Your questions answered

Postpartum psychosis (also called Puerperal Psychosis or postnatal psychosis) is a serious mental illness which affects women after childbirth. It affects around one to two women per 1000 births. Half of the women who develop postpartum psychosis have no history of mental illness. However, women who have a diagnosis of Bipolar Disorder or Schizoaffective Disorder have a much higher risk of developing postpartum psychosis.

Symptoms (see below) of postpartum psychosis usually develop in the first one to two weeks after a baby is born. Early warning signs such as sleeplessness can quickly give way to more severe symptoms. Postpartum psychosis should be treated as a medical emergency, and women usually need a period of hospital treatment and medication. With the right treatment and support, women can and do make a full recovery. You can read people’s personal experiences of postpartum psychosis here.

Common symptoms of postpartum psychosis are listed below. Your partner may have had some or all of these symptoms. In the early days of the illness it is common for women to have periods of seeming 'back to normal' but then symptoms reappear again. Symptoms can vary a lot throughout the day, so try to write down the things you have noticed to show health professionals when they make an assessment. Getting the correct treatment as soon as possible can reduce the illness severity and recovery time.

Women with postpartum psychosis may be:

• Excited, elated, or 'high'
• Depressed, anxious, or confused
• Excessively irritable or changeable in mood

Postpartum psychosis includes one or more of the following:

• Strange beliefs that could not be true (delusions)
• Hearing, seeing, feeling or smelling things that are not there (hallucinations)
• High mood with loss of touch with reality (mania)
• Severe confusion

These are also common symptoms:

• Being more talkative, sociable, on the phone an excessive amount
• Having a very busy mind or racing thoughts
• Feeling very energetic and like 'super-mum' or agitated and restless
• Having trouble sleeping, or not feeling the need to sleep
• Behaving in a way that is out of character or out of control
• Feeling paranoid or suspicious of people’s motives
• Feeling that things stories on the TV or radio have special personal meaning
• Feeling that the baby is connected to God or the Devil in some way

Seeing your partner unwell with the symptoms of postpartum psychosis can be a confusing and distressing experience, especially when you were expecting the joy of a new baby. The most important thing to remember is that, although postpartum psychosis is a severe mental illness, the symptoms are treatable – with medication most women find that their symptoms are improving within a few weeks.

Postpartum psychosis is not your fault. It is not caused by anything you or your partner have thought or done. Relationship problems, stress, or the baby being unwanted, do not cause postpartum psychosis.

There are likely to be many factors that lead to an episode of postpartum psychosis. We know that genetic factors play a role. Your partner is more likely to have postpartum psychosis if a close relative has had it. Women with Bipolar Disorder or Schizoaffective Disorder are also significantly more likely to experience postpartum psychosis.

Changes in hormone levels and disrupted sleep patterns may also be involved, however more research is needed to fully understand how changes in hormones and other factors interact to cause an episode of postpartum psychosis.

There is not yet conclusive evidence to suggest that there is a link between postpartum psychosis and the experience of a traumatic birth. It is possible that there are overlaps with physical illnesses that occur during childbirth, such as thyroid problems, preeclampsia and infection.

We are working with Birmingham and Cardiff Universities to try to understand more about the causes of postpartum psychosis. If you want to help with our research into PP you can join our network.

Medication is a very effective treatment for postpartum psychosis. Most women find that their symptoms are beginning to improve within 3-6 weeks of starting medication. Your partner's prescribing Psychiatrist should be able to explain to you what medications and dosages your partner is taking and it can be helpful to write these down.

Unfortunately medication may have some unpleasant side-effects, particularly when starting treatment. The Choice and Medication website is a good starting point where you can look up medications your partner has been prescribed and read high quality patient information, including possible side-effects and advice about whether the medications are safe for breastfeeding.

Antipsychotics are used to help treat psychotic symptoms such as unusual beliefs (delusions) and seeing or hearing things that are not there (hallucinations). They can also help to reduce anxiety and high mood (mania).

Sleeping tablets can be used in the short term to help regain normal sleeping patterns.

Benzodiazepines (minor tranquilisers) are used to help to reduce agitation and anxiety.

Mood stabilisers are used to treat high mood (mania), low mood (depression) and dramatic changes in mood.

Antidepressants are used to help improve low mood, but in women with PP they would most often be used alongside a mood stabiliser, due to their risk of causing high mood or agitation.

If you would like to find out more about the medication your partner is taking, MIND have produced excellent in-depth leaflets about the main groups of medications used to treat PP:

• Antipsychotics
• Sleeping pills and minor tranquilisers
• Mood stabilisers
• Antidepressants

If you have any concerns about your partner's medication, talk to the doctor who prescribed it. This might be the Psychiatrist on the hospital ward if your partner is an inpatient, or the Community Psychiatrist if she has been discharged, or in some cases your GP. It can be unsafe to stop taking psychiatric medication suddenly - discourage your partner from doing this until you have talked to the health professional who prescribed the medication. If you are not under the treatment of a specialist perinatal team, you can ask your GP or mental health team to engage the specialist advice of a Perinatal Psychiatrist.

Common side-effects of antipsychotics such as extreme tiredness and weight gain can be really difficult to manage in the longer term and it is OK to ask your partner's mental health team if they can work together with you to reduce dosages to a level which minimises side-effects but still keeps your partner well.

If you feel the Psychiatrist or the GP is not listening to your concerns, you could try:

• Requesting a joint meeting with a specialist pharmacist. These NHS professionals have specialist knowledge of drug interactions and side effects.
• Requesting a joint meeting with a mental health advocate.
• Writing down your concerns or your partner’s concerns about her medication.

I took my mood graph. The consultant was fantastic and very open to examining the graph and hearing my account and worries, even explaining the whole lithium option again. It was from discussing the graph that he agreed he was happy to try weaning [my partner] off the venlafaxine completely and seeing what would happen, with the hope that everything continued to get better. Leaving that meeting, I was much happier.

In some cases, severe symptoms of postpartum psychosis persist even when your partner has been taking medication for a considerable length of time. In these circumstances, the Psychiatrist treating your partner may recommend that you consider ECT. The way ECT works is not known, however it can be an effective treatment for PP. There are a lot of things to consider when making the decision about whether to consent to ECT treatment. The Royal College of Psychiatrists has provided a really helpful overview of things to think about.

Your partner may not be willing to go in to hospital for treatment as a voluntary patient. In this situation it may be necessary for her to be treated under the Mental Health Act, to make sure she gets the treatment and help she needs. An Approved Mental Health Practitioner will assess your partner carefully, to make sure that being sectioned is the most appropriate course of action.

If you need more information about the process of receiving treatment under the Mental Health Act, MIND have produced a comprehensive guide.

Information about the Mental Health Act specific to Scotland.

It can be a very difficult process agreeing for your partner to be compulsorily admitted to hospital, and you may feel guilty or shocked about this outcome. It's important to remember that hospital is the safest place for your partner to receive treatment when she is very ill, and that you will be able to talk it through with your partner when she is beginning to recover. What matters most is that your loved one is getting the help she needs to recover as quickly as possible.

It was a complete shock when this was brought up and didn’t feel right, however talking it through and understanding it and the other options brought me round.

The way I dealt with it was to be open and honest with both our families and let them know what was going on; I talked it all through with them, in particular my wife's brother and sister-in-law who were very supportive and had taken the main 'contact' role from that side of the family. I let them know how I was feeling.

On the day of admission you may need to pack a case for your partner (and for baby if going into a MBU). It can be really upsetting having to pack for your partner (and baby's) hospital stay. Try to remember that this is just for a time, and your partner will be getting the help she needs ready to come home. Lots of mums tell us that a few 'home comforts' such as slippers or baby photos are really nice to have. For your partner's safety, hospital staff will take away any sharp items such as razors or tweezers, and potentially poisonous items such as perfume.

¹ May need to be safety-tested at the hospital

Managing your partner, new baby and any older children at home can be tough if you have to wait for a bed to become available. Here are some practical tips to keep the situation as calm as possible:

• Ask one or two trusted family members or friends to come and stay.
• Ask friends or family to help with looking after the baby or older children.
• Help your partner to get as much rest or sleep as possible.
• Keep surrounding noise and stimulation, such as TVs and radios, to a minimum.

If your partner is experiencing psychotic symptoms (loss of touch with reality) she may have delusions or hallucinations that are very real to her. Here are some tips for dealing with acute psychosis:

• Sitting beside your partner, rather than in front of her, can seem more comforting and less confrontational if she is confused. Try to remain a 'friend' and talk to her, although she might not be able to take it all in.
• Try to keep things quiet and calm, loud noises and TV images may be too stimulating for her.
• Try to limit your partner’s mobile phone use if possible, so she doesn't have the embarrassment later of realising she made calls to distant friends or work colleagues when unwell.
• Try to be understanding about what she thinks is real.
• Try not to take upsetting things she says or does personally. These things are caused by the illness and not what she really thinks.
• Don't hesitate to call 999 or ring the mental health crisis team if you are at all concerned for the safety of your partner, your baby or yourself.

The day that your partner is admitted to hospital will be upsetting and exhausting. You will have a lot of questions and will still be dealing with the shock of your partner becoming ill.

Here are some things to consider for all admissions...

Waiting

• You may have a long wait on arrival at the hospital.
• Don’t be afraid to ask staff if you need support while waiting.
• Get some rest if you can; take a break if you need to.

After admission

• Find out about when the ward rounds are and ask if you can attend. These will be the times that your partner's Psychiatrist will be with her and will give you an opportunity to discuss treatment with the Psychiatrist and your partner's nursing team.
• Find out if your partner has a named nurse.
• Find out about visiting hours.
• Help to settle your partner in if possible, help her to look through any information leaflets about staying on the ward e.g. mealtimes, medication times, visiting times.
• Although your partner might not be able to take much in, and what she says might not make much sense, talk to her calmly and as a friend. Try to ensure that the experience is not frightening for her.
• Find out how your partner's midwifery care (e.g. looking after stitches or c-section scars, feeding support, monitoring infections) will happen on the ward.
• Find out if your partner can use her mobile phone or where her phone will be kept. Discuss the wards policy on phone usage.
• Make sure you have the telephone number for the ward before you leave.

When you go home

• You will probably be feeling exhausted and emotional when you leave the hospital. It's worth asking someone to drive you home from the hospital or getting a taxi if you don’t feel up to driving safely.
• You may really need to talk to someone about what has happened, but it’s also OK to wait until tomorrow to ring friends and family. Your role for a few weeks is going to be balancing looking after yourself, your partner and bonding with your baby whether at home or in the MBU.

I left the hospital and started calling family to let them know what was happening. This was probably the worst thing I could have done. I was tired and had no answers.

At 1am I phoned my best mate who lived 30 minutes away. His wife was at my front door 45 minutes later. She was wonderful. She phoned the hospital and got a duty midwife to call with supplies of formula. She swept up the broken glass and shattered crockery and, most importantly made me a cup of tea.

There will be a lot of information for you to take on board in the coming days, as well as dealing with the normal exhaustion of having a new baby. You might find it helpful to get a notebook to record:

• Key telephone numbers
• The best times to ring to find out how your partner is doing
• Names of the Psychiatrist and nursing staff caring for your partner
• Dates of meetings e.g. ward rounds
• The names of medications prescribed, and how to spell them
• How the staff feel your partner is doing each day
• Advice given by the professionals involved
• Things you want to say or any questions you have for the professionals

Whether in a Mother & Baby Unit or an adult psychiatric hospital, your partner will value your support and encouragement to help her build confidence in bonding with baby. When you visit, you can do simple things like feeding, changing or dressing the baby together. Encourage your partner to have as many cuddles with the baby as possible, she might find a sling helpful rather than a pram if you are taking the baby for a walk around the hospital grounds.

Here are some specific questions you might want to ask if your partner and baby are staying in a Mother and Baby Unit:

• Will staff be supporting your partner to breastfeed or bottle feed?
• How much babycare do they envisage your partner doing in the first few days (e.g. nappy changing, feeding, dressing, bathing)? Often in the first few days nursing staff will do much of this to help your partner to sleep, but it’s important to find a balance so your partner can stay confident in her skills as a new mum.
• How can you stay involved in babycare when you visit?
• Do they have visiting hours for partners or can you come whenever you like?
• Can you stay overnight with your partner? (Not all Mother and Baby units have facilities for partners to stay overnight)

The hospital did not talk to me about baby care and I did not think of it. So I just left my partner and baby at the hospital and went home. In hindsight this was not the best thing to do. My partner lost all confidence in her ability as a mother.

Here are some specific questions you might want to ask if your partner is in a General Psychiatric hospital:

• Is there somewhere to have some privacy when you visit – e.g. family rooms or ward rooms?
• Can you visit with the baby? When and for how long?
• Are there facilities to refrigerate/warm formula?
• How do they plan to manage any postpartum physical issues (e.g. Caesarian-section care)
• Will your partner have short leave periods when you could take the baby for a walk around the grounds or go to a café?
• Is there the possibility of transferring to a Mother and Baby Unit when a bed becomes available?

When your partner is first admitted to hospital for treatment, it can feel that there is a whole new language to begin to understand. You may have to get to grips with legal terminology around sections of the Mental Health Act and there will be processes such as ward rounds and negotiations around periods of leave to get used to. In an ideal world you will be given lots of opportunity to ask questions and feel included as a part of your partner’s care team.

However, this is not always the case and you may disagree with the care team at times during your partner’s treatment. Here are some tips for dealing with tricky interactions:

• Ask health professionals to explain anything you don’t understand.
• Have confidence in your own opinion. You know your partner best, and can give an insight into who she is when not unwell.
• Give yourself time to think and research treatment options.
• Negotiate where at all possible – for example if you would like more leave away from the ward, suggest that this could be accompanied leave with a member of the ward staff to start with.
• If you feel you are not being listened to, you could look in to working with a Mental Health Advocate.
• Visit APP’s forum to ask questions of other families and discuss issues that are worrying you.

Coping with being a new parent and having a seriously ill partner at the same time is very challenging. Your expectations of new parenthood will have been turned upside down and you will feel as though you are operating in 'crisis mode' for the first few weeks. This section gives practical tips on your role as a parent of a new baby, looking after yourself as a carer and talking to your employer.

If your partner has been admitted to a general psychiatric ward, you may have to take responsibility for babycare. Try to remember that all new parents need help and advice in the early days. So don’t be afraid to ask the midwife or health visitor for any support you need in terms of feeding, holding, sleep routines and bonding with your baby. In the first few days your midwife may be able to supply you with cartons of ready-made milk (also available in supermarkets) so that you don’t have to worry about making up bottle feeds from scratch.

Here are some excellent videos from the Commando Dad website going over some of the basics: nappy changing, bottle feeding, winding and holding your baby.

If your partner is in a Mother & Baby Unit (MBU) you will need to be really involved with babycare when you visit. Don’t be afraid to ask the staff on the MBU to support you with caring for and bonding with your baby, giving you practical tips on feeding and sleep routines etc for when you go home.

The Family Lives website has some excellent tips for early bonding, including videos.

Finding yourself in this situation is a shock. You may need help dealing with the sudden change in your relationship with your partner. Looking after your partner and family is a lot to cope with. It is particularly difficult when the person you normally rely on for support is your partner, but she cannot be there for you. Parenthood is something everyone grows into over time and most people make mistakes along the way. However, you must now cope with an ill partner as well as adjusting to parenthood. These are both difficult tasks. Here are some tips from other partners who have faced this situation:

• Visit as often as you can – short visits are ok and can be better to start with for both of you. Emotionally, it may be hard on you to visit your partner, especially as it can be hard to predict how she’ll be feeling and behaving. Short visits also allow your partner more time for sleep and rest. It’s ok sometimes to go and just spend time with your baby.
• Make sure you rest and take care of yourself. Looking after yourself helps you to have the energy to care for your partner and baby. Many dads find that taking an hour or so a week away from hospital visiting, baby care and work is vital for their own health and wellbeing. Find out what helps to take your mind off things – it might be a bike ride, doing some work, catching up with a friend, or doing things around the house. Whatever works for you.
• Most importantly: ask for help - don’t feel you have to go it alone. It’s a difficult time for all new parents, and most new parents don’t have to cope with what you are going through.

Here are some sources of help:

• Friends and family often really want to know how to help – you could ask them to support you in practical ways like making meals or keeping people updated on your partner and baby.
• Talk to the health professionals supporting your partner and ask if there is a carer’s support worker available to you.
• Talk to your Midwife or Health Visitor if you need support with babycare and bonding with your baby.
• Home Start provides volunteer who can offer practical support for families going through challenging times.
• Family lives offers a helpline and parenting advice website.
• Visit APP’s forum to ask questions of other Partners and discuss issues that are worrying you.

As soon as your partner has been admitted to hospital, or begun treatment at home for PP, it may be worth letting your employer know. It’s really normal to feel worried about work, and the possible impact of time off on your finances after your paternity leave ends. However, your employer has a responsibility to look after your health and wellbeing and a period of paid sick leave, compassionate leave or unpaid parental leave should be negotiable. If you do have to return to work after a period of leave it is worth also asking for a 'phased return to work' – i.e. if you can work fewer hours for the first 2-3 weeks and build up slowly to your normal workload.

If your partner is in a Mother & Baby Unit with your baby, and you do not have other children to care for, you may find that working some reduced hours can be helpful. Some people find that having something to focus on at work is therapeutic and helps them to retain a sense of control and normality.

I was offered a sick note, though I never used it. If you do then I suppose it depends on who you work for and what their sickness pay is and for how long. I found going to work helped get me back to what I knew and, to a degree, took my mind off things.

Parental leave entitlements are explained here.

Sick leave and doctors ‘fit notes’ are explained here.

Emergency time off to care for dependants is explained here.

Turn2Us is an organisation that can help individuals access financial help.

• Your partner will probably have lost confidence as a mum. Try not to be the 'baby expert'. Let her know there are things you're unsure of and worried about too.
• Try to support her taking small steps with independent babycare, rather than backing out and letting you do it.
• Make time to talk to each other – you are both getting over a big ordeal.
• Try to have fun together and enjoy some of the things you've missed.
• Prioritise spending time together.
• Take lots of photos of yourselves and your baby. It will help your partner to recall this time better and order her memories when she looks back.
• Make sure that you have a plan in place should your partner's symptoms get worse again, and that you know who to call in an emergency.

Ideally there will be a plan in place for community mental health services to continue supporting your partner at home and you should have quite frequent visits to start with. In different areas this support is delivered by different teams such as Recovery and Independent Living, or Early Intervention in Psychosis.

Your partner should ideally have a named care co-ordinator and as this person gets to know you as a family, a care plan should be drawn up. You and your partner should have a copy of this.

Gradually, over time, your partner's care will be handed back to her GP, but community support can be in place for at least a year, and sometimes up to 3 years with some Early Intervention in Psychosis teams.

You should also have access to support from a Health Visitor in the same way as any other parents. You can ask for more regular visits if support with babycare, bonding and recommendations for local parent and baby groups would be helpful. Some areas of the UK also have parent-infant specialists such as clinical psychologists who can help with attachment and supporting your partner in regaining her confidence.

All families with a baby need help. It takes a community to raise a child! If you ask around friends who haven't been through PP, you are likely to find that many of them needed help from friends, relatives and baby groups at some point.

When you are first back at home, it's OK to restrict visitors, as you will probably all still be very tired and keen to just have some uninterrupted family time. Time together is more important than housework, cooking and shopping especially in the first few days.

Don't be afraid to ask friends and relatives to help out in practical ways. You could ask local family and friends to organise a meal rota, or just to be available by text when you need some shopping or laundry doing. You can also get in touch with Homestart who provide volunteers to come to your home and help out.

Most areas have a huge number of privately run parent-infant groups, such as baby massage, singing and signing, baby yoga etc. Some mums find these groups helpful and others find it too daunting to attend alone when recovering. Most groups are also open to dads, co-parents and babies.

Major life events, like having a baby and your partner being seriously ill, will have an impact on your life. While your partner is unwell and in recovery, your relationship will probably be very different to how it was before. Many couples who have been through PP say that their relationship did change due to the illness. Some feel the illness had a negative impact on their lives, that things were hard and that their relationship suffered. Others feel that their relationship improved due to the shared experience of going through PP, and feel that they have learned a new-found respect for the strength, resilience and determination their partners showed in the recovery period. In between the needs of the new baby, the needs of an unwell mother, and work, the relationship between you may not take centre-stage for a while. But as time goes on, it might become important that you think together about how your relationship is going and whether you both feel you are coping under the strain.

Relate is an organisation which help couples and individuals to access counselling around their relationships.

The experiences you go through during your partner's illness may leave you feeling shocked, frightened or overwhelmed. You might feel that it would be helpful to talk to a counsellor about what you've been going through. If you think it might be right for you, you might find you can access 'talking treatments' on the NHS.

There are a number of options open to you:

• Talk to your GP, who may be able to refer you to a counsellor.
• Relate offers counselling for individuals and couples.
• Private counsellors can be expensive, but can offer longer-term therapy, which can give you the opportunity to explore the issues you are facing at a deeper level. Look for a BACP accredited counsellor here.
• If you would like counselling and you find that you do not get on with a particular counsellor, or feel they do not understand your experiences or needs, don’t give up. Try a different counsellor.

Many women who have been through PP find that there are significant ups and downs in mood over the first year of recovery. It can sometimes feel like a real setback, if things had been going well and your partner was gaining in confidence, to be faced with another period of low energy or depressed mood. But it's important to remember that all new Mums (and Dads) of young children have good days and bad days, so exhaustion and bad moods aren't necessarily signs that your partner is getting ill again. Some symptoms during recovery are more worrying, like periods of sleeplessness and high energy. Talk to the health professionals about any concerns you have. During the first year of recovery, your partner's medication might need to be adjusted to help keep her well.

There are things you can do to support your partner in staying well:

• Encourage her to set herself small goals. As she monitors her progress she'll see that every setback does not take her back to square one. It will be important for her to see how far she is coming.
• Encourage her to keep a mood diary. This will help her see what her various triggers are for low and high moods. You can then work together to try to do more of the things that help her to feel level.
• Keep a mood diary of your own. Getting to know yourself better could also help if it allows you to notice any things you do which particularly affect the mood at home, for better or worse.
• If your partner has made a list of things that make her feel happy and energised, remind her to try something from the list when she is feeling low. If she has a list of things that help her feel calmer and more relaxed, encourage her to try something from it if she is feeling stressed or high.

It can be very distressing if your partner is having suicidal thoughts during recovery, but these can happen. There is no evidence that asking about suicidal thoughts can 'give someone the idea' so it is best to discuss this subject openly. Encourage her to speak to her mental health workers or GP about her thoughts, and to use support lines such as the Samaritans (116 123). If you are concerned that your partner is making plans to commit suicide, get help urgently by calling your crisis team or 999, or taking her to A&E.

The long-term outcome after an episode of PP tends to be very good. However, some women who have had PP will have other episodes of illness after childbirth, or at other times not related to childbirth.

The best safeguard is for your partner to get to know her own moods and her sleep patterns really well. This will allow you both to spot the early warning signs and get treatment quickly before she becomes too unwell.

Before she is discharged from her Psychiatrist or the community support services, you and your partner should ask for help in drawing up a plan of action in case of illness. This type of plan can also be written up with your Midwife and Mental Health Team if you decide to have more children.

The plan should include:

• Triggers that could make your partner more vulnerable, such as stress or bereavement.
• Any early warning signs to look out for, such as sleeplessness.
• Which medications, and what doses, have worked well for your partner in the past?
• Any medications she would prefer to avoid?
• Where your partner would like to be treated if she was to go back in to hospital.
• The phone numbers of any health professionals and services you might need.
• Activities that your partner finds helpful to her recovery.