Postpartum Psychosis

Postpartum psychosis is a rare but severe illness that starts suddenly, usually in the first days or weeks after giving birth. A new parent may become confused, sleepless, unusually energized or deeply withdrawn, and may see or hear things or hold beliefs that are not real. It is a medical emergency because it can put both parent and baby at risk, and it is very treatable with prompt care. It is closely linked to bipolar disorder. This page covers the warning signs, timing, the bipolar connection and how people with bipolar disorder can plan to prevent it.

If you see these signs, get help now

Willow & Stone provides outpatient, scheduled care and is not an emergency service. Postpartum psychosis needs same-day emergency evaluation, and researchers note that hospital care is usually required to keep everyone safe, complete the medical workup and start treatment.

Warning signs

Postpartum Support International lists these symptoms of postpartum psychosis:

• Delusions or strange beliefs
• Hallucinations, seeing or hearing things that are not there
• Feeling very agitated
• Hyperactivity or having more energy than usual
• Severe depression or lack of emotion
• Decreased need for sleep, or being unable to sleep
• Paranoia and suspiciousness
• Rapid mood swings
• Difficulty communicating at times

Symptoms can come and go, so a parent may seem fine for a few hours and then become confused again. That does not mean the danger has passed. Partners and family are often the first to notice, because the person who is ill may not recognize that anything is wrong.

How it differs from baby blues and postpartum depression

Frightening intrusive thoughts about the baby, which the parent finds upsetting and does not want to act on, are common in postpartum anxiety and depression and are different from psychosis. They still deserve care; see postpartum depression treatment.

When it starts and how common it is

PSI describes onset as usually within the first two weeks after delivery, though it can occur up to a year postpartum. In a large UK study of women with mood disorders, manic and psychotic episodes after birth started earlier than depressive ones, and most perinatal episodes began within the first month.

Estimates of how often it happens vary with how cases are counted. A 2017 systematic review put the rate at 0.89 to 2.6 per 1,000 women, and PSI cites roughly 1 to 2 per 1,000 deliveries. Rare as that is overall, the risk is many times higher for people with bipolar disorder.

The link to bipolar disorder

PSI calls a personal or family history of bipolar disorder "the most significant risk factor" for postpartum psychosis; a previous psychotic episode and prolonged lack of sleep are also on its list. A 2016 review in the American Journal of Psychiatry by Bergink and colleagues found that after a first episode, 20% to 50% of women have postpartum psychosis only, while the rest go on to have mood episodes outside the perinatal period, usually within the bipolar spectrum. In other words, for many women postpartum psychosis is the first sign of bipolar disorder.

For women already diagnosed, a 2016 meta-analysis found that about 17% of those with bipolar disorder had a severe postpartum episode such as mania or psychosis, rising to 29% in those with a past postpartum psychosis. Bergink and colleagues note that the trigger is probably the hormonal, immune and sleep-cycle changes after birth acting on a genetic vulnerability. They also stress that some cases have medical causes that must be ruled out, such as autoimmune thyroid disease, infection or, rarely, autoimmune encephalitis, which is one more reason emergency evaluation matters. Learn more about psychosis in bipolar disorder.

Treatment and recovery

Postpartum psychosis responds to treatment, and most women recover. Fewer than 30 published studies have focused on its treatment, but the largest found lithium highly effective for both acute and maintenance treatment, and another described successful ECT (Bergink 2016). Treatment usually starts in a hospital. Afterward, follow-up care focuses on preventing relapse, rebuilding sleep and supporting bonding with the baby.

Recovery takes time, and many women feel guilt or grief about the episode. Peer support through PSI and therapy can help with that part.

Prevention planning if you have bipolar disorder

If you have bipolar disorder or a past postpartum psychosis, a plan made during pregnancy can lower the risk. Bergink and colleagues list lithium prophylaxis started immediately after delivery and proactive safety monitoring among prevention strategies. For women with bipolar disorder, continuing preventive medication through pregnancy was linked to far lower postpartum relapse (23% versus 66%) in the 2016 meta-analysis. Which approach is right depends on your history and is a decision for you, your prescriber and your OB.

• Write the plan down by the third trimester and share it with your partner, your OB and the hospital team.
• Medication decisions for pregnancy and right after delivery, made in advance (details on bipolar disorder, pregnancy and postpartum).
• Sleep protection from the first night: someone else covers at least one night feed.
• A warning-signs list your support people can check, plus who to call and when to go straight to an emergency room.
• Early follow-up in the first days and weeks after birth, when risk peaks.

Women who had postpartum psychosis once without other episodes face about a 31% chance of it returning after a later pregnancy, according to the same review, so planning matters for future pregnancies too.

At Willow & Stone

Willow & Stone does not provide emergency care; if postpartum psychosis is suspected, call 911 or go to an emergency room. For people with bipolar disorder who are planning ahead, care plans are discussed at an outpatient evaluation with Dr. Stacey Forbes, a board-certified psychiatric-mental health nurse practitioner; talk with your prescriber and OB before making any change. Learn about bipolar disorder treatment at Willow & Stone or read the complete bipolar disorder guide.

Common Questions

Sources & Further Reading

• Postpartum Support International: Postpartum Psychosis
• Postpartum Support International: PSI HelpLine
• Bergink V et al. Postpartum psychosis: madness, mania, and melancholia in motherhood. Am J Psychiatry 2016
• Wesseloo R et al. Risk of postpartum relapse in bipolar disorder and postpartum psychosis: meta-analysis. Am J Psychiatry 2016
• VanderKruik R et al. The global prevalence of postpartum psychosis: a systematic review. BMC Psychiatry 2017
• Di Florio A et al. Perinatal episodes across the mood disorder spectrum. JAMA Psychiatry 2013
• 988 Suicide & Crisis Lifeline: SAMHSA FAQ

This article is general education, not a diagnosis or advice for your situation. Do not start, stop, or change a medication without talking to the clinician who prescribes it; stopping a mood stabilizer suddenly can trigger relapse.