Introduction

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 commonly takes the form of mania, severe
depression, or a 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 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 the main, explanation.16Given 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
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.21Women 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 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 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
 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.

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 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 assessment. PP is a true
psychiatric emergency and it is vital that it is recognised early and treated
aggressively