Mental illness after childbirth

Professionals tend to refer to this group of illnesses as "puerperal psychoses". "Puerperal" means the six weeks after having a baby and "psychosis" a serious mental illness. So "Puerperal psychosis" means a serious mental illness, developing in a woman shortly after she has given birth. This is often a shock, because there is no obvious reason why it should happen - it's not that the baby was unwanted, or that the pregnancy or birth were complicated or, as a rule, that there is anything wrong with the baby.

Puerperal psychosis is rather rare and happens after only 1 in 500 births. It has been recognised for centuries - since the days of Hippocrates, the Greek physician who practised thousands of years ago. A woman is most likely to be affected if she has already experienced such an illness previously, or if someone in her family has suffered a mental illness, serious enough to have involved psychiatric treatment.

It used to be thought that puerperal psychosis was a special mental illness, unlike those occurring at other times. However, it is now recognised to be manic-depression or schizophrenia - although somewhat altered by the baby's presence.

Mania
A mother suffering from mania will be full of energy and confidence, even if she has never had a baby before. She will not rest, will tend to stay up all night, and will eat little, even though she is so active and talkative. She will tend to neglect her baby because she feels that she has so many other things to do - shopping, making plans, rearranging her home and her life. Though mostly cheerful and amusing, she may become very irritable if her unrealistic plans and impulses are - as is almost inevitable - thwarted. Both she and her baby are at serious risk of neglect.

Depression
A seriously depressed mother is very different. She will be deep in misery, to the point of despair, and have little energy or initiative, although she may be restless with frantic agitation.

Feelings of guilt, wickedness and worthlessness are common, as is the feeling that other people think this of her. She will eat very little and sleep poorly, with a tendency to wake up early in the morning (often at about 3am) feeling at her absolute worst. Not surprisingly, she may be suicidal. Rarely, a mother will kill her baby as well as herself. The law on infanticide recognises that a woman who kills her baby within a year and a day of giving birth may be mentally ill.

Schizophrenia
Schizophrenia is a remote dreamy state in which a mother's thoughts and feelings are muddled. She may believe that everything that happens around her, is in some special way connected with her.

She may hear voices talking to or about her and her baby, and believe that her baby is strange - a changeling, or the devil, or even a new Messiah. She may feel that she is under the influence of others who may wish her good or harm. This mixture of muddled thinking and strange ideas can make it difficult for other people to make sense of what she says.

She may neglect her baby, or do odd things with it, or she may be fiercely protective, shielding it from people whom she thinks want to harm it.

These different forms of mental illness sometimes merge or replace each other - mania may be followed by depression, or schizophrenia may have manic or depressive features.

Why does it happen?

Puerperal psychosis is most likely to be due to the effect of the huge hormone changes which happen at the end of pregnancy and giving birth.

The risk of developing this illness is highest around the time of the birth - especially during the first few days afterwards. Some women seem to be born with a tendency to develop puerperal psychosis, others may be vulnerable because of earlier experiences in their lives.

Can it be helped?

This kind of mental illness is serious, but it responds very well to the proper treatment and the outlook is excellent.

The most important thing is that it is recognised sooner rather than later. This means that obstetricians, general practitioners, midwives and health visitors need to know both that psychosis happens, and how to recognise the warning signs - severe sleeplessness, extreme withdrawal or restlessness.

When a woman is going to have a baby, it is very important that she is asked if she, or any members of her family, have experienced mental illness in the past. If there is any suspicion of such an illness developing, a psychiatrist needs to become involved.

What is the treatment?

The psychiatrist is concerned with the welfare of the mother, baby and the immediate family. He or she will want to treat the mother in hospital. In some parts of the UK, it is possible to offer treatment at home - provided that the mother is not too disturbed - that is suicidal or irrational.

If possible the baby will be admitted with the mother, so that the bonding between the two is not disrupted. They might be admitted to one of the country's few mother-and-baby units, or else to an ordinary acute admission ward with a nursery facility.

Drug or physical treatment is always needed for puerperal psychosis. Speed is of the essence to ensure that the relationship between mother and baby is disturbed for as little time as possible.

The effects of psychological treatments are not usually evident for weeks, or more often months, whereas drug and physical treatments work within days or weeks.

The usual medications used are antidepressant and antipsychotic drugs. The only physical treatment is electroconvulsive therapy (ECT) which although may sound alarming, is extremely effective in severe depression and may be life-saving.

We can't just use hormones because we don't yet understand the ways in which the hormone changes work. However, they may have some effect in preventing another puerperal psychosis in women who have already suffered one.

Breast feeding is a powerful bond between mother and baby, so drugs which come through the breast milk should be avoided. Fortunately, antidepressants appear in the breast milk in such tiny amounts, they need not stop that form of feeding and ECT is no barrier at all.

However, Lithium Carbonate which is the most powerful treatment for manic depression, does come through in breast milk, so if it is needed, bottle feeding may be necessary.

How can other people help?

A serious mental illness such as puerperal psychosis, is a huge handicap to a new mother. It is important to help her in doing things with and for her baby, for example, feeding, washing, nappy changing and simple playing.

The psychiatric team will do their best to help mother and baby come together happily, whilst reducing the risk of violence or neglect.

Partners and families need support too, to stop them blaming themselves or feeling resentful, apprehensive or guilty.

Other people may also be able to give support - the extended family, the GP or other members of the primary health care team, the health visitor, the community psychiatric nurse or psychiatrist, and social worker (if there is thought to be any risk to the baby).

There are also voluntary groups, like the Association for Post Natal Illness, whose members are women who have survived puerperal psychosis or post-natal depression, and who are ready to befriend and support other sufferers.

How likely is it to happen again?

The risk of having another puerperal psychosis is at least 1 in 5 - probably greater still in the case of manic-depression. Careful supervision is needed if a woman who has had such an illness, has another baby, especially in the early days after the birth. Treatment can then be given at once if there is any sign of the illness returning. However, half the women who suffer a puerperal psychosis never become mentally ill again.

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