HealthPostpartum

Postpartum Psychosis Is Rare (and Can Be Scary), but It’s Highly Treatable—Here Are 9 Warning Signs To Watch For

Explore the major signs of postpartum psychosis, including early symptoms, and when to seek help for the health of you and baby.

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Photo: Getty Images/Staticnak
Published May 25, 2024

Written by 

Jaime Osnato

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

Thalia Robakis

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:

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  • 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.

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“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):

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  • 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):

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  • 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.

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If you’re looking for someone to speak to about your experience with PPP, here are some resources to help you get started:

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.

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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.

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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.

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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.

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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

  1. 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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HealthPostpartum

‘I’m a NICU Nurse Who Had Postpartum Depression 3 Times—Here’s What I’ve Learned’

Learn from one nurse's experience taking zuranolone for postpartum depression, including what she wishes more people knew about treating PPD.

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Photo: Lilla Caho Photography
Published Aug 28, 2024

Written by 

Sarah Klein

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Kristina Leos gave birth to her third child unexpectedly early. All she wanted was to be thankful she and her new daughter were healthy, and to be enveloped in a bubble of newborn joy. But almost immediately, a dark cloud settled over her.

Experts in This Article

Jill Zechowy

physician, perinatal psychotherapist, and author of Motherhood Survival Manual: Your Prenatal Guide to Prevent Postpartum Depression and Anxiety

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“I just remember sitting in my [hospital] room, and everything just felt super overwhelming, and I was very tearful,” Leos recalls. “I thought to myself, ‘I need help. I can feel it already.’”

“It” was postpartum depression, or PPD, characterized by feelings of sadness, hopelessness, or anxiety that last longer than two weeks and start around the time of delivery, according to the Office on Women’s Health (OWH). Leos, 39, who lives in Midlothian, Texas, and works as a nurse in a neonatal intensive care unit (NICU), had experienced it twice before, when her two older children were born.

But even though she recognized PPD this time, it still took Leos months to feel better. Here’s what she wants everyone to know about this emotional experience.

You might feel *everything*—or nothing at all

PPD—also sometimes called perinatal depression—can occur anytime during pregnancy or in the year after, explains Jill Zechowy, MD, a physician, perinatal psychotherapist, and author of Motherhood Survival Manual: Your Prenatal Guide to Prevent Postpartum Depression and Anxiety. “It’s characterized by exhaustion, feeling overwhelmed, sometimes tearful, other times numb,” Zechowy says. “These moms feel like they are failures as mothers.”

Other new moms might experience anger, rage, or anxiety, which often shows up as disturbing, intrusive thoughts. “These can be really scary images that women have in which they imagine harm coming to the baby,” she says.

The smallest tasks, like taking leftovers out of the fridge to reheat for dinner, were overwhelming for Leos—if she had the motivation to do them at all. “I would start a task, and forget what I was doing, so my house got really crazy. I didn’t have a lot of motivation to do tasks to begin with, so once I actually got the motivation, it was even worse, because I couldn’t finish them,” she says.

She remembers cloudy moments of brain fog when she felt like she was living outside of her body, watching her family from afar without feeling the joy or love she usually felt being with them.

That was a big difference from the emotional peaks and valleys she had experienced after her first two deliveries. About eight weeks after having her first daughter, Kristina talked to her OB/GYN about how she was feeling and started a type of antidepressant called a selective serotonin reuptake inhibitor or SSRI. After her second delivery, she started the antidepressant right away. (Once you’ve had postpartum depression once, you’re more likely to have it again, Dr. Zechowy says.)

It’s more common in certain people

No one knows exactly what causes postpartum depression, and it’s probably a combination of many factors. Experts think the major hormone changes that happen so quickly after giving birth likely trigger mood changes, according to the OWH.

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You’re also more likely to develop postpartum depression, per the OWH, if you have a family history of depression (even in male relatives; had an unplanned, difficult, traumatic, or premature pregnancy or delivery; don’t have much support from your partner, family, or friends; or are facing other life stressors, like financial challenges or relationship problems.

Leos conceived her third child through IVF, and her daughter was born premature. Parents who go through IVF and those who deliver before full-term are both more likely to have postpartum depression symptoms, according to an August 2023 Acta Psychologica2 study and a January 2022 Scientific Reports1 study, respectively. “Everything just happened so fast for me this time, and I wasn’t expecting it at all,” Leos says of her third delivery.

Finding the right treatment can take time

What didn’t happen fast was finding an effective treatment. Leos delivered her second daughter in March 2023. She went back on the SSRI after delivery, and she says she would feel some improvement, then feel a little worse. Her OB/GYN kept increasing her dose. They added a second medication to her routine, but the same pattern—one step forward, two steps back—repeated. “I would feel a little bit better, but then I would just slide backwards,” she says. “It was a roller coaster, down and up and down.”

Her OB/GYN suggested speaking with a psychiatrist. At first, Leos didn’t feel comfortable opening up to a stranger. “It was hard enough for me to open up to [my doctor], and I trusted her so much,” she says. “But I realized at some point that this was beyond what she could offer to me.” She started seeing a psychiatrist in the summer of 2023. The psychiatrist adjusted the doses of her medications, tried some different options, and still couldn’t relieve Leos’s symptoms.

In December 2023, Leos remembers her psychiatrist looking at her and saying, “This is not working. We need to do something else.” Her options included electroconvulsive therapy, ketamine treatment, and hospitalization. “I couldn’t believe I had gotten to a point in my life where I could have to be in the hospital for Christmas without my kids,” she says.

She remembered hearing about a relatively new postpartum depression treatment called zuranolone on Facebook, so she asked her psychiatrist for more information. The psychiatrist hadn’t prescribed it to anyone yet—it had only been approved by the FDA for PPD treatment that August—but after looking into it more, they determined Leos would be a good candidate.

Zuranolone, sold under the brand name Zurzuvae, “is the first oral pill that the FDA has specifically approved for postpartum depression,” Dr. Zechowy says.

Previously, the only medication specifically approved for PPD was a 60-hour intravenous infusion that had to be delivered in the hospital, according to Yale Medicine.

Rather than target the neurotransmitter serotonin, zuranolone works on different feel-good receptors in the brain that depend on the hormone allopregnanolone, Dr. Zechowy explains. Allopregnanolone levels drop dramatically after giving birth. Consequently, “it works much quicker than SSRIs,” she says. “Whereas they may take two to four weeks to start becoming effective, sometimes zuranolone works as quickly as in three days.”

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Plus, you only take zuranolone for 14 days, compared to the 12 months or so you’d probably be treated with SSRIs, Dr. Zechowy estimates. This makes it an especially exciting development for people with severe postpartum depression who need relief quickly, she adds.

Leos started taking zuranolone in January 2024. By day three, she could already tell she was feeling differently. “Every day, I got better and better, and then at the end, I was just like, wow, I don’t feel like [I’m having] an out-of-body experience.”

Treatment, in some cases, is a life-or-death matter: “Most families are not aware of the harm of untreated postpartum depression,” Dr. Zechowy says. But perinatal mental health concerns (which includes PPD as well as postpartum anxiety and postpartum psychosis) are the top cause of death among new moms via suicide or overdose, according to the American College of Obstetricians and Gynecologists. “I know someone who died from postpartum depression a few weeks ago,” Leos says. “It really, really shook me hard, because it could be any of us.”

There are some side effects of the PPD pill to be aware of

Leos decided to start treatment when she had five days off from work in a row, to give herself some time and space in case she experienced any side effects.

The biggest side effects of zuranolone are dizziness and sedation, Dr. Zechowy says. Because of these concerns, you shouldn’t drive within 12 hours of taking the pill (which you take every evening with a meal rich in fat to help your body absorb the medication, per the manufacturer’s website), which simply might not work for everyone, she says.

“My main thing was dizziness, but the side effects were not as bad as I thought they would be. For me, the benefits outweigh the little side effects,” Leos says.

Breastfeed with caution while on zuranolone

Breast and chestfeeding people were left out of the original studies on zuranolone, but that doesn’t mean it’s not safe to take while breast/chestfeeding. According to the National Library of Medicine, the amount of zuranolone that makes it into milk is low, so it’s not expected to cause side effects in infants. That said, until more data is available, most medical experts support breast/chestfeeding with caution, monitoring your baby for any signs of excessive drowsiness or sedation.

In Leos’ case, she decided to be extra careful. “I pumped and dumped, and it was just for two weeks, so it wasn’t that long,” she says. Still, it was challenging emotionally for her: “When I felt like such a failure, one thing I could do for my daughter was to provide milk. So the fact that I couldn’t breastfeed made me not want to take zuranolone. But I realized I could pump and dump, and for two weeks, you can do anything.”

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Your doctor can help you decide if taking zuranolone while breastfeeding is right for you and your baby.

There’s a hefty price tag for the pill, but insurance can help

The wholesale price of Zurzuvae was announced at $15,900 by manufacturer Sage Therapeutics. They do have a financial assistance program, and anecdotally, at least, Dr. Zechowy says most insurance companies are covering the cost if your doctor gets approval from them first (called a prior authorization).

Leos didn’t have to pay that much, but she thinks it would have been worth it. “Now that I’ve taken it, I would gladly pay $16,000,” she says. “I’d have to take out a loan, but I would gladly pay that, because you can’t put a price tag on your life.”

You are not alone if you have PPD

One in 8 new moms experiences symptoms of PPD, per the OWH, but it can feel like you’re the only one struggling. Postpartum depression was isolating for Leos. “I didn’t want to burden anyone by telling them how I was feeling,” she says. “My best friends, my husband—they didn’t know the extent of my issues. But it’s a time [when] you need the most help and you need someone to talk to.”

Shame often keeps new parents from speaking out about how they’re feeling, Dr. Zechowy says. “Women see a significant part of their value as a human being by their role as a mother, and postpartum depression makes you feel like you’re a terrible mother. You don’t realize you’re depressed. You just think you’re not good at this.”

Leos just overcame that shame recently. “I only started talking about my experience a few months ago,” she says. There were many opportunities when someone in the health care system could have extended more support to her. For example, she says, she scored high on measurements of depression during multiple evaluations, but providers shrugged it off as normal. “I think people are just afraid to talk about it,” she says. “I started to think maybe I shouldn’t be worried about it.”

That’s emboldened her to speak up publicly and at work. “As a health care professional who works with postpartum women, I think it’s important to bring up postpartum depression to them, and tell them that it’s real,” she says. “In our discharge instructions, I think there’s, like, one line about postpartum depression. Now I just take a lot more time to actually educate moms [about it].”

Need support for PPD? Call or text the Postpartum Support International helpline at 1-800-944-4773 or the National Maternal Mental Health Hotline at 1-833-852-6262.

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—reviewed by Andrea Braden, MD, OB/GYN

  1. Girchenko, P., Robinson, R., Rantalainen, V.J. et al. Maternal postpartum depressive symptoms partially mediate the association between preterm birth and mental and behavioral disorders in children. Sci Rep 12, 947 (2022). https://doi.org/10.1038/s41598-022-04990-w

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  2. Li, Chuan-Chen et al. “Factors associated with postpartum depressive symptoms among women who conceived with infertility treatment.” Acta psychologica vol. 238 (2023): 103987. doi:10.1016/j.actpsy.2023.103987

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Over Half of Women Have Urine Leakage at Some Point in Life—but Why Are We Still Afraid to Talk About It?

Discover why urinary incontinence in women is common but often overlooked in health care and how to break the taboo around this topic.

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Photo: Getty Images/Morsa Images
Published Aug 11, 2024

Written by 

Tabitha Britt

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Get ready to start peeing a little when you sneeze. This is a common refrain many people start hearing when they get pregnant or give birth. In fact, you’ve probably heard your mother, grandmother, aunts, or friends laugh off (or cringe at) a story about when they’ve “leaked.”

Experts in This Article

Aldene Zeno

double board-certified OB/GYN and urogynecologist in Los Angeles, California

Heather Jeffcoat

doctor of physical therapy, owner of Femina Physical Therapy, and author of Sex Without Pain

Jennifer Anger

urogynecologist, professor of urology, and vice chair of research at UC San Diego department urology

Karyn Eilber

urogynecologist, associate professor of urology, and OB/GYN at Cedars-Sinai Hospital

Victoria Scott

urogynecologist and co-author of A Women’s Guide to Her Pelvic Floor: What the F*@# Is Going on Down There?

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Even doctors say leaking a little pee every now and then—from seemingly benign activities like laughing or jumping up and down—is totally normal. If this happens to so many of us, why are we still embarrassed when we talk about it? And more importantly, why don’t we seem to take it seriously?

Urinary incontinence (or the inability to completely control your bladder) is a topic many of us shy away from—whether we’ve had a baby or not. But behind medical communities telling us it’s “normal” and “just part of life” are the women who manage (and even struggle) with it in day-to-day life.

One of those women is Jennifer Souiade—a mom of three—who says urinary incontinence was a huge part of her postpartum experience.

“Even after my daughter’s first birthday, I couldn’t jump on the trampoline without feeling like my uterus would fall out, while my pee actually did,” she says. “And that was after six months of pelvic floor therapy.”

Souiade’s problems with incontinence began after the birth of her first child, which she says was a traumatic experience for her body. “[My daughter] was born like ‘The Thinker’ statue, with her hand on her chin, tearing my vaginal wall along the way, enough to need internal stitches to repair me afterward,” she says.

Despite getting the standard postpartum care in France (where she lived at the time), which included pelvic floor therapy, she still dealt with bladder leaks that affected her daily life. “It was mentally and physically challenging,” she says. “I’d lost the mind-to-muscle connection [between my bladder and brain] and couldn’t figure out how to flex my pelvic floor.” This can not only lead to potentially embarrassing leaking incidents, but also to other side effects of pelvic floor dysfunction, like pain during sex or peeing during exercise.

With the help of her health care team, Souiade was able to fully address her incontinence issues and regain control of her pelvic floor muscles, “but I still avoid trampolines if I have a full bladder,” she says, just in case.

Souiade is just one of many who deal with urinary incontinence on a daily basis—no matter their age. It’s often seen as an embarrassing or “taboo” topic, leaving lots of us in the dark about what really causes it and how to regain control of our bladders and pelvic floors. Women may feel hesitant to bring it up to their doctors for fear of being gaslit or told that it’s “normal.”

Here, we take a deep dive into why urinary incontinence is still so taboo and how we can start serious conversations about bladder leaks so we can end the embarrassment (and associated health effects) once and for all.

How prevalent is urinary incontinence in women?

From the “oops” moment after you sneeze, to that sudden “can’t hold it anymore” urge to pee, urinary incontinence can happen for many reasons, and it’s incredibly common—affecting millions of women at all phases of life. It’s not just a product of pregnancy; it can happen to athletes like gymnasts and track runners, those who have health conditions that affect their pelvic floor (like diabetes or multiple sclerosis), people who’ve had hysterectomies, and more.

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About 54 percent of women ages 20 and older will experience bladder leakage at some point in their lives, per a June 2021 study in the Journal of Urology1. Other April 2022 research in Female Pelvic Medicine and Reconstructive Surgery2 found that number could be even higher, with estimates reaching over 60 percent.

Is urinary incontinence a normal part of aging?

While it’s true that our bladders can get weaker as we age, leakage is not an inevitable part of aging. In other words, losing full control of your bladder is not always due to simply getting older. According to Victoria Scott, MD, urogynecologist and co-author of A Woman’s Guide to Her Pelvic Floor: What the F*@# Is Going on Down There?, other causes of urinary incontinence can be:

  • Pregnancy
  • Childbirth
  • Menopause
  • Having overweight
  • Prior pelvic surgery
  • Medications
  • Family history of incontinence

And as we mentioned before, even young, active people can get bladder leaks. Female athletes that participate in high-impact sports like running and gymnastics are three times more likely to experience urinary incontinence than non-athletes, per a December 2020 review in Sports Medicine3. Rough landings after jumps can put pressure on the pelvic floor. And it just goes to show: You can be in “peak health” and still deal with this issue.

“Urinary incontinence is not just an ‘old lady’ issue,” says Heather Jeffcoat, DPT, a physical therapist and owner of Femina Physical Therapy. “Young athletes have high rates of urinary incontinence, as well as bowel (fecal) incontinence.”

Okay, if it’s common, then why is it so taboo?

In general, societal taboos around bodily functions, fear of embarrassment, and the outdated notion that bladder leaks are just a “normal” part of being a woman all contribute to stigma.

But here’s the problem: Staying silent doesn’t make the issue go away. In fact, it can make things worse, according to Karyn Eilber, MD, urogynecologist and co-author with Dr. Scott. Women might avoid social activities, miss out on things they enjoy, and even isolate or have depression and anxiety—all because they’re afraid of what might happen in public without supplies like spare underwear, pads, or a change of clothes.

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This often applies to other women’s health concerns— like bleeding in public due to menstruation. Women may feel embarrassed or less equipped if it’s not openly talked about or perceived as an “embarrassing” issue.

The lack of open conversation about women’s health issues in general also fuels misinformation and perpetuates the idea that it’s something to be ashamed of or kept hidden. Consequently, many women are unaware of the availability of effective treatments or where to turn for help. As Dr. Jeffcoat puts it, “Our society doesn’t want to talk about any women’s issues, much less [what happens] ‘down there.'”

Other reasons why urinary incontinence continues to be a taboo topic include the following:

  • Societal expectations and norms: Women may feel pressure to appear perfect and in control, and admitting to an issue like urinary incontinence can be seen as a sign of weakness or failure to meet those unrealistic expectations. Society’s discomfort with natural bodily functions, perceiving them as “gross” (e.g., tampon commercials still use blue liquid for demonstration!) combined with the expectation to “bounce back” quickly after childbirth makes it even harder to openly talk about post-birth issues, including urinary incontinence.
  • Fear (especially fear of aging): “Anything embarrassing can become a taboo topic, but incontinence is even more taboo because it’s often associated with being old,” says Dr. Eilber. Society also tends to fear aging, or pressure women into remaining as youthful as possible, which could further lead to fear of incontinence issues.
  • Limited education and awareness: This fear can also lead to a lack of knowledge, as we’ve mentioned. Women are less inclined to ask their doctors about it, and doctors are then less inclined to offer up treatment options, solutions, and reassurance that helps de-stigmatize the issue. “The message that should be amplified is that urinary incontinence is common but definitely not normal,” says Dr. Jeffcoat.
  • Systemic barriers in health care: In some countries, like France where Souiade lives, getting postpartum pelvic floor therapy is standard practice. This helps women re-stabilize their pelvic floor after giving birth, to help strengthen the muscles that support their back, help them have regular bowel movements, and yes, keep control of their bladder. But this therapy is not always recommended or available right away in the U.S., or women are told to just “wait and see” if symptoms improve. The lack of proactive care (especially postpartum care), combined with systemic issues of how women’s health care is addressed (or ignored), can leave women feeling unsupported and uninformed, according to a research article in Harvard Public Health.

“When doctors normalize it, women aren’t taking the next steps to heal,” Dr. Jeffcoat says.

How we can start talking about urinary incontinence in women

The first step to breaking the taboo is acknowledging that many people go through this issue. Having open and honest conversations will also help normalize urine leaks—no matter the phase of life you’re in—and encourage women to treat and strengthen their pelvic floors and bladders, for a happier, healthier life.

Here are some things you can do:

1. Educate yourself

As with most things, knowledge is power—especially when it comes to your health. Start paying attention to when and why leaks happen. Do they happen after sneezing, coughing, laughing, or lifting something heavy? Or maybe you feel a sudden, intense urge to pee that’s hard to ignore?

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Understanding the specific types of incontinence can guide you towards the right treatment. “There are two main types of urinary incontinence,” says Jennifer Anger, MD, urogynecologist, professor of urology, and vice chair of research at UC San Diego department of urology.

“Stress urinary incontinence is leakage with cough or sneeze and is common after vaginal delivery. Urgency urinary incontinence is leakage with an urge to get to the toilet. This is largely age-related,” says Dr. Anger, noting that about 40 percent of women have both types of incontinence.

2. Be your own advocate

If the inability to control your bladder is affecting your quality of life, and you bring it up to your doctor, don’t settle for a “wait and see what happens” approach. Your bladder health matters, and finding a health care provider who knows this can make all the difference.

“Be specific about your symptoms and focus on how it impacts your quality of life: Do you skip social outings? Are you having a hard time keeping up with your kids? Do you avoid the gym or wear pads/diapers every day that irritate your skin?,” says Aldene Zeno, MD, FACOG, a double board-certified OB/GYN and urogynecologist in Los Angeles, California.

Dr. Anger echoes this, and says it’s important to be vocal about your concerns. “Because your doctor may want to spend more time discussing more serious health issues (especially postpartum), they may not have enough time to talk about urinary incontinence at visits. Be sure to keep bringing it up and emphasize how much it’s impacting your quality of life.”

3. Share with people you can trust

Remember, you are not alone in this. Talking about bladder leakage with friends or family you trust can be a good source of support and comfort. They can share tips they’ve learned if they’ve dealt with it before, or accompany you to doctor’s visits—and postpartum check ups—to be a pillar of support.

“It’s important to acknowledge that urinary incontinence is embarrassing to many women, and it has profound effects on their relationships,” says Dr. Zeno. “It impacts intimacy, and many feel self-conscious even talking to their significant other about it. If you have the opportunity to discuss it with a trusted friend, you may be surprised to learn you’re not alone.”

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4. Find an online support group

Finding an online support group can provide a safe and anonymous space to discuss your experiences with others who can relate. The Simon Foundation for Continence and National Association for Continence offer online forums and resources. Or you can find Facebook groups dedicated to urinary incontinence, where you can connect with women from around the world and share advice, support, and resources.

The bottom line

Whether you’re an athlete dealing with leaks during training, a postpartum parent with incontinence, or an older adult adjusting to menopause and changing pelvic floor health, urinary incontinence does not have to just be accepted as the “norm.” Talking with your doctor, trying things like pelvic floor therapy or bladder training, and opening up to your friends and family about your struggles (or even feelings of shame and embarrassment!) around incontinence will help de-stigmatize the issue—and health issues that affect women overall.

That way, like Souiade, you can go ahead and play with your kids, jump on that trampoline, or laugh at that joke without a thought except “this is fun.”

  1. Lee, Una J., et al. “Prevalence of Urinary Incontinence among a Nationally Representative Sample of Women, 2005–2016: Findings from the Urologic Diseases in America Project.” 2021. Journal of Urology, vol. 205, no. 6, WoltersKluwer, June 2021, pp. 1718–1724, doi:10.1097/JU.0000000000001634.

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  2. Patel, Ushma J et al. “Updated Prevalence of Urinary Incontinence in Women: 2015-2018 National Population-Based Survey Data.” Female pelvic medicine & reconstructive surgery vol. 28,4 (2022): 181-187. doi:10.1097/SPV.0000000000001127

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  3. Bø, Kari, and Ingrid Elisabeth Nygaard. “Is Physical Activity Good or Bad for the Female Pelvic Floor? A Narrative Review.” Sports medicine (Auckland, N.Z.) vol. 50,3 (2020): 471-484. doi:10.1007/s40279-019-01243-1

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