DOI: 10.1111/tog.

12041 2013;15:145–50
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Postpartum psychosis
a b c,
Arianna Di Florio MD PhD, Sue Smith MBBCh MRCPsych, Ian Jones MRCPsych PhD *
a
Clinical Research Fellow, MRC Centre for Neuropsychiatric Genetics and Genomics, Department of Psychological Medicine and Neurology, School
of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XN, UK
b
Consultant Perinatal Psychiatrist, Cardiff Mother and Baby Unit, Cardiff and Vale University Health Board, Cardiff, UK
c
Reader in Perinatal Psychiatry, MRC Centre for Neuropsychiatric Genetics and Genomics, Department of Psychological Medicine and Clinical
Neurosciences, School of Medicine, Cardiff University, Henry Wellcome Building for Biomedical Research, Academic Avenue, Heath Park, Cardiff
CF14 4XN, UK
*Correspondence: Ian Jones. Email: jonesir1@cf.ac.uk

Accepted on 30 July 2012

Key content Learning objectives

 Postpartum psychosis is a severe mental illness with a dramatic  To recognise women at high risk for severe postpartum mental
onset shortly after childbirth. illness.
 All women should be screened antenatally for the known risk  To recognise and appreciate the severity of postpartum psychosis
factors. and the need for prompt assessment and treatment.
 Women with bipolar disorder have at least a 1 in 4 risk and need
Ethical issues
close contact and review during the perinatal period even if they  Who should ultimately make decisions about taking medications
are well.
 Prompt recognition of the illness and rapid institution of
in pregnancy – the clinician or the woman and her family?
 What advice should a woman at high risk of postpartum psychosis
treatment are of vital importance.
be given if she is considering pregnancy?
Keywords: postpartum psychosis / puerperal psychosis / mood
disorders / bipolar disorder

Please cite this paper as: Di Florio A, Smith S, Jones I. Postpartum psychosis. The Obstetrician & Gynaecologist 2013;15:145–50.

Introduction commonly takes the form of mania, severe depression, or a

mixed picture with features of both high and low mood. In
Postpartum mood disorders are of great clinical and public
addition, women show evidence of psychosis with delusions
health importance, with suicide a leading cause of maternal
and hallucinations common, and also will often demonstrate
death in the UK. They are commonly divided into three
marked confusion or perplexity.2
categories: the ‘baby blues’, postnatal depression, and
postpartum (or puerperal) psychosis. This review focuses
on postpartum psychosis (PP), emphasising the importance Classification
of recognising women at high risk, and the early recognition
and prompt treatment of women who develop the illness. There is little consensus regarding the classification of
According to the Confidential Enquiries into Maternal postpartum psychosis. Modern classification systems do not
Deaths in the United Kingdom report,1 a diagnosis of recognise PP as a separate nosological entity. In the
severe affective illness was present in about 60% of the International Classification of Diseases (ICD-10),4 the
women who committed suicide. Although suicide after category ‘mental and behavioural disorders associated with
childbirth is rare, affecting about 1 pregnancy in 100 000, the puerperium, not elsewhere classified’ should only be used
suicide remains a leading cause of maternal death. Suicide in when unavoidable and includes only mental disorders
a new mother is a great tragedy, and for each woman who commencing within 6 weeks of delivery that do not meet
takes her life there are many near misses.2 the criteria for other diagnoses. In the Diagnostic and
Statistical Manual of Mental Disorders, fourth edition
(DSM-IV)5 postpartum affective episodes are treated as
The concept of postpartum psychosis
mood disorders with a postpartum trigger: patients must
The term ‘postpartum psychosis’ refers to a severe mental meet the criteria for a mood episode and the criteria for the
illness with a dramatic onset shortly after childbirth.3 It most postnatal-onset specifier. In DSM-IV a postnatal onset is

ª 2013 Royal College of Obstetricians and Gynaecologists 145

 Postpartum psychosis

considered to be within 4 weeks of delivery. Despite these the main, explanation.16 Given that there is little evidence of an
issues, however, the term postpartum (puerperal) psychosis association between PP and psychosocial factors, the
has remained in common clinical use. possibility remains that the effect of primiparity is, at least in
part, due to biological differences between first and subsequent
pregnancies. In this regard, the overlap with other pregnancy
Epidemiology
related disorders that also occur more frequently in first
Record-linkage studies estimate the admission rates to pregnancies, such as pre-eclampsia, is of interest. Hormonal,
psychiatric hospital in the postpartum as about 1–2 per immunological and other biological differences between first
1000 births in the general population.6 However, the true and subsequent pregnancies are interesting targets for further
incidence rates for severe postpartum affective disorder may investigation into the aetiology of PP.16
be higher, as at least some women with PP are likely to be
treated at home – particularly if facilities for admission with Changes in medications
the baby are not available.3 Women with BD often come off mood stabilisers, such as
There is consistent evidence of a specific relationship lithium, preconception or in early pregnancy because of
between PP and bipolar disorder (BD). Women with BD concerns over toxicity to the fetus. A survival analysis
have at least a 1 in 4 risk of suffering a severe recurrence comparing women with BD who stopped taking lithium
following delivery.7 Bipolar women with a personal or family because of pregnancy compared with age-matched
history of PP are at particularly high risk with greater than non-pregnant women who discontinued lithium for other
1 in 2 deliveries affected by PP.8 reasons, reported similar rates of recurrence during the first
40 weeks after lithium discontinuation for both groups.
However, among subjects who remained stable over the first
Aetiology and pathophysiology
40 weeks after lithium discontinuation, postpartum
Most episodes of PP can be considered as affecting women recurrences were 2.9 times more frequent than recurrences
with a bipolar disorder diathesis acted on by a specific in non-pregnant women during weeks 41–64 (70% versus
puerperal trigger.3 A number of factors have been suggested 24%).17 Thus, the increased risk of recurrence following
that increase vulnerability to the puerperal triggering of childbirth for women with BD does not appear to be merely a
episodes of BD. result of stopping mood-stabilising medication.

Genetic factors Hormonal factors

There is robust evidence that the vulnerability to the The lack of evidence implicating psychosocial factors and
triggering of affective psychosis by childbirth aggregates in consideration of the abrupt onset during a time of major
families and may define a genetically relevant subtype of physiological change suggest that biological, possibly
bipolar disorder.8 Evidence from family studies suggests that hormonal, factors are important. The role of several
episodes of PP are a marker for a more familial form of BD9 hormones (including estrogen, progesterone, prolactin,
and that a specific vulnerability to the puerperal triggering of follicular stimulating hormone and luteinising hormone)
BD is familial.8 Evidence from a linkage study indicated the has been considered, but the evidence pointing to hormones
possible location of a susceptibility gene on chromosome in the aetiology of PP remains predominantly circumstantial.
16.10 Particular candidate genes, such as those involved in the
serotoninergic11,12 hormonal13,14 and inflammatory15 Sleep deprivation
pathways, have also been investigated. It is hoped that A plausible hypothesis is that the sleep deprivation of delivery
identifying the genetic factors that increase risk will lead to and the immediate postpartum period is responsible for
more individualised risk assessment, earlier identification of puerperal triggering of illness.18 Sleep loss can effectively
women at risk, and improved treatments for women who trigger the onset of mania in people with BD and sleep loss is,
become ill. of course, common for new mothers.

Obstetric risk factors

Prevention
An increased risk of PP has been reported with a number of
obstetric factors including: primiparity; pregnancy and Screening for risk factors
delivery complications; delivery by caesarean section; having In addition to a history of BD or PP, other risk factors for PP
a female baby; and a shorter gestation period. However, include having a first-degree relative who has experienced PP
findings are consistent only for primiparity.16 The bias that and having a first degree relative with BD.7 For women who
women with a severe postpartum episode may be less likely to themselves have a history of mood disorder, particularly on
go on to have further children is unlikely to be the sole, or even the bipolar spectrum, a family history of severe postpartum

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 Di Florio et al.

episodes is very important and may indicate a risk in excess period should also be developed and discussed with the
of 50%. For women who have not suffered episodes of woman and her family.19
psychiatric illness themselves, it is not so clear that family
history is relevant. While a risk of PP of 1–3% in such women Pre-conception
represents a considerable increase on the population rate of The possibility of future pregnancy should be considered in
around 1–2 in 1000 deliveries, it is unclear whether extensive all women with BD who are of childbearing age. Ideally the
efforts to identify women who are well but with a family pre-conception counselling should be conducted by a
history is a worthwhile strategy. These women may benefit perinatal psychiatrist,20 however, depending on availability,
from the risks being discussed with them if it is something other psychiatric teams or GPs can provide the necessary
they have identified as a concern, but it also is possible that it information to woman. The risks of illness following
may cause unnecessary worry in women who will not go on childbirth should be discussed with women and the
to develop illness. importance of seeking help emphasised. Decisions about
Because of the relapsing and remitting nature of BD, continuing or stopping medications before, or during,
women at high risk are often currently well and not in pregnancy are difficult and should be the result of a
contact with mental health services and may fail to recognise detailed and individualised risk analysis.19 Although there
the serious risk of their situation. Thus, all women should be are significant concerns about the teratogenic effects of the
screened for known important risk factors at their antenatal medications used to treat BD, the risks of stopping
booking visit.1 Protocols should be put in place to ensure that medication must also be considered. Data suggest that
women at potential risk receive a formal risk assessment and women with BD who stopped medication during pregnancy
management plan.19,20 were more than twice as likely to experience a recurrence
Women with schizophrenia also have an increased risk of than those who remained on medication.24 Data on the
hospitalisation after childbirth. However, the specificity of teratogenicity of psychotropic agents are often controversial
the childbirth trigger in schizophrenia is still controversial.21 and an exhaustive discussion is beyond the scope of this
Women with schizophrenia have a four-fold lower relative review. Consistent evidence suggest that valproate should be
risk of admission in the postpartum period compared with avoided, because of the high risk of malformations,25 and
those with BD.22 In many cases, schizophrenia is a severe because of negative effects on neurodevelopment.26 On the
chronic illness and women are commonly admitted for contrary, a recent meta-analysis found no significant
assessment of parenting or to help them to cope with the association between any major congenital abnormality and
newborn rather than for the acute onset of a new episode.21 lithium.27 However, due to the wide confidence limits,
considerable uncertainty about the risk of lithium remains.
Management of women at high risk
Women at high risk of PP need very careful care before During pregnancy and after childbirth
conception, throughout pregnancy and during the postpartum Perhaps the most important aspect of care is to maintain
period. The high risk of illness in the weeks following delivery close contact and review during the perinatal period. Women
in a woman with a history of BD must be recognised both by at high risk, even if they are well, should be referred in
healthcare professionals and by the woman herself.19,20 pregnancy for psychiatric assessment and monitored
regularly for at least 3 months following delivery. The good
Ethical issues practice guidelines developed by Royal College of
The management of women at risk raises ethical questions on Obstetricians and Gynecologists20 suggest that the following
the role of the patient and her family in the decision-making scenarios are indications for referral to specialised perinatal
process. Ethical principles of patient-centred care provide the mental health services where available, otherwise general
foundation for the doctor–patient relationship: autonomy, psychiatry services:
justice, beneficence and nonmaleficence.23 The clinician
 current severe psychiatric symptom
should avoid paternalistic attitude, exploring and
 a history of serious postpartum illness or bipolar disorder
considering the values and the expectations of the patient
or schizophrenia
and leaving the final informed decision to the woman. If the
 on complex psychotropic medications schemes.
woman wishes, family members can be involved in the
decision making process. The NICE guidelines suggest to Moreover, the guidelines suggest that referral should be
discuss the teratogenic risk explaining the background risk of considered for those with moderate symptoms developed in late
fetal malformations in the general population (around 2–4%) pregnancy or early postpartum or mild symptoms and a family
and to describe the risk using natural frequencies rather than history of bipolar disorder or puerperal psychosis (COG).
percentages (for example, 1 in 10 rather than 10%).19 A Psychiatric services should have priority care pathways for
written plan covering pregnancy, delivery and the postnatal pregnant and postpartum women and care by multiple

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 Postpartum psychosis

psychiatric teams should be avoided.1 Ideally, women should be  Exogenous toxic substances or hormones: History of
managed by multiprofessional/multidisciplinary teams, with a therapeutic use and/or abuse of known causative
named obstetrician (possibly with special interest in perinatal substances or hormones, other symptoms and signs
mental health), midwives, perinatal psychiatrist, community specific to the substance or substances involved should
psychiatric nurse, health visitors and GP. All communication be investigated. Urine drug screen may be positive in
between maternity and mental health services should include substance abuse and identifies the substance taken,
primary care. A written care plan should be developed in although it is not definitive for drug misuse.
collaboration with all relevant healthcare professionals and  Other psychiatric disorders of the puerperium: Baby blues
recorded in all versions of the woman’s notes.19,20 affects 30–80% of births and causes transient emotional
It may also be important to address other avoidable factors lability during the first postpartum week. The mother
that may increase risk – such as decreasing general levels of typically presents mood swings ranging from elation to
stress and paying attention to sleep in late pregnancy and the sadness, insomnia, tearfulness, crying spells, irritability,
early postpartum weeks. Liaison with maternity services anxiety, and decreased concentration. Care of the baby is not
should involve discussion about how to manage the labour to impaired, hopelessness and worthlessness are not
reduce the sleep deprivation that can occur if labour is prominent, and women do not feel suicidal. It is
prolonged. For women with a history of BD who have been self-limiting, but assessment should ensure that the
off medication in pregnancy the introduction of prophylactic woman is not and does not become more severely depressed.
medication in the immediate postpartum period should be  Postnatal depression (for a review see Musters et al.29).
considered. Some evidence exists for the use of lithium in this The tendency for all postpartum episodes to be labelled
context, but the few studies have been open and retrospective as postnatal depression can lead to suboptimal care and,
and there are practical problems with reaching therapeutic in some cases, have dramatic consequences on mothers
levels quickly to cover the period of risk. These issues have and babies.
led some perinatal psychiatrists to use typical or atypical
Any psychotic symptoms, particularly delusions or
antipsychotics as prophylaxis.3
hallucinations, substantially increase risk for both mother
and child. The woman should be referred for a same day
Diagnosis of postpartum psychosis (PP) emergency appointment so that a detailed risk assessment can
be carried out.
History and examination
Although all women should be assessed antenatally for
known risk factors, such as personal or family history of BD Management of women with postpartum
and psychosis, it is important to bear in mind that 50% or psychosis (PP)
more of women who develop PP have no history that puts
them in a high-risk group.3
Hospital admission
PP is a psychiatric emergency. The clinical picture may
The distinctive clinical features include sudden onset and
mislead, quickly become extremely severe and vary
rapid deterioration. The vast majority of episodes have their
significantly from hour to hour. Admission is usually
onset within 2 weeks of delivery, with over 50% of symptom
necessary, even for women with the most supportive of
onsets occurring on days 1–3.28 The clinical picture often
families. The NICE guidelines19 recommend that women
changes rapidly, with wide fluctuations in the intensity of
within a year of childbirth should be offered admission to a
symptoms and severe swings of mood. Common symptoms
specialist mother and baby unit, however, the provision of
and signs include:
services across the UK is patchy and for the majority of
 A wide variety of psychotic phenomena such as delusions
women there is no option of admission with her baby.3
and hallucinations, the content of which is often related to
the new child.
 Affective (mood) symptoms, both elation and depression. Pharmacological treatment
 Disturbance of consciousness marked by an apparent A range of psychotropic medication may need to be
confusion, bewilderment or perplexity. employed. The treatment used depends on a number of
factors, including the symptoms that the woman experiences,
her level of disturbance and her previous response to
Differential diagnosis medication. For many women the severity of the illness
 Primary cerebral or systemic disease (such as eclampsia or does not allow breastfeeding. If breastfeeding is being
infection) should be excluded. The misattribution to considered, factors in the baby such as prematurity and
psychiatric disorder has led to a number of deaths in systemic illness should be considered in addition to the
new mothers.1 particular properties of the medication itself. Limited data

148 ª 2013 Royal College of Obstetricians and Gynaecologists

 Di Florio et al.

suggest that the use of lithium during breastfeeding is not as assessment. PP is a true psychiatric emergency and it is vital
problematic as once thought30 but is usually avoided because that it is recognised early and treated aggressively.
of the risk of toxicity in the baby.
Disclosure of interests
Follow-up ADF, IRJ and SS report no conflict of interest.

Prognosis
The short-term prognosis for PP is generally good. However, References
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