With the rapid drop in hormones, lack of sleep, and worries about parenting, the days, weeks, and months after you give birth can become a very sensitive period for your mental health. “Postpartum is a time of heightened risk for many types of mental health issues, including depression, anxiety, and obsessive-compulsive disorder,” says Thalia Robakis, MD, PhD, a reproductive psychiatrist and co-director of the Women’s Mental Health Program at Mount Sinai. And while not as common, it’s even possible to develop postpartum psychosis (PPP).
Experts in This Article
a reproductive psychiatrist and co-director of the Women’s Mental Health Program at Mount Sinai.
PPP is rare (affecting between 0.089 and 2.6 out of every 1,000 births), but it’s a serious and potentially dangerous condition, according to the Cleveland Clinic. People with PPP can have hallucinations, delusions, and even have trouble telling the difference between what’s real and what’s not. In severe cases, they may even try to harm themselves or their baby. For this reason, PPP is a mental health emergency that requires immediate medical care.
Though a PPP diagnosis can be a scary thing, “the good news is that there are many mental health professionals who specialize in this area, and most women respond very well and rapidly to treatment,” says Dr. Robakis. And most importantly: You are not alone. Read on to learn more about why PPP happens, who’s most at risk, and how it’s treated so you can live a happier, healthier life with your baby.
WARNING
If you or someone you know shows symptoms of PPP, dial 911 or 988 for the National Suicide Prevention Hotline. People with PPP can be a danger to themselves or others and need help as soon as possible.
What causes postpartum psychosis?
“We actually do not know this,” says Dr. Robakis. “The actual pathophysiological mechanisms of postpartum psychiatric decompensation are not understood.”
But there are some theories starting to emerge. Researchers hypothesize that postpartum psychosis is related to physiological changes—including hormonal, immunological, and circadian rhythm shifts— that happen after birth, according to the MGH Center for Women’s Mental Health. These changes seem to disrupt the equilibrium and trigger mental issues in people who are genetically vulnerable (more on this later).
“There is [also] some research suggesting increased immune activity in women with PPP, but we don’t know enough to say where this belongs in the causal chain,” Dr. Robakis says. This may help to explain why some cases of postpartum psychosis appear to be connected to issues with the immune system such as autoimmune thyroid disease, infection, and N-methyl-d-aspartate-encephalitis—an autoimmune disease where the body creates antibodies against certain brain receptors, per the MGH Center for Women’s Mental Health.
What we do know is that postpartum psychosis is “highly related to bipolar disorder,” says Dr. Robakis. “About half of women who have PPP either had a diagnosis of bipolar disorder beforehand or will go on to develop one afterwards.”
Though it’s still unclear whether bipolar disorder causes postpartum psychosis, there definitely seems to be a link to a history of mental health conditions. Approximately one-third of people with PPP also have a previous mental health diagnosis, according to the Cleveland Clinic. Likewise, you have a higher chance of PPP if you have a family member with a history of PPP or other related mental health conditions.
Approximately one-third of people with PPP also have a previous mental health diagnosis.
Risk factors of PPP
The above theories are only part of the puzzle, as PPP is a complex condition that’s likely caused by a combination of factors. Other significant risk factors include the following, per the Cleveland Clinic:
- Number of pregnancies: PPP is more common in people giving birth for the first time. But if you’ve had PPP before, there’s up to a 50 percent chance it will happen again after future childbirths.
- Sleep deprivation: Lack of sleep can trigger mania in people with bipolar disorder. Experts suspect that sleep deprivation can also play a role in why a person develops PPP.
- Hormone changes: Experts suspect major hormonal fluctuations that happen during pregnancy and birth (especially with estrogen and prolactin) might play a role, but more research is needed to confirm this theory.
- Other medical conditions: Psychosis can also happen as a result of health problems. Some examples include eclampsia and preeclampsia, autoimmune and inflammatory diseases, electrolyte imbalances, vitamin deficiencies (B1 and B12), thyroid disorders, and stroke.
Signs of postpartum psychosis
Because we’re all unique, postpartum psychosis can affect every person differently. That said, some of the most common signs to watch out for include the following, per the Cleveland Clinic:
- Hallucinations: When you sense things such as visions, sounds, or smells that seem real but are not.
- Delusions: False beliefs that you feel strongly about. Examples include persecutory delusions (believing someone is out to get you), control delusions (feeling that someone else is controlling your body), or somatic delusions (insisting you didn’t have a child or weren’t pregnant).
- Mood changes: This can include mania (an increase in activity and mood) and hypomania, or depression (a decrease in mood).
- Depersonalization: Some people describe this as an out-of-body experience.
- Paranoia and suspiciousness
- Disorganized thinking or behavior
- Insomnia
- Irritability or agitation
- Thoughts of self-harm: or harming others—especially their newborn
Complications of postpartum psychosis
Because postpartum psychosis can alter your sense of reality and how you perceive the world, it can majorly affect your relationships, especially with your baby.
“Mother-to-infant bonding is often highly impaired during the period of acute psychiatric illness,” says Dr. Robakis. In some cases, PPP can even trigger violent thoughts toward your newborn or yourself. “A mother can develop delusions that could lead her to harm herself or the child,” she says. “For this reason, it is imperative to have other people available who can manage the care of the newborn while the mother receives treatment,” says Dr. Robakis.
Fortunately, once treated, most people with PPP go on to to bond with their babies. “Many mother-infant pairs can recover quickly,” Dr. Robakis says. Still, “a minority of women may experience more prolonged difficulties in bonding with their infants,” she adds. When this happens, it’s important to have continuing mental health support to help you process this extremely difficult and often scary experience.
How is postpartum psychosis diagnosed?
A diagnosis of PPP is usually based on your symptoms, which can be categorized into three types: depressive, manic, and atypical/mixed. Here are the symptoms you might have with each subtype, per the Cleveland Clinic:
Depressive symptoms (the most common, affecting 41 percent of people with PPP):
- Anxiety or panic
- Delusions and hallucinations
- Depression
- Feelings of guilt
- Loss of appetite
- Loss of enjoyment related to things they usually enjoy (anhedonia)
- Thoughts of self-harm, suicide, or of harming their child.
Manic symptoms (affects about 34 percent of people with PPP):
- Agitation or irritability
- Disruptive or aggressive behavior
- Talking more or faster than usual (or both)
- Needing less sleep
- Delusions of greatness or importance (such as believing their child is a holy or religious figure)
Atypical/mixed symptoms (affects about 25 percent of people with PPP):
- Disorganized speaking or behavior
- Disorientation or confusion
- Disturbance of consciousness (where a person doesn’t appear to be awake or isn’t aware of activities or things taking place nearby)
- Hallucinations or delusions
- Inappropriate comments, behaviors, or emotional displays
- Catatonia or mutism (being totally silent)
Along with taking down your symptom history, your doctor might also do other tests (like tests on blood, urine, or other body fluids) or imaging scans (like an MRI) to see if another underlying health condition is causing the psychosis, according to the Cleveland Clinic.
Your provider may also need to rule out other postpartum and maternal mental health conditions, which can have some overlapping symptoms. The most common postpartum mood disorders include the following, per the Cleveland Clinic:
- Postpartum “blues” (known as “baby blues”): Up to 85 percent of birthing people will have negative feelings (read: anxiety, sadness, frustration, or anger) or mood swings (think: crying more than usual) within four to five days after the birth of their baby. These symptoms—which might be related to major hormonal changes or lack of sleep while caring for a newborn—usually subside within two weeks and don’t require treatment.
- Postpartum depression (PPD): A more serious form of postpartum “blues,” this condition affects 1 in 7 new parents. Symptoms—like frequent crying, irritability, fatigue, as well as feelings of guilt, anxiety, and inability to care for your baby or yourself—last longer (up to several months) and tend to be more intense (i.e., they affect your day-to-day functioning). Unfortunately, postpartum depression is on the rise, but more treatment options are becoming available.
- Postpartum anxiety: This condition happens when nervous, anxious, or worried feelings after birth (or adoption) become excessive and overwhelming and affect your ability to function.
Treatment for postpartum psychosis
While research is still evolving on the best ways to help people with PPP, there are several treatments that appear to be effective. In severe cases, hospitalization or inpatient mental health care may be necessary to ensure the birthing parent is safe. Other forms of treatment include:
1. Medication
Many types of medication can treat people with PPP including the following, per the Cleveland Clinic and National Health Service (NHS):
- Antipsychotic medications: to help with symptoms like delusions or hallucinations
- Lithium and other mood stabilizers: to help stabilize mood, and treat and prevent manic episodes
- Antiseizure drugs: to treat manic or mixed episodes, i.e., symptoms of mania and depression that happen at the same time
- Antidepressants: to relieve depressive symptoms
Based on current research (which is limited), people treated with lithium had lower relapse rates of PPP compared with those treated with antipsychotics alone, according to the MGH Center for Women’s Health. That said, everyone is different; one medication may work better than another depending on your symptoms.
What about newer medications like zuranolone (aka, the first FDA-approved pill for postpartum depression)? Though studies show this drug can relieve PPD symptoms in just three days, it hasn’t been “tested for efficacy in postpartum psychosis,” says Dr. Robakis. In other words, more research is needed to confirm whether it can be used to effectively treat PPP.
2. Electroconvulsive therapy
If multiple tries with medication have proven ineffective, health-care providers may suggest electroconvulsive therapy (ECT). This therapy involves sending mild electric currents through certain parts of the brain to trigger a small, mild seizure, lasting less than two minutes, per the Cleveland Clinic.
While ECT sounds intimidating (and has often been negatively portrayed in the media), new versions of the treatment are standardized and, of course, require patient consent in advance. Like with any other mental health treatment, there are risks, but providers can help weigh out the potential pros and cons, per the American Medical Association’s Journal of Ethics.
Modern-day versions of ECT are generally safe and painless; you won’t feel anything because the procedure happens under general anesthesia while you’re asleep. The recovery time after each session is quick, too—you can be up and walking as soon as 30 minutes after you receive ECT, per the Cleveland Clinic.
3. Talk therapy
Even after psychotic symptoms have been managed, PPP can be a devastating experience for a new parent. But you shouldn’t have to navigate the aftermath alone. Speaking with a perinatal mental health professional can offer you a safe space to process your feelings. “Reproductive psychiatry is a whole specialty dedicated to the mental health care of pregnant and postpartum individuals, so help is out there and available,” says Dr. Robakis.
If you’re looking for someone to speak to about your experience with PPP, here are some resources to help you get started:
- Postpartum Support International (PSI): Postpartum psychosis coordinators are available to assist you in finding the right PPP resources for you.
- Women’s Mental Health Center at Mount Sinai: Experts diagnose and treat perinatal psychiatric issues using medication management and psychotherapy.
- The Motherhood Center (based in NYC and virtual): This comprehensive treatment center for new and expecting birthing parents specializes in perinatal mood and anxiety disorders and offers therapy and medication management.
Other strategies to support PPP recovery
On top of medication, ECT, and therapy, there are other lifestyle changes you can make to help the healing process.
1. Prioritize sleep
As we learned, lack of sleep can trigger a manic episode in people with bipolar disorder, and it appears to play a part in why someone develops PPP, as well. So it goes without saying: “Regular nighttime sleep is extremely important in aiding with recovery,” Dr. Robakis says. During sleep, your brain recharges. To help your brain reset and function at its best, new parents going through PPP should log eight hours of uninterrupted sleep per night, she says.
We know what you’re thinking: that’s an unrealistic goal when caring for a newborn who needs to feed (sometimes several times) overnight. Here’s where partners, family, and friends become essential. On your path to healing, you must lean on loved ones or other support people to help, Dr. Robakis says. Family and friends can take turns assisting with overnight baby care, so you can get the rest you need to recover.
2. Attend a support group
Because PPP is a rare condition, it can feel isolating at times. Connecting with others who’ve been through similar struggles with PPP can be helpful during your recovery journey once your symptoms are stable (i.e., you’re no longer in psychosis), according to PSI. Not sure how to find a support group in your area? PSI offers a free, online peer-to-peer support group for PPP survivors.
How to get emotional support
PPP affects your sense of reality, so it may be hard to reach out to those around you, or understand that you’re having a psychiatric emergency. “Usually, the symptoms are noticeable by family members,” Dr. Robakis says. Often, partners and family members are the first to recognize something is wrong and play a critical role in ensuring the safety of a person with PPP and their baby.
If your loved one is going through PPP, here’s how you can support and help them take the first step in getting help, per the Cleveland Clinic:
- Don’t judge or argue: While your loved one’s behaviors may be confusing, scary, or strange to you, try not to judge or argue. People with PPP can’t always distinguish between what is and isn’t reality, so attempting to explain what’s real may just agitate, anger, or scare them and make the situation worse.
- Stay calm: People with PPP often have paranoid and anxious thoughts, so it’s important to make them feel safe and unthreatened.
- Don’t leave them unsupervised (either by themselves or with their child): Because people with PPP have a higher risk of dying by suicide or harming their children, you should never leave them alone.
- Get emergency help: PPP is a medical emergency that requires emergency medical care immediately.
- Seek out support: Not only does PPP affect the birthing parent, but it also affects the entire family. Being your loved one’s rock can take a toll, so it’s important to take care of your own mental health, too. This might look like talking to your own therapist or joining a support group. PSI offers a free, virtual support group for families touched by PPP. There you can find peer support, useful information, and resources to help you better understand and navigate your loved one’s experience with PPP.
Can PPP be prevented?
There’s still so much we don’t understand about PPP and why it happens, so preventing it isn’t always possible. However, there are ways to lower your odds, especially if you have known risk factors.
“Women with a history of bipolar disorder, or with a blood relative who experienced postpartum psychosis, are at elevated risk,” Dr. Robakis says. “These women should seek mental health care well before their delivery so that an appropriate personalized prevention plan can be put into place, and they have someone to reach out to quickly if symptoms develop,” she says.
For these high-risk groups, lithium (a mood stabilizing medicine that’s used to treat PPP) may be given as a preventive treatment. For example, some studies show taking lithium right after birth is effective in preventing a recurrence of psychosis in people with histories of PPP, per an October 2023 review in the Journal of Psychopharmacology1 and the MGH Center for Women’s Mental Health.
If you have a higher risk for developing PPP, start talking to your doctor about your options early on in your pregnancy. Together you can weigh the risks and benefits of taking medication and decide which ones are best for you.
You should also share your situation with the people you trust and come up with a plan of action together. By educating your partner, family, and friends about PPP ahead of time, they will know what signs to look out for and what to do to keep you and your baby safe in case you develop symptoms, according to the Cleveland Clinic.
When to see a doctor
If you’ve just given birth, and you feel like something is off, tell someone right away. “I would suggest that all new mothers have a low threshold to seek mental health care,” Dr. Robakis says. That means get help as soon as you notice even the slightest change in your mood, thoughts, or behaviors. Your midwife or obstetrician is a good place to start, she says. They can usually direct you to appropriate mental health services.
But many people with PPP lose touch with reality, so they might be unaware that they’re unwell or starting to have symptoms of psychosis. Making matters worse, delusions or hallucinations might cause paranoia and fear, which can prevent a person from seeking medical care.
In many cases, those closest to the person are often the first to spot signs of the condition. If you suspect your loved one is going through PPP, or poses a danger to themselves or their baby, get them help immediately. You may have to have your loved one involuntarily hospitalized for a short time to keep them safe. While making this decision can be scary and heartbreaking, it might be necessary to prevent any harm to them or their newborn.
Thankfully, once a person gets treatment for PPP, it’s possible to make a full recovery. And with preventive care, they can even have future pregnancies without a relapse of PPP. But many people with PPP (between 50 and 80 percent) tend to develop psychiatric conditions (usually bipolar disorder) down the line, according to the MGH Center for Women’s Health. In these situations, you’ll need to work with your provider to protect your mental health and manage this condition over the long term.
FAQ
Can you fully recover from postpartum psychosis?
Yes, PPP is a temporary and treatable condition. While the recovery timeline is different for each person, many people with PPP become stable quickly (in just a few weeks) once they get help. Left untreated, PPP can last much longer (even months) and become more dangerous, according to the Cleveland Clinic. Simply put: The earlier PPP is detected, the better the outlook.
What helps postpartum depression?
Like PPP, you can make a full recovery from postpartum depression (PPD) with medication, counseling, and support from other parents who’ve had PPD. In fact, treatments for PPD are becoming more effective as scientists develop better medicines to target the condition. Case in point: In 2023, the FDA approved zuranolone, the first pill designed to treat PPD. This new drug can improve symptoms in as fast as three days (which is much quicker than traditional antidepressants that take at least three to four weeks to kick in), according to UT Southwestern Medical Center.
Other things that can help you cope with postpartum depression include the following, per the Cleveland Clinic:
- Try to eat a well-balanced diet and find time for exercise
- Prioritize rest for yourself
- Go out with friends or talk to them on the phone
- Find time for self-care and doing things you enjoy, like reading or other hobbies
- Get help with household chores or errands
PPD is a serious condition that can also affect your baby. Getting help is critical. If you have any of the following symptoms, tell your doctor ASAP, per the Cleveland Clinic:
- Thoughts of harming yourself or your baby
- Recurrent thoughts of death or suicide
- Depressed mood for most of the day, or nearly every day for the last two weeks
- Feeling anxious, guilty, hopeless, scared, panicked, or worthless
- Difficulty thinking, concentrating, making decisions, or dealing with everyday situations
- Loss of interest or pleasure in most activities nearly every day for the last two weeks
Can you have both bipolar and postpartum psychosis?
“Yes, you can have both a baseline diagnosis of bipolar disorder and a postpartum [psychotic] episode,” Dr. Robakis says.
While PPP can happen in people without bipolar disorder, it often happens in people who have been diagnosed with this condition. Probably half (or more) of people with PPP have both, she says. Though not everyone with bipolar will develop PPP.
—medically reviewed by Andrea Braden, MD, OB/GYN
Jairaj, Chaitra et al. “Postpartum psychosis: A proposed treatment algorithm.” Journal of psychopharmacology (Oxford, England) vol. 37,10 (2023): 960-970. doi:10.1177/02698811231181573
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