Recognizing postpartum psychosis

For the birthing parent

Postpartum psychosis is very rare, and occurs in about 1–2 of every 1,000 births. It is not caused by anything the birthing parent did or did not do, and is not a reflection of their character or capacity as a parent. With proper treatment, most people recover fully.

One of the most protective factors during this time is having someone nearby who knows what to look for. If thoughts feel out of control, if things are being heard or seen that others cannot hear or see, if there are thoughts of harming oneself or the baby, urgent help is needed: you can call or text 9-8-8 (Suicide Crisis Helpline) any time, or call 9-1-1 for immediate emergencies. Reaching out is not an overreaction. It’s the right step.

Something feels different, and you can't quite name it

People experiencing psychosis often have no awareness of it. Therefore, non-birthing partners and the people closest to a birthing parent are often the first to notice that something is wrong and must act to get them the medical care they need. For example, the birthing parent is saying things and doing things that are very unusual or concerning and out of line with who they usually are. This may show up as days without sleep with no signs of tiredness. They may be doing or saying things that don’t make sense or feel alarming. Their mood may be swinging in ways that feel deeply intense and unfamiliar. There may be a sense of confusion that a hard night with a newborn simply cannot explain.

These changes can be subtle at first, or they can feel sudden or jarring. They may evolve from somewhat concerning to very concerning, including hallucinations and aggressive or violent behaviour. Either way, noticing them and naming them matters, and it’s important to understand it quickly and act to get medical help as soon as possible — even when the birthing person doesn’t want help — as people experiencing postpartum psychosis are at a risk of harming themselves and others.

What postpartum psychosis is and what it isn't

Postpartum psychosis is a rare but serious mental health condition that requires urgent medical care. Symptoms usually appear within the first two weeks after birth, typically peaking between the third and tenth day postpartum, but can begin as early as the first day. Many birthing parents have already been discharged from hospital when symptoms first appear. Because of this, partners, family members and close friends are often the first to notice that something is wrong, which is why understanding this condition matters.

It also helps to know what postpartum psychosis is not. It is not the baby blues or pinks, which are very common mood shifts in the first two weeks after birth that ease on their own. It is not postpartum depression, which develops more gradually and does not involve a break from reality. It is not postpartum anxiety, even when that anxiety is severe.

Postpartum psychosis is its own condition, and what sets it apart is the speed and nature of the change. Symptoms can appear suddenly and shift rapidly from hour to hour in a way that feels unlike anything else.

Postpartum psychosis often involves a mix of mood symptoms, like low mood or an extreme high mood and excessive energy (sometimes called mania), along with symptoms that make it hard for a person to tell what is real from what is not.

It’s important to know that the person experiencing this often has little to no awareness that anything is actually wrong. They may feel completely certain that their perceptions and beliefs are real. It’s that lack of awareness that makes it so critical for the people around them to recognize what is happening and know what to look for. When suggesting to those with postpartum psychosis that something might be wrong, they can become very defensive, at times even physically aggressive, to the point where you might feel fearful of them. This can make it very difficult for their loved ones to seek help.

Why it happens to the birthing parent

Postpartum psychosis is unique to the person who has given birth, and while the exact cause is not fully understood, researchers believe that several factors work together to bring it on. These include a dramatic drop in reproductive hormones, specifically estrogen and progesterone in the hours and days after delivery or loss, along with severe sleep deprivation, genetic vulnerability and, in some cases, complications during childbirth. It’s likely that a combination of these factors, rather than any single one, contributes to this condition.

Certain things are known to raise the risk factors, including a personal or family history of bipolar disorder, schizoaffective disorder or postpartum psychosis in a previous pregnancy. When any of this history is present, speaking with a care provider before or during pregnancy is worthwhile so that a plan can be put into place. Postpartum psychosis can also occur in people without this history or a previous episode.

Lack of sleep is another major contributing factor, which is one reason sleep protection in the early weeks after birth is taken seriously in the care of those who are considered higher risk.

If this conversation hasn't happened yet, you should raise it with a care provider sooner than later.

What you might be seeing

Because postpartum psychosis can look different from person to person, and because symptoms can come and go, it helps to know the kinds of changes that are worth taking seriously.

From the outside, you might notice that the birthing parent seems to be living in a different reality in a way that goes beyond tiredness. They may be disoriented about where they are, what time it is or what has recently happened. Their speech might feel scattered or hard to follow. Their mood might shift dramatically and without apparent reason, from intense agitation to strange calm, from euphoria to despair, within hours or even minutes.

You might notice that they seem to believe something that isn't true, like a fixed belief that is not shaken by reassurance or evidence. This might involve fears about the baby, about you or about themselves that feel completely out of character. They may hear or see things that others cannot. They may seem deeply suspicious of people they usually trust, including you, which can be confusing and painful for those on the receiving end.

Postpartum psychosis is different from intrusive thinking and OCD

Most new parents experience intrusive thoughts. These are unwanted, frightening thoughts about harm coming to their baby. This isn’t the same as postpartum psychosis. The key difference is that the person having intrusive thoughts knows they’re unwanted and is distressed by them.

In postpartum psychosis, the beliefs feel real and are not recognized by the person experiencing them as symptoms at all. They are not disturbed by their thoughts, but believe them, and will defend them as being real. Reasoning with a person experiencing psychosis is extremely difficult. Keeping that distinction in mind can help you understand what you’re seeing and whether urgent action is needed.

What to do right now

If what you’re reading here matches what you’re seeing, the most important thing you can do is act quickly. Postpartum psychosis is a psychiatric emergency. Call 9-1-1 or go to the emergency department as soon as possible. If it’s unclear what the birthing person is experiencing, an assessment is a safer approach. It can feel difficult to know when to act, especially when changes are subtle or have come on gradually. When in doubt, reaching out sooner than later is the safer choice.

The birthing parent should not be left on their own, either alone or with the baby, until they’ve been assessed by a medical professional and it’s been deemed safe to do so.

What recovery looks like

With prompt treatment, most people who experience postpartum psychosis recover fully. The early weeks of this condition can be frightening and disorienting for everyone involved, and it's important to have realistic expectations for what the path forward looks like.

Treatment typically involves medication, close monitoring and, in many cases, a stay in hospital. Recovery takes time, and it looks different for everyone. They will likely need ongoing support from their care team after the acute phase has passed.

The role of the family and support people during this time is meaningful. Being present, staying in contact with care providers and attending to personal wellbeing during this time are all meaningful contributions. Partners and family members of people who have experienced postpartum psychosis often describe the experience as frightening and isolating. Those feelings are real and valid, and support is available.

If you’re noticing sudden or unusual changes in how someone close to you is thinking or feeling in the weeks after birth, it’s important to reach out to a care provider today. If you’re concerned about their immediate safety, go to the emergency department or call 9-1-1. You are not overreacting. You’re paying attention to someone you love.

If you have been through the experience of psychosis or are experiencing other mental health challenges during the perinatal period, speak with your medical or mental health care provider about services that are most appropriate for you. You can also use our Services Finder to find available support options.

This article was developed using sourced educational content from Canadian Perinatal Mental Health Trainings (CPMHT), and informed by the collective knowledge and expertise of CPMHT professionals and Karen Clarke, BA, MSW, RSW, Doula (Open Book Doula, Counselling and Consulting Services), as well as the following cited research and clinical practice guidelines: