Five weeks after giving birth, a woman arrived at The Motherhood Center in New York City, a clinic specializing in perinatal mental health. The woman seemed composed, but Catherine Birndorf, MD, noticed subtle warning signs: guardedness, emotional distance, and creeping paranoia. The patient’s family told Birndorf that something seemed off, but assumed it was the exhaustion because of the upheaval of early motherhood.

Beneath this patient’s otherwise coherent presentation was postpartum psychosis, a severe psychiatric emergency that can include delusions, paranoia, and mania.

Recent high-profile cases of postpartum women killing their children, including episodes in the Boston suburbs and New York City, have intensified a focus on the condition. But postpartum psychosis often waxes and wanes, making early recognition difficult. Many patients with perinatal mental health conditions, postpartum psychosis included, might conceal their symptoms because of stigma or fear of losing custody of their children.

“Most patients could be hiding in plain sight,” Birndorf said. But “if you can identify them, if people have access to the care they need, which is no small thing, and if you have an expert knowledgeable enough, we can treat these things and prevent really poor outcomes.”

While postpartum depression or anxiety affects roughly 200 in 1000 women, postpartum psychosis occurs in an estimated 1 to 2 per 1000 births among those without prior psychiatric history. The risk is far higher in women with bipolar disorder.

Clinicians, psychiatrists included, receive limited formal training in maternal mental health. Further complicating a clinician’s ability to spot cases is a lack of a diagnosis code or criteria.

Last year, an international panel of experts recommended adding the disorder to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the International Classification of Diseases.

Without criteria and diagnosis, there is “no way we can accurately investigate it or report on it; we only know it when we give it a label, and then we can start counting,” said Veerle Bergink, MD, PhD, director of the Women’s Mental Health Center at the Icahn School of Medicine at Mount Sinai in New York City, who advocates for formal recognition of the condition.

But like all mental health conditions, the condition is highly treatable when identified promptly.

The Presentation

Postpartum psychosis is a medical emergency. Left untreated, it can become severe and debilitating, causing distress for patients and their loved ones, disconnection between mothers and infants, and introducing risk for extreme exhaustion and self-neglect. While most women with the condition do not die by suicide or harm their children, most cases of infanticide do occur in those who have postpartum psychosis. Women with the condition have a 5% risk for suicide. While the risk for infanticide has been reported at 4%, Bergink suggested the figure is actually less than 1%.

But the first symptoms of postpartum psychosis often present in the first days to weeks after delivery, which can include subtle signs like irritability, mood swings, or acting out of character.

More severe symptoms include auditory or visual hallucinations or delusions, sometimes with religious themes such as believing a baby is possessed by the devil. Birndorf said patients can develop a fixation or fear that something is wrong with their baby, which might include a specific body part like the nose.

Patients sometimes become consumed and search out clinicians to corroborate these worries, Brindorf said.

Birndorf said, some of her patients with the condition present with “catatonia or blankness.” 

Those with the condition can also fluctuate between moments of lucidity and moments of psychosis. Symptoms such as insomnia or withdrawal may be written off as typical for new mothers when they are instead signs of a serious psychiatric illness.

“Close attention to the mother prior to discharge from the hospital and at the early pediatric follow-up visits can be crucial times for care providers to recognize that something may be amiss,” said Kara Brown, MD, a reproductive psychiatrist and founder of NOLA Reproductive Psychiatry in New Orleans.

Most women with postpartum psychosis also have some form of mania, which can fluctuate with depression, Bergink said.

“One moment they’re over the moon, the other moment really low in mood, or even at the same time,” she said. “Their thoughts tend to go faster. They think the rest of the world is too slow.”

Screening and Solutions

Identifying the condition in clinical practice can be complex in part because of a lack of robust screening tools.

The American College of Obstetricians & Gynecologists recommends all pregnant patients be screened for mental health conditions during, including after birth. Yet data suggest fewer than 20% receive assessment.

The traditional screening tool, the Edinburgh Postnatal Depression Scale, may fail to identify mothers with postpartum psychosis, as it was designed for depression and does not include questions about mania or delusions. The Mood Disorder Questionnaire can be used to screen for bipolar disorder, including mania, Birndorf said.

Spotting delusions or hallucinations requires that clinicians act as “investigators,” said Camilia L. Arnaudo, MD, assistant professor of clinical psychiatry at Indiana University School of Medicine in Bloomington, Indiana.

“Don’t assume it’s only depression,” she said. Clinicians can ask questions such as, “Are you having any unusual thoughts or fears that you hadn’t experienced before since having the baby?”

Bergink encouraged clinicians to educate themselves on the difference between psychotic beliefs and intrusive thoughts, the latter of which are unwanted and distressing to a mother and in conflict with a person’s sense of self or values.

A new parent with an intrusive thought of stabbing her baby might report being terrified by these thoughts and hide all the knives in her house. These thoughts do not reflect a loss of reality. Some studies suggest that 70% or more of new mothers report intrusive thoughts.

Psychotic thoughts or delusions are, on the other hand, grounded in a distorted sense of reality. A mother experiencing postpartum psychosis may believe and explain within a delusional framework that harming her baby is a logical action.

Clinicians should pay special attention to their pregnant patients with bipolar disorder, who have a 1 in 6 risk for developing postpartum psychosis.

Onouwem U. Nseyo, MD, an ob/gyn at Sutter Health in Berkeley, California, said ob/gyn need to have “frank conversations” around psychiatric history, particularly with those with a history of bipolar disorder. They should also discuss risk factors and interventions to lower the risk with patients.

“There’s so much power in how we [as clinicians] frame things,” she added. “We can really shift from something feeling like a closed door where you have to barge through vs an open door where you can ease your way in when you feel ready to share,” Nseyo said.

Clinicians should also ask to speak with family members or friends to better understand the patient’s symptoms and to provide psychoeducation. Partners and loved ones often notice behavioral changes in these patients.

Nseyo said she typically has an early postpartum visit between 1 and 3 weeks following birth. Paired with early mental health screening throughout pregnancy to identify at-risk patients, this can make a “huge difference” in patient outcomes, she said.

Clinicians should also pay special attention to women of color. While race-specific statistics on postpartum psychosis are sparse, Black women are twice as likely as White women to experience perinatal mental health conditions. They are also half as likely to receive treatment.

These inequities extend to survival itself, too. T wo-thirds of pregnancy-related deaths occur in the year postpartum, with mental health as the top complication of birth. Black women die from pregnancy-related causes at more than three times the rate as White women, a gap that has widened even as overall maternal mortality declined.

“Women of color frequently are overlooked in healthcare settings, and so standardized approaches to evaluating women are crucial for helping to close gaps in diagnosis and treatment,” Brown said.

Treating Postpartum Psychosis

Physicians should refer patients they have identified for immediate evaluation, often to the nearest emergency department, and to a reproductive psychiatrist if available.

Brown said, she wants her colleagues in obstetrics and pediatrics to know that they “don’t need to do everything on their own,” and can request a psychiatry consult.

Developing a local resource guide of perinatal mental health clinicians can also help patients access care. Physicians in under-resourced areas can tap a comprehensive database of clinicians trained in the condition and access educational and training opportunities. Many states also have their own perinatal hotlines that allow clinicians to consult with specialists.

Women with bipolar disorder or a history of postpartum psychosis can be medicated in pregnancy or immediately following birth in an effort to prevent or to treat postpartum psychosis. Second-generation antipsychotics (SGAs) like olanzapine or quetiapine are relatively safe during pregnancy and breastfeeding, Birndorf said.

“We often medicate with lithium and an SGA depending on someone’s illness, current symptoms, previous illness, and when it presented,” she said.

Postpartum psychosis also carries a high risk for recurrence in future pregnancies, so ongoing psychiatric care is critical. Sometimes clinicians also diagnose bipolar disorder as a result of catching postpartum psychosis.

Other steps can be taken to mitigate risk, including constructing a postpartum plan. This might include a plan for sleep and having patients check in more often with a therapist postpartum.

“Best case scenario a couple months after having a baby, someone will be feeling really good and have their village, but realistically, most people are going to need that support — and it’s way harder to ask for that help when you’re in the trenches,” Nseyo said.

Cassie Shortsleeve is a freelance journalist.