Puerperal Psychosis

Puerperal (also known as postpartum or postnatal) psychosis is a very rare but severe mental health disorder that some women experience in the weeks after having a baby.

The onset of puerperal psychosis is unexpected and rapid.  It usually occurs within 48 hours to 2 weeks of giving birth but may occur up to 12 weeks after the birth.  The woman may experience mood swings, confusion, strange beliefs and hallucinations that represent a dramatic change from her previous functioning.

The cause of puerperal psychosis is unknown, but women with a history of bipolar disorder or who have experienced puerperal psychosis after previous births are at much greater risk.

The potential consequences associated with puerperal psychosis are severe, as the mother may be at risk of self-harm and there is risk of harm to the infant and/or other children.  Urgent mental health assessment and involvement of a psychiatrist are necessary.

Symptoms of postpartum psychosis

Puerperal psychosis is characterised by marked changes in mood, thoughts, perceptions and behaviours.  Symptoms of puerperal psychosis can be extremely distressing for the woman experiencing them and for her family, and they affect the mother’s ability to care for her infant properly.

Many women experience manic symptoms and may be inattentive towards the baby due to agitation and an inability to focus.  For some women, this manic phase is followed by a severe depression where the woman is unable to function and may be at risk of harming herself and/or her baby.

Symptoms Manic Symptoms Depressed Symptoms
Sleep, energy, appetite, libido Lack of need for sleep
Increase in energy and libido
Lacking in energy
Unable to sleep or eat
Loss of libido
Thoughts and experiences (including thoughts of self-harm and harming the baby) Feeling strong, powerful, unbeatable
Hearing voices or seeing things that aren't there (hallucinations)
Having false beliefs e.g. that they or baby have special powers or someone is trying to harm the baby (delusions)
Wanting to die
Thoughts of harming herself (and/or her baby)
Hearing critical voices (hallucinations)
Having false beliefs e.g. that they are a bad person or should be punished for being a bad person/ mother (delusions)
Difficulty concentrating
Behaviour Being disorganised
Talking quickly, often not finishing sentences
Making lots of unrealistic plans
Seeming confused and forgetful
Overspending, getting into arguments, sexual indiscretions
Difficulty coping with usual activities e.g. caring for baby, home duties
Withdrawing from everyone
Unable to enjoy anything
Feeling hopeless, helpless, and worthless, especially as a mother
Mood Changing moods in a short space of time e.g. from elevated to irritable
Excessively happy
Persistently depressed mood, not reactive in any way

Assessing puerperal psychosis

The onset of puerperal psychosis may occur up to 12 weeks after the birth.  The combination of psychosis and lapsed insight and judgement endangers the safety and wellbeing of the affected woman and her infant and requires urgent, careful assessment.

As puerperal psychosis is a serious and complex mental health disorder, a specialist psychiatrist needs to be consulted.

Diagnosis of puerperal psychosis is based on accepted diagnostic criteria (DSM-V or ICD-10).

A woman with puerperal psychosis will almost always need to be admitted to a psychiatric hospital setting.  Hospital admission facilitates stabilisation of symptoms and initiation of medications with ongoing monitoring by health professionals.  Admission to a psychiatric setting with a mother and baby unit is preferable to enable continued contact between mother and baby.

Management of puerperal psychosis

Due to the high risk of suicide or infanticide, management of puerperal psychosis needs to be ongoing, often for many weeks or months.  Treatment with medication is essential.  Assessment and monitoring of the mother–infant interaction is a key part of care of both mother and infant.

Medications

  • Mood stabilisers are used to treat manic episodes and psychotic symptoms and help reduce relapse.  Antipsychotics and antidepressants may also be of benefit, depending on the range of symptoms.
  • A psychiatrist should be consulted when medications are prescribed, changed or ceased, and the potential risks and benefits to the woman and baby should be considered.  Medication should not be ceased suddenly.
  • Given the need for medication and maximising sleep in women with puerperal psychosis, the advantages and disadvantages of breastfeeding for mother and baby need to be discussed with the woman and her partner.
  • Sodium valproate and clozapine should not be used without consultation with a psychiatrist.
  • Lithium should be used cautiously.  Advice should be sought from a psychiatrist if breastfeeding and it is important to ensure close monitoring of the baby by a specialist (e.g. neonatologist/paediatrician).
  • A woman’s physical activity levels and diet need to be considered if she is taking antipsychotics, due to their association with weight gain.

Electroconvulsive therapy (ECT)

ECT may be used or even essential to treat acute mania, psychosis and severe depression. This treatment is only used in major hospital settings with close monitoring of the woman.

Psychological therapies

Psychological therapies, such as cognitive behavioural therapy (CBT) or interpersonal psychotherapy (IPT), can assist women to develop effective coping strategies as they recover.  Mother-infant therapy can be useful in promoting mother-infant bonding.  Counselling/support is also recommended for the partner and key support people.

Things to remember

Some things to remember when assessing and managing puerperal psychosis are:

  • The possibility of puerperal psychosis should be considered in women experiencing mood swings, confusion, strange beliefs and hallucinations in the early postnatal period, particularly if they have a history of puerperal psychosis or bipolar disorder.
  • Following discharge from hospital, ongoing support and care of mother and baby by a specialist psychiatrist is required.  In most instances, the woman will need to be supported and monitored on a daily basis, which may require drawing on family or community support services.
  • Minimising stress, maximising sleep and reducing stimuli are vital not only for the mother but also her baby, partner and key support people.  Where possible, it is beneficial to advise women to draw on support from family members, friends, the community and/or health services, including in-home support or respite services.

Fact sheet for health professionals