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Principles of Health: Anxiety and Stress

Postpartum Psychosis

by Chris Bates, Lynn B. Cooper, D. Crim, Melissa Rosales Neff

Description

Psychosis refers to specific symptoms such as hallucinations, delusions, grossly disorganized thought, abnormal motor behaviors. Treatment providers then assess the severity and duration of the psychotic episode. (For more information on psychosis, see T709378.) Experiencing these symptoms does not automatically lead to a diagnosis of psychosis. Currently postpartum psychosis (PPP) is not a distinct diagnosis in the Diagnostic and Statistical Manual, 5th Edition (DSM-5). The classifications “with peripartum onset” or “with postpartum onset” can be applied to a variety of mood disorders as an impacting element. Despite its absence from the DSM-5 there is consensus on which elements of psychosis combine in PPP. There is also consensus that PPP is the most extreme manifestation of postpartum psychological occurrences, which range from sadness to postpartum depression to PPP.

Briefly, sadness may be reported as transient disturbances or problems of adjustment that usually appear within the first few days after delivery and that do not significantly impair function. Between 50 and 70% of postpartum women experience sadness, which may include tearfulness, headaches, low self-esteem, emotional lability, fatigue, and ambivalent feelings toward the new infant. Postpartum depression includes the same symptoms as major depressive disorder; it impacts functioning and affects 10 to 20% of women who have recently delivered, usually within 12 weeks of delivery with an onset up to a year postpartum. Since the mother’s functioning is impacted by mood disturbances such as a depressed mood, loss of interest in activities, and possibly intrusive thoughts about harming the newborn or guilt about not being a good mother, it is extremely important to seek professional assessment and treatment as soon as possible. In more severe cases when the mother’s level of functioning is significantly impacted and the health and development of the newborn may be compromised it may be necessary to have involvement of agencies, such as Child Protective Services (CPS).

Due to the severity of the symptoms, PPP is a medical emergency that requires immediate intervention. Early intervention is necessary to address the increased risk of suicide and harm to the baby and to decrease the impact of the current episode. Onset is sudden and rapid, usually from two days to four weeks after delivery, and most often starts with mania (hyperactivity or elevated mood) or other mood symptoms and progresses rapidly to symptoms that may include delusions (frequently centered on the new baby), mood lability, hallucinations, bizarre behavior, mania, severe depression, confusion, and obsessions (frequently centered on the new baby). Although PPP frequently occurs in women with a history of mental health diagnoses, the symptoms of PPP appear suddenly. PPP has a profound negative impact on functioning, although if mania is present the mother’s vastly increased activity level may mask the impairment. It was found that 73% of women who developed PPP recalled symptoms appearing within three days of delivery and that the most common symptoms were feeling excited, elated, or “high” (52%); not needing sleep or not being able to sleep (48%); feeling active or energetic (37%); and very talkative (31%). Symptoms of PPP may appear similar to those of a primary psychotic disorder (e.g., schizophrenia) or a mood disorder (e.g., bipolar disorder). Aside from the obvious factor of recently having delivered, other factors associated with the onset of PPP are a history of mental health disorder(s), including previous PPP, family history of psychotic disorders, recent stressful events beyond the immediate impact of delivery, absence of a family or social support system, delivering one’s first child, emergency caesarean section or otherwise complicated birth, and perinatal death.

A mother holds her newborn child (photo courtesy of Pippa Ranger, Department for International Development)

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Numerous causes for postpartum psychological distress have been investigated, including increased levels of emotional stress caused by pregnancy and the responsibilities of child rearing, sudden endorphin decrease with labor, abrupt hormone level changes after delivery, low serum levels of free tryptophan (which is an essential amino acid associated with the development of major depression), thyroid gland dysfunction, a prior mental health diagnosis, a family history of mental health disorder(s), occurrence of unexpected adverse life events, lack of social or family support, genetic factors, and maternal age > 35 years. One approach (Spinelli, 2009) views PPP as the manifestation of a lifetime vulnerability to mood disorders that is precipitated by childbirth. The outcome varies with speed of diagnosis and treatment. Most women recover within 12 weeks, but up to 15% continue to experience depressive symptoms for more than 24 weeks. Approximately 40% have the same symptoms again after a subsequent pregnancy. Treatment may include voluntary or involuntary hospitalization, medications, and psycho-educational therapy for the affected individual and the family.

Facts and Figures

Heron et al. (2008) and Spinelli (2009) report that PPP occurs in one to two mothers per 1,000 deliveries. Spinelli found that approximately 4% of women with PPP commit infanticide. Sadock et al. (2015) stated 50 to 60% of PPP episodes occur after the birth of a first child, 50% of cases involve women with a family history of mood disorders, and 50% of cases involve deliveries that had complications of a nonpsychiatric nature.

Assessment

Shame about not being able to care for a newborn infant may prevent or delay seeking treatment. A brief assessment for postpartum depression and PPP should be conducted at every contact with women who have recently delivered a baby. If the brief assessment indicates there is a need, an in-depth assessment using relevant diagnostic and assessment tools should be conducted.

When assessing for PPP consider the following:

  • Complete a standard biopsychosocial history;

  • Thoroughly assess personal and family mental health history, including prior mental health diagnoses and medication;

  • Assess for suicidal ideation, intent, or plans and homicidal ideation, intent, or plans specifically geared toward the baby or other children in the home;

  • Assess family support and care system for the newborn.

  • Monitor changing medication regimens, or nonadherence to regimen, particularly if breastfeeding.

  • Evaluate mother-child attachment, as it may be adversely impacted by PPP.

Assessments and Screening Tools

  • Postpartum Bonding Questionnaire (PBQ)

  • Edinburgh Postnatal Depression Scale (EPDS)

  • Postpartum Depression Screening Scale (PDSS)

  • Mood Disorder Questionnaire (MDQ)

Treatment

Treatment of PPP should start with preventive measures throughout the pregnancy, including assessment of prior PPP or other mental health disorders, family history of mental health disorders, education about possible postpartum mood lability ranging from sadness to PPP, involvement of family and support network with the pregnancy, and brief assessments of mood at every visit.

When PPP occurs, treatment should first include considerations of the safety, health, and well-being of the newborn. Appropriate referrals should be made immediately for assessment and intervention if needed to care for the newborn. CPS or analogous agencies may need to be involved. There may be instances when the best interests of the mother and those of the child are in conflict.

It is important to be aware of cultural values, beliefs, and biases when working with different populations. Treatment should include knowledge about the histories, traditions, and values of the individuals with whom you are working.

Applicable Laws and Regulations

Each jurisdiction has its own standards, procedures, and laws for involuntary restraint and detention of persons who may be a danger to themselves or others. The lack of a formal DSM-5 diagnosis for PPP may complicate legal and detention issues. It is important to understand protocols in your jurisdiction to best help support mothers struggling with PPP. However, the International Classification of Disease lists postpartum depression and PPP (i.e., Puerperal Psychosis) as diagnoses. Thus, this may mitigate any complications regarding legality of detention.

As mandated reporters, all medical and mental health professionals must report any suspicion of neglect or abuse of a child to CPS or a local agency.

Since 1922 the laws of England recognized the biological and psychiatric circumstances that may surround infanticide, and probation and psychiatric treatment are mandated when appropriate. Twenty-nine other countries made similar adjustments to their laws; however, the US judicial system continues to punish rather than treat mothers with postpartum mental health difficulties who murder their children.

Each country has its own standards for cultural competency and diversity in mental health practice. Mental health providers must be aware of the standards of practice set forth by their governing body (e.g., National Association of Social Workers in the US, British Association of Social Workers in England), and practice accordingly.

Case Example

The case of Andrea Yates, the Texas woman who drowned her five children in June of 2001, encapsulates many issues surrounding PPP and infanticide, including the failure of family, society, as well as the failure of the mental health and legal communities to intervene appropriately. Yates was pregnant or breastfeeding for seven years, cared for her bed-ridden father, homeschooled her older children, taught evening Bible study, baked cookies, designed crafts, made costumes—in short, she engaged in a variety of tasks, some of which were emotionally and physically challenging. However, she also had a history of psychiatric illness, with the first reported psychotic episode after the birth of her first child, two suicide attempts that were attributed to efforts to resist satanic voices commanding her to kill her fourth child soon after birth, numerous additional psychiatric hospitalizations and disrupted medication regimens, and an immediate family history of bipolar disorder and major depressive disorder. At her first trial, the jury acknowledged the tragedy of the situation and their own conflicted feelings by returning a guilty verdict after 3.5 hours of deliberations and took only 35 minutes to deny the prosecutor’s request for the death penalty. The incident failed to take into account the possibility of mental health aliments. A second trial overturned the first verdict on a technicality and she is now in a state psychiatric hospital receiving treatment. This case highlights the fact that PPP is an extremely serious mental health crisis, and immediate intervention is necessary.

References

1 

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth ed. DSM-5. American Psychiatric Publishing, 2013, pp. 45–47.

2 

Doucet, S., C. Dennis, N. Letourneau, and E. R. Blackmore. “Differentiation and Clinical Implications of Postpartum Depression and Postpartum Psychosis.” Journal of Obstetric, Gynecologic & Neonatal Nursing, vol. 38, no. 13, 2009, pp. 269–79.

3 

Hall, S. D., and R. A. Bean. “Family Therapy and Childhoodonset Schizophrenia: Pursuing Clinical and Bio/psycho/Social Competence.” Contemporary Family Therapy, vol. 30, no. 2, 2008, pp. 61–74.

4 

Heron, J., M. McGuinness, E. R. Blackmore, N. Craddock, and I. Jones. “Early Postpartum Symptoms in Puerperal Psychosis.” BJOG: An International Journal of Obstetrics & Gynaecology, vol. 115, no. 3, 2008, pp. 348–53.

5 

Jones, D. W. “Families and Serious Mental Illness: Working with Loss and Ambivalence.” British Journal of Social Work, vol. 34, no. 7, 2004, pp. 961–79.

6 

Mizrahi, T., and R. W. Mayden. NASW Standards for Cultural Competency in Social Work Practice. social-workers.org/practice/standards/NASWCultural-Standards.pdf.

7 

Monzon, C., T. L. di Scalea, and T. Pearlstein. “Postpartum Psychosis: Updates and Clinical Issues.” Psychiatric Times, vol. 31, no. 1, 2014, pp. 1–6.

8 

Noorlander, Y., V. Bergink, and M. P. den Berg. “Perceived and Observed Mother-child Interaction at Time of Hospitalization and Release in Post-partum Depression and Psychosis.” Archives of Women's Mental Health, vol. 11, no. 1, 2008, pp. 49–56.

9 

“The Policy, Ethics, and Human Rights Committee, British Association of Social Workers.” The Code of Ethics for Social Work: Statements of Principles, Jan. 2012, cdn.basw.co.uk/upload/basw_112315-7.pdf.

10 

Posmontier, B. “The Role of Midwives in Facilitating Recovery in Postpartum Psychosis.” Journal of Mid-wifery and Women's Health, vol. 55, no. 5, 2010, pp. 430–37.

11 

Sadock, R. J., V. A. Sadock, and P. Ruiz. Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. Wolters Kluwer, 2015, pp. 831–40.

12 

Sit, D., A. J. Rothschild, and K. L. Wisner. “A Review of Postpartum Psychosis.” Journal of Women's Health, vol. 15, no. 4, 2006, pp. 352–68.

13 

Spinelli, M. G. “Maternal Infanticide Associated with Mental Illness: Prevention and the Promise of Saved Lives.” American Journal of Psychiatry, vol. 161, no. 9, 2004, pp. 1548–57.

14 

—. “Postpartum Psychosis: Detection of Risk and Management.” American Journal of Psychiatry, vol. 166, no. 4, 2009, pp. 405–8.

15 

“Statement of Ethical Principles.” International Federation of Social Workers, ifsw.org/policies/statement-of-ethical-principles/.

16 

Walther, V. N. “Postpartum Depression: A Review for Perinatal Social Workers.” Social Work in Health Care, vol. 24, nos. 3/4, 1997, pp. 99–111.

Citation Types

Type
Format
MLA 9th
Bates, Chris, and Lynn B. Cooper, and D. Crim, and Melissa Rosales Neff. "Postpartum Psychosis." Principles of Health: Anxiety and Stress, edited by Lindsey L. Wilner & Megan E. Shaal, Salem Press, 2020. Salem Online, online.salempress.com/articleDetails.do?articleName=POHAnxiety_0016.
APA 7th
Bates, C., & Cooper, L. B., & Crim, D., & Neff, M. R. (2020). Postpartum Psychosis. In L. L. Wilner & M. E. Shaal (Eds.), Principles of Health: Anxiety and Stress. Salem Press. online.salempress.com.
CMOS 17th
Bates, Chris and Cooper, Lynn B. and Crim, D. and Neff, Melissa Rosales. "Postpartum Psychosis." Edited by Lindsey L. Wilner & Megan E. Shaal. Principles of Health: Anxiety and Stress. Hackensack: Salem Press, 2020. Accessed October 22, 2025. online.salempress.com.