Understanding Depression During Pregnancy and Postpartum, Part 4: Postpartum Psychosis

Postpartum psychosis is a very serious psychiatric illness that can be life threatening. Across all cultures, it affects approximately 1 per 1000 women in the first days to weeks postpartum.  Often the symptoms of postpartum psychosis begin very quickly--- even within the first 48 hours after delivery.  Overall, over 90% of women experience postpartum psychosis within the first few weeks after delivery (Harlow et al 2007). Although postpartum psychosis is relatively rare, it can be devastating.  The psychotic symptoms include delusions (thoughts that are not based in reality), hallucinations (hearing or seeing things that aren’t there) or disorganized thinking and confusion.  Often mothers who develop postpartum psychosis are having a severe episode of a mood disorder, usually bipolar (manic-depression) disorder with psychotic features.  In fact, at highest risk for postpartum psychosis are women with a personal history of bipolar disorder (manic-depression) or those with a previous episode of postpartum psychosis.   It is essential for women with symptoms of postpartum psychosis to get evaluation and treatment immediately.

Symptoms of postpartum psychosis include:

•    Delusions (false beliefs)
•    Hallucinations (hearing voices or seeing things that are not there)
•    Inability to sleep
•    Poor appetite or refusal to eat
•    Highly disorganized thinking (the patient is not making sense)
•    Rapid mood swings (depression to euphoria)
•    Extreme anxiety or agitation
•    Frantic energy (mania)
•    Suicidal thoughts
•    Thoughts of harming the baby

Although it remains unclear what causes such a sudden and powerful break with reality in the acute postpartum period, research suggest that the rapidly changing hormonal levels and stress of childbirth are important factors in vulnerable women. Also, underlying genetic factors may play a role.

Treatment
Many women who experience postpartum psychosis tend to know that something is very wrong or abnormal, but they are often terrified to let anyone else know, and fear having their babies taken away from them.  It is critical that both health professionals and family members recognize that psychotic symptoms (delusions and highly erratic behavior) in the early postpartum period are serious symptoms that require immediate medical evaluation. Treatment for postpartum psychosis usually involves inpatient psychiatric admission and treatment with mood stabilizing and anti-psychotic medications in order to achieve stabilization as quickly as possible. Psychotherapy is also helpful and additional support for the mother and family is needed.  This condition can be treated and can usually be prevented in subsequent pregnancies with appropriate medical management.  In particular, for women with a psychiatric history who desire to become pregnant again, it is important to have collaborative care and ongoing communication between their obstetricians and psychiatrists throughout the pregnancy and postpartum period.