In this latest blog in our spotlight on maternal mental health Dr Amy Perry, Research Psychologist from the Mood Disorders Research Group, University of Worcester, provides an overview of postpartum psychosis.

New mothers are vulnerable to mood disturbances within the first year of childbirth. In more severe cases, these episodes can negatively affect not only the mother but also have short- and longer-term implications for her baby and wider family. Sadly, suicide continues to be a leading cause of maternal death in the United Kingdom [1], highlighting the importance of prompt identification and treatment of perinatal mental ill-health.

Most women and healthcare professionals are familiar with the concepts of the ‘baby blues’ and postpartum depression, both are which are common in the postpartum period (affecting between 50-80% and 10-15% women respectively) [2,3]. However, comparatively less is known about postpartum psychosis. This is surprising, given these episodes are among the most severe psychiatric illnesses that women can experience in relation to childbirth and, arguably, during their lifetime. This disparity in awareness is reflected by the fact that the baby blues and postpartum depression are frequently discussed during parental education classes and educational materials, while postpartum psychosis is often omitted. Recent research also shows that midwives and other related healthcare professionals frequently cite lack of knowledge and training in identifying cases of postpartum psychosis compared to other forms of perinatal mental illness [4]. Increasing awareness of postpartum psychosis among women, their families and healthcare professionals is therefore crucial to detecting cases early, to ensure the best possible outcomes for women and their families.

So, what then is postpartum psychosis and how is this different to other forms of perinatal mood disturbances? Who is most at risk and what is our understanding of the causes of this lesser-known childbirth related illness? Here, I summarise highlights from our recently published review of postpartum psychosis [5], to address these important questions.

What is postpartum psychosis?

Though the term postpartum psychosis can be difficult to define, the concept is widely-used in psychiatry (and by women themselves who experience it; (www.APP-network.org) to describe severe cases of mood disorder that have very sudden onset following childbirth, typically within the first two weeks. Postpartum psychosis occurs in 1-2 in every 1000 deliveries in the general population and it is estimated that for more than 40% of women affected, is the first episode of psychiatric illness experienced. Symptoms of postpartum psychosis are varied and can change rapidly from hour to hour (or even minute to minute), presenting with a unique ‘kaleidoscopic’ picture that may include:

• Mania (feelings of high mood, elation or euphoria that can be accompanied by periods of increased activity and energy, a reduced need to sleep, pressured speech, feelings of increased confidence)
• Extreme confusion or ‘perplexity’
• Symptoms of depression (which may be present at the same time as symptoms of mania)
• Anxiety or irritability
• Disinhibited behaviour that is out of character
• Hallucinations (seeing or hearing things that are not really there)
• Delusional beliefs that are fixed and are abnormal for the woman experiencing them. These often relate to the baby (for example, these may be religious in nature or the mother believing that she or her baby has special powers or abilities)
• Lack of insight (the mother is unable to identify that she is unwell)

Postpartum psychosis is a psychiatric emergency that in most cases requires hospitalisation (ideally in a specialised mother and baby psychiatric unit) and treatment with psychotropic medications. With treatment, recovery from the initial episode is favourable. However, many women unfortunately also experience more prolonged episodes of depression following the initial episode and around 50% of women are at risk of further episodes of postpartum psychosis following a subsequent delivery.

Who is most at risk of postpartum psychosis?

While postpartum psychosis is considered rare in the general population, women with a previous history of psychiatric illness, in particular bipolar disorder, are known to be at especially high risk. Bipolar disorder is a severe mood disorder characterised by episodes of mania and usually depression and as many as 1 in 5 women with this diagnosis also experience postpartum psychosis. The close relationship between postpartum psychosis and bipolar disorder is now well established. Additional research shows that for a significant number of women without a history of psychiatric illness, postpartum psychosis marks the onset of bipolar disorder. As a result, episodes of postpartum psychosis are usually defined as a manifestation of bipolar disorder.

What are the risk and triggering factors for postpartum psychosis?

While a history of bipolar disorder is one of the strongest known risk factors for postpartum psychosis, the factors that play a role over and above the risk conferred by this diagnosis are not well understood. Many women who experience postpartum psychosis may feel guilt or shame that they or their partner are in some way to blame for their symptoms, however research in this area suggests this is not the case, primarily implicating biological factors in the onset of this illness. So far, evidence points to genetic, hormonal and immunological factors being involved, while acute sleep loss during labour and delivery may also be important. In contrast to postpartum depression, psychosocial factors, such as adverse life experiences and reduced social support appear to play less of a role in the onset of postpartum psychosis.

While we are starting to learn more about the nature of this complex illness, there is still much we do not yet understand. Further research in this area is greatly needed, which is why our research group is currently investigating potential protective and triggering factors of postpartum psychosis in women who have bipolar disorder (The Bipolar Disorder Research Network; (www.BDRN.org, @BDRN_org). Such research data is vital not only for predicting who is most at risk of postpartum psychosis but also to help inform the many difficult decisions women with bipolar disorder (and their healthcare providers) face regarding care and, in particular, medication use during the perinatal period.

1           Knight M. The findings of the MBRRACE-UK confidential enquiry into Maternal Deaths and Morbidity. Obstet Gynaecol Reprod Med 2019;29:21–3. doi:10.1016/j.ogrm.2018.12.003

2           Rezaie-Keikhaie K, Arbabshastan ME, Rafiemanesh H, et al. Systematic Review and Meta-Analysis of the Prevalence of the Maternity Blues in the Postpartum Period. JOGNN – J. Obstet. Gynecol. Neonatal Nurs. 2020. doi:10.1016/j.jogn.2020.01.001

3           Woody CA, Ferrari AJ, Siskind DJ, et al. A systematic review and meta-regression of the prevalence and incidence of perinatal depression. J Affect Disord 2017;219:86–92. doi:10.1016/j.jad.2017.05.003

4           Carroll M, Downes C, Gill A, et al. Knowledge, confidence, skills and practices among midwives in the republic of Ireland in relation to perinatal mental health care: The mind mothers study. Midwifery 2018;64:29–37. doi:10.1016/j.midw.2018.05.006

5           Perry A, Gordon-smith K, Jones L, et al. Phenomenology, Epidemiology and Aetiology of Postpartum Psychosis: A Review. Brain Sci 2021;11.

Useful resources

Action on Postpartum Psychosis (the largest national UK support charity for women and their families affected by postpartum psychosis): www.app-network.org

Bipolar UK (the UK’s leading patient support charity for those affected by bipolar disorder): www.bipolaruk.org

Royal College of Psychiatrists (the professional body responsible for education, training and setting standards in psychiatry): Postpartum psychosis | Royal College of Psychiatrists