These notes have been adapted from a booklet by the Royal College of Psychiatrists and the treatment options are UK specific.
Postpartum psychosis and symptoms
Postpartum psychosis or puerperal psychosis is a severe mental illness which takes place after childbirth. It is a severe episode of mental illness which begins suddenly in the days or weeks after having a baby. Postpartum psychosis differs from postnatal depression or baby blues. Many women experience mild mood changes after childbirth and over half of new mothers will have the baby blues. They may have mood swings, be tearful and feel low, anxious or irritable. This usually starts 3 to 4 days after birth and stops by the time the baby is 10 days old. No treatment is required. Postpartum psychosis is different from postnatal depression or the baby blues. It is a more severe illness. The episodes tend to begin in the first two weeks after birth. Symptoms vary and can change rapidly from hour to hour or day to day. Postpartum psychosis is a psychiatric emergency. Help should be sought immediately. The symptoms of postpartum psychosis include high mood (mania), depression, confusion, hallucinations and delusions. The following is a more comprehensive list:
- Feeling ‘high’, ‘manic’ or ‘on top of the world’
- Low mood and tearfulness
- Anxiety and 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- Being very withdrawn and not talking to people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. You might think your baby is possessed by the devil. You might believe people are out to get you.
- Hallucinations: this means you see, hear, feel or smell things that aren’t really there.
Why does it happen and to who and what can you do if you are high risk?
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. More research is required to understand the cause. Genetic factors are important. You are more likely to have postpartum psychosis if a close relative has had it. Many factors can lead to an episode. Changes in hormone levels and disrupted sleep patterns may be involved. For many women with postpartum psychosis there may be no warning. Some women are more high risk, such as women who have a diagnosis of bipolar or schizoaffective disorder. Women who have had postpartum psychosis before are at very high risk. If you are considered high risk, you should tell everyone involved in your care about your pregnancy. People who are considered high risk should try to reduce the stress in their lives. They should also get as much sleep and rest as possible in late pregnancy. When the baby is born, a family member or partner could do some of the night time feeds so the mother can rest. You should also talk to your psychiatrist about medication. Some women with high risk of postpartum psychosis start medication in late pregnancy or after delivery in order to reduce the risk of becoming ill. If you are planning a pregnancy and have a history of mental illness, you could see a perinatal psychiatrist as they specialise in this area.
Care during pregnancy and after childbirth
People who have a high risk of postpartum psychosis should receive specialist care during pregnancy. This means being referred to a perinatal psychiatrist or a general psychiatrist if one is not available in your area. The psychiatrist will discuss your risk of being unwell during and after pregnancy, risks, benefits and choices of medication and they will explain who will be involved in your care before and after birth. In the UK you should have a pre-birth meeting at around 32 weeks of pregnancy. Everyone who is involved in your care attends this meeting; partner, friends, family as well as the relevant mental health professionals, midwife, GP, obstetrician and health visitor. Together they will agree a plan for your care. This will include early warning symptoms and what action is required should you become unwell.
On the maternity unit you will be cared for by the midwives as usual but if you have any symptoms of mental illness you will see a psychiatrist. In some cases, you may see a mental health nurse or psychiatrist even if you are well, to check that you are ready to go home. Your pre-birth plan will be checked and you will be given any necessary medicine.
Once back at home, midwives, health visitors and mental health nurses will visit you regularly to monitor you closely in the first few weeks. Your family will be provided with emergency comtact numbers for local crisis services. If you think you are becoming unwell, act promptly.
If you or someone close to you thinks you have the symptoms of postpartum psychosis, you need to be seen urgently. Those with a plan may already have contact numbers for relevant services but if you do not have a plan or have not suffered from mental illness before contact your GP urgently or go to A&E at the hospital.
Most women with postpartum psychosis need to be treated in hospital. Ideally treatment will be offered in a Mother and Baby Unit. Places in Mother and Baby Units are limited and these units are not available everywhere. In that case you will be admitted to a general psychiatric unit and your partner or family will need to care for the baby. A Mother and Baby Unit is a special psychiatric unit where mothers with mental illness are admitted with their babies. Nurses offer support to help you care for your baby whilst you receive treatment and get well. Staff are trained to assist you with practical aspects as well as bonding. Some mothers who have suffered from an episode of postpartum psychosis find bonding difficult and this can be very distressing. Usually these problems do not last long and the mothers go on to have good relationships with their babies. During your stay in hospital and after you are discharged you will work with health visitors and mental health professionals. There may be a local perinatal or parent-infant mental health service. Local Children’s Centres and voluntary organisations can also help. It is normal to lack confidence with mothering after postpartum psychosis, mothers who have not suffered this illness also feel like this. You may find it hard to attend mother and baby groups while in recovery. Health visitors and community psychiatric nurses can give you one-to-one advice until you feel able to going to these groups.
Allow your partner, family or friends to help and support you while you get better. Your mental health care team will work with you until you fully recover. Seek advice about contraception. It is a good idea to avoid getting pregnant too soon after suffering an episode of postpartum psychosis.
Referral to Children and Families Social Services
Some women will be referred to Children and Families Social Services (UK) either during pregnancy if you are at high risk of postpartum psychosis or after birth when you develop it. This referral does not usually mean that people think you cannot look after your baby, instead assessment takes place to check you have the relevant support from family, friends and professionals. It is also to make sure there is a safe plan for the baby if you are too unwell to care for him/her. Referral will 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 then people may think they can’t care for their baby. On the contrary, seeking help and having treatment is seen as a positive step and shows you are doing your best for your baby. You may need extra help and support from family members during illness and recovery. If this is not available social services may be able to help and if necessary, Social workers can find a temporary carer for your baby. Although recovery may take some time, most women recover fully from postpartum psychosis 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 and frightening for you. It is important that you ask for help as soon as you recognise any symptoms. In some cases women do not recognise they are ill. Use your own good judgement. If your partner is hospitalised with the baby, you may feel very isolated and alone. You may also feel frustrated that things are beyond your control. Seek help from friends and family as well as talking to the professionals involved and support organisations listed below. It can be difficult to live with someone recovering from postpartum psychosis. Try to remain healthy by exercising, eating well and getting enough rest. Don’t use drugs or alcohol to cope. Be patient. Recovery from an episode of postpartum psychosis takes time. In the long term counselling or couple therapy may help.
It is important for partners to ensure life is as stable as possible. Take time for yourself and prepare for when mother and baby return home. Once they are at 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 rest and sleep as much as possible
- Let friends and family help with shopping, cooking, chores. This will allow you more time to spend with your partner and baby
- Curb the amount of visitors
- Keep your home as calm and quiet as possible
It can take 6 – 12 months or more to recover from postpartum psychosis. The most severe symptoms usually last between 2 and 12 weeks. Most women recover fully. You may have further episodes of illness at a later time.
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 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. Talking about your emotions with family and friends can help, as can seeking the professional help of a psychiatrist, psychotherapist or counsellor. The vast majority of women get back to feeling like their usual selves again.
How likely is it to happen again?
Many women who have had postpartum psychosis go on to have more children. There is a high risk of having another episode. About 50% of women who have had postpartum psychosis will have this again after the birth of another baby. Professionals will monitor you closely so you get help quickly.
More than half of women who have suffered an episode of postpartum psychosis will have a further episode of illness not related to childbirth. Avoiding having more children is not a guarantee of remaining well.
Action Postpartum Psychosis Network
A network of women across the UK who have experienced postpartum psychosis. They aim to increase public awareness and promote research into the condition. Run by a team of academics, health professionals and women who have recovered from postpartum psychosis. Follow this link to their site
The Association for Postnatal Illness (APNI)
Provides support for mothers with postnatal illness, aims to increase public awareness and encourage research in the field. Click here
A charity offering support for pre-natal and post-natal illness. Click here
Post Natal Illness
A support website and forum run by sufferers and past-sufferers of post natal illness. Click here
National Centre for Mental Health – Bipolar Education Programme Cymru
Information about pregnancy and childbirth for women with bipolar disorder. Read more here
A blog about postnatal mental illness. Read here