Postnatal psychosis

Also known as postpartum psychosis

Postnatal psychosis is a rare condition. In most cases it begins within the first two to four weeks following the birth of a baby but can occur later than this. Mood disturbances and being out of touch with reality (psychosis) are the key signs of postnatal psychosis. 

There are three types of childbirth-related depression that are talked about:

• Postnatal or maternity blues are very common. A new mother feels down and tearful in the week after her baby is born. This feeling passes after a few days.
• Postnatal depression, a more serious condition, is also common. The mother becomes seriously depressed in the first months following the baby's birth. It can occur any time during the baby’s first year. 
• Postnatal psychosis involves symptoms of psychosis (being out of touch with reality) associated with changes in mood – either a depressed or an extremely high mood. It usually begins in the first two weeks after the child is born.This is the focus of this web page.

There is a significant increase in risk of harm to the baby if the mother has postnatal psychosis, which is why early recognition and treatment as well as support is very important.

Outlook for postnatal psychosis

The course of postnatal psychosis can be quite variable, with some women making a rapid recovery and returning to their everyday activities and relationships within a few weeks. Others improve over a number of weeks but continue having residual symptoms or difficulties getting back to normal activities for some months. For a minority, an episode of postnatal psychosis can lead to an ongoing psychotic condition such as bipolar affective disorder (manic depression) or schizophrenia.

Where there is a pre-existing psychotic condition, addressing risk factors and early treatment of any signs of emerging psychosis are most important during pregnancy and following the birth of the baby.

Myths about postnatal psychosis

Women who have had an episode of postnatal psychosis are dangerous to others.

NOT TRUE The main myth about psychotic illnesses is the image of the dangerous psychotic continually portrayed by the media. Women who have had an episode of postnatal psychosis are not dangerous to others. During an episode of the condition, there is an increased risk of violent behaviour, especially towards the baby, if the mother doesn’t receive prompt assessment and treatment, and adequate support to monitor risk through the time of her illness. 

Outside these brief periods of increased risk, women with this condition are no more likely to behave in a violent manner than anyone else.

What causes postnatal psychosis?

As with many mental health conditions, the exact cause of postnatal psychosis remains unknown, although it is known that it is not the fault of you or your partner.

For all women, childbirth is rated high on the scale of life stress, with many adjustments to be made and many stressful situations, including the birth itself. For women who are vulnerable to depression or psychosis, (and who may have had a previous episode) this can be a time of increased risk.

While anyone who gives birth is vulnerable, there are certain factors that increase the chances of developing postnatal psychosis. The risk factors for developing the disorder are the same as for postnatal depression. The strongest risk factor, however, is a past history of a psychotic condition.

If you’ve had a mental illness in the past, and are worried about postnatal psychosis, talk to your midwife or doctor.

Signs to look for (symptoms)

Mood disturbance AND being out of touch with reality (psychosis) are the key signs of postnatal psychosis.

Mood disturbance

• Persistently high or elated mood, or sometimes there may be a mainly irritable mood.
• Decreased need for sleep.
• Increased amount and volume of talk, such that it is difficult to interrupt.
• Racing thoughts, and rapid changes of topic when speaking.
• Picking up the baby frequently and not seeming aware of the baby's needs.
• Rapid changes of intense feeling states, from laughter to tears to anger and back again.
• Increased activity, e.g.embarking on spring cleaning the house, making many plans for the future etc.
• Increase in pleasurable activities with no regard for the consequences, such as spending sprees, foolish business investments or increased sexual activity.
• Increase in sense of self-importance.

Mixed mood symptoms may also occur. This is where there are features of both depression and mood changes at the same time. Often the woman seems high or irritable, and has increased speech and thought patterns, but her underlying mood and thinking is depressed.

Psychosis

• Delusions – an unusual belief that seems quite real to you, but not to those around you. A delusional woman is convinced her belief is true. An example would be the belief that someone is plotting to harm her or the baby (where there is no obvious danger).
• Thought disturbances – when you feel your thoughts being interfered with. You may feel that thoughts are put into or taken out of your head, or spoken aloud so everyone can hear them. People with these experiences sometimes develop delusions to explain the experience, e.g., that thoughts are put into their head by a computer.
• Hallucinations – this is when someone hears, sees, feels or smells something that is not there. Hearing voices, which others cannot hear or when there is no-one else in the room, is very typical of psychosis. Sometimes these voices will talk about or to you. They will sometimes command you to do things. For some, these voices can be inside their head; occasionally they may seem to come from within their body.
• Changed perceptions means that you experience things differently from usual. Sensations may take on a different quality from normal, e.g. colours and sounds may seem unusually intense.

Other signs of psychosis include:

• Changed feelings – your emotions may seem uncontrollable, intense and changeable so you may laugh one minute then cry without knowing why.
• Changed behaviour – if you have any of the symptoms above you are likely to behave differently from normal. You may become agitated, jumpy and not sleep at night if you believe others are plotting against you. Some kinds of behaviour changes are symptoms of the illness itself. Other people may notice that you have become careless in your dress and self-care, or have periods of seeming to do little and periods of being extremely active. You may behave in a very disorganised or confused manner.
• Loss of insight – is the loss of awareness that these experiences are the result of being unwell. It is a particular feature of psychotic illnesses, and is the reason why the Mental Health Act (1992) has been developed to ensure people with these conditions can get the assessment and treatment they need.

The altered beliefs and voices of postnatal psychosis tend to reflect the underlying mood. For example, if your mood is manic, your beliefs will be of having special powers or being a special person. You may believe you are the Virgin Mary and that your baby is Jesus. Alternately if your mood is depressed, you will believe negative things or think you are a bad person, e.g. believing you are evil and have given birth to the devil's child.

How to decide if you have a problem (diagnosis)

If you have postnatal psychosis there is a significant increase in risk of harm to your baby.

If you’re concerned, or suspect you (or a loved one) has postnatal psychosis, it’s important to talk to your midwife, doctor or plunket nurse immediately; or in an emergency dial 111.

Close monitoring of risk by a skilled health professional is critical during this period. When risk is present, high levels of support, or separation of mother and baby until the risk has passed, may sometimes be necessary.

Treatment options

Treating postnatal psychosis can involve a number of aspects, each of which will be tailored to your individual situation.

Your doctor will recommend a mix of treatment options that best suits you.

Talk to him or her if you are considering stopping treatment and work together with them to find some compromise that will ensure continuing wellness but address your concerns about the treatment. If you are on medication, it is very important that the decision to stop taking it is made with the input of your doctor and anyone else involved in your treatment.

Medication

While the best and safest option during pregnancy or breastfeeding is not to take medication, the risks relating to becoming mentally unwell for both you and your baby need to be weighed against the risks of treatment with medication. Research regarding which medications are safe in pregnancy or while breastfeeding and which are useful for treating postnatal psychosis, is ongoing. It is therefore most important that you check with your doctor about the latest information on which medications are considered safe and effective.

If you are prescribed medication you should receive clear instructions about how you should take them and what precautions are necessary. Find out:

• the names of the medicines
• what symptoms they are supposed to treat
• how long it will be before they take effect
• how long you will have to take them for and what their side effects (short and long-term) are. 
• Most psychiatric medicines tend to react with each other when taken in combination.

It’s important the doctor knows all the medications (including any herbal medicines) you are taking, as some taken together can be dangerous. You should not mix different types of antidepressants unless instructed by your doctor as this could be very dangerous. 

Alcohol and other drugs may aggravate mental health conditions and are not good for the baby. 

Psychotherapy (talking based therapies)  

Talking therapies have been found to be effective for women as they recover. Therapy may be one-to-one; it may include partners or families/whānau for some sessions; or it may be group therapy with other women who have similar issues. Unlike antidepressants, which are only effective as long as they are taken, the benefits of therapy may protect against future episodes of depression. 

The focus of psychotherapy or counselling in the treatment of postnatal psychosis is on education and support for you to understand what is happening to you, to learn coping strategies, and to pursue a path of recovery. Through these processes women can regain their confidence and belief in themselves that is critical to recovery.

Treatment for postnatal psychosis may be available free of charge at a community mental health service. At a number of community service agencies, the cost is based on your ability to pay. Your doctor can recommend how to proceed and where to go.

Psychoeducation (providing education)

A health professional works with you, and your family/whānau, to provide information about the condition, its treatment, and how to support recovery.

Central to this approach is that family/whānau, along with the woman herself, are critical members of the treatment team. Together you identify ways of dealing with symptoms, difficult to understand behaviour and stress. The early signs that indicate a possible relapse are identified and a plan of early response is developed. There is also attention to the kinds of support that everyone needs, and how to get this support.

Complementary therapies

The term complementary therapy is generally used to indicate therapies and treatments that differ from conventional western medicine and that may be used to complement and support it.

Certain complementary therapies may enhance your life and help you to maintain wellbeing. In general, mindfulness, hypnotherapy, yoga, exercise, relaxation, massage, mirimiri and aromatherapy have all been shown to have some effect in alleviating mental distress. When considering taking any supplement, herbal or medicinal preparation you should consult your doctor to make sure it is safe and will not harm your health, for example, by interacting with any other medications you are taking.

Physical health

It is also really important to look after your physical wellbeing. Make sure you get an annual check up with your doctor. Being in good physical health will also help your mental health.

Thanks to Janet Peters, registered psychologist for reviewing this content. Date last reviewed: October, 2014.