‘They are like puppets’: What to know about postpartum psychosis

The pregnancy and postpartum period is defined by changes – many of them invisible.

“Being pregnant is stressful, physically and psychologically,” says Dr Giles Berrisford, a consultant psychiatrist who provides perinatal care in Birmingham, England, and Abu Dhabi, United Arab Emirates.

Women are at a greater risk of mental illness during late pregnancy and the first year postpartum than at any other time in their lives. One in eight new mothers will experience postpartum depression, with symptoms including extreme sadness, insomnia and social withdrawal that can emerge in the first year after giving birth.

Postpartum psychosis is considerably rarer – it affects between one and two women per 1000 births worldwide. Some experts say the number may be higher, however, as women are often misdiagnosed.

“The consequences of missing a diagnosis of postpartum psychosis can be serious. Both the mum and children are at high risk of harm,” says Wendy Davis, the executive director of the nonprofit Postpartum Support International.

Postpartum psychosis is rare, but not as rare as many people might assume.Credit: iStock

What is postpartum psychosis? And what are the signs?

The condition affects expectant or new mothers up to one year after they give birth. Symptoms often begin within two weeks of childbirth – sometimes, just hours after – but can also develop months later.

Postpartum psychosis is characterised by hallucinations and delusions that cause women to disconnect from reality. The symptoms can vary: some women might be high-energy, talking faster than usual or staying awake for days. Others might feel depressed and disconnected from their baby.

Symptoms often come and go. A woman might see or hear something that isn’t there, only to appear completely normal a few minutes later.

In some cases, a woman with postpartum psychosis may have thoughts of harming herself or her baby. These can include what are known as command hallucinations, where a woman hears powerful voices that instruct her to perform a specific action. In rare cases, when women do not receive proper treatment, they may act on these thoughts.

“These delusions take over their mind and their body,” says Dr Margaret Spinelli, a clinical professor of psychiatry at Columbia University who has evaluated more than 30 women who were on trial for killing their children while experiencing postpartum psychosis. “They are like puppets.”

Many new mothers without mental illness will have intrusive thoughts about accidentally harming their babies. This is normal, says Berrisford, and it might even help us stay alert to potential dangers. But if the thoughts become debilitating, or a woman reports hearing a voice telling her to act on them, they warrant immediate medical attention, experts say.

What causes it?

Postpartum psychosis is thought to be triggered by a combination of the hormonal and immunological changes that accompany childbirth, as well as genetics and environmental factors such as sleep deprivation.

Research shows that women with a personal or family history of bipolar disorder are at much higher risk of developing postpartum psychosis. It can be the first presentation of bipolar disorder that endures beyond the postpartum period.

But some research suggests about two-thirds of women with postpartum psychosis have no prior psychiatric history. That is why it’s important for family and friends to pay attention to the behaviours of new mothers, especially in the first weeks after giving birth, experts say.

How is it treated?

Postpartum psychosis requires emergency care. With proper treatment, women can recover fully. One study of women with the diagnosis found that nearly all participants achieved remission.

In the majority of cases, psychiatric hospitalisation is required to protect the health of both the mother and the baby.

Many experts consider mother-and-baby units, or MBUs, which allow mothers and babies to remain together under careful supervision, the gold standard of care for postpartum psychosis. Women can stay for months if needed in these inpatient wards, which are found in Australia, as well as Britain, France, India and other parts of the world. One study of mothers with severe postpartum psychosis who were admitted to an MBU – most of them involuntarily – found that all of them had improved by the time of discharge, and all left with custody of their child.

One of the first goals of treatment in any type of facility is to help new mothers catch up on sleep, as doctors believe that sleep deprivation can trigger psychosis. Most women also receive medication. Research has shown that electroconvulsive therapy, or ECT, can effectively treat severe cases.

Davis says there are three things she tells any woman experiencing postpartum psychosis: “You’re not alone, you’re not to blame, and with help, you will get well.”

The New York Times

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