DOI: 10.1111/tog.

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

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

Accepted on 30 July 2012

Key content Learning objectives

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

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

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

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

ª 2013 Royal College of Obstetricians and Gynaecologists 145

 Postpartum psychosis
considered to be within 4 weeks of delivery. Despite these
issues, however, the term postpartum (puerperal) psychosis
has remained in common clinical use.
Epidemiology
Record-linkage studies estimate the admission rates to
psychiatric hospital in the postpartum as about 1–2 per
1000 births in the general population.6 However, the true
incidence rates for severe postpartum affective disorder may
be higher, as at least some women with PP are likely to be
treated at home – particularly if facilities for admission with
the baby are not available.3
There is consistent evidence of a specific relationship
between PP and bipolar disorder (BD). Women with BD
have at least a 1 in 4 risk of suffering a severe recurrence
following delivery.7 Bipolar women with a personal or family
history of PP are at particularly high risk with greater than
1 in 2 deliveries affected by PP.8
Aetiology and pathophysiology
Most episodes of PP can be considered as affecting women
with a bipolar disorder diathesis acted on by a specific
puerperal trigger.3 A number of factors have been suggested
that increase vulnerability to the puerperal triggering of
episodes of BD.
Genetic factors
There is robust evidence that the vulnerability to the
triggering of affective psychosis by childbirth aggregates in
families and may define a genetically relevant subtype of
bipolar disorder.8 Evidence from family studies suggests that
episodes of PP are a marker for a more familial form of BD9
and that a specific vulnerability to the puerperal triggering of
BD is familial.8 Evidence from a linkage study indicated the
possible location of a susceptibility gene on chromosome
16.10 Particular candidate genes, such as those involved in the
serotoninergic11,12 hormonal13,14 and inflammatory15
pathways, have also been investigated. It is hoped that
identifying the genetic factors that increase risk will lead to
more individualised risk assessment, earlier identification of
women at risk, and improved treatments for women who
become ill.
Obstetric risk factors
An increased risk of PP has been reported with a number of
obstetric factors including: primiparity; pregnancy and
delivery complications; delivery by caesarean section; having
a female baby; and a shorter gestation period. However,
findings are consistent only for primiparity.16 The bias that
women with a severe postpartum episode may be less likely to
go on to have further children is unlikely to be the sole, or even
146
the main, explanation.16 Given that there is little evidence of an
association between PP and psychosocial factors, the
possibility remains that the effect of primiparity is, at least in
part, due to biological differences between first and subsequent
pregnancies. In this regard, the overlap with other pregnancy
related disorders that also occur more frequently in first
pregnancies, such as pre-eclampsia, is of interest. Hormonal,
immunological and other biological differences between first
and subsequent pregnancies are interesting targets for further
investigation into the aetiology of PP.16
Changes in medications
Women with BD often come off mood stabilisers, such as
lithium, preconception or in early pregnancy because of
concerns over toxicity to the fetus. A survival analysis
comparing women with BD who stopped taking lithium
because of pregnancy compared with age-matched
non-pregnant women who discontinued lithium for other
reasons, reported similar rates of recurrence during the first
40 weeks after lithium discontinuation for both groups.
However, among subjects who remained stable over the first
40 weeks after lithium discontinuation, postpartum
recurrences were 2.9 times more frequent than recurrences
in non-pregnant women during weeks 41–64 (70% versus
24%).17 Thus, the increased risk of recurrence following
childbirth for women with BD does not appear to be merely a
result of stopping mood-stabilising medication.
Hormonal factors
The lack of evidence implicating psychosocial factors and
consideration of the abrupt onset during a time of major
physiological change suggest that biological, possibly
hormonal, factors are important. The role of several
hormones (including estrogen, progesterone, prolactin,
follicular stimulating hormone and luteinising hormone)
has been considered, but the evidence pointing to hormones
in the aetiology of PP remains predominantly circumstantial.
Sleep deprivation
A plausible hypothesis is that the sleep deprivation of delivery
and the immediate postpartum period is responsible for
puerperal triggering of illness.18 Sleep loss can effectively
trigger the onset of mania in people with BD and sleep loss is,
of course, common for new mothers.
Prevention
Screening for risk factors
In addition to a history of BD or PP, other risk factors for PP
include having a first-degree relative who has experienced PP
and having a first degree relative with BD.7 For women who
themselves have a history of mood disorder, particularly on
the bipolar spectrum, a family history of severe postpartum
ª 2013 Royal College of Obstetricians and Gynaecologists

episodes is very important and may indicate a risk in excess
of 50%. For women who have not suffered episodes of
psychiatric illness themselves, it is not so clear that family
history is relevant. While a risk of PP of 1–3% in such women
represents a considerable increase on the population rate of
around 1–2 in 1000 deliveries, it is unclear whether extensive
efforts to identify women who are well but with a family
history is a worthwhile strategy. These women may benefit
from the risks being discussed with them if it is something
they have identified as a concern, but it also is possible that it
may cause unnecessary worry in women who will not go on
to develop illness.
Because of the relapsing and remitting nature of BD,
women at high risk are often currently well and not in
contact with mental health services and may fail to recognise
the serious risk of their situation. Thus, all women should be
screened for known important risk factors at their antenatal
booking visit.1 Protocols should be put in place to ensure that
women at potential risk receive a formal risk assessment and
management plan.19,20
Women with schizophrenia also have an increased risk of
hospitalisation after childbirth. However, the specificity of
the childbirth trigger in schizophrenia is still controversial.21
Women with schizophrenia have a four-fold lower relative
risk of admission in the postpartum period compared with
those with BD.22 In many cases, schizophrenia is a severe
chronic illness and women are commonly admitted for
assessment of parenting or to help them to cope with the
newborn rather than for the acute onset of a new episode.21
Management of women at high risk
Women at high risk of PP need very careful care before
conception, throughout pregnancy and during the postpartum
period. The high risk of illness in the weeks following delivery
in a woman with a history of BD must be recognised both by
healthcare professionals and by the woman herself.19,20
Ethical issues
The management of women at risk raises ethical questions on
the role of the patient and her family in the decision-making
process. Ethical principles of patient-centred care provide the
foundation for the doctor–patient relationship: autonomy,
justice, beneficence and nonmaleficence.23 The clinician
should avoid paternalistic attitude, exploring and
considering the values and the expectations of the patient
and leaving the final informed decision to the woman. If the
woman wishes, family members can be involved in the
decision making process. The NICE guidelines suggest to
discuss the teratogenic risk explaining the background risk of
fetal malformations in the general population (around 2–4%)
and to describe the risk using natural frequencies rather than
percentages (for example, 1 in 10 rather than 10%).19 A
written plan covering pregnancy, delivery and the postnatal
ª 2013 Royal College of Obstetricians and Gynaecologists
Di Florio et al.
period should also be developed and discussed with the
woman and her family.19
Pre-conception
The possibility of future pregnancy should be considered in
all women with BD who are of childbearing age. Ideally the
pre-conception counselling should be conducted by a
perinatal psychiatrist,20 however, depending on availability,
other psychiatric teams or GPs can provide the necessary
information to woman. The risks of illness following
childbirth should be discussed with women and the
importance of seeking help emphasised. Decisions about
continuing or stopping medications before, or during,
pregnancy are difficult and should be the result of a
detailed and individualised risk analysis.19 Although there
are significant concerns about the teratogenic effects of the
medications used to treat BD, the risks of stopping
medication must also be considered. Data suggest that
women with BD who stopped medication during pregnancy
were more than twice as likely to experience a recurrence
than those who remained on medication.24 Data on the
teratogenicity of psychotropic agents are often controversial
and an exhaustive discussion is beyond the scope of this
review. Consistent evidence suggest that valproate should be
avoided, because of the high risk of malformations,25 and
because of negative effects on neurodevelopment.26 On the
contrary, a recent meta-analysis found no significant
association between any major congenital abnormality and
lithium.27 However, due to the wide confidence limits,
considerable uncertainty about the risk of lithium remains.
During pregnancy and after childbirth
Perhaps the most important aspect of care is to maintain
close contact and review during the perinatal period. Women
at high risk, even if they are well, should be referred in
pregnancy for psychiatric assessment and monitored
regularly for at least 3 months following delivery. The good
practice guidelines developed by Royal College of
Obstetricians and Gynecologists20 suggest that the following
scenarios are indications for referral to specialised perinatal
mental health services where available, otherwise general
psychiatry services:
 current severe psychiatric symptom
 a history of serious postpartum illness or bipolar disorder
or schizophrenia
 on complex psychotropic medications schemes.
Moreover, the guidelines suggest that referral should be
considered for those with moderate symptoms developed in late
pregnancy or early postpartum or mild symptoms and a family
history of bipolar disorder or puerperal psychosis (COG).
Psychiatric services should have priority care pathways for
pregnant and postpartum women and care by multiple
147
 Postpartum psychosis
psychiatric teams should be avoided.1 Ideally, women should be
managed by multiprofessional/multidisciplinary teams, with a
named obstetrician (possibly with special interest in perinatal
mental health), midwives, perinatal psychiatrist, community
psychiatric nurse, health visitors and GP. All communication
between maternity and mental health services should include
primary care. A written care plan should be developed in
collaboration with all relevant healthcare professionals and
recorded in all versions of the woman’s notes.19,20
It may also be important to address other avoidable factors
that may increase risk – such as decreasing general levels of
stress and paying attention to sleep in late pregnancy and the
early postpartum weeks. Liaison with maternity services
should involve discussion about how to manage the labour to
reduce the sleep deprivation that can occur if labour is
prolonged. For women with a history of BD who have been
off medication in pregnancy the introduction of prophylactic
medication in the immediate postpartum period should be
considered. Some evidence exists for the use of lithium in this
context, but the few studies have been open and retrospective
and there are practical problems with reaching therapeutic
levels quickly to cover the period of risk. These issues have
led some perinatal psychiatrists to use typical or atypical
antipsychotics as prophylaxis.3
Diagnosis of postpartum psychosis (PP)
History and examination
Although all women should be assessed antenatally for
known risk factors, such as personal or family history of BD
and psychosis, it is important to bear in mind that 50% or
more of women who develop PP have no history that puts
them in a high-risk group.3
The distinctive clinical features include sudden onset and
rapid deterioration. The vast majority of episodes have their
onset within 2 weeks of delivery, with over 50% of symptom
onsets occurring on days 1–3.28 The clinical picture often
changes rapidly, with wide fluctuations in the intensity of
symptoms and severe swings of mood. Common symptoms
and signs include:
 A wide variety of psychotic phenomena such as delusions
and hallucinations, the content of which is often related to
the new child.
 Affective (mood) symptoms, both elation and depression.
 Disturbance of consciousness marked by an apparent
confusion, bewilderment or perplexity.
Differential diagnosis
 Primary cerebral or systemic disease (such as eclampsia or
infection) should be excluded. The misattribution to
psychiatric disorder has led to a number of deaths in
new mothers.1
148
 Exogenous toxic substances or hormones: History of
therapeutic use and/or abuse of known causative
substances or hormones, other symptoms and signs
specific to the substance or substances involved should
be investigated. Urine drug screen may be positive in
substance abuse and identifies the substance taken,
although it is not definitive for drug misuse.
 Other psychiatric disorders of the puerperium: Baby blues
affects 30–80% of births and causes transient emotional
lability during the first postpartum week. The mother
typically presents mood swings ranging from elation to
sadness, insomnia, tearfulness, crying spells, irritability,
anxiety, and decreased concentration. Care of the baby is not
impaired, hopelessness and worthlessness are not
prominent, and women do not feel suicidal. It is
self-limiting, but assessment should ensure that the
woman is not and does not become more severely depressed.
 Postnatal depression (for a review see Musters et al.29).
The tendency for all postpartum episodes to be labelled
as postnatal depression can lead to suboptimal care and,
in some cases, have dramatic consequences on mothers
and babies.
Any psychotic symptoms, particularly delusions or
hallucinations, substantially increase risk for both mother
and child. The woman should be referred for a same day
emergency appointment so that a detailed risk assessment can
be carried out.
Management of women with postpartum
psychosis (PP)
Hospital admission
PP is a psychiatric emergency. The clinical picture may
mislead, quickly become extremely severe and vary
significantly from hour to hour. Admission is usually
necessary, even for women with the most supportive of
families. The NICE guidelines19 recommend that women
within a year of childbirth should be offered admission to a
specialist mother and baby unit, however, the provision of
services across the UK is patchy and for the majority of
women there is no option of admission with her baby.3
Pharmacological treatment
A range of psychotropic medication may need to be
employed. The treatment used depends on a number of
factors, including the symptoms that the woman experiences,
her level of disturbance and her previous response to
medication. For many women the severity of the illness
does not allow breastfeeding. If breastfeeding is being
considered, factors in the baby such as prematurity and
systemic illness should be considered in addition to the
particular properties of the medication itself. Limited data
ª 2013 Royal College of Obstetricians and Gynaecologists

suggest that the use of lithium during breastfeeding is not as
problematic as once thought30 but is usually avoided because
of the risk of toxicity in the baby.
Follow-up
Prognosis
The short-term prognosis for PP is generally good. However,
women need to be counselled about the risks they run of a
further puerperal or non-puerperal episode. This will include
discussing the need for longer-term mood stabilising
medication and other measures that can reduce the risk of
recurrence. Despite the high risk of recurrence following
further deliveries, many women make the decision to become
pregnant again and it is our view that women with PP, or
indeed women with bipolar disorder more generally, should
not be told that they should not have children.3
Complications
Neglect of the baby
Referral to safeguarding teams should not be routine, but
should take place as the result of a risk assessment. Extra
vigilance and care are required in these cases, as it may
increase the risk of deterioration in the mother’s mental
health, and even lead to suicide.1
Suicide or infanticide
When discussing symptoms of low mood, sensitively asking
whether the woman feels that life is not worth living and
whether she has ever thought of harming her baby enables the
clinician to assess the most serious aspects of risk. It is
important to note that asking about suicidal thoughts does
not increase, but rather is likely to reduce, the risk of a
woman taking her life.
Non-puerperal recurrences
Although there is a paucity of information on rates of
non-puerperal recurrences, Robertson et al.31 found that
following the index episode of PP, 62% of women
experienced at least one non-puerperal affective episode
during a median 9 years of follow-up.
Conclusion
Postpartum psychosis is a severe condition complicating
childbirth following approximately 1 in 1000 deliveries. In
50% of cases there is no prior history of psychiatric
disorder. In other women, however, there are clear factors –
a history of bipolar disorder or previous episode of PP –
that identify women who are at very high risk (50% or
more). Women at high risk need to be identified in
pregnancy and referred to psychiatric services for further
ª 2013 Royal College of Obstetricians and Gynaecologists
Di Florio et al.
assessment. PP is a true psychiatric emergency and it is vital
that it is recognised early and treated aggressively.
Disclosure of interests
ADF, IRJ and SS report no conflict of interest.
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ª 2013 Royal College of Obstetricians and Gynaecologists