What Is Postpartum Psychosis (PP)?
Postpartum Psychosis (PP) is a severe, yet treatable, form of postpartum mental illness that occurs to some women after they’ve had a baby. It can happen to women without previous experience of mental illness, and usually begins in the first few days to weeks after childbirth. About half of women who experience it have no risk factors; but women with a prior history of mental illness, like bipolar disorder, a history of prior episodes of postpartum psychosis, or a family history are at a higher risk. Postpartum psychosis is different from postpartum depression and the Baby Blues Baby blues is common 2-3 days after childbirth but should pass. In some cases, the depressed mood lingers for more than 2 weeks and months after the labor, when some women receive a diagnosis of postpartum depression.
Postpartum Psychosis is a rare mental illness, compared to the rates of postpartum depression or postpartum anxiety. It occurs in approximately 1 to 2 out of every 1,000 deliveries, or approximately .1 -.2% of births. The onset is usually sudden, most often within the first two weeks postpartum, Unlike the Baby Blues symptoms, postpartum psychosis is treated as a medical emergency and requires urgent treatment. Most women get committed to a mental hospital, residing either in Mother and Baby units, at the general psychiatric ward, or in postpartum depression treatment centers.
Postpartum psychosis can worsen extremely quickly and should always be treated as a medical emergency. Most women need to be treated with medication and admitted to hospital for emergent care to treat the woman for the symptoms of this frightening mental illness.
Of the women who develop a postpartum psychosis, research has suggested that there is approximately a 5% suicide rate and a 4% infanticide rate associated with the illness. This is because the woman experiencing psychosis is experiencing a break from reality. In her psychotic state, the delusions and beliefs make sense to her; they feel very real to her and are often religious. Immediate treatment for a woman going through psychosis is imperative.
It is also important to remember that many survivors of postpartum psychosis never experience delusions that give violent commands. Delusions can take many forms, and not all of them are destructive. Most women who experience postpartum psychosis do not harm themselves or anyone else. However, there is always the risk of danger because psychosis includes delusional thinking and irrational judgment, and this is illness must be quickly assessed, treated, and carefully monitored by a trained mental healthcare team.
Postpartum psychosis is temporary and treatable with professional help, but it is an emergency and it is essential that you receive immediate help. If you feel you or someone you know may be suffering from this illness, know that it is not your fault and you are not to blame. Call your doctor or an emergency crisis hotline right away so that you can get the help you need.
Fortunately, with the right treatment, women with PP can and do make a full recovery. Recovery takes time and the journey may be tough. The illness can be frightening and shocking for both the woman experiencing it and her partner. Women do return to their normal selves, and are able to regain the mothering role they expected. There is no evidence that the baby’s long term development is affected by Postpartum Psychosis.
Postpartum mood disorders can include severe depression (sometimes mixed with anxiety), as well as other seriously disabling problems labeled with terms such as anxiety/ \panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and, very rarely, psychosis. Postpartum depression is by far the most common of postpartum mood disorders, affecting about one in seven new mothers. It can start anytime in the first year after giving birth. Symptoms of postpartum depression can include hopelessness, suicidal thoughts, sleep and eating problems, inability to feel good or be comforted, and withdrawing into oneself. A woman experiencing postpartum depression may have a hard time caring for her baby or meeting the other demands of daily life.
Besides postpartum depression, women sometimes experience other postpartum mood disorders. Feelings of intense anxiety, fear, or panic, along with rapid breathing, an accelerated heart rate, hot or cold flashes, chest pain, and shaking or dizziness are symptoms of an anxiety/panic disorder. Recurrent frightening thoughts, including obsessing over the baby’s health or acting out repetitive behaviors such as compulsive hand washing, are symptoms of an obsessive-compulsive disorder. A combination of depression with anxiety/panic disorder or obsessive-compulsive disorder is also possible.
Postpartum Psychosis is the label used by most professionals for an episode of mania or psychosis that occurs soon after childbirth. However, other names can be used, including: Puerperal Psychosis; Postnatal Psychosis; Mania or Bipolar Disorder triggered by childbirth (this doesn’t necessarily mean that your partner will develop ongoing Bipolar Disorder); Schizoaffective Disorder with onset following childbirth (this doesn’t necessarily mean that you will develop ongoing Schizoaffective Disorder); Postnatal Depression with psychotic features.
While there appears to be a strong link between postpartum psychosis and bipolar disorder, it’s estimated that about half of women who present with postpartum psychosis have no psychiatric history prior to delivery, making it difficult to identify women who are at greatest risk for this illnessThere are many other mental health conditions that occur following childbirth, including Postpartum Depression, Postpartum Anxiety, and Postpartum Obsessive Compulsive Disorder (P-OCD). It is important that these conditions are not grouped under the term Postpartum Depression. PPD is much more common than PP, but tends to require different treatments and has different causes and outcomes.
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What Are The Causes Risk Factors For Postpartum Psychosis?
If you’re at high risk of developing postpartum psychosis, you should have specialist care during pregnancy, though about half of women who experience postpartum psychosis have no risk factors. While research into Postpartum Psychosis is ongoing, we still have much to learn about this serious mental illness. What is currently known about Postpartum Psychosis is this:
- Lower birth weight increases the risk of postpartum psychosis, whereas gestational diabetes and birth weight were associated with a reduced risk of first-onset psychoses during the postpartum period.
- Older mothers (over 35 years) are about 2.4 times as likely to experience postpartum psychosis than younger mothers (under 19 years).
- PP is not your fault. It is not caused by anything you or your partner have thought or done.
- Relationship problems, family, money troubles, or an unwanted baby do not cause PP.
- The dramatic changes in hormone levels following birth are thought to trigger PP, but studies have not yet identified how these factors are involved.
- For a woman with no history of mental illness who has a close relative (a mother or sister) who had postpartum psychosis, the risk is about 3%
- The first month after delivery is the time of greatest risk for psychotic illness.
- Genetic factors are thought to play a role. Women are more likely to have PP if a close relative has had PP. There may be a genetic component; while mutations in chromosome 16 and in specific genes involved in serotoninergic, hormonal, and inflammatory pathways have been identified, none had been confirmed as of 2019
- Women with a history of Bipolar Disorder or schizophrenia are at very high risk of PP.
- Disrupted sleep patterns may cause PP for some
- Women who already have a diagnosis of bipolar disorder, schizoaffective disorder, schizophrenia, or another psychotic illness are considered to be at a higher risk for developing postpartum psychosis.
- Women with a history of bipolar disorder, schizophrenia, prior episode of postpartum psychosis, or a family history of postpartum psychosis are at high risk; about 25-50% of women in this group will have postpartum psychosis.
- After one episode of postpartum psychosis, the risk for additional episodes of postpartum psychosis increases to 30-50%.
- There is mixed evidence about whether the type of delivery or a traumatic delivery plays a role. It is possible that there are overlaps with physical illnesses that occur during childbirth, such as pre-eclampsia and infection..
What Are The Symptoms of Postpartum Psychosis?
Symptoms of postpartum psychosis usually start suddenly within the first two weeks after giving birth. Rarely, they can develop several weeks after the baby is born. For some women, Postpartum Psychosis may develop very quickly and become obvious that something is wrong. For other people, symptoms may emerge more gradually. This can be difficult to determine if the symptoms are part of the natural childbirth process, or if it’s an actual emergency. When in doubt, call for help.
The symptoms vary and can change quickly. The most severe symptoms last from 2 to 12 weeks, and recovery usually takes 6 months to a year.
Postpartum Psychosis is a medical emergency and must be treated immediately.
Women with Postpartum Psychosis experience some or all of the following symptoms:
- Excited, elated, or feeling “high”
- Depressed, anxious, or confused.
- Excessively irritable or changeable in mood (also called mood lability)
Postpartum Psychosis must also include 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 Mom
- 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 are connected in special ways or that stories on the TV or radio have special personal meaning.
- Feeling that the baby is connected to God or the Devil in some way.
The majority of postpartum survivors rarely or never experience violent tendencies and delusions. The vast majority of women who survive postpartum psychosis won’t harm themselves or the baby. However, staying quiet about the debilitating condition, the loneliness deprives both mother and child of bonding and forming the strong connection that would otherwise occur.
Suicide and infanticide, the most devastating outcomes of severe postpartum psychosis, occur in between 4 and 5% of women afflicted with the illness. Tragic outcomes happen when the symptoms in a mother worsen to the point of detaching from reality. Mothers become deeply affected by irrational, paranoid ideas that make sense to them.
Most often, infanticide takes place when the mother believes that the child is in danger, often from supernatural forces, so ending the baby’s life looks like the only remaining option. Tragic outcomes can only be avoided through urgent medical treatment.
How is Postpartum Psychosis Diagnosed?
Diagnosis of postpartum psychosis always requires hospitalization, where treatment is antipsychotic medication, mood stabilizers, and, in cases of strong risk for suicide, electroconvulsive therapy. Women who have been hospitalized for a psychiatric condition immediately after delivery are at a much higher risk of suicide during the first year after delivery.
The rapid and accurate diagnosis of postpartum psychosis is essential to expedite appropriate treatment and to allow for quick, full recovery, prevention of future episodes, and reduction of risk to the mother and her children and family.
How Is Postpartum Psychosis Treated?
Postpartum Psychosis is a psychiatric EMERGENCY and must be treated immediately.
Call 911 or your doctor.
Treatment of Postpartum Psychosis has no official guidelines. Once tests are administered and all the proper medical causes have been excluded from the diagnosis then the proper treatment is given based on the symptoms. Before the mother is released from the hospital, the team that administered treatment will work with the mother and her family to create a discharge plan that will strengthen her support, along with close follow-up, and prevent stressors that will risk the mother relapsing. Also, for future pregnancies, the mother’s primary care provider is advised to work jointly with other specialists on her care team giving her care in thought of anti-manic prophylaxis during pregnancy or after childbirth.
The mother may not recognize that she has anything wrong with her, so it may be up to the family to insist upon proper psychiatric care. At no time should the mother be left alone with the child until it is determined that the mother is being properly treated and the mother and child are both safe. It is vital that there be a supportive network of family and friends to care for both the mother and the baby.
The mother should be thoroughly evaluated by a doctor both during the episode and for some time afterwards. Symptoms may reappear within a year or two postpartum. Hospitalization is required in order for the mother’s treatment, particularly any medication regimens, to be properly administered and monitored. Women do return to their normal selves, and are able to regain the mothering role they expected. There is no evidence that the baby’s long term development is affected by Postpartum Psychosis.
Note: It is not uncommon for people to think the term postpartum schizophrenia is interchangeable with the diagnosis of postpartum psychosis. Postpartum schizophrenia is not a real diagnosis. Schizophrenia itself is a different diagnosis than psychosis. The disease of schizophrenia is treatable, but not curable. Postpartum psychosis, on the other hand, is both treatable and curable.
Admission To The Hospital:
As Postpartum Psychosis is an actual emergency, the very best and safest place for someone who has PP is in the hospital, which can cause major feelings within the family. Often, people don’t want to go or stay in the hospital for treatment, but as PP can lead to murder, suicide, and infanticide, ensuring your safety is the most important goal. In the hospital, you will be treated using a variety of different medications, other therapies, and therapy.
If you’re the partner of someone who has postpartum psychosis, it’s very likely that you may have to involuntarily to commit your loved one – for the safety of all involved. The length of time for hospital admission is highly individual. An average stay for PP is around 8 –12 weeks, but some women are admitted for only 2 weeks and some for much longer
Partners say that seeking treatment can bring about a vast array of difficult emotions – feelings of disloyalty, guilt, relief, helplessness, stress and frustration. The health system can be hard to navigate, and a great deal of tenacity is sometimes needed.
Before you is discharged from the hospital, you and your partner should ask for help in making a plan of action with your treatment team in case she gets ill again. The plan should include:
- Triggers that may make you more vulnerable to high or low moods, such as stress.
- Early warning signs to look out for, such as sleeplessness.
- Which treatments or medications, and what doses, have worked well in the past.
- Any medications you’d like to avoid.
- Where you would like to be treated if you were to go back into a hospital.
- The phone numbers of any health professionals and services you’ll need.
- Activities you find helpful to your recovery.
Medication For Postpartum Psychosis:
You may only be in hospital for a short time, but it’s likely that you’ll probably need to take medication for a longer period after being discharged from hospital.
Different medications and dosages work for different people and it’s hard to find the right balance of psychiatric medications, so you may have to change medications and treatment at any time. Many medications used to treat Postpartum Psychosis have some side effects, so be sure to continue to chat with your treatment team about your treatment, including any side effects you are experiencing. Dosage can be changed or taken at different times of the day depending upon the side effects.
Many medications for postpartum psychosis can take 3 – 4 weeks to have an effect, which can cause major anger and frustration for all involved. Your doctors will be keeping an eye on how you and may change medication as needed. Be sure to ask the doctors and nurses any questions you have about your medications.
It’s very likely that your treatment team will use some of the medications listed below. It’s important to note that some of the medications for PP may have some unpleasant side effects for some, people, particularly when just starting to take them. Make certain to report any and all side effects to your treatment plan.
- Antidepressants are used to help improve low mood and are often used alongside a mood stabilizer.
- 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). At higher doses, many antipsychotics can cause you to feel sleepy and unmotivated, but remember that you may need these higher doses to fully recover.
- Benzodiazepines may be used to help to reduce agitation and anxiety.
- Mood stabilizers may be used to treat high mood (mania), low mood (depression) and dramatic changes in mood.
- Sleeping medications can be used in the short term to help regain normal sleeping patterns.
- ECT (Electroconvulsive therapy) In some cases, severe symptoms of Postpartum Psychosis persist even when you’ve been taking medication for quite awhile.If this is the case, or if the illness is particularly severe, the psychiatrist treating your partner may recommend that you consider ECT. ECT can be an effective treatment for PP.
- Other types of therapies may also be used to help you, including psychological therapy. As you move forward with your recovery, you will receive a referral to a therapist for therapy.
Most women who have recovered say that taking medication was vital to their recovery as medications help bring the symptoms of psychosis under control and to stabilize your mood.You may feel, however, that medication only helps with half the problem – symptoms but not self confidence. It is important to use more active recovery methods alongside medication to help with self confidence and the social side of recovery.
The great majority of women with postpartum psychosis make a full recovery as long as they receive the right treatment.
The Aftermath of Postpartum Psychosis:
You and your family should have emergency contact numbers for local crisis services, if you, your partner, or family think you are becoming unwell. If you think you are becoming unwell again, don’t wait to seek help.
Postpartum psychosis can go undetected and pass spontaneously in many women. Considering the risks, the best way to help yourself is to surround yourself with support. Being open and honest about your feelings, thoughts and fears will help your family and friends understand your condition better.
In the early days after being diagnosed and/or receiving treatment in hospital you may feel a sense of confusion about the events of your baby’s birth and your illness. Many women find it hard to remember the exact sequence of events. Some of the following ideas may help you to piece together what happened:
- Ask your treatment for a summary of events and your treatment.
- Talk to your partner or family about what happened – but some people find this very hard and need time to recover first.
- Write your story as you can remember it.
- Use photos or memories to put together a timeline of events. This can help you look back on your baby’s first days even though they weren’t how you expected them to be.
- Read other women’s stories Many women behave in ways that are really out of character during an episode of Postpartum Psychosis. It may help just to know that these experiences are usual symptoms of the illness.
These ideas may help you learn to cope with what has happened:
- You may feel let down, angry, and/or unhappy about the way treatment was started, especially if you had to go to hospital under an involuntary admission.Remind yourself that these were symptoms of the illness and not a permanent change in you.
- It is very common during PP to become angry, excitable, use inappropriate language, be overfamiliar with strangers, or believe you have special insight or powers.
- Distressing thoughts about harming yourself or your baby are also common, though very upsetting. It is very normal to feel embarrassment or shock at the things you did when unwell.
- Talk through upsetting symptoms with your partner.
- Ask to speak to a health professional (such as a support worker, specialist midwife, community psychiatric nurse, or another member of the your treatment team) about how you feel about your symptoms.
- A psychologist or counsellor (particularly one with specialist knowledge of postnatal illness) may be able to help you talk through your experiences.
It’s normal to feel a whole range of emotions when you begin to recover from Postpartum Psychosis (PP). Below are some common emotions:
- Why me?
- Worries and anxiety about bonding with your baby, your relationships, and your future health.
People recover from distressing experiences in different ways. Some need to talk about it, others may find that they’d like to face recovery in a different way, and you may find that you and your partner are dealing with the impact of PP in the same way, or in very different manners. This is where you and your partner must work together, be patient with each other, provide support and love, and don’t hesitate to ask the treatment team if what you’re experiencing is normal.
Here are some of the things you can do to cope with postpartum psychosis:
- Be open about your thoughts, fears, and doubts. The postpartum period is always a rocky emotional and mental journey and a time of great mental adjustment.
- Beat fear and shame. Most women who experience aggressive or irrational thoughts about themselves and their babies feel ashamed of talking about it. Sharing your thoughts with close ones helps them help you. Once you’ve experienced and received support, you will feel more confident in your recovery and gradually regain faith in your own judgment.
- Be kind to yourself and understand that postpartum psychosis doesn’t define you. You’re no less of a mother because you have a mental illness. You didn’t choose to get sick, and you are equally valuable to your baby and your family regardless of your mental state.
- Follow your care plan. Stay devoted to taking medication as prescribed and keeping up with appointments. At times, you might too tired or drowsy to stay on schedule. Make sure to have a backup plan to meet all of your appointments, including someone to drive you and someone to stay with the baby.
- Focus on rest, recovery, and bonding with your child. Recovery from postpartum psychosis isn’t the time to worry about housework. Rely on friends and relatives to help as much as possible so that you can spend plenty of time resting and bonding with the baby.
Many women who have been through PP find that there are ups and downs in their mood over the first year of recovery, which can lead to feelings of a relapse or setback, if things have been otherwise going well. Having another bout of anxiety, depression, and other symptoms can make women feel as they’ll never recover. An episode of postpartum psychosis is sometimes followed by a period of depression, anxiety and low confidence.
It might take a while for you to come to terms with what happened. Some mothers have difficulty bonding with their baby after an episode of postpartum psychosis, or feel some sadness at missing out on time with their baby. With support from your partner, family, friends, and your mental health team, you can overcome these feelings.
Neither you or your partner can make this mental illness get better by toughing it out. It’s something that must be closely monitored and treated and watched and talked about. Try to have a discussion about PP at least every day.
Set small achievable goals. As you monitor your progress you’ll see that every setback doesn’t take you back to square one. It’s important for you to see how far you’ve come.
Keep a mood diary, which can help you track triggers for high and low moods. This is handy to bring to the treatment team, so they can best monitor and treat your mental illness Partners may want to keep a mood diary of their own. Getting to know yourself better allows you to notice any things you do which particularly affect the mood at home, for better or worse.
Make a a list of things that make you feel happy, and try them out when you’re feeling down and make a list of things that help you feel calmer and more relaxed, use them to try something from it if you’re feeling stressed or high.
What Are The Outcomes For Women Who Have Postpartum Psychosis?
The most severe symptoms of PP usually last from 2 to 12 weeks; it can take between six months and a year to recover – every woman is different in her recovery. Women often experience low self-esteem and difficulties as they recover, but most women fully recover. Many women who have PP have a hard time bonding with their child as they recover, but end up with healthy relationships with their babies.
Postpartum psychosis can disappear gradually in the months after labor, but can also linger for years. Women who choose to speak openly about the illness and seek help often find that antepartum psychiatrists and medication have a beneficial long-term impact.
About half of women who experience postpartum psychosis have further experiences of mental illness unrelated to childbirth; further pregnancies do not change that risk. Women hospitalized for a psychiatric illness shortly after giving birth have a 70 times greater risk of suicide in the first 12 months following delivery.
Should I Have Another Baby?
Making the decision to have another baby isn’t straightforward. Thinking about it might bring a lot of worries – will you and your partner go through the same painful experiences all over again? The more you can both share about your
hopes and fears, the easier it will be to make an informed decision together.
Many women who have had Postpartum Psychosis go on to have more children, and about 50% do not experience PP again after the birth of another baby. With the right care, if your partner does have another episode, you should be able to spot the signs, get help before it becomes too severe, and recover more quickly the second time around.
You can plan as many children as you want, even with history of postpartum psychosis. However, you will have to set up a support system and be prepared for the illness right after childbirth. Those with high risk from postpartum psychosis should have a support team monitoring their state during the pregnancy and after childbirth. If you’re expecting to experience postpartum psychosis after childbirth, specialist care during the pregnancy, as well as consultations with a psychiatrist are a good way to support mental health.
At around 32 weeks of pregnancy, everyone involved with your care, including family and friends, midwife, GP, and obstetrician, should meet to exchange information and agree on the postpartum care plans. 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 and set up any support services as possible.
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.
The best solution for your postpartum care is to define the treatment course after the delivery. Some women have symptoms so severe that they need to be admitted to the psychiatric ward right after the childbirth. Others rely on the help of friends and family with housework and the baby. In some cases, mothers are under constant supervision from family members and never left alone with the baby. Though it might seem unsettling to know you can’t be alone with your child, this is the only way to ensure the safety of both of you. When someone is always present to help out with the baby, you are left with more time to recover and bond with the child.
You should discuss:
- The risk of developing postpartum psychosis.
- Risks and benefits of medication in pregnancy and after birth. This should give you the information you need to make decisions about your treatment.
- The type of care you can expect in your local area from perinatal mental health and maternity services and how professionals work together with you and your family.
- If you are at high risk of postpartum psychosis, you should have specialist care in pregnancy, If you are already under the care another mental health service they can work together