The first few weeks of motherhood can be a time of celebration. But it can also be a time of high vulnerability to mental illness. Among other challenges, the postpartum period can introduce mental health risks like postpartum depression and, for some, postpartum psychosis.
Postpartum psychosis is a rare but serious condition that impacts an estimated one in 1,000 mothers in the weeks after they give birth. Sometimes it’s compared to the much more common postpartum depression, a type of depression that typically occurs shortly after giving birth and affects one in eight new mothers, according to the CDC. Postpartum psychosis also involves symptoms of depression, but combines those symptoms with that of mania and delusions. Without the right treatment, people with postpartum psychosis can develop false realities, suicidal ideology or intrusive thoughts of harming themselves or their babies.
[SEE: 11 Signs of Postpartum Depression.]
Symptoms of Postpartum Psychosis
Some signs and symptoms of postpartum psychosis include:
— Mood swings.
— Intense emotions.
— Depressive symptoms, like intense sadness.
— Irritability.
— Insomnia.
— Confusion with vision — seeing things that other people do not see.
— Confusion with hearing — hearing things that other people do not hear.
— Believing false realities about themselves, their partner or child — such as thinking their child is a god, or that their child is a threat to them, when in reality they are not.
— Thoughts of harming one’s child.
With the right treatment, symptoms can improve.
Exactly which symptoms manifest and how they progress can vary from person to person, but most start within days of giving birth. Because the onset is so soon, people who do not experience symptoms a few weeks into the postpartum period are unlikely to develop postpartum psychosis later.
“Typically, the first symptoms are clear within one or two weeks of delivery: irritability, sleep loss, ideas getting more and more weird, mood swings going one way or the other,” says Dr. Veerle Bergink, a psychiatry and OBGYN professor at the Icahn School of Medicine at Mount Sinai. “If left untreated, there’s a high risk of both suicide and infanticide — especially suicide.”
Barriers to Treatment
Despite the severity of the situation, people with postpartum psychosis face barriers to treatment — not the least of which is that the disorder is not individually recognized in the Diagnostic and Statistical Manual of Mental Disorders, or DSM 5. In the DSM 5, postpartum psychosis is classified under the “short psychotic disorder” section, which includes schizophrenia spectrum and other psychotic disorders. Postpartum depression is also not uniquely classified in the manual, but is described as a major depressive episode timed with the onset of peripartum, which is the very beginning of the postpartum period.
Bergink is leading an initiative to get postpartum psychosis uniquely classified in the DSM. She calls the lack of recognition and education on the condition a “tragedy.”
“There have been case reports (on postpartum psychosis) for hundreds of years, and we know how high the risk is and how specific this disease is and it’s not included in our classification system,” she adds.
The condition is currently diagnosed through symptoms, the patient’s story and input from close friends or family, such as a partner, she says.
[What Are the Early Signs of Pregnancy?]
Who Is at Risk for Postpartum Psychosis?
Postpartum psychosis can occur suddenly and randomly. So, although the number of occurrences is small, anyone who has given birth may be at risk after pregnancy.
When looking at how many people are at risk of being affected, “you could say the prevalence is low — but it’s not that low,” says Bergink. “It happens to women from all cultures, all socioeconomic classes, all personalities. There are many women with no psychiatric history at all, who live perfectly organized lives, who deliver a child and — within days or weeks of the birth — get severely psychotic, out of the blue.”
Nevertheless, there are two conditions that can exponentially increase a person’s risk for developing postpartum psychosis: These are bipolar disorder and/or a previous history of postpartum psychosis.
Having bipolar disorder increases a person’s risk of postpartum psychosis from 0.001% to about 20%, according to a review of studies published in the American Journal of Psychiatry.
For people with a prior case of the condition, they are at a risk of developing postpartum psychosis again at just over 30%. With a second or subsequent child, “the moment they deliver, they are at a very high risk for having it again,” says Bergink.
[Read: Top Pharmacist-Recommended Women’s Health Medicines]
Medical Treatments for Postpartum Psychosis
Postpartum psychosis can be treated with medications like antipsychotics and lithium, a mood-stabilizing medication. These can be taken together, and are given after a diagnosis is made or quickly after pregnancy for people in high-risk groups. Taken as directed, these medications can be very successful in preventing and treating the condition, Bergink says.
“It typically takes a few weeks (for symptoms to resolve),” Bergink says. “The psychotic and manic symptoms resolve first, and then the depressive symptoms usually linger a bit longer.”
In a 2015 study led by Bergink, she found that 98% of patients who take these treatments can fully recover from postpartum psychosis, with the medium time period for recovery being about one month.
Bergink stresses the importance for patients to stay on the medication for their entire course and not stop when they “start” to feel better. She compares psychosis to an infection, and the treatments to antibiotics. In either scenario, stopping treatment early can result in an unresolved issue.
After recovery, it is also recommended that people stay on lithium for about nine months to a year, after which they may discontinue or be titrated off the dosage, Bergink says. This can be important in preventing a relapse, she adds.
Interventions to Treat Postpartum Psychosis
In addition to medication, some people may require in-patient stays to recover from their conditions. Unfortunately for patients in the United States, facilities that specialize in treating postpartum psychosis are scarce, and the rest are often not adequate at treating these patients, says Bergink.
Depending on how severe their case is, some people who are institutionalized may be forced into a facility against their will or separated from their baby — which can have negative effects on mother-child bonding, she says.
To better serve those who develop, and who are at risk, for developing postpartum psychosis, Bergink says more robust treatment centers and aftercare providers are needed in the country. Doctors and medical students should also undergo more training for treatment of the condition and clearer diagnostic criteria should be established to guide care.
“We need facilities specifically for women with mental illnesses — not only to benefit women with postpartum psychosis, but also women with severe postpartum depression,” says Bergink.
Early Interventions May Help Patients and Practitioners Avoid Force
Forcing a patient into a hospital setting isn’t fun for anyone involved, says Dr. G. Thomas Ruiz, an OBGYN Lead at MemorialCare Orange Coast Medical Center in Fountain Valley, California. He points out that this process is a flaw in the healthcare system in general, as OBGYNs like himself cannot directly refer a patient to psychiatric care. They can only make recommendations for them or call in police intervention in certain circumstances, like if the patient poses a danger to themselves or others.
To avoid these kinds of scenarios, he tries to offer patients early interventions to help reduce the risk of developing severe mental illness. This includes evaluating people with tools like the Edinburgh postnatal depression scale, which was designed to screen for postpartum depression.
The test is recommended at regular intervals for all pregnant patients — not just those pegged as high risk for postpartum psychosis, he explains. The scale is a 10-question evaluation, with the last two questions asking if the patient has desires to harm herself.
Ruiz has on two occasions dealt with patients in the postpartum period that he believed posed dangers to themselves. In both situations, he requested they be admitted to a facility. These patients suffered from postpartum depression, not psychosis, and went willingly, he adds.
What Makes the Postpartum Period So Risky?
Pregnancy ushers in both a “huge life event” and “tremendous changes” to the body, as it returns from a state of pregnancy to not-pregnant, says Bergink. As a result, it’s normal — although not enjoyable — to experience mood swings, heightened emotions or the baby blues soon after giving birth, she adds.
Among other things, changes in hormones during and after pregnancy can cause chemical fluctuations that trigger physical and mental health side effects. Progesterone in particular, a hormone that increases during pregnancy, “can act as a mood suppressant,” which can influence risks of depression, says Ruiz. However, not enough studies have been conducted to confirm if, or how, these hormones impact postpartum psychosis.
While patients and doctors await more research, experts agree that the postpartum period puts mothers in a vulnerable state, and they don’t know why it can cause these mental illnesses specifically. While some mental changes can be expected, not everyone who gives birth presents with postpartum psychosis. It’s important not to write this issue off as “normal,” without giving it the care it deserves.
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What to Know About Postpartum Psychosis originally appeared on usnews.com
Update 08/22/23: This story was previously published at an earlier date and has been updated with new information.
