Postpartum Psychosis Risk Highest With Bipolar History

Postpartum psychosis occurs in one to two births per thousand, according to perinatal psychiatrist Nancy Byatt. The condition presents a heightened risk for people with a personal or family history of bipolar disorder.

Byatt, a professor at UMass Chan Medical School, told MedPage Today that the pregnancy and postpartum periods are a time of general risk for mood disorders due to intense physiological and hormonal changes. She stressed the importance of monitoring when new symptoms occur, as different time periods are linked to different changes.

The Link to Bipolar Disorder

Postpartum psychosis often appears in the context of bipolar disorder. It can still occur in people with other mood disorders or no psychiatric history. Byatt emphasized the particular risk with bipolar disorder.

Clinicians should monitor pregnant individuals with a personal or family history of bipolar disorder more closely. Bipolar disorder is typically chronic, but some develop it during pregnancy or postpartum without it becoming long-term.

Intrusive Thoughts Versus Psychosis

New parents commonly have intrusive thoughts of harming their baby, even if they have no desire to act. These thoughts can stem from depression, anxiety, or OCD.

Byatt gave an example. A patient one month postpartum might report intrusive thoughts of throwing their baby down the stairs. They would be terrified, unable to shake the thoughts, and avoid stairs. This person has insight and is very unlikely to act. "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 psychiatric emergency, someone may develop an altruistic delusion. They might believe something is wrong with their baby, that they caused it, and that both would be better off dead.

Recognizing the Signs

Early signs can be subtle, like a fluctuating mental status or unusual confusion. A person may think something is wrong with them or their baby. Loved ones might notice they are not acting like themselves.

Symptoms can escalate quickly to auditory or visual hallucinations. A person might hear voices saying the world is better off without them and their baby. "That's why recognizing these things as early as possible and treating it as early as possible is important," Byatt said. The goal is to prevent escalation to a psychiatric emergency.

Diagnosis and Treatment Challenges

Correct diagnosis is critical. Many patients with bipolar disorder are incorrectly diagnosed with unipolar depression, which is treated differently. Prescribing an antidepressant to someone with bipolar disorder risks worsening symptoms, potentially triggering mania.

Continuing mental health treatment during pregnancy is also vital. Byatt noted attitudes are changing. While not all medications are safe in pregnancy, most are. Clinicians can counsel patients on how to best continue care for the mother-baby dyad postpartum.

Postpartum psychosis is not currently in the DSM-5, but there is momentum to add it. Byatt said severe psychiatric illness can hijack the brain, requiring compassion and understanding of what led to the behavior.