New mothers (puerperal psychosis)

Mental health care


Puerperal (postpartum) psychosis

Almost straight away after the birth of their baby, some mothers will experience psychosis symptoms. When a woman has a psychotic episode after giving birth, it is called postpartum, or puerperal, psychosis.

Postpartum psychosis is completely different to postnatal depression although many women who have puerperal psychosis do feel depressed.

The symptoms of puerperal psychosis normally surface from three to seven days following childbirth and they come on very suddenly. After around three months, the risk of a woman getting puerperal psychosis ends.

Symptoms include feeling agitated, insomnia, feeling irritated and restless, feeling unusually happy or depressed, and swinging quickly between different states of mind. When women have puerperal psychosis they might behave oddly, feel confused and have brief hallucinations. They might seem to be worrying excessively or believe that their baby has something wrong with him/her. A woman might try to avoid her baby or find it hard to bond with him/her. In the most severe cases, she might try to harm herself, or her child.

Who experiences this sort of psychosis?

Women with a diagnosis of schizoaffective disorder or bipolar disorder might experience puerperal psychosis following their first child’s birth. For these patients, this is considered to be a relapse of their condition that is triggered by childbirth.

Women that have a diagnosis of schizoaffective disorder or bipolar disorder in their medical history might also relapse.

Between 25% and 50% of women with schizoaffective or bipolar disorder will experience a relapse after childbirth. Women who have experienced puerperal psychosis after giving birth to their first child is highly likely to have it again for subsequent births.

For women who have no history of mental health problems, around one in every one thousand will experience puerperal psychosis. For some, this might be their first episode of what is later diagnosed as schizoaffective disorder or bipolar disorder. Others, though, might never experience psychotic episode again or will have symptoms in a subsequent post-partum period only.

If a woman has female relatives who experienced puerperal psychosis, she has a higher risk of developing the illness. Research shows that women are much more likely to have it if their mothers did, even if they have no mental health problems currently.

The risk of experiencing puerperal psychosis is no greater if a person’s mother (or another close relative) experienced postpartum depression or another postnatal mental health condition.

What causes puerperal psychosis?

Research suggests that puerperal psychosis is caused somehow by hormonal changes that occur during pregnancy and during birth. They do not know yet what the changes are. Studies show that there could be a genetic link – women with mothers who have psychosis after birth have a greater risk of developing the illness. Researchers don’t yet know which genes are involved in this.

Studies are ongoing to try and understand the causes of this illness and why one woman with a diagnosis of bipolar disorder will experience is when another with the same illness won’t.

How is it treated?

Puerperal psychosis is treated with antipsychotic medication and drugs that are used in treating bipolar disorder. Women who have to take medication might not be able to breastfeed their babies and their psychiatrist will need to give them advice regarding this.

Electroconvulsive therapy (ECT) is used sometimes to treat puerperal psychosis symptoms when they do not respond to medication.

With treatment, it takes several months for the majority of women to become well again.

Staying in hospital

If a woman experiences puerperal psychosis, she might be given treatment as an inpatient in the hospital. The NHS has specialist mother and baby units so that women can be treated without being separated from their babies. These units are staffed by specialised perinatal mental health workers. This means that they are experts in mental health before and after birth.

These mother and baby units aren’t available in every region but many hospitals will transfer a woman to the nearest unit. Typically, a woman stays on the mother and baby units for between four and eight weeks while her symptoms are treated. While she is in hospital, staff also help to develop the mother-baby relationship. It is often difficult for these women to feel attached to their child due to their puerperal psychosis symptoms.

If there is no availability in a mother and baby unit, women might stay in an obstetric ward for her care. If a woman becomes agitated or she has symptoms that mean she isn’t able to safely care for her baby, she might be admitted as an inpatient on a psychiatric ward with her baby being cared for by family. If there is no support available at home, social services will need to arrange for temporary care for the woman’s baby while she is undergoing treatment. This should always be a last resort.

Women who have had puerperal psychosis will be cared for by mental health professionals in the community when they are discharged from the mother and baby unit or hospital until they have fully recovered.

Preparing for puerperal psychosis

Women who have a bipolar or schizoaffective disorder diagnosis should discuss the possibility of developing puerperal psychosis with their obstetrician and psychiatrist when pregnant. Ideally, they should discuss their plans to start a family beforehand with their psychiatrist. Some bipolar disorder medication, e.g. valproate, is not allowed to be taken during pregnancy as it could harm the baby. Therefore, women need to change to other medications when pregnant and their psychiatrist can advise on alternatives.

Women who develop psychosis after their first baby are highly likely to experience it again in subsequent births. This means that they can prepare well in advance with support from their family as well as mental health professionals. The preparation can involve beginning to take medication immediately after birth.

Since the risk of puerperal psychosis is at its highest right after birth, mental health professionals might arrange for a woman to stay in hospital for a few days longer where she can be supported by an on-call psychiatrist. If a woman is discharged, community-based mental health workers might visit daily to ensure that symptoms are spotted and given immediate treatment.

There are teams of dedicated perinatal psychiatry professionals in all NHS trusts in England who are able to advise about measures that can be taken to prevent psychosis. They can also coordinate a woman’s care if she is at risk of experiencing puerperal psychosis. A care coordinator, obstetrician or GP will have information about what there is on offer locally. If there isn’t a specialist perinatal psychiatry service in the area, a general psychiatrist will advise and help to plan the patient’s care for the birth and afterwards.