Postpartum psychosis for carers

Postpartum psychosis (sometimes known as puerperal psychosis) is a severe mental illness.  It affects around 1 in every 1000 women who give birth ⁽¹⁾. It most often begins in the first two weeks after birth, with symptoms starting in the first few days after having a baby ⁽²⁾. A new mother can become very unwell within just a few days. See our main leaflet about postpartum psychosis.

Anyone with postpartum psychosis will need to get treatment as soon as possible. This is usually best done in hospital, ideally in a specialist Mother and Baby Unit (MBU) ⁽³⁾. See our information about Mother and Baby Units.

Some of the early signs (for example not being able to sleep) can be difficult to spot at first, but most women with postpartum psychosis become unwell very quickly.  

Someone with early symptoms of postpartum psychosis may feel ⁽²⁾:

• Excited, elated or ‘high’.
• Overactive and energetic.
• Like talking a lot
• That their thoughts are racing.
• Confused or disorientated.
• Unable to get to sleep, even when your baby is asleep, or feeling no need for sleep.
• Irritable or angry.
• Anxious, fearful, suspicious or paranoid.
• Easily distracted.
• Weakened inhibitions, behaving ‘out of character’.
• That their senses are heightened, e.g. colours looking more vivid than usual.

As the illness develops, a woman will often:

Hear, see or feel things that are not there (hallucinations), such as:

• Hearing a voice threatening her, telling her she is special, or telling her to do something.
• Seeing ‘ghosts’ or ‘spirits’.
  

Believe strange things that cannot be true (delusions), such as:

• There are messages specifically for her in the TV or radio.
• That she or the baby need to be protected from something.
• She is famous or has special powers.

Some women with postpartum psychosis can have thoughts of harming themselves or their baby.  Sometimes irritability and anger can turn into verbal or even physical aggression.

Any of these can be both frightening and upsetting. Remember that these are symptoms of your partner/relative’s illness, not her true feelings. 

It is important to seek help immediately via 999 or A&E if you believe your partner/relative, the baby or anyone else is in danger.

• A woman with bipolar disorder type I, or schizoaffective disorder, will have around a 1 in 5 (20%) risk after her first baby is born ^(4-6). 
• A woman with bipolar disorder type I, or schizoaffective disorder, who also has a mother or a sister who has had postpartum psychosis, will have an even higher risk- at least 1 in 2 (50%) ⁽⁷⁾.
• If a woman has had a postpartum psychosis before, her risk is at least 1 in 2 (50%) ^(4,6,8)
• If she has not had any past mental illness BUT her mother or sister has had postpartum psychosis the risk is around 3 in every 100 births ⁽⁷⁾.

If a woman has ever had a diagnosis of bipolar disorder, a psychotic illness, or a family history of postpartum psychosis, she should discuss this with her midwife and a psychiatrist.  

She should be able to have continuing support and advice, preferably from a specialist perinatal mental health service, during her pregnancy.  

Decisions about using medication during pregnancy, and while breastfeeding, can be difficult. It’s important to have the time to weigh up the risks and benefits, together with a partner or family.

See our main page on postpartum psychosis for more information.

Often, the family are the first people to notice that something is wrong, and they will usually tell the midwife, health visitor or GP. But sometimes people misinterpret early symptoms of elation as someone just coping very well with being a new mum. 

If it is suspected that a mother has postpartum psychosis, she should be assessed urgently (within 4 hours) ⁽³⁾ by a mental health crisis team (if at home) or a psychiatric liaison team (if in A&E or maternity hospital). A definite diagnosis of postpartum psychosis is not usually made until a woman has been admitted to hospital and seen by a psychiatrist.

The safest, and most effective, way to deal with postpartum psychosis is for the mother to come into hospital and take medication – usually antipsychotic medication. Mood-stabilisers, or other medications can also be used to reduce agitation and improve sleep ^(3,9-10).  

ECT (electroconvulsive therapy) may sometimes be suggested ⁽⁹⁾. This is a safe, effective treatment and can reduces symptoms quickly. It can be worrying for families when ECT is suggested. More information can be found on our page about ECT.

Alongside medication, a mother with postpartum psychosis will need emotional and practical support to make a good recovery.  While in hospital, she will be treated by a psychiatrist and nursing team, with support from occupational therapists, psychologists, parent-infant specialists, social workers and nursery nurses.

Your feelings

When talking to health professionals about your concerns, you may feel scared or guilty about describing what’s been happening.  Remember - the more you can tell staff about your partner/relative (and how she usually is compared to how she is now), the better they will be able to understand and support her.

Once your partner is admitted to hospital, you may feel a whole range of emotions:

• Shocked by what you have seen your partner/relative go through 
• Exhausted.
• Relieved that your partner/relative is safe.
• Guilty for agreeing she needs to be in hospital – particularly if she has needed to be Sectioned under the Mental Health Act.
• Worried about her recovery and how long it will take.
• Helpless - especially if both mum and baby are in hospital, or if you are in charge of a baby on your own, without any other support.

Postpartum psychosis can be traumatic for the whole family, so it’s not surprising that people often have these feelings. Remember, nearly all women recover completely from postpartum psychosis. Your partner/relative just needs time, the right treatment, and support from her family, friends and professionals. 

Recovery

The length of time it takes to recover from postpartum psychosis is unpredictable.  Even after the worst has passed, it can take someone several months or even longer to feel “back to normal”.

Don’t worry if your partner/relative seems anxious when she first comes home. She may need a lot of support with seemingly simple every-day decisions and tasks. In time, she will get back her confidence.

Once home from hospital, the mother will usually be supported by the community mental health team or specialist perinatal mental health team, along with her health visitor and GP. 

Working in partnership with the health care team

Family members, and the professionals caring for your partner/relative, need to communicate well.  It can be hard to feel involved in your partner/relative’s treatment when she is in hospital.

However, you are really important in her recovery. You know her best and can help the team to understand her needs and preferences. Don’t be afraid to ask the health care team for information about what treatment has been recommended, any side-effects – and anything else you are concerned about.

When you are visiting, or on the phone, make time to talk to your partner/relative’s named nurse. Ask questions and share your views about her treatment and recovery.

If you are attending a ward round meeting, take time with your partner/relative beforehand to think about what you would like to say.

Think about any observations you want to share with the team.  You might want to ask to talk to the psychiatrist separately, as well as together. This can help if you need to talk about any concerns about symptoms or treatment decisions.

Useful questions when your partner/relative is in hospital

How do I contact the ward?

• What is the best time to phone?
• When do ward rounds happen and can I attend?
• Who is my partner/relative's named nurse?

How is she finding the ward?

• Is she sleeping well?
• Is she needing support with feeding and baby care?
• Has she been able to talk to staff or other mothers?

What medications have been prescribed?

• What doses?
• Will she be able to breastfeed with the medication?
• How long might she need to stay on the medication after recovery?

What psychological support will she have?

• Is there any peer support available on the ward?
• Are there any talking therapies  available on the ward or for when she comes home?

Can she take some time off the unit?

• If not, when will her leave be reviewed?
• When might she have some periods of leave at home?
• What would help to make leave feel safe and enjoyable?
• Should I expect her to be back to her normal self when she has leave?

What is included in the care plan?

• Can I make suggestions for the care plan?
• Is there a plan for my needs as a partner/carer?

Do you have any information leaflets?

• Explaining postpartum psychosis
• Explaining medications/ECT
• Explaining other therapies

How will baby be cared for?

• Will nursery nurses be involved in baby care?
• Is the baby going to sleep in with my partner/relative?
• When can I visit and spend time bonding with the baby?
• When the baby comes home who can support and help us?

Taking care of yourself as a carer

• Don't be afraid to ask for practical support from friends or family members - helping with other children or cooking meals.
• Talk to your employer and take time off if at all possible.
• Look after your physical health:
  • Try and eat well even when you are busy and visiting.
  • Make time to rest.
  • Exercise when you can.

• Look after your own emotional health:
  • Make time to talk to trusted friends or family.
  • Seek support from organisations such as Action on Postpartum Psychosis

• Ask for a carer’s assessment through the ward or your GP. This looks at how being a carer affects you. It helps to identify any emotional and practical support you need for yourself. 

Communication with the whole family is essential when supporting a woman with a postpartum psychosis. Partners and family members are usually the first to suspect that something is wrong when the early symptoms of postpartum psychosis present. They often feel that their concerns are not heard. 

Similarly, once a woman is admitted to hospital and begins treatment, partners and family members can often feel left out, frightened and disempowered.  Working collaboratively will enable you as a professional to understand a woman in her family context. This helps to promote a recovery which can be sustained once the mother returns home.

Checklist

We hope this checklist can help to enhance good practice in work with families affected by postpartum psychosis:

In response to initial concerns about a woman's mental health do you:

• Try to see the woman and her partner/relative separately as well as together?
• Notice differences in their perceptions of what is happening?
• Try to see them at home?
• Arrange for a mental health assessment immediately if you suspect postpartum psychosis?

As a mental health professional assessing a patient, do you?

• Listen and ask questions of both the woman and her partner/relative?
• Take time over a number of sessions to obtain a full history? (patient may not be well enough to understand questions fully and you may need to ask the partner/family for information).
• Leave time for questions and discussion?
• Explain what the diagnosis of postpartum psychosis means?
• Talk about recovery?

When providing care and treatment do you?

• Talk about the possible side-effects of medications?
• Consider the preferences of mothers who want to continue breastfeeding?
• Consider psychological interventions to support bonding and recovery?
• Spend time asking about the partner/relative's health - physical and emotional?
• Discuss how to meet the health needs of the woman, baby and the partner/relative?
• Discuss the risk of postpartum psychosis for future pregnancies?

Points to remember

• Signpost all families affected by postpartum psychosis to organisations which can offer information and support such as Action on Postpartum Psychosis
• Make sure families know who the named professional is, and how to contact that person at any time.
• The woman may not take in all the information she has been told about postpartum psychosis when she is very unwell.  You should discuss this again when she recovers.
• It’s helpful to tell women and their families that most women fully recover from postpartum psychosis and can look after their babies.

Action Postpartum Psychosis Network - A network of women across the UK who have experienced postpartum psychosis. They aim to increase public awareness and promote research into the condition. Run by a team made up of academics, health professionals and women who have recovered from postpartum psychosis. Tel: 020 3322 900; email: app@app-network.org

Bipolar Education Programme Cymru - Information about pregnancy and childbirth for women with bipolar disorder, including an online interactive module. Email: info@ncmh.info

Further Reading

The following are personal accounts of postpartum psychosis which some women, partners, friends and family may find helpful:

Eyes without Sparkle by Elaine Hanzak

Saving Grace: My journey & survival through postnatal depression by Grace Sharrock

Out of me: the story of a Postnatal Breakdown by Fiona Shaw

Understanding Postpartum Psychosis: A Temporary Madness by Teresa Twomey

Hillbilly Gothic: A Memoir of Madness and Motherhood by Adrienne Martini

1. VanderKruik R, Barreix M, Chou D, Allen T, Say L, Cohen LS. VanderKruik et al. The global prevalence of postpartum psychosis: a systematic review. BMC Psychiatry. 2017; 17:272
2. Heron J, McGuinness M, Blackmore ER, Craddock N, Jones I. Early postpartum symptoms in puerperal psychosis. BJOG 2008; 115: 348–53.
3. National Institute for Health and Care Excellence (2014) Antenatal and postnatal mental health: Clinical management and service guidance. NICE Guidelines CG192. www.nice.org.uk/ guidance/CG192
4. Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet. 2014; 384: 1789-99.
5. Di Florio A, Forty L, Gordon-Smith K, Heron J, Jones L, Craddock N, Jones I. Perinatal Episodes across the Mood Disorder Spectrum. JAMA Psychiatry. 2013;70:168-75.
6. Wesseloo R, Kamperman AM, Munk-Olsen T, Pop VJ, Kushner SA, Bergink V. Risk of Postpartum Relapse in Bipolar Disorder and Postpartum Psychosis: A Systematic Review and Meta-Analysis. Am J Psychiatry. 2016;173:117-27.
7. Jones I, Craddock N. Familiality of the puerperal trigger in bipolar disorder: results of a family study. Am J Psychiatry. 2001;158: 913–17.

This information was produced by the RCPsych Public Engagement Editorial Board.

The ‘Building Capacity, Psychiatry Leadership in Perinatal Mental Health Services’ project: commissioned by NHS England in partnership with Health Education England and delivered by the Royal College of Psychiatrists.

• Service users and carers: Naomi Gilbert and Action on Postpartum Psychosis.
• Series Editor: Dr Phil Timms  
• Series Manager: Thomas Kennedy
• Expert review: Dr Bhanu Chadalavada, Prof. Ian Jones and Dr Lucinda Green