Postpartum Psychosis Is Not Rare: The Signs Every Perinatal Provider Needs to Know
Postpartum Psychosis: The Signs Every Perinatal Provider Needs to Know
Postpartum psychosis has received more media attention in recent weeks than ever before. With that attention has come a lot of worry, fear and questions, from families and from the professionals who support them. And while visibility matters, what matters most is that providers can recognise the signs and act quickly when it counts.
Here we will unpack the myth that postpartum psychosis is "rare," explore why it is a complication of pregnancy and never a personal or moral failing, and walk through the key signs that often get overlooked, from changes in sleep and mood to confusion and paranoia. We also look at delusions and hallucinations, what you might actually hear from a client or their family, and why this is a psychiatric emergency that needs immediate action.
This article is for every provider who wants to feel more confident recognising postpartum psychosis, even if it's something you may only encounter a handful of times in your career. There is a lot of nuance here, and this is just the beginning of the conversation, but it's an important place to start.
In This Episode We Cover:
Why postpartum psychosis is less common, but not rare
Postpartum psychosis as a complication of pregnancy, not a choice or a moral failing
The often overlooked signs: sleep changes, shifting moods, acting out of character, confusion and paranoia
Understanding delusions and hallucinations
What you might hear from a client, or from their family
Why postpartum psychosis is a psychiatric emergency, and what to do next
A helpful discussion tool from Postpartum Support International
Resources + Links
Postpartum Support International Postpartum Psychosis Discussion Tool
FREE PMADs Training: Symptoms and Screening for Perinatal Mood and Anxiety Disorders
Postpartum Psychosis Is Not Rare: The Signs Every Perinatal Provider Needs to Know
Postpartum psychosis is being talked about now more than I can ever remember. And in my community and with my students, I'm hearing so much worry, concern and fear, alongside a real desire to understand it better.
I want to acknowledge from the start that there is far more nuance here than I can fit into one article or one episode, and we will come back to this topic and give it the time it deserves. But right now, I want to offer a more accurate, more nuanced understanding of what postpartum psychosis is, break apart some of the myths, and share what to keep your ear out for so you know when a referral is needed.
"It's Rare" Is a Myth
We often hear that postpartum psychosis is rare, and I'll be honest, that always gets under my skin. Because it isn't particularly rare.
It is less common than the other perinatal mood and anxiety disorders. We typically say it affects one to two in every thousand births. But think about how many births happen in a day, a week, a month, a year. That number becomes quite large very quickly.
What "less common" means for us as providers is that we might go our entire career without having someone in our care who experiences psychosis. Or, depending on our setting, it might happen fewer than a handful of times. But that doesn't mean we don't need to be able to identify it. Postpartum psychosis is a psychiatric emergency. We need to recognise the signs quickly and connect someone with emergency care as soon as possible, so that we can keep them, their family and everyone around them safe and well.
What Is Postpartum Psychosis?
Postpartum psychosis is a complication of pregnancy, in the same way that hyperemesis or a postpartum haemorrhage are complications of pregnancy. It is not a choice. It is not a moral failing. It has absolutely nothing to do with how that person feels about or is experiencing their transition to motherhood.
We know that certain psychiatric conditions make postpartum psychosis more likely. But we also know that people who don't meet criteria for any of those conditions can experience psychosis anyway. There is no single "type" of birthing person who will experience postpartum psychosis. It can truly happen to anyone, which is why we need to keep an eye out for it with every client we support.
The Signs That Often Get Overlooked
When we talk about postpartum psychosis, the conversation often jumps straight to hallucinations and delusions. We'll get there. But I want to start with some of the other signs that don't get as much attention, and which you may be more likely to see or hear about.
Sleep changes. One of the key indicators is an inability to sleep, or a feeling of not needing to sleep. "When I lie down, I just can't fall asleep." A person may feel tired, but not nearly as tired as you'd expect after long stretches without sleep. They may even feel energised: "I've been surprised to find that as a new mum, I don't actually need as much sleep as I thought."
This is tricky, because onset is most common in the first days and weeks after birth, with the first month being the most common time. And sleep is hard to come by then for everyone. So we look at the "why" behind why they are not sleeping. If a parent has a very colicky baby keeping them up all night, and they go straight to sleep the moment they get the chance, baby is the barrier to sleep. That's a completely different picture. But if they have ample opportunity to sleep and still can't get their body to rest, that's a key indicator.
Shifting moods. We often hear this described as waxing and waning, or mood lability. A person might feel anxious and overwhelmed one moment, euphoric and delighted the next, and then low and depressed. There can also be periods where they show up very much like themselves.
Psychosis affects insight, our ability to check our own behaviour and recognise whether it's normal for us. So even when someone seems more like themselves, they may not recognise that they were just acting very out of character.
Acting out of character. This is another core sign, and it's often noticed by family members, support people or professionals rather than the individual themselves. "Something's not quite right. They're not acting like themselves." A family member might say, "I can't put my finger on it." They may wonder whether this is just what their loved one is like as a new mother. But there's an uneasy sense that something has changed. It's very easy to brush this off as "just new motherhood" or "just tired," and that is exactly why we need to take it seriously.
Confusion. Look for difficulty tracking time, days or events. The timeline doesn't quite make sense, they struggle to recall what has happened, or they seem easily confused.
Paranoia. Anxiety may be very high, but this goes beyond anxiety. There's a sense that someone is out to get them, that someone is going to take their baby, or that a person they previously trusted is no longer trustworthy.
Delusions and Hallucinations
These are the core features of psychosis, and they're often the symptoms that people protect or keep hidden. That's another reason the signs above are so important.
Delusions are strongly held beliefs that a person cannot be talked out of. They might see specific, tangible patterns or connections: colours mean something, a song on the radio is speaking directly to them, the pattern of traffic is sending them a message. When someone points out that it doesn't make sense, they cannot be dissuaded.
Delusions can also involve long and elaborate stories. Their baby was switched at birth, isn't theirs, or has changed in some way. Their baby has a special purpose, or they do as their mother. They may believe they or their baby have new special abilities, such as being able to sense or change the emotions of people who walk into the room, or to communicate with people who aren't there. To you, these beliefs just won't make sense.
Hallucinations are experiences of something that isn't happening in reality, but that feels completely real to the person. They cannot tell the difference between reality and the hallucination.
Hallucinations can hijack any of the five senses. Most commonly, people hear things that aren't there: someone in the next room, voices coming from the radiator, their baby crying when baby is quiet, or voices giving commands. They may also see things that aren't there.
Sometimes hallucinations are distressing, such as images of their baby being hurt, of a disaster unfolding, or of blood dripping down the walls. But they aren't always frightening. Someone might see angel wings on themselves in the mirror, or see their face morph into their mother's and find great comfort in it. Hallucinations can also involve taste, smell and touch, feeling, smelling or tasting things that aren't there.
What You Might Hear
So what might this actually sound like in the room?
You might hear "I just can't sleep," or "I don't need to sleep." You might hear some of those delusions: baby was switched at birth, baby is special in some way. Interestingly, there is often a religious or spiritual element, which can stand out as particularly out of character for someone who isn't usually religious or spiritual.
You'll hear the paranoia. "My partner is having an affair, I just know it." "My mum secretly wants to hurt the baby." "The neighbours are planning a break-in." There's a sense that something doesn't add up. You may hear about hidden messages, and there will often be a lot of confusion.
You might also hear stories of behaviour that isn't like them: reckless spending, reckless driving, or an argument with a family member that just doesn't fit.
And it's important to know that it may not be the individual who shares these things with you at all. Very often it's the people around them who reach out and say, "Something's wrong. I can't put my finger on it, but I don't think this is how it's supposed to be."
How We Keep Our Ears Open
It starts with what you're doing right now: gathering information from reputable sources, expanding your training and knowledge, and building the confidence and competence to recognise what you're seeing.
One tool I really recommend is Postpartum Support International's postpartum psychosis discussion tool, linked in the resources above. It isn't a screening tool. We don't currently have a validated screening measure for perinatal or postpartum psychosis. But it's a great starting point for the questions you might ask someone you're concerned about, or ask their family member. When we know what to ask, we're much more likely to catch psychosis and take immediate action.
This Is a Psychiatric Emergency
Postpartum psychosis is a medical and psychiatric emergency. That means we need to get the person into care immediately. We are not scheduling an appointment for next week, arranging a follow-up, or waiting to see how it goes.
That might mean a trusted person or emergency contact takes them to emergency services. It might mean contacting their medical provider for an urgent appointment, reaching their psychiatrist if they already have one, or connecting with crisis services.
It's also important to know that the person may not want to go. Because of the loss of insight that comes with psychosis, they may not believe anything is wrong or recognise that they're acting out of character. Sometimes that means taking steps to make sure they are connected with care even when they don't want to be, such as calling an ambulance or finding a supportive way to get them to emergency care. At this point, we are focused on the best possible actions to support someone in a psychiatric crisis.
We Are One Leg on the Table
No individual provider can care for postpartum psychosis alone. This is a condition that needs a lot of legs on the table. We get to be one of them. But our job, as soon as we notice psychosis may be present, is to bring in the other legs, and specifically someone who can carry out an assessment, make a diagnosis, clarify what's happening and plan next steps. That might be emergency services, a psychiatrist, or a perinatal or reproductive psychiatrist wherever possible.
Our entire job in that moment is to get those legs on the table.
Bringing It Into the Room
You may only meet postpartum psychosis a handful of times in your career, if at all. But when you do, recognising it quickly can make an enormous difference for that person and their family.
Keep your ear out for the quieter signs: changes in sleep, shifting moods, acting out of character, confusion and paranoia. Listen to the concerns of family members. And remember that this is an emergency that calls for immediate action and a team around the table.
This is only the beginning of the conversation, and we will return to it. But if you can carry a little more confidence and competence in recognising postpartum psychosis into your next appointment, then this episode has done its job.
Want to Go Deeper?
If you'd like to build your confidence recognising and responding to perinatal mental health conditions, these are a great place to start:
Introduction to Perinatal Mental Health: a strong foundation for anyone supporting families through pregnancy and postpartum.
Take our FREE PMADs Training: Symptoms and Screening for Perinatal Mood and Anxiety Disorders
This article is based on episode three of Perinatal in Practice: Supporting Providers Through the Entire Perinatal Arc. Each week we take one piece of the puzzle and work through it together.
If you find it useful, please subscribe so you don't miss the next piece of the puzzle, and share it with a colleague who is also part of someone's village. You can't pour from an empty cup, and your village really needs you well.
