are. They may also behave in ways that are out of character.
Which women are at risk of postpartum psychosis?
Postpartum psychosis is relatively rare, occurring in 1–2 women per 1000 deliveries in the general population. However, some women are at greater risk. Indeed, research has shown that up to 50% of women with a diagnosis of bipolar disorder or schizoaffective disorder, and most of those who have experienced an episode of postpartum psychosis following a previous delivery, will experience an episode of the illness after giving birth. It is therefore important for women at increased risk to be closely monitored throughout pregnancy and the postnatal period.
Several other risk factors have also been proposed, including becoming a mother for the first time (primiparity), sleep disturbance, and the dramatic fluctuation in hormones that occurs during pregnancy and the early postnatal period. We also know that genetic factors are likely to play a role, as women whose mother or sister have experienced postpartum psychosis are at increased risk of having an episode themselves.
Our own research, which we have previously discussed in Inspire the Mind, has shown that stress might also be an important factor, particularly for those women already at high risk for postpartum psychosis.
It is likely that there are many factors involved in determining whether or not women will develop postpartum psychosis, and much more research is needed to better understand exactly which factors play a role.
How is postpartum psychosis different from other mental health problems that occur during the postnatal period?
It is extremely common for women to experience mood symptoms during the postnatal period. Indeed, up to 80% of new mothers will experience the ‘Baby Blues’, a normal condition that is thought to occur due to the hormonal changes that happen after childbirth. Symptoms of the Baby Blues include fluctuating mood, and feeling tearful or anxious. Although these can appear similar to the early signs of postpartum psychosis, symptoms of the Baby Blues resolve without treatment, while those of postpartum psychosis escalate very quickly and soon become severe.
It is also important that postpartum psychosis is not confused with postnatal depression, which is much more common than postpartum psychosis, affecting 10–15% of women after they give birth.
Symptoms of postnatal depression include low mood, sadness, and a loss of interest and enjoyment, but not the manic and psychotic symptoms and confusion that women with postpartum psychosis typically experience. Furthermore, unlike postpartum psychosis, which often begins within the first couple of weeks from delivery, postnatal depression usually starts later in the postnatal period, typically around two or three months from delivery.
What about treatment, prognosis, and prevention?
Considering the severity of postpartum psychosis, treatment with medications and, in most cases, admission to hospital are necessary. When possible, it is always preferable for women to be admitted to a specialist “Mother and Baby Unit” (MBU) rather than a general psychiatry ward. MBUs are specialised inpatient units for treatment of psychiatric disorders during pregnancy and in the postpartum period and are considered the ideal option for women developing postpartum psychosis.
In fact, these units prevent the separation of mother and baby and offer specific interventions aimed at promoting mother-infant relationship, supporting the family and informing about the illness. Furthermore, women admitted to MBUs generally report higher satisfaction in the service than women admitted to general psychiatric wards, as we have also heard from Eve’s experience.
Despite postpartum psychosis being among the most severe psychiatric disorders, the prognosis is usually good. In fact, with appropriate treatment, most women can recover within a fairly short period of time, usually within two months, although some women may develop depression afterwards, so full recovery may take 12 months or more.
However, for women who have experienced an episode of postpartum psychosis, the risk for future episodes during or outside the perinatal period remains high and, therefore, it is important to implement adequate psycho-education about the illness, as well as appropriate monitoring of the woman, particularly in case of a new pregnancy.
What are the potential consequences for mother and baby?
Considering the severity of postpartum psychosis, it is very important that women are identified early on and that adequate treatment is provided, to avoid potential negative outcomes for women and their babies.
The postpartum period is a time of increased risk for maternal suicide and, according to the Confidential Enquiries into Maternal and Child Health, suicide represents the leading cause of maternal death within the first year postpartum. There is evidence that the majority of women who commit suicide are experiencing a severe depressive illness or an episode of postpartum psychosis.
Indeed, until the creation of the national charity Action on Postpartum Psychosis (APP), aimed at supporting women and families, training health professionals, supporting research in the field, and disseminating information about the illness, half of suicides within the first year postpartum were of women experiencing postpartum psychosis. Nowadays, this percentage is much reduced.
Considering the severe alteration in mental state and behaviour that can be present during an episode of postpartum psychosis, there is also a risk that the mother will not be able to attend to the baby’s care and, in very rare cases, of infanticide. Although these episodes are not frequent, postpartum psychosis represents a psychiatric emergency and it is paramount to protect the safety of the mother and the baby.
Many studies have documented that perinatal depression, particularly if severe and left untreated, can have a negative impact on the mother-infant relationship and on infant development. On the contrary, only a few studies have to-date been conducted to understand whether this could also be observed in postpartum psychosis.
Some studies, including our own longitudinal study, reassuringly suggest an absence of a negative impact of the postpartum psychosis episode on the mother-infant relationship and on infant development. You can read about it in our blog here. These results are promising and may be explained by the fact that acute symptoms of postpartum psychosis tend to resolve within a fairly short period of time, resulting in a limited time of exposure for the child.
However, other studies suggest that postpartum psychosis or a severe postnatal mental illness can have a negative impact on the mother-infant relationship.
Therefore, more studies are needed to clarify whether postpartum psychosis can be associated with difficulties in the mother-infant relationship and in infant development so that, if necessary, interventions can be developed to protect both mother and baby in the long term.