Postpartum Psychosis

Postpartum psychosis (PPP) is a psychiatric emergency that requires immediate medical attention.

Women experience PPP. Women have experienced PPP. And women in the future could avoid this tragedy by recognizing this mental illness. PPP is frequently confused with postpartum depression in public and professional nomenclature. It has been very obvious that even trained professionals still struggle with the differences between postpartum depression and postpartum psychosis symptomatology, onset, and prognosis. It is extremely important to emphasize the difference in discussion of perinatal mental health with clients, students, family members and providers–as the word “postpartum” means different things to different providers.

Postpartum psychosis is not postpartum depression, lack of sleep, or postpartum anxiety, or post-traumatic stress disorder. PPP is a psychiatric emergency, tantamount to a medical emergency that requires immediate medical attention.

Prevalence

Postpartum psychosis affects 1-2 women per 1,000 births globally, and while rare, it is an extremely severe postpartum mood disorder (Kendell, Chalmers, & Platz, 1987; Munk-Olsen, Laursen, Pedersen, Mors, & Mortensen, 2006). Postpartum psychosis (PP) occurs in all cultures, affecting mothers across socioeconomic, ethnic, and religious communities (Kumar, 1994).

Symptoms

Symptoms of postpartum psychosis are sudden in onset, usually occurring within 48 hours to 2 weeks following birth. Postpartum psychosis represents “psychiatric emergency and warrants hospitalization” (Beck & Driscoll, 2009, p. 47).

  • Waxing and waning delirium and amnesia (Spinelli, 2009)
  • “Cognitive Disorganization/Psychosis”
    • Wisner, Peindl, and Hanusa (1994) discovered that disturbances of sensory perceptions were a feature of the cognitive disruption experienced in postpartum psychosis. These include auditory, tactile, visual, and olfactory hallucinations.
    • Memory and cognitive impairment such as confusion and amnesia (Wisner et al., 1994).
    • Agitation, irritability
    • Paranoid delusions
    • Confusion
    • Bizarre and changing delusions
    • Suicidal or infanticidal intrusive thoughts with ego syntonic feature (Spinelli, 2009; Wisner et al., 1994)

In other perinatal mood or anxiety disorders, intrusive thoughts of self-harm or harming the baby are known as ego-dystonic and are common (41%-57%; Brandes, Soares, Cohen, 2004). Ego dystonic cognitions are thoughts are experienced by the woman as abhorrent, and she recognizes that they inconsistent with her personality and fundamental beliefs (see: Kleiman & Wenzel, 2010 Dropping the Baby and Other Scary Thoughts).

In contrast, for a woman experiencing postpartum psychosis, the intrusive thoughts or ideations, of harming self or other are ego-syntonic—intrusive thoughts are experienced as reasonable, appropriate and are “associated with psychotic beliefs and loss of reality testing, with a compulsion to act on them and without the ability to assess the consequences of their actions” (Spinelli, 2009, p. 405).

If left untreated, some dire potential outcomes include:

  • 5% of women who experience PP commit suicide (Appleby, Mortensen, & Faragher, 1998; Knopps, 1993).
  • 2%-4% are at risk of harming their infants (Knopps, 1993; Spinelli, 2004).
  • As high as a 90% recurrence rate (Kendell et al., 1987)

Risk Factors

  • Women with history of bipolar disorder or previous postpartum psychosis

“A personal history of bipolar disorder is the most significant risk factor for developing PP.” (Dorfman, Meisner, & Frank, 2012, p. 257)

  • Having a first-degree relative who has bipolar disorder, or experienced an episode of postpartum psychosis
  • Current research demonstrates that contrary to popular beliefs, PPP is often the result of either bipolar disorder or major depressive disorder with psychotic features, and there is little frequency of PPP caused by reactive psychosis or schizophrenia (McGorry & Connell, 1990).

Suggestions for Providers: Reflect/Remind/Review/Refer

Given the stigma, misinformation and professional confusion regarding postpartum mental illness and particularly postpartum psychosis– it is important to clearly, and objectively identify and differentiate the full spectrum of perinatal mood and anxiety disorders. From the most prevalent and benign ‘baby blues’ to the most rare and severe postpartum psychosis, women and partners need accurate, accessible information to dispel myths, and give resources. In discussing mental health some basic suggestions may be helpful:

Reflect: You are not alone

Fear, confusion and misinformation feed stigma. Our opportunity is to reflect back to childbearing women that questions and concerns are normal. We can then reflect back to women that their experience of concern is a launching point for care providers giving trustworthy, informed, evidence-based, practical information and resources.

Remind: PPP is Rare but Real

Remind that the incidence of PPP is extremely rare. Only 1-2 per 1,000 women develop postpartum psychosis. Secondly, with medical attention and treatment, PP is preventable, and treatable. It is different than postpartum blues, depression, PTSD, or anxiety. Symptoms of PPP require immediate medical attention.

Review the Facts

  • Rates: Only occurs in 1-2 per 1,000
  • Risk: Women with history of bipolar disorder or previous postpartum psychosis, and women with family history of bipolar disorder or first degree relative with history of postpartum psychosis are at higher risk.
  • PPP is preventable
  • PPP is treatable
  • PPP prevention and treatment require medical evaluation, intervention and care

Refer to Resources

What makes a good resource? Referring to accurate and accessible resources is an essential response to questions and concerns regarding postpartum psychosis (PP).  Avoid any anecdotal advice regarding complimentary alternative medicine. The onset of PP is tantamount to a medical emergency and requires immediate medical attention.

Have resources available in several formats and languages. Make sure your links, telephone numbers, and local resources are working and up to date.

Resources for Women and Partners

Include or display posters and images of well-established organizations in your office and on your practice website.

National Suicide Prevention Lifeline

Mother to Baby (formerly OTIS)

Postpartum Support International (PSI)

Postpartum Progress

The Marce Society

MedEdPPD

References

Appleby, L., Mortensen, P., & Faragher, E. (1998). Suicide and other causes of mortality after post-partum psychiatric admission. British Journal of Psychiatry, 173, 209-211.

Beck, C. & Driscoll, J. (2006). Postpartum mood and anxiety disorders: A clinician’s guide. Sudbury, MA: Jones and Bartlett.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77-101. doi:10.191/1478088706qp063oa

Brockington, I. F., Cernik, K. F., Schofield, E.M., Downing, A.R., Francis, A.F., & Keelan, C. (1981). Puerperal psychosis: phenomena and diagnosis. Archives of General Psychiatry, 38, 829-833.

Dorfman, J., Meisner, R., & Frank, J.B. (2012). Prevention and diagnosis of postpartum psychosis. Psychiatric Annals, 42(7), 257-261. doi:10.3928/00485713-20120705-05.

Doucet, S., Letourneau, N., & Blackmore, E. R. (2012). Support needs of mothers who experience postpartum psychosis and their partners. Journal of Obstetric, Gynecological & Neonatal Nursing, 41(2), 236-245.

Healey, D. (2013). Melancholia: Past and present. Canadian Journal of Psychiatry, 58(4), 190-194.

Kendell, R., Chalmers, J., & Platz, C. (1987). Epidemiology of puerperal psychosis. British Journal of Psychiatry, 150, 662-673.

Knopps, G. (1993). Postpartum mood disorders: A startling contrast to the joy of birth. Postgraduate Medicine, 93, 103-116.

Kumar, R. (1994). Postnatal mental illness: A transcultural perspective. Social Psychiatry and Psychiatric Epidemiology, 29, 250-264. doi:10.1007/BF00802048

McGorry, P., & Connell, S. (1990). The nosology and prognosis of puerperal psychosis: A review. Comprehensive Psychiatry, 31, 519-534.

Munk-Olsen, T., Laursen, T., Pederson, C., Mors, O., & Mortensen, P. (2006). New parents and mental disorders: A population-based register study. Journal of the American Medical Association, 296(21), 2582-2589. doi:10.1001/jama.296.21.2582

Spinelli, M. (2004). Maternal infanticide associated with mental illness: Prevention and promise of saved lives. American Journal of Psychiatry, 161(9), 1548-1557.

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