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What is postpartum psychosis (PP)?
Postpartum psychosis (or puerperal psychosis) affects thousands of women in the UK each year. It is a severe episode of mental illness which begins suddenly in the days or weeks after having a baby. Symptoms vary and can change rapidly. They can include high mood (mania), depression, confusion, hallucinations and delusions. Postpartum psychosis is a psychiatric emergency. You should seek help as quickly as possible.
Postpartum psychosis can happen to any woman. It often occurs ‘out of the blue’ to women who have not been ill before. It can be a frightening experience for women, their partners, friends and family. Women usually recover fully after an episode of postpartum psychosis.
It is much less common than Baby Blues or Postnatal Depression. It occurs in about 1 in every 1,000 women (0.1%) who have a baby.
How do the symptoms of PP differ from Postnatal Depression or Baby Blues?
Many women experience mild mood changes after having a baby. It is common to feel many different emotions. More than half of new mothers will have the 'Baby Blues'. This usually starts 3 to 4 days after birth. You may have mood swings. You may burst into tears easily. You can feel irritable, low and anxious at times. You may also over-react to things. It usually stops by the time your baby is about 10 days old. You don’t need treatment for Baby Blues.
Postnatal Depression affects 10 to 15 in every 100 women after childbirth. The symptoms are similar to those in depression at other times. These include low mood and other symptoms lasting at least two weeks.
Postpartum psychosis is different from postnatal depression. It is a more severe illness. There are many different ways the illness can start. Women often have symptoms of depression or mania or a mixture of these. Symptoms can change very quickly from hour to hour and from one day to the next.
There are many symptoms that occur in postpartum psychosis. These may include:
- feeling ‘high’, ‘manic’ or ‘on top of the world’
- low mood and tearfulness
- anxiety or irritability
- rapid changes in mood
- severe confusion
- being restless and agitated
- racing thoughts
- behaviour that is out of character
- being more talkative, active and sociable than usual
- being very withdrawn and not talking to people
- finding it hard to sleep, or not wanting to sleep
- losing your inhibitions
- feeling paranoid, suspicious, fearful
- feeling as if you’re in a dream world
- delusions. These are odd thoughts or beliefs that are unlikely to be true. For example, you might believe you have won the lottery. You may think your baby is possessed by the devil. You might think people are out to get you.
- hallucinations. This means you see, hear, feel or smell things that aren’t really there
You may not be able to look after yourself as well as you would when you are well. Your symptoms may make it very difficult for you to look after your baby.
If you have postpartum psychosis you may not realise you are ill. Your partner, family or friends may recognise that something is wrong and need to ask for help.
Most commonly these episodes begin in the first two weeks after birth. Often symptoms begin in the first few days after having a baby. More rarely, the illness starts later – several weeks after the baby is born.
Why does it happen?
Postpartum psychosis is not your fault. It is not caused by anything you or your partner have thought or done. Relationship problems, or the baby being unwanted do not seem to be associated with postpartum psychosis. Episodes can occur in women under considerable stress, but more often PP seems to come out of the blue.
There are likely to be many factors that lead to an episode of postpartum psychosis. We know that genetic factors are important. You are more likely to have postpartum psychosis if a close relative has had it. Changes in hormone levels and disrupted sleep patterns may also be involved. Postpartum psychosis might be more common in women with thyroid problems or pre-eclampsia, but further research is desperately needed though to understand the complex interaction of biological, psychological and social factors that are involved. For this reason, we are very keen for people to help us with research into PP.
Who is most likely to get postpartum psychosis?
For many women with postpartum psychosis there may be no warning. For other women it is clear that they have a high risk. If you have ever had a diagnosis of bipolar disorder (see Pregnancy for Bipolar Women article) or Schizoaffective disorder your risk of postpartum psychosis is high. You may also be in this high risk group if you have had a diagnosis of Schizophrenia or another psychotic illness. If you also have a mother or sister who has had postpartum psychosis, your risk may be even higher. Women who have had postpartum psychosis before are also at very high risk. If you are in one of these high risk groups your chance of having postpartum psychosis is between 1 in 4 and 1 in 2 (25% to 50%). You should discuss your individual risk with a psychiatrist.
You may be worried about your risk if a close relative has had postpartum psychosis. If your mother or sister had postpartum psychosis but you have not had any mental illness, your risk is around 3 in 100 (3%). This is higher than the risk in the general population. It is still much lower than for the very high risk groups.
For more information, you may wish to view this guide for women with bipolar disorder.
For women at high risk can anything be done to prevent it?
Ideally let your psychiatrist and GP know that are planning a pregnancy before you start trying for a baby. You can discuss with them any medications you are taking. They can advise you what you can do to ensure you are as well as possible before becoming pregnant. Many pregnancies are not planned. In that case, let people know as soon as possible.
If you are pregnant it is important to tell everyone involved in your care about your previous illness. This includes your midwife, obstetrician, GP and health visitor. Your mental health team and GP need to know you are pregnant. They all need to know you have a high risk of postpartum psychosis to make sure you get the care you need. They should help you to make a plan for your care (see below).
Paying attention to other factors known to increase the risk of becoming ill may be important. These could include trying to reduce other stressful things going on in your life. Try to get as much sleep and rest as you can in late pregnancy and after the birth. With a new baby this may difficult. Ask your partner or family to take on some of the night time feeds if possible. Think about any factors which usually trigger your episodes of illness. Try to do whatever you can to reduce the chance of these happening.
You can read more in our guide for women at increased risk of PP.
Will medication stop me getting ill after the baby is born?
For women taking medication to help keep them well, the decision to continue or stop medication in pregnancy is very difficult. There are no right and wrong answers. There are risks involved with all possible options. The options you can consider include:
- continuing on all or some of your current medication;
- switching to other options which may be safer in pregnancy;
- coming off all medications.
It is important to discuss these with your psychiatrist. This will help you decide what is best for you and your baby.
Some women at high risk of postpartum psychosis may decide to start medication in late pregnancy or after delivery. This may reduce the risk of becoming ill. There is not enough research evidence to be sure about this. A number of medications are sometimes used in this way. These include antipsychotics and lithium. You should discuss this with your psychiatrist.
What help is available if I am well but have a high risk of postpartum psychosis?
Preconception (when you are planning a pregnancy)
If possible you should seek specialist advice when you are planning a pregnancy. Your GP can refer you. You should see a perinatal psychiatrist if there is one in your area. This is a doctor who specialises in the care of pregnant and postnatal women with current or previous mental health problems. If there is no local perinatal psychiatrist you should see a general psychiatrist for advice. You will be able to discuss:
- Your risk of developing postpartum psychosis
- Risks and benefits of medication in pregnancy and after birth. This will mean you have the information you need to make decisions about your treatment.
- The type of care you can expect in your local area. For example, how professionals work together with you and your family. Also whether there is a perinatal mental health service or a specialist midwife
Care during pregnancy
If you have a high risk of postpartum psychosis you should have specialist care in pregnancy. If there is a perinatal psychiatrist in your area you should be referred when you find out you are pregnant. Otherwise you should be seen by a general psychiatrist. Your psychiatrist should discuss with you:
- The risk of you becoming unwell in pregnancy or after birth;
- The risks and benefits of medication. They should help you make choices about treatment;
- Who will be involved in your care in pregnancy and after birth of your baby.
Ideally you should have a pre-birth planning meeting at around 32 weeks of pregnancy. This is a meeting involving you and everyone involved in your care. This includes your partner, family or friends you choose to bring. It also includes mental health professionals, your midwife, obstetrician, health visitor and GP. The aim is to make sure that everyone involved in your care knows about your risk of postpartum psychosis. You should all agree on a plan for your care.
You should get a copy of your written care plan. This should include early warning symptoms and a plan for your care. There should also be details of how you and your family can get help quickly if you do become unwell.
Care on the maternity unit
Your maternity care in labour will depend on what you and your baby need. The midwives will support you with feeding and caring for your baby.
If you have any symptoms of mental illness a psychiatrist will see you when you are in hospital. The care you have will depend on how unwell you are.
In some maternity units you may see a psychiatrist or mental health nurse before you leave hospital even if you are well. This is to check that you are well at the time you go home. They should also check the plan made at your pre-birth planning meeting. They can make sure you have any medication you need.
Care when you go home from hospital with your baby
Your mental health should be closely monitored. Your midwives, health visitor and mental health nurse should visit you regularly in the first few weeks after your baby is born. If you become unwell this can be picked up quickly so you get treatment early.
You and your family should have emergency contact numbers for local crisis services. You can use these, see your GP or go to A&E if you, or your partner or family think you are becoming unwell.
If you think you are becoming unwell don’t wait. It is better to be seen quickly as symptoms can worsen rapidly.
What help is available if I develop postpartum psychosis?
If you, your partner or family think that you have symptoms of postpartum psychosis you need to be seen urgently. If you have been told during pregnancy that you have a high risk of postpartum psychosis you may have a care plan. This should include emergency contact numbers for your mental health team or local crisis service.
You may not have this type of plan, or you may not have had any mental illness before. In that case you should see your GP urgently (the same day) or attend your local A&E department. If you are told you do not have postpartum psychosis but your symptoms worsen, you should make sure you are seen again.
Most women with postpartum psychosis need to be treated in hospital. Ideally you should be offered a bed in a Mother & Baby Unit (MBU). This is a specialist psychiatric unit where mothers with mental illness are admitted with their babies. You will be supported in caring for your baby whilst you have the care and treatment you need.
There are many parts of the country with no Mother and Baby Unit. Even where there are MBUs there may not be a bed available. You may be admitted to a general psychiatric ward. If that happens, your partner or family will need to care for your baby. If you have nobody else who can look after your baby, social workers can find a temporary carer. This will only be until an MBU bed is available or until you are well enough to care for your baby yourself. You may choose to be admitted to a general ward if the nearest specialist MBU is far from your home.
Medication and breastfeeding
Most women with postpartum psychosis need treatment with medication. This is usually an antipsychotic, a mood stabiliser or both. It is possible to breastfeed whilst taking some medications. Your psychiatrist can discuss the risks and benefits of medications in breastfeeding with you.
You may be unable to breastfeed. There are several reasons for this. You may be too unwell, or you may be admitted to hospital without your baby. You may need a medication which is not safe in breastfeeding. Some women feel guilty about being unable to breastfeed, but you should not feel this way. If you have postpartum psychosis it is not your fault. It is important for your baby that you have the treatment you need so that you get better.
Help in caring for my baby
During the severe part of the illness you will probably need help caring for your baby. You are likely to need practical help. You may also need help to bond with your baby. Mother and Baby Unit (MBU) staff are trained to support you with all aspects of caring for your baby. If you do not go to an MBU, there are people who can help and support you once you go home. These include health visitors and mental health professionals. There may be a local perinatal or parent-infant mental health service. In some areas Children’s Centre staff or voluntary organisations can also help.
It is normal to lack confidence with mothering after postpartum psychosis. Remember that most new mothers who have not had an illness also feel like this. You may find it hard to attend mother and baby groups when recovering from postpartum psychosis. Health visitors and community psychiatric nurses can give you one to one advice until you feel up to attending groups with other mothers.
Some mothers have difficulty bonding with their babies after an episode of postpartum psychosis. This can be very distressing. Usually these problems don’t last long. Most women who have had postpartum psychosis go on to have very good relationships with their babies. Talk to your health visitor or other professionals involved in your care. They can tell you what help is available in your area. Health professionals can support you in learning how to interact with and respond to your baby. You may find baby massage and other groups for new parents helpful.
Care and support for you during recovery
Allow your partner, family or friends to help and support you while you recover (see section on partners below).
Usually you will need to have care from a mental health service until you fully recover. This team can advise you about treatment. They can support you and your family in recovering from the difficult experience of postpartum psychosis. In some areas there are perinatal or parent-infant mental health services. These specialist teams do not exist in all areas. In that case your local community mental health team, your health visitor and GP will continue to support you whilst you recover.
It is important to ask for advice about contraception. It is a good idea to avoid getting pregnant again too soon after an episode of postpartum psychosis.
Will I be referred to children and families social services?
Some women will be referred to Children & Families Social Services. You may be referred in pregnancy because of your high risk of postpartum psychosis. You may be referred if you develop postpartum psychosis. Sometimes women worry that this means that people think they cannot care for their baby. This is not usually the case. The reason is to assess the support you have from family, friends and professionals and to make sure there is safe plan for your baby if you are too unwell to care for him/her. If referral is needed, this should be discussed with you (unless you are too unwell).
Some women and their partners worry that if they seek help for symptoms of mental illness people may think they can’t care for their baby. On the contrary, seeking help and having treatment means you are doing the best for your baby.
You may need extra help from family members during illness and recovery. If you have no support from family or friends, social services may be able to help. Social workers can find a temporary carer for your baby if there is no MBU bed.
Although it might take a while, most women recover fully and become good mothers. It is very rare for babies to be removed from women with postpartum psychosis.
What about partners?
If your partner has postpartum psychosis it can be very distressing for you. At first you may be frightened or shocked. It is important that you ask for help when your partner first has symptoms. This is particularly important if they do not recognise that they are ill. If your partner is hospitalised with the baby you may feel very alone and isolated. You may feel frustrated that there is little you can do to help. It is important that you seek help too if you feel you need it. You can read more about support for dads and co-parents here.
It is important that your life is as stable as possible. Take time for yourself and prepare for when mum and baby return home. Once your partner and baby are home try to:
- Be as calm and supportive as you can
- Take time to listen to your partner
- Help with housework and cooking
- Help with baby care
- Help with night time feeds as much as possible
- Let your partner get as much rest and sleep as possible
- Let other family members and friends help with shopping, cooking etc if they can. This will give you more time to spend with your partner and baby.
- Try not to have too many friends and relatives visiting
- Try to keep your home as calm and quiet as possible
It can be difficult living with someone recovering from postpartum psychosis. Ensure you remain healthy by exercising, eating well and getting enough rest. Don’t use drugs or alcohol to cope.
Ask to speak to the Perinatal Psychiatrist or the other staff involved in your partner’s care if you have any concerns or questions. They are usually very supportive.
Be patient. It takes time for women to recover from an episode of postpartum psychosis.
In the long term being willing to talk about your experiences may aid recovery. Counselling or couple therapy may be helpful for some couples.
When will I get better?
It can take 6 -12 months or more to recover from postpartum psychosis. The most severe symptoms tend to last 2 to12 weeks. The vast majority of women will recover fully.
Postpartum psychosis is often followed by a period of depression, anxiety and low social confidence. It can take time to come to terms with what has happened to you. It’s normal to feel some sadness for missing out on early motherhood. It can take time to rebuild confidence in relationships and friendships. Most women get back to feeling like their usual selves again.
Talking emotions through with family and friends can help. Seek advice about getting expert help from a psychologist, psychotherapist or counsellor. For advice on practical steps that can be taken during recovery, view our guide to recovery.
Will I get postpartum psychosis again after a future pregnancy?
Many women who have had postpartum psychosis go on to have more children. There is a risk of having another episode of PP and so it is important to plan carefully and to put the right support in place.
About 1 in 2 (50%) women who have had postpartum psychosis do not experience it again after the birth of another baby – but about half do.
It is important to ask your GP or Midwife for referral to a specialist Perinatal Psychiatrist when planning pregnancy and again when you become pregnant for advice about medication and care planning. Even with the best advice and planning it is not always possible to avoid another episode, but with the right care in place, if you have another episode, you should be able to get help quickly and recover more quickly the second time.
For more in-depth information about pregnancy care plans, please read our guide for women at high risk of PP, view our page on planning pregnancy, or visit our peer support forum to talk to other women about their care plans and experiences. If you are currently pregnant, you can take part in research to help us understand more about factors that increase and decrease risk of relapse. Elaine Hanzac has written a useful book “Another Twinkle in the Eye” about having more children after severe postpartum mood disorder.
Am I likely to have an episode of psychiatric illness at other times?
The long-term outlook after an episode of PP tends to be very good and women recover fully. However, some women who have had PP will have further episodes of illness unrelated to childbirth.
Just over half of women with postpartum psychosis will experience an episode of depression, bipolar disorder or related illness at some point in their lifetime. (This estimate includes women with and without experience of mental illness before their PP episode, and so the risk may be lower for women whose PP episode was ‘out of the blue’.)
It has been suggested that some women who experience PP may be vulnerable to relapse at times of major hormonal fluctuation, such as during the perimenopause (the time from the onset of menopausal symptoms, such as hot flushes and irregular periods, until the menopause itself).
A case series review of post-menopausal women with a history of PP found that 30% reported an episode of illness (including depression or mania/psychosis) during the perimenopause. Strikingly, most women who relapsed during the perimenopause had been well during the years in between childbirth and the menopause. Further studies are needed to explore this potential risk period more fully and identify which women might be at risk of perimenopausal relapse. Women, their partners and families should be vigilant for signs of relapse during the perimenopause and seek help from their GP or mental health team should symptoms develop. For more information about PP and the menopause, you may wish to visit this page. You can also find information about relapse planning on page 14 of our guide on recovery after PP.
APP is here to support women and families who suffer illness episodes following their PP, no matter how many years have elapsed since the PP episode. If you would like to talk to others with similar experiences and concerns, please visit our peer support forum or request email support. We are campaigning and conducting research to improve understanding of this illness.
Some of this information was included in the Royal College of Psychiatrists PP information leaflet written by Nicola Muckelroy (APP), Jess Heron (APP), Ian Jones (APP, RCPsych) and Lucinda Green (RCPsych).