AMSTERDAM — Postpartum psychosis (PP) is a distinct psychiatric phenotype with specific prevention and treatment strategies and should be classified as a distinct mental illness diagnosis within the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) and International Classification of Diseases-10, a new international expert panel recommends.

Because PP is not formally recognized as a distinct condition, treatment guidelines are based on results from naturalistic cohort studies and expert consensus groups due to a lack of controlled trials, the panel argued.

“We argue that with its specific onset, phenotype, phenomenology, risk profile, and prognosis, postpartum psychosis has distinct prevention and treatment recommendations,” lead author Veerle Bergink, MD, PhD, director of the Women’s Mental Health Center and professor of psychiatry at the Icahn School of Medicine at Mount Sinai, New York City, said during a recent presentation.

Bergink and coauthors have recommended a new classification for PP be created within the bipolar disorder (BD) chapters and have proposed new diagnostic criteria.

The recommendations were presented on October 11 at the 38^th European College of Neuropsychopharmacology Congress (ECNP) 2025 and published online on October 22 in Biological Psychiatry.

Time for a Distinct Classification?

PP is a rare but acute and severe psychiatric illness that sets in within weeks after delivery. It is considered a psychiatric emergency, usually requiring maternal hospitalization, and is associated with high risks for suicide and infanticide if left untreated, she added.

However, if it is detected and treated in time, patients respond, with most returning to their previous functioning.

Currently, the only way to document PP within the DSM is with a specifier of “perinatal onset” for another diagnosis, such as bipolar 1 disorder (BD1) or brief psychotic disorder, said Bergink.

But the expert panel argues that the “perinatal onset” specifier inaccurately describes the timing of illness onset and could result in a clinician missing PP and negative outcomes for the patient and/or the child, including death. 

Instead, the expert panel recommends that PP be classified as part of the bipolar disorders chapter of the DSM, citing evidence that PP falls within the bipolar spectrum. 

Postpartum women with a first psychosis episode have around a 50% risk of developing BD1, and women with BD1 are 37 times more likely to be readmitted to the hospital for psychiatric reasons in the postpartum period compared with women without BD1, Bergink said. In addition, standard BD treatment — lithium and electroconvulsive therapy (ECT) — is similarly effective for PP.

“We recommend classification within the bipolar disorders chapter of the DSM because recognition of PP as part of the bipolar spectrum will improve clinical outcomes and facilitate evidence-based treatment,” the authors wrote.

“This is particularly important for women who present with postpartum depression with psychotic features or psychosis without mania, who are currently not recognized as having a bipolar spectrum disorder,” they added.

New Diagnostic Criteria Proposed

The expert panel has also proposed new criteria for a diagnosis of PP in the DSM, including: 

• Onset of at least one of the following five states within 12 weeks of childbirth, lasting at least 1 week and present most of the day, nearly every day, or any duration if hospitalization is necessary:
  • Mania/mixed state
  • Delusions
  • Hallucinations
  • Disorganized speech or formal thought disorder
  • Disorganized, confusional, or catatonic behavior
  • Depression with psychotic features
• The episode is associated with an unequivocal change in functioning that is uncharacteristic of the postpartum period.
• The disturbance in mood and the change in functioning are observable by others.
• The episode is sufficiently severe enough to cause marked impairment in social functioning and in the care of the baby or to necessitate hospitalization to prevent harm to the patient, baby, or others.

Currently, most patients presenting with these symptoms are misdiagnosed with a wide range of other psychiatric disorders, resulting in “misinformed treatment that has contributed to increased morbidity and mortality,” Bergink said.

Bergink and colleagues said they have been working with the American Psychiatric Association and the DSM steering committee on the issue and are committed to continuing to work toward a solution that promotes more accurate diagnosis and treatment. 

“Doing so carries the potential to 1) improve the quality of treatment and outcomes for women with PP, and 2) prevent the tragic outcomes of suicide and infanticide,” they wrote.

Treatment Recommendations

Although standard treatment for both BD and PP is lithium and ECT during the acute episode, there should be different approaches for each disorder when it comes to prevention and long-term management, Bergink said.

Management of BD1 involves a lifelong risk of manic and psychotic episodes, whereas management of PP should focus on full recovery in the first year postpartum and prevention for the subsequent postpartum period, she noted.

An evidence-based proposed treatment algorithm, which Bergink co-authored, recommends a combination of antipsychotics and lithium or ECT in the acute phase of the illness, followed by maintenance therapy with lithium for relapse prevention and prophylaxis. 

Her group also published a study showing full remission rates in 98% of 64 patients with PP after a treatment protocol involving benzodiazepines, antipsychotics, and lithium. Patients maintained on lithium had a lower relapse rate at 9 months than those on antipsychotics. 

“We stop lithium or taper it after 1 year, and most women remain completely stable with no medication; they only get sick again after another childbirth if they do not get prevention, and we can prevent it by starting prophylactic medication immediately postpartum,” Bergink said.

Treatment Instead of Punishment

Margaret Spinelli, MD, a perinatal psychiatrist and clinical professor of psychiatry at Columbia University Vagelos College of Physicians and Surgeons in New York City, was not part of the expert panel but said she has been advocating for the same diagnostic distinction for many years.

“It would encourage treatment instead of punishment,” she told Medscape Medical News. “I have evaluated more than 30 women who committed infanticide. Not one was diagnosed properly.”

Spinelli said she has testified in court in many cases, pressing for treatment in lieu of punishment. 

While treatment is the usual recommendation under infanticide laws in the UK, Canada, Australia, and more than 20 European countries, the US is different, she said. 

“In the United States, the lack of a formal diagnostic label for women charged with murder may initiate a life sentence in prison,” she said.

“Without the distinctive diagnosis, the DSM cannot provide clinical utility, a top priority of the DSM to help clinicians communicate, select effective interventions, and predict course, prognosis, and treatment.”

DSM Response

Asked for comment, Kimberly Yonkers, MD, a representative of the DSM-5 steering committee and chair of psychiatry at the University of Massachusetts Chan Medical School/UMass Memorial Medical Center, Worcester, Massachusetts, acknowledged receipt of the expert panel’s recommendations.

However, she said that PP is already recognized as a distinct, but not codable, category in the DSM-5-TR, meaning that a major depressive disorder with onset within 4 weeks of delivery will be given a specifier of “perinatal onset.”

“But the most rigorous request that can be made is for a new diagnosis, and that’s what this group is asking, and the requirements for a new diagnosis are extremely rigorous,” Yonkers said. “There are going to be stakeholders that fall on both sides of the point here. And I think it’s incumbent upon the DSM group to be very cautious with the changes that we make.”

There are pros and cons to making PP a distinct diagnosis, she said. 

“For example, if someone has a diagnosis of bipolar disorder and they relapse after delivery, and they’re given a diagnosis of postpartum psychosis instead of bipolar disorder, will a clinician take them off their lithium?” she asked.

Alternatively, if illness onset occurs in the postnatal period and a patient becomes psychotic, it’s unclear if a PP diagnosis is helpful, Yonkers said. 

“Maybe. I’m not coming down on one side or another, but I’m just saying that these are some of the issues,” she said.

Bergink said her group has tried to emphasize to the DSM committee that specifiers fail to capture the full spectrum of PP.

“A psychotic episode postpartum does not fit into the current categories in the psychotic chapter, and a depression with psychotic features postpartum does not fit into the current category ‘depression,’” she explained.

The current bipolar peripartum specifier also leads to reduced incidence of bipolar disorder diagnosis in the peripartum period, Bergink added. 

“In addition to our clinical experience of patients being misdiagnosed, we found the odds of getting a first bipolar diagnosis (all bipolar codes) around childbirth are more than two times lower than at other times in age-matched women,” she said.

DSM is processing the request, Yonkers said. Any change in the DSM, especially adding a new diagnosis, is a very thorough process, with multiple steps and checks, by multiple committees, the public, as well as the APA’s Assembly and Board of Trustees, she added.

The work was funded by the National Institutes of Health. Bergink, Spinelli, and Yonkers declared having no conflicts.