Postpartum Psychosis: Who Is Most at Risk?

The trial of Lindsay Clancy, a former nurse who killed her three kids, has brought renewed attention to the most tragic outcomes of postpartum psychosis. However, an expert told MedPage Today that postpartum psychosis is a complicated condition with a continuum of severity, and one group in particular has heightened risk.

Nancy Byatt, DO, MS, MBA, a perinatal psychiatrist and professor at the UMass Chan Medical School in Shrewsbury, explained that postpartum psychosis occurs in 1 to 2 per 1,000 births.

“The pregnancy and postpartum periods are a time of risk for mood and anxiety disorders in general,” she said, as this time is full of intense physiological and hormonal changes. It’s important to pay attention to when new symptoms occur within the perinatal period, since different time periods are associated with different physiological changes.

“A lot of times when we see postpartum psychosis, we see it in the context of bipolar disorder,” she said, adding that it can still occur in people with any mood disorder or without a psychiatric history. However, she emphasized that “there’s a particular risk with bipolar disorder.”

So when clinicians see a pregnant person with a personal or family history of bipolar disorder, it’s important to monitor them more closely for the development of postpartum psychosis. Typically, bipolar disorder is chronic, but some people develop it during pregnancy or postpartum and don’t go on to have it long-term.

Byatt encouraged clinicians to focus on asking questions about symptoms, like sleep quality or racing thoughts, and the patient’s feelings about themselves and their baby before diving into touchier subjects.

While shocking and disturbing, it’s actually quite common for new parents to have intrusive thoughts of harming their baby in the perinatal time period — even if they do not actually want to, Byatt said. These thoughts can stem from several conditions, like depression, anxiety, or obsessive compulsive disorder (OCD).

For example, Byatt said, a patient 1 month postpartum could report having intrusive thoughts of throwing their baby down the stairs. They might tell their doctor that they’re terrified of doing it and that they can’t get rid of the thoughts and have been avoiding stairs. Importantly, this person has the insight that they don’t actually want to do it, reflecting that they’re still based in reality. Byatt said that someone with those kinds of thoughts is very unlikely to act on them.

“That is very different than what we could see when we see severe postpartum psychosis — when it’s a psychiatric emergency,” Byatt noted. In a case like that, somebody may think there’s something wrong with their baby and that they caused it, and that they’re both better off dead.

“It’s like an altruistic delusion,” she said.

Postpartum psychosis can also present in more subtle ways, like fluctuating mental status. The person may start thinking that there’s something wrong with them or their baby or may be more confused than usual. Loved ones might express concern that the person isn’t acting like their usual self. But things can escalate quickly into auditory or visual hallucinations, like hearing voices that tell them the world is better off without them and their baby in it.

“That’s why recognizing these things as early as possible and treating it as early as possible is important,” Byatt said. “We hope to prevent it from becoming more severe and becoming a psychiatric emergency.”

Byatt said it’s also important to correctly diagnose patients. Many patients with bipolar disorder are incorrectly diagnosed as having unipolar depression, which is treated differently. Prescribing an antidepressant to someone who actually has bipolar disorder carries the risk of making their symptoms worse, like potentially triggering mania.

Continuing to treat mental health and psychiatric conditions while pregnant is also important, and Byatt noted that attitudes have been changing. While not all medications that treat these conditions are safe in pregnancy, most are, and clinicians can counsel their patients on how to best continue care for the mother-baby dyad postpartum.

Postpartum psychosis is not currently included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), but there’s momentum to have it added, Byatt said. She added that severe psychiatric illness — whether anxiety, depression, or psychosis — can “hijack” the brain.

“We really need to have compassion and think about what has happened to this person that led them to behave that way,” she said.